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Nursing HomeMedicaid Investigative

Legend Oaks Healthcare and Rehabilitation Fort Worth

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

4240 Golden Triangle Boulevard, Fort Worth, TX 76244132 bedsLicensed & Active
2/5
Medicare
Inspection
Quality
Staffing
Google rating
4.2/5

based on 162 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 staffing rating (2/5 stars)
  • High staff turnover (68%)
  • High RN turnover (77%)

Top 25% in Texas · Below recommended RN staffing · Chain outperformer · $50,633 in fines

Source: Medicare data

What this means for your family

This facility is an excellent choice for short-term rehabilitation, as the therapy teams are consistently rated as top-tier. However, if your loved one requires long-term care, you must verify staffing levels for weekends and nights, as multiple families have reported slow response times and inadequate care during those periods.

Google Reviews

Google Reviews

162 reviews on Google
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 details
Food4.0Staff6.0Clean9.0Activities8.0Meds2.0MemoryN/AComms3.0ValueN/A

Strengths

  • Exceptional physical and occupational therapy teams
  • Clean and modern facility atmosphere
  • Friendly and professional admissions and administrative staff
  • Compassionate wound care nursing

Concerns

  • Understaffing on weekends and night shifts (mentioned by 4 reviewers)
  • Slow response times to call buttons (mentioned by 3 reviewers)
  • Inconsistent medication management and errors (mentioned by 3 reviewers)
  • Poor communication from social workers and administration (mentioned by 3 reviewers)

Rating Trends

Tap a year to see what changed

234'18(7)'20(14)'22(6)'24(17)'26(34)

Distribution · 169 analyzed

5
127
4
6
3
3
2
3
1
30
16 reviews posted between Mar 27, 2026Mar 28, 2026 · 16 were 5-star
11 reviews posted between May 12, 2019May 15, 2019 · 10 were 5-star

How They Respond to Reviews

45%response rate
Good

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.

Questions for Your Tour

  • 1We've heard wonderful things about your physical and occupational therapy teams; could you tell us more about how they work with residents to maintain mobility?
  • 2With the facility feeling so clean and modern, what kind of daily activities or social events are organized to keep residents engaged in the common areas?
  • 3How do you ensure that medication administration remains consistent and accurate, especially during the transition between shifts?
  • 4What protocols are in place to ensure that call buttons are answered promptly during the night shifts and over the weekends?
  • 5How does the administration and social work team keep families updated on a resident's progress or any changes in their care plan?
  • 6In the event of a medical emergency during the late evening or weekend hours, what is the specific process for notifying the family and providing immediate care?

Personalized based on this facility's data


Key Review Excerpts

The other home treated her like a nursing home resident but Legend Oaks treated her like they just wanted her to her get better!

Long-term resident's family · 2026★★★★★

The therapy (Rehab) is great. (Lots of amazing therapist). Administration and leadership are constantly striving and making positive changes

Rehab patient/family · 2025★★★★★

My father, a 100% disabled veteran, was there less than a week and was treated horribly... He was told to stop calling the call button and that he was a pain in the butt.

Long-term resident's family · 2025☆☆☆☆
Source: 162 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.54hrs
72%
Registered nurses for medical care
Total Nursing
3.18hrs
78%
All nurses + aides combined
Staff Turnover
69%
Lower is better (< 30% = good)
RN Turnover
77%
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

5

measures

Mixed Results

2

measures

Long-Stay Residents
💊

Residents on antipsychotic medication

↓ Lower is better
This Facility5.7%
Better than Avg
Here
5.7%
US
15.4%
TX
9.4%
Tarrant
8.7%
😔

Residents with depression symptoms

↓ Lower is better
This Facility2.5%
Better than Avg
Here
2.5%
US
12.1%
TX
2.5%
Tarrant
2.7%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility10.1%
Better than Avg
Here
10.1%
US
19.5%
TX
18.4%
Tarrant
16.8%
🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility13.4%
Better than Avg
Here
13.4%
US
19.4%
TX
14.2%
Tarrant
14.9%
💉

Residents vaccinated for pneumonia

↑ Higher is better
This Facility99.0%
Better than Avg
Here
99.0%
US
93.4%
TX
96.9%
Tarrant
97.8%
💉

Residents vaccinated for the flu

↑ Higher is better
This Facility100.0%
Better than Avg
Here
100.0%
US
95.5%
TX
98.0%
Tarrant
98.1%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility75.9%
Worse than Avg
Here
75.9%
US
79.7%
TX
88.0%
Tarrant
89.7%
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility86.5%
Mixed vs Avgs
Here
86.5%
US
81.8%
TX
89.2%
Tarrant
91.5%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility1.0%
Better than Avg
Here
1.0%
US
1.6%
TX
1.5%
Tarrant
1.6%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

9deficiencies
4penalties
Near state avg (9.1)
8 complaint-triggered
$50,633 in fines

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.

Mar 26, 2026Complaint
1
0686Actual harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Mar 5, 2026Routine
8
0812Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0814Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

Dispose of garbage and refuse properly.

0842Potential for harm · PatternCorrected

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.

0656Potential for harm · IsolatedCorrected

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.

0690Potential for harm · IsolatedCorrected

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.

0695Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0755Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

0321Potential for harm · IsolatedCorrected

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Sep 11, 2025Complaint
1
0689Immediate jeopardy · IsolatedResolved (past non-compliance)

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 26, 2025Complaint
1
0600Actual harm · IsolatedResolved (past non-compliance)

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.

Dec 19, 2024Routine
8
0693Potential for harm · IsolatedCorrected

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.

0694Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

0698Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide safe, appropriate dialysis care/services for a resident who requires such services.

0355Potential for harm · IsolatedCorrected

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

0693Potential for harm · IsolatedCorrected

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.

0694Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

0698Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide safe, appropriate dialysis care/services for a resident who requires such services.

0355Potential for harm · IsolatedCorrected

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

Oct 8, 2024Complaint
2
0689Immediate jeopardy · IsolatedResolved (past non-compliance)

Quality of Life and Care Deficiencies

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

0684Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

Federal Penalties

Fine

Sep 11, 2025

$10,361

Fine

Feb 26, 2025

$9,110

Fine

Oct 8, 2024

$8,827

Fine

May 25, 2023

$22,335

Ownership & Operations

Who Operates This Facility

Owner / Operator

Eastland Memorial Hospital District

Organization Type

for profit

Management Company

NB BROWN ROCK HEALTHCARE, INC

Administrator

TERESA KENNEDY

Chain Affiliation

Chain Name

The Ensign Group

Chain Size

338 facilities nationwide

Chain avg rating: 2.9/5 · Rank 19 of 84

Ownership & Management

Owners

Eastland Memorial Hospital District

Owner · Organization

100%

Key personnel

Cantrell, ChristopherManaging Control - Governing BodyPorter, KrisManaging Control - Governing BodyBurnam, SoonOfficer / DirectorKeetch, ChadOfficer / DirectorTaylor, StephenOfficer / 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 6 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.

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