LEGACY AT TOWN CREEK

CCN 675998 · LIBERTY COUNTY HOSPITAL DISTRICT NO 1 · Government - Hospital district · SOUTHWEST LTC chain · 199 certified beds · Anderson · TX


LEGACY AT TOWN CREEK is a 199-bed nursing home in PALESTINE, Texas. CMS has certified it for Medicare and Medicaid since 2004-01-08. It averages 77.2 residents a day.

What harm was found in the violations cited at LEGACY AT TOWN CREEK?

CMS lists 38 health-inspection deficiencies for LEGACY AT TOWN CREEK since 2023-04-26, 22 of them in the three years to 2026-08-01: the highest scope-and-severity letter on record is K; the most recent health inspection was 2026-01-07.

Survey dateTagDeficiencySeverity
2026-01-07F0580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.D
2025-10-08F0695Provide safe and appropriate respiratory care for a resident when needed.G
2025-08-06F0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.E
2025-08-06F0755, F0813, F0880Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. / Have a policy regarding use and storage of foods brought to residents by family and other visitors. / Provide and implement an infection prevention and control program.D
2024-07-31F0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.F
2024-07-31F0689, F0755, F0761, F0880, F0925Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. / Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. / 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. / Provide and implement an infection prevention and control program. / Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.D
2024-07-31F0640Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.B
2024-06-06F0600, F0607, F0610Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. / Develop and implement policies and procedures to prevent abuse, neglect, and theft. / Respond appropriately to all alleged violations.K
2024-06-06F0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.G
2024-06-06F0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.E
2024-06-06F0880Provide and implement an infection prevention and control program.D
2024-01-22F0761Ensure 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.E
2024-01-22F0695Provide safe and appropriate respiratory care for a resident when needed.D
2023-08-08F0607Develop and implement policies and procedures to prevent abuse, neglect, and theft.D
2023-04-26F0552, F0584, F0655, F0656, F0677, F0695, F0758, F0921Ensure that residents are fully informed and understand their health status, care and treatments. / 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. / Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted / Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. / Provide care and assistance to perform activities of daily living for any resident who is unable. / Provide safe and appropriate respiratory care for a resident when needed. / 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. / Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.E
2023-04-26F0550, F0657, F0690, F0692, F0698, F0755, F0880, F0926Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. / Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. / Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. / Provide enough food/fluids to maintain a resident's health. / Provide safe, appropriate dialysis care/services for a resident who requires such services. / Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. / Provide and implement an infection prevention and control program. / Have policies on smoking.D

Why was LEGACY AT TOWN CREEK fined 2 times?

DateTypeAmount
2025-10-08Fine$10,358
2024-06-06Fine$284,250

How is LEGACY AT TOWN CREEK staffed relative to the TX average?

MeasureThis facilityTX average
Total nurse staffing hours per resident per day3.368873.38539
Total nursing staff turnover (%)53.855.3
Average number of residents per day77.275.8

Who owns LEGACY AT TOWN CREEK, and what chain is it in?

LEGACY AT TOWN CREEK is registered with CMS as Government - Hospital district, operates under the legal business name LIBERTY COUNTY HOSPITAL DISTRICT NO 1 and belongs to the SOUTHWEST LTC chain.

RoleOwnerAssociation date
5% OR GREATER DIRECT OWNERSHIP INTERESTLIBERTY COUNTY HOSPITAL DISTRICT NO 1since 04/01/2018
CORPORATE OFFICERSTRATTON, CHARLESsince 04/01/2018
OPERATIONAL/MANAGERIAL CONTROLPMG OPCO- PALESTINE LLC, ADEWALE, ADEBAYO, FRANKLIN, BRADLEYsince 10/01/2025
INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFBOULWARE, DOUGLAS, BOULWARE, SANDRAsince 03/24/2026
ADP OF THE SNFBAUDER FAMILY INVESTMENTS, LLC, BOULWARE ST JAMES LLC, PMG REALCO- PALESTINE LLC, STEVEN BOULWARE FAMILY INVESTMENTS LLC, ADEWALE, ADEBAYO, BAUDER, KELLY, BAUDER, MADISON, BAUDER, PARKER, BAUDER, WILLIAM, BOULWARE, STEVEN, BOULWARE, THOMAS, FRANKLIN, BRADLEY, WALKER, KATIEsince 10/01/2025

Were you or a family member harmed at LEGACY AT TOWN CREEK?