The nursing home failed to protect residents from abuse and neglect by others. Cited May 2023 — isolated incident, immediate jeopardy to residents.
View the original federal record
F-Tag 600 — 42 CFR §483.12 — S/S: J
Nursing home report
Legend Oaks Healthcare and Rehabilitation Garland
Garland, TX · Medicare-certified · 132 beds
In good standing
For-profitChain member
2 of 5 overall
Legend Oaks Healthcare and Rehabilitation Garland has a 2 out of 5 overall rating, with 2 stars for health inspections, 3 stars for staffing, and 3 stars for quality measures. Reported nurse staffing is 3.38 hours per resident per day versus the 4.1-hour federal benchmark; there were $0 fines in the last 24 months, but recent inspection citations included abuse/neglect protections, accident hazards, and drug storage rules.
Facility ratings
Health inspections
Staffing
3.3787 hrs/resident/day
Quality measures
Last inspection: March 6, 2026Penalties, last 24 months: $0
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 3.3787.
Staffing detail
- Registered nurses
- 0.64
- Licensed practical nurses
- 0.69
- Nurse aides
- 2.05
- Weekend nursing
- 2.89
Hours per resident per day.
Total staff turnover: 38%
Registered nurse turnover: 33%
Resident outcomes
How often residents experience these outcomes, with the direction over the past year.
Long-stay residents on antipsychotic medication
1.2%Improving
Residents with a fall causing major injury
6.3%Improving
Residents with pressure ulcers (bedsores)
0.7%Improving
Residents with a urinary tract infection
0.6%Steady
Residents who lost too much weight
3.2%Steady
Residents who were physically restrained
0%Steady
Residents needing more help with daily activities
19.9%Worsening
Residents whose ability to walk got worse
21.6%Worsening
Show all measures
Long-stay residents on antianxiety or sleep medication
11.1%Worsening
Short-stay residents newly given an antipsychotic
1%Worsening
Residents with a long-term catheter
0%Steady
Residents with new or worsening incontinence
19.6%Worsening
Residents with depressive symptoms
2.8%Improving
Long-stay residents given the seasonal flu vaccine
97.7%Steady
Long-stay residents given the pneumonia vaccine
94%Improving
Short-stay residents given the seasonal flu vaccine
55.4%Steady
Short-stay residents given the pneumonia vaccine
55.3%Worsening
What the inspectors found
The nursing home failed to keep the area free of hazards and provide enough supervision to prevent accidents. Cited May 2023 — isolated incident, immediate jeopardy to residents.
View the original federal record
F-Tag 689 — 42 CFR §483.25(d) — S/S: J
The home failed to properly label and securely store medications and biologicals. Cited July 2023 — widespread issue, potential for harm.
View the original federal record
F-Tag 761 — 42 CFR §483.45(g) — S/S: F
The nursing home failed to keep medication mistakes below the allowed level. Cited February 2025 — limited pattern, potential for harm.
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F-Tag 759 — 42 CFR §483.45(f)(1) — S/S: E
The home failed to make sure food was safely sourced, stored, prepared, and served according to professional standards. Cited February 2025 — limited pattern, potential for harm.
View the original federal record
F-Tag 812 — 42 CFR §483.60(i) — S/S: E
Recent history
- STAFFING
Reported nurse staffing was below the federal recommendation of 4.1 hours per resident per day.
- INSPECTION
Health inspection found 2 health deficiencies.
See what inspectors found
- INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
- INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
Operator & ownership
- Ownership
- For profit - Corporation
- Chain
- Part of THE ENSIGN GROUP · 338 homes · 3.2 stars avg
- Occupancy
- 101.6 residents on an average day (77% of 132 beds)
- Resident voice
- Resident council
- Medicare history
- Certified for 9 years
Things at a nursing home change — inspections, staffing, ownership, news.
Source: Centers for Medicare & Medicaid Services — public records, updated monthly. GoodStanding presents official records with plain-language summaries. Always visit a facility in person.