Legend Oaks Healthcare And Rehabilitation Center Gladewater

Penalties

• Oct 23, 2024 — Fine ($16,801)
• Oct 23, 2024 — Fine ($16,801)
• Oct 23, 2024 — Fine ($16,801)
• Oct 23, 2024 — Fine ($16,801)
• Jun 19, 2024 — Fine ($43,070)
• Sep 13, 2023 — Fine ($14,285)

Inspection findings

1. May 23, 2026 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0686 Quality of Life and Care Deficiencies

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

     Corrected May 26, 2026 · CMS health inspection

2. Apr 15, 2026 Health · 11 findings
   • Not serious Scope/severity E

     F0572 Resident Rights Deficiencies

     Give residents a notice of rights, rules, services and charges.

     Corrected May 1, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0576 Resident Rights Deficiencies

     Ensure residents have reasonable access to and privacy in their use of communication methods.

     Corrected May 1, 2026 · CMS health inspection

   • Not serious Scope/severity C

     F0577 Resident Rights Deficiencies

     Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

     Corrected Apr 16, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0585 Resident Rights Deficiencies

     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.

     Corrected May 1, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0679 Quality of Life and Care Deficiencies

     Provide activities to meet all resident's needs.

     Corrected May 1, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0690 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.

     Corrected May 1, 2026 · CMS health inspection

   • Not serious Scope/severity C

     F0732 Nursing and Physician Services Deficiencies

     Post nurse staffing information every day.

     Corrected May 1, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0755 Pharmacy Service Deficiencies

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

     Corrected Apr 24, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0761 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.

     Corrected May 1, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected May 1, 2026 · CMS health inspection

   • Not serious Scope/severity B

     K0521 Services Deficiencies

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

     CMS fire safety

3. Jan 29, 2026 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

     Corrected Feb 18, 2026 · CMS health inspection

4. Jan 21, 2026 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0689 Quality of Life and Care Deficiencies

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

     Corrected Feb 4, 2026 · CMS health inspection

5. Feb 12, 2025 Health · 7 findings
   • Not serious Scope/severity E

     F0558 Resident Rights Deficiencies

     Reasonably accommodate the needs and preferences of each resident.

     Corrected Mar 14, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0695 Quality of Life and Care Deficiencies

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

     Corrected Mar 14, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0761 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.

     Corrected Mar 14, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0802 Nutrition and Dietary Deficiencies

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

     Corrected Mar 14, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0807 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.

     Corrected Mar 14, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Mar 14, 2025 · CMS health inspection

   • Not serious Scope/severity C

     K0521 Services Deficiencies

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

     CMS fire safety

6. Oct 23, 2024 Health · 4 findings
   • Serious Scope/severity J Complaint

     F0600 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.

     Corrected Aug 30, 2024 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0607 Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

     Corrected Aug 30, 2024 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

     Corrected Aug 30, 2024 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected Aug 30, 2024 · CMS health inspection

7. Jun 19, 2024 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0684 Quality of Life and Care Deficiencies

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

     Corrected Jul 16, 2024 · CMS health inspection

   • Serious Scope/severity G Complaint

     F0925 Environmental Deficiencies

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

     Corrected Jul 16, 2024 · CMS health inspection

8. Feb 22, 2024 Health · 3 findings
   • Not serious Scope/severity D Complaint

     F0563 Resident Rights Deficiencies

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

     Corrected Mar 21, 2024 · CMS health inspection

   • Serious Scope/severity H Complaint

     F0603 Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

     Corrected Mar 21, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Mar 21, 2024 · CMS health inspection

9. Jan 24, 2024 Health · 10 findings
   • Not serious Scope/severity D

     F0558 Resident Rights Deficiencies

     Reasonably accommodate the needs and preferences of each resident.

     Corrected Feb 23, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0607 Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

     Corrected Feb 23, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0641 Resident Assessment and Care Planning Deficiencies

     Ensure each resident receives an accurate assessment.

     Corrected Feb 23, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0657 Resident Assessment and Care Planning Deficiencies

     Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

     Corrected Feb 23, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0689 Quality of Life and Care Deficiencies

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

     Corrected Feb 23, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0695 Quality of Life and Care Deficiencies

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

     Corrected Feb 23, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0757 Pharmacy Service Deficiencies

     Ensure each resident’s drug regimen must be free from unnecessary drugs.

     Corrected Feb 23, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0758 Pharmacy Service Deficiencies

     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.

     Corrected Feb 23, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0761 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.

     Corrected Feb 23, 2024 · CMS health inspection

   • Not serious Scope/severity B

     K0521 Services Deficiencies

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

     CMS fire safety

10. Sep 13, 2023 Health · 2 findings
    • Not serious Scope/severity D Complaint

      F0600 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.

      Corrected Oct 12, 2023 · CMS health inspection

    • Serious Scope/severity J Complaint

      F0689 Quality of Life and Care Deficiencies

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

      Corrected Oct 12, 2023 · CMS health inspection

Owners and managers (as published by CMS)

• BURNAM, SOON — corporate officer, NOT APPLICABLE, since 04/01/2017
• KEETCH, CHAD — corporate officer, NOT APPLICABLE, since 03/01/2011
• KEGARISE, BRANDON — operational/managerial control, NOT APPLICABLE, since 04/01/2017
• KEGARISE, BRANDON — adp of the snf, NOT APPLICABLE, since 04/01/2017
• KEGARISE, BRANDON — managing control - governing body, NOT APPLICABLE, since 04/01/2017
• SANDERSON, CLARK — corporate officer, NOT APPLICABLE, since 04/01/2017
• SHEN, HONG-I — adp of the snf, NOT APPLICABLE, since 05/06/2021
• SHEN, HONG-I — operational/managerial control, NOT APPLICABLE, since 05/06/2021
• SHEN, HONG-I — managing control - governing body, NOT APPLICABLE, since 05/06/2021
• DAFFODIL HEALTHCARE, INC. — operational/managerial control, NOT APPLICABLE, since 04/01/2017
• DAFFODIL HEALTHCARE, INC. — adp of the snf, NOT APPLICABLE, since 09/29/2025
• ENSIGN SERVICES INC — adp of the snf, NOT APPLICABLE, since 05/01/2016
• FANNIN COUNTY HOSPITAL AUTHORITY — 5% or greater direct ownership interest, 100%, since 04/01/2017
• NATIONAL HEALTH INVESTORS, INC. — adp of the snf, NOT APPLICABLE, since 04/01/2017
• TEXAS NHI INVESTORS, LLC — adp of the snf, NOT APPLICABLE, since 04/01/2017