Nursing homes › Texas › Legend Oaks Healthcare and Rehabilitation Center -
1201 Fm 2685, Gladewater, TX 75647 · 9038452175 · 100 certified beds
Per CMS filings, this facility is affiliated with The Ensign Group, a group operating 346 facilities in 17 states. Group record: average rating 3.2/5, 33 abuse citation icons, 9 facilities on the Special Focus list, $7,179,329 in federal fines. This facility rates below its group average (3.2/5).
Total nurse staffing: 3.11 (Texas median: 3.27). RN hours: 0.37. Weekend total: 2.58. Nursing staff turnover: 43%.
All-time on record: 39 deficiency citations, including 5 at immediate-jeopardy level. Below: citations from 2023 onward (severity letters explained in methodology).
| Survey date | Deficiency | Sev. | Type | Status |
|---|---|---|---|---|
| 2026-05-23 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | D | complaint | corrected 2026-05-26 |
| 2026-04-15 | Give residents a notice of rights, rules, services and charges. | E | Health | corrected 2026-05-01 |
| 2026-04-15 | Ensure residents have reasonable access to and privacy in their use of communication methods. | E | Health | corrected 2026-05-01 |
| 2026-04-15 | Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | E | Health | corrected 2026-05-01 |
| 2026-04-15 | Provide activities to meet all resident's needs. | E | Health | corrected 2026-05-01 |
| 2026-04-15 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | E | Health | corrected 2026-04-24 |
| 2026-04-15 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | D | Health | corrected 2026-05-01 |
| 2026-04-15 | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | D | Health | corrected 2026-05-01 |
| 2026-04-15 | Provide and implement an infection prevention and control program. | D | Health | corrected 2026-05-01 |
| 2026-04-15 | Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | C | Health | corrected 2026-04-16 |
| 2026-04-15 | Post nurse staffing information every day. | C | Health | corrected 2026-05-01 |
| 2026-01-29 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | complaint | corrected 2026-02-18 |
| 2026-01-21 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | complaint | corrected 2026-02-04 |
| 2025-02-12 | Reasonably accommodate the needs and preferences of each resident. | E | Health | corrected 2025-03-14 |
| 2025-02-12 | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | E | Health | corrected 2025-03-14 |
| 2025-02-12 | Provide and implement an infection prevention and control program. | E | Health | corrected 2025-03-14 |
| 2025-02-12 | Provide safe and appropriate respiratory care for a resident when needed. | D | Health | corrected 2025-03-14 |
| 2025-02-12 | Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | D | Health | corrected 2025-03-14 |
| 2025-02-12 | Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | D | Health | corrected 2025-03-14 |
| 2024-10-23 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | J | complaint | corrected 2024-08-30 |
| 2024-10-23 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. | J | complaint | corrected 2024-08-30 |
| 2024-10-23 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | J | complaint | corrected 2024-08-30 |
| 2024-10-23 | Respond appropriately to all alleged violations. | J | complaint | corrected 2024-08-30 |
| 2024-06-19 | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | G | complaint | corrected 2024-07-16 |
| 2024-06-19 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | complaint | corrected 2024-07-16 |
| 2024-02-22 | Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). | H | complaint | corrected 2024-03-21 |
| 2024-02-22 | Provide and implement an infection prevention and control program. | E | complaint | corrected 2024-03-21 |
| 2024-02-22 | Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | D | complaint | corrected 2024-03-21 |
| 2024-01-24 | Ensure each resident receives an accurate assessment. | E | Health | corrected 2024-02-23 |
| 2024-01-24 | Provide safe and appropriate respiratory care for a resident when needed. | E | Health | corrected 2024-02-23 |
| 2024-01-24 | Ensure each resident’s drug regimen must be free from unnecessary drugs. | E | Health | corrected 2024-02-23 |
| 2024-01-24 | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | E | complaint | corrected 2024-02-23 |
| 2024-01-24 | Reasonably accommodate the needs and preferences of each resident. | D | Health | corrected 2024-02-23 |
| 2024-01-24 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. | D | complaint | corrected 2024-02-23 |
| 2024-01-24 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D | Health | corrected 2024-02-23 |
| 2024-01-24 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Health | corrected 2024-02-23 |
| 2024-01-24 | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | D | Health | corrected 2024-02-23 |
| 2023-09-13 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | J | complaint | corrected 2023-10-12 |
| 2023-09-13 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D | complaint | corrected 2023-10-12 |
| Date | Type | Amount |
|---|---|---|
| 2024-10-23 | Fine | $16,801 |
| 2024-10-23 | Fine | $16,801 |
| 2024-10-23 | Fine | $16,801 |
| 2024-10-23 | Fine | $16,801 |
| 2024-06-19 | Fine | $43,070 |
| 2023-09-13 | Fine | $14,285 |
| Name | Role | Type | % | Since |
|---|---|---|---|---|
| FANNIN COUNTY HOSPITAL AUTHORITY | 5% Or Greater Direct Ownership Interest | Organization | 100% | since 04/01/2017 |
| KEGARISE, BRANDON | Managing Control - Governing Body | Individual | NOT APPLICABLE | since 04/01/2017 |
| SHEN, HONG-I | Managing Control - Governing Body | Individual | NOT APPLICABLE | since 05/06/2021 |
| BURNAM, SOON | Corporate Officer | Individual | NOT APPLICABLE | since 04/01/2017 |
| KEETCH, CHAD | Corporate Officer | Individual | NOT APPLICABLE | since 03/01/2011 |
| SANDERSON, CLARK | Corporate Officer | Individual | NOT APPLICABLE | since 04/01/2017 |
| DAFFODIL HEALTHCARE, INC. | Operational/Managerial Control | Organization | NOT APPLICABLE | since 04/01/2017 |
| KEGARISE, BRANDON | Operational/Managerial Control | Individual | NOT APPLICABLE | since 04/01/2017 |
| SHEN, HONG-I | Operational/Managerial Control | Individual | NOT APPLICABLE | since 05/06/2021 |
Source: CMS Provider Data Catalog (July 2026 release) — provider file, deficiency file, ownership file, penalty file. CCN 676048. Corrections: data@carerecords.org.