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Nursing HomeMedicaid Investigative

Legend Oaks Healthcare and Rehabilitation Center Gladewater

Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.

1201 Fm 2685, Gladewater, TX 75647100 bedsLicensed & Active
2/5
Medicare
Inspection
Quality
Staffing
Google rating
4.7/5

based on 86 Google reviews

5
4
3
2
1

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3/ 10
moderate Risk

Quality Concerns Identified

Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.

  • Low overall rating (2/5 stars)
  • High staff turnover (51%)

Below average in Texas · Below recommended RN staffing · Below chain average · $124,559 in fines

Source: Medicare data

What this means for your family

This facility's physical therapy and nursing staff are frequently praised for their compassion and skill in post-surgical recovery. However, families should be extremely vigilant about hygiene standards and medication accuracy, as multiple reviewers have reported serious lapses in basic care and communication.

Google Reviews

Google Reviews

86 reviews analyzed
Families considering Legend Oaks can expect a highly compassionate rehabilitation and nursing team that many reviewers describe as treating residents like family. While many praise the physical therapy and the kindness of the staff, there are serious, documented allegations regarding neglect, medication errors, and poor communication between staff and doctors that should be investigated during a visit.

Quality Themes

Tap a score for details
Food4.0Staff8.0Clean9.0Activities5.0Meds1.0MemoryN/AComms3.0ValueN/A

Strengths

  • Compassionate and attentive nursing staff
  • Effective and professional physical therapy
  • Clean and well-maintained environment
  • Welcoming and friendly atmosphere

Concerns

  • Allegations of resident neglect and hygiene issues (mentioned by 2 reviewers)
  • Unreliable communication between staff and physicians
  • Medication management errors

Rating Trends

Tap a year to see what changed

234'16(3)'20(4)'22(2)'24(5)'26(23)

Distribution

5
71
4
2
3
2
2
1
1
5
23 reviews posted between Nov 12, 2019Nov 23, 2019 · 23 were 5-star
12 reviews posted between Nov 20, 2019Nov 23, 2019 · 12 were 5-star

How They Respond to Reviews

20%response rate
Good

The owner provides highly personalized and empathetic responses to detailed reviews, often addressing specific staff members or patient situations. However, for simple star ratings without text, the responses shift to repetitive, templated gratitude.

Questions for Your Tour

  • 1I noticed some wonderful comments about how friendly and welcoming the atmosphere is here; how do you foster that sense of community among the residents?
  • 2Could you walk me through your specific protocols for medication administration and how you ensure accuracy for every resident?
  • 3What is your process for ensuring seamless communication between the nursing staff and the attending physicians, especially regarding changes in a resident's condition?
  • 4How do you manage daily hygiene routines and personal care to ensure every resident feels clean and comfortable?
  • 5What does the daily meal schedule look like, and how do you involve residents in their dining experience?
  • 6In the event of a medical emergency during the night, what are the immediate steps the on-site staff takes to coordinate care?

Personalized based on this facility's data


Key Review Excerpts

Tamika was so gentle with my mother in law who had bad fall. She showed me that my mother in law is in good hands!

Family member of a rehab patient · 2026★★★★★

The first facility we had her in just kept her in bed and we need physical therapy!! Legend Oaks has done an outstanding job taking care of our mother and getting her the rehab she’s needed.

Family member of a rehab patient · 2023★★★★★

My mother is currently at the facility for extended rehab after a massive stroke left her partially paralyzed. Communication between the staff and her doctor is incredibly unreliable.

Family member of a rehab patient · 2026★★★☆☆
Source: 86 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.40hrs
53%
Registered nurses for medical care
Total Nursing
3.15hrs
77%
All nurses + aides combined
Staff Turnover
40%
Lower is better (< 30% = good)
RN Turnover
25%
Lower is better (< 30% = good)

Both RN and total nursing hours are below national benchmarks. This can mean less clinical attention per resident, so ask about their staffing plan.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 17 measures

Medicare Rating
3/ 5
Better Than Avg

10

measures

Worse Than Avg

4

measures

Mixed Results

3

measures

Long-Stay Residents
🛏️

Residents needing more daily help over time

↓ Lower is better
This Facility27.8%
Worse than Avg
Here
27.8%
US
14.4%
TX
16.1%
Gregg
15.7%
💊

Residents on antipsychotic medication

↓ Lower is better
This Facility2.6%
Better than Avg
Here
2.6%
US
15.4%
TX
9.4%
Gregg
7.0%
💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility28.7%
Worse than Avg
Here
28.7%
US
19.5%
TX
18.4%
Gregg
24.8%
😔

Residents with depression symptoms

↓ Lower is better
This Facility3.3%
Mixed vs Avgs
Here
3.3%
US
12.1%
TX
2.5%
Gregg
1.4%
🚶

Residents whose walking got worse

↓ Lower is better
This Facility19.4%
Worse than Avg
Here
19.4%
US
15.3%
TX
14.9%
Gregg
12.3%
🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility13.0%
Mixed vs Avgs
Here
13.0%
US
19.4%
TX
14.2%
Gregg
9.7%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility88.0%
Better than Avg
Here
88.0%
US
79.7%
TX
88.0%
Gregg
87.5%
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility89.9%
Better than Avg
Here
89.9%
US
81.8%
TX
89.2%
Gregg
89.1%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility2.5%
Worse than Avg
Here
2.5%
US
1.6%
TX
1.5%
Gregg
0.6%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

8deficiencies
6penalties
Near state avg (9.1)
15 complaint-triggered
$124,559 in fines

This facility has serious concerns with 15 family-reported complaints triggering inspections, including recent severe issues with abuse prevention and reporting that families complained about in 2024. The most recurring problems involve resident safety and accident prevention, medication management, and infection control. While most deficiencies show correction plans, the pattern of repeated issues across the same care areas and the high volume of family complaints suggest ongoing quality challenges that warrant careful consideration.

Jan 29, 2026Complaint
1
0609MinorCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Jan 21, 2026Complaint
1
0689MinorCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Feb 12, 2025Routine
7
0558ModerateCorrected

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

0761ModerateCorrected

Pharmacy Service Deficiencies

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.

0880ModerateCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0695MinorCorrected

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

0802MinorCorrected

Nutrition and Dietary Deficiencies

Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

0807MinorCorrected

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.

0521Minor

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Oct 23, 2024Complaint
4
0600Severe

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

0607Severe

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

0609Severe

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

0610Severe

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Jun 19, 2024Complaint
2
0925ModerateCorrected

Environmental Deficiencies

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

0684MinorCorrected

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Feb 22, 2024Complaint
3
0603ModerateCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).

0880ModerateCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0563MinorCorrected

Resident Rights Deficiencies

Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.

Federal Penalties

Fine

Oct 23, 2024

$16,801

Fine

Oct 23, 2024

$16,801

Fine

Oct 23, 2024

$16,801

Fine

Oct 23, 2024

$16,801

Fine

Jun 19, 2024

$43,070

Fine

Sep 13, 2023

$14,285

Ownership & Operations

Who Operates This Facility

Owner / Operator

Fannin County Hospital Authority

Organization Type

for profit

Management Company

DAFFODIL HEALTHCARE, INC

Administrator

LUCAS ARAGON

Chain Affiliation

Chain Name

The Ensign Group

Chain Size

338 facilities nationwide

Chain avg rating: 2.9/5 · Rank 57 of 84

Ownership & Management

Owners

Fannin County Hospital Authority

Owner · Organization

100%

Key personnel

Kegarise, BrandonManaging Control - Governing BodyShen, Hong-iManaging Control - Governing BodyBurnam, SoonOfficer / DirectorKeetch, ChadOfficer / DirectorSanderson, ClarkOfficer / Director
Source: Medicare provider data

Contact

Get in Touch

Contact this facility directly and verify the details that matter most to your family.

References & Resources

EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.

Safer Alternatives Nearby

Based on current clinical data, we identified 2 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.

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