Legend Oaks Healthcare and Rehabilitation Garland
2625 Belt Line Road · Garland, TX · 75044 · 9725437700
132 certified beds For profit - Corporation Chain: The Ensign Group
- No federal fines or payment denials in CMS’s 3-year window.
- Inspection results have improved across recent cycles.
The composite number cleared 78 points, but Recommended is gated: inspection record below the Recommended bar. That rule is part of the published method.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
Cited under the freedom-from-abuse rule
Cited 1 time under F600 (freedom from abuse/neglect) below the actual-harm level — worth asking about on a tour.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 3 of 5 Inspections: 3 of 5 Staffing: 3 of 5 Quality measures: 3 of 5
| Total nurse hours / resident-day | 3.38 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.64 | 0.55–0.75 |
| Weekend hours / resident-day | 2.89 | ≈ weekday level |
| Nursing turnover / year | 38% | median 45% |
| Fines (3-yr window) | none |
Inspection citations (29 in the current record)
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Potential for harm · D March 6, 2026 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected March 7, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D March 6, 2026 · found via complaint
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected March 7, 2026 · Quality of Life and Care
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Potential for harm · D December 30, 2025 · found via complaint
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 December 31, 2025 · Pharmacy Service
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Potential for harm · D December 5, 2025 · found via complaint
Provide safe and appropriate respiratory care for a resident when needed.
Corrected December 15, 2025 · Quality of Life and Care
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Potential for harm · E February 20, 2025
Ensure medication error rates are not 5 percent or greater.
Corrected February 21, 2025 · Pharmacy Service
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Potential for harm · D February 20, 2025 · found via complaint
Keep residents' personal and medical records private and confidential.
Corrected February 21, 2025 · Resident Rights
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Potential for harm · E February 20, 2025 · found via complaint
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected February 21, 2025 · Nutrition and Dietary
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Potential for harm · E January 19, 2024
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected January 20, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · E January 19, 2024
Provide safe and appropriate respiratory care for a resident when needed.
Corrected January 20, 2024 · Quality of Life and Care
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Potential for harm · E January 19, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected January 20, 2024 · Nutrition and Dietary
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Potential for harm · D January 19, 2024 · found via complaint
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected January 20, 2024 · Resident Rights
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Potential for harm · D January 19, 2024 · found via complaint
Reasonably accommodate the needs and preferences of each resident.
Corrected January 20, 2024 · Resident Rights
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Potential for harm · E January 19, 2024 · found via complaint
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected January 20, 2024 · Resident Rights
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Potential for harm · D January 19, 2024 · found via complaint
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 January 20, 2024 · Resident Rights
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Potential for harm · D January 19, 2024 · found via complaint
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected January 20, 2024 · Resident Assessment and Care Planning
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Potential for harm · E January 19, 2024 · found via complaint
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected January 20, 2024 · Quality of Life and Care
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Potential for harm · D January 19, 2024 · found via complaint
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.
Corrected January 20, 2024 · Quality of Life and Care
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Potential for harm · E January 19, 2024 · found via complaint
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected January 20, 2024 · Pharmacy Service
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Potential for harm · D January 19, 2024 · found via complaint
Provide and implement an infection prevention and control program.
Corrected January 20, 2024 · Infection Control
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Potential for harm · D October 14, 2023 · found via complaint
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected November 21, 2023 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · E October 14, 2023 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected November 21, 2023 · Quality of Life and Care
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Potential for harm · D October 14, 2023 · found via complaint
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected November 21, 2023 · Pharmacy Service
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Potential for harm · D October 14, 2023 · found via complaint
Ensure that residents are free from significant medication errors.
Corrected November 21, 2023 · Pharmacy Service
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Potential for harm · F July 21, 2023 · found via complaint
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 July 21, 2023 · Pharmacy Service
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Potential for harm · E July 21, 2023 · found via complaint
Provide and implement an infection prevention and control program.
Corrected July 21, 2023 · Infection Control
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 676413 · certified since February 7, 2017. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.