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Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.
based on 169 Google reviews
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These current public-data fields deserve follow-up with the facility and the official Medicare record. They are not a clinical risk score or a substitute for an in-person assessment.
This facility has areas of concern that warrant careful consideration. Registered Nurse hours are 65% of the EveryPlace reference benchmark; ask how RN coverage is allocated across shifts. The latest standard survey recorded 10 findings, above the TX average of 9.1. We recommend asking the administrator directly: "How are you addressing recent staffing shortfalls?" These are not reasons to panic, but they are reasons to ask tough questions and visit in person.
Families considering Legend Oaks can expect high-quality rehabilitation services and a clean, modern facility, with many praising the physical therapy team. However, there are significant, recurring reports of understaffing on weekends and nights, as well as serious allegations regarding inconsistent medication management and patient neglect.
Quality Themes
Tap a score for detailsStrengths
Concerns
Rating Trends
Tap a year to see what changed
Distribution · 176 analyzed
The owner provides highly personalized responses to positive reviews, often addressing specific staff members or facility features mentioned. For negative reviews, the response shifts to a professional, standardized template that invites direct communication to resolve issues.
Personalized based on this facility's data
Key Review Excerpts
“The therapy (Rehab) is great. (Lots of amazing therapist). Administration and leadership are constantly striving and making positive changes”
“The rehab staff is superb, which is why the hospital recommended Legend Oaks.”
Both RN and total nursing hours are below the EveryPlace reference benchmarks. Ask the facility how it staffs each shift for current resident needs.
Reference benchmarks (0.75 RN and 4.1 total nursing hours per resident/day) are comparison targets, not current federal minimum requirements.
Resident outcomes compared with national, state, and local averages · 17 measures
9
measures
4
measures
4
measures
Residents on anti-anxiety or sleep medication
Residents with depression symptoms
Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.
Residents on antipsychotic medication
Residents whose bladder or bowel control got worse
Residents vaccinated for the flu
Residents vaccinated for pneumonia
Short-stay residents vaccinated for the flu
Short-stay residents vaccinated for pneumonia
Short-stay residents newly given antipsychotics
US average from Medicare published data
Detailed Medicare record · up to 3-year lookback
Multiple families have filed complaints about recurring accident prevention failures, with the same safety deficiency appearing three times across two years, suggesting ongoing supervision and hazard control problems. Other frequent issues include care planning, accommodating resident preferences, and facility safety systems. While all deficiencies show correction dates, the repeated accident prevention citations from family complaints indicate persistent safety concerns that warrant careful consideration during your visit.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies
Dispose of garbage and refuse properly.
Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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.
Quality of Life and Care Deficiencies
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Quality of Life and Care Deficiencies
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Quality of Life and Care Deficiencies
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Smoke Deficiencies
Properly select, install, inspect, or maintain portable fire extinguishes.
Federal Penalties
Fine
Mar 5, 2026
$18,150
Fine
Mar 5, 2026
$19,135
Fine
Sep 11, 2025
$10,361
Fine
Feb 26, 2025
$9,110
Fine
Oct 8, 2024
$8,827
Eastland Memorial Hospital District
for profit
NB BROWN ROCK HEALTHCARE, INC
TERESA KENNEDY
The Ensign Group
346 facilities nationwide
Chain avg rating: 2.9/5 · Rank 19 of 84
Owners
Eastland Memorial Hospital District
Owner · Organization
Key personnel
Contact this facility directly and verify the details that matter most to your family.
Medicare Care Compare
Official Medicare quality ratings, inspections & staffing data
Google Maps
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Google Reviews
169 reviews from families & visitors
Official Website
Visit legendoaksfortworth.com
Medicare data downloads
Original nursing home datasets
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. Some summaries, interpretations, suggested questions, and pricing research are AI-generated or AI-assisted and may contain errors or omit important context. 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.
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