01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-08-06 | 6 | 2025-08-06 | 2 |
| Cycle 2 | 2024-07-31 | 7 | 2024-07-31 | 1 |
| Cycle 3 | 2023-04-26 | 25 | 2023-04-26 | 1 |
CMS CCN 6759982026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Legacy At Town Creek
2212 W Reagan St · Palestine, TX 75801 · Anderson County
Certified beds199CMS provider file
Recent citation rows42current CMS citation release
Penalty rows2current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
42 rows in the current release
5 rows carry G–L scope/severity codes; 3 carry J–L. 7 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-01-07 · HEALTHF0580Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Correction field: Deficient, Provider has date of correction · 2026-01-08 · complaint2025-10-08 · HEALTHF0695Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Correction field: Deficient, Provider has date of correction · 2025-10-09 · complaint2025-08-06 · HEALTHF0755Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Correction field: Deficient, Provider has date of correction · 2025-09-102025-08-06 · HEALTHF0812Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2025-09-102025-08-06 · HEALTHF0813Severity D · isolated; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Correction field: Deficient, Provider has date of correction · 2025-09-102025-08-06 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-09-102025-08-06 · FIREK0321Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Deficient, Provider has date of correction · 2025-09-102025-08-06 · FIREK0372Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Correction field: Deficient, Provider has date of correction · 2025-09-102024-07-31 · HEALTHF0640Severity B · pattern; potential for minimal harm
Resident Assessment and Care Planning Deficiencies
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Correction field: Deficient, Provider has date of correction · 2024-08-122024-07-31 · HEALTHF0689Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2024-08-122024-07-31 · HEALTHF0755Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Correction field: Deficient, Provider has date of correction · 2024-08-122024-07-31 · HEALTHF0761Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2024-08-122024-07-31 · HEALTHF0812Severity F · widespread; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2024-08-122024-07-31 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2024-08-122024-07-31 · HEALTHF0925Severity D · isolated; potential for more than minimal harm
Environmental Deficiencies
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Correction field: Deficient, Provider has date of correction · 2024-08-12 · complaint2024-07-31 · FIREK0353Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2024-08-222024-06-06 · HEALTHF0600Severity K · pattern of immediate jeopardy
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.
Correction field: Deficient, Provider has date of correction · 2024-06-07 · complaint2024-06-06 · HEALTHF0607Severity K · pattern of immediate jeopardy
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Correction field: Deficient, Provider has date of correction · 2024-06-07 · complaint2024-06-06 · HEALTHF0609Severity E · pattern; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Correction field: Deficient, Provider has date of correction · 2024-06-07 · complaint2024-06-06 · HEALTHF0610Severity K · pattern of immediate jeopardy
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Correction field: Deficient, Provider has date of correction · 2024-06-07 · complaint2024-06-06 · HEALTHF0689Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2024-06-07 · complaint2024-06-06 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2024-06-07 · complaint2024-01-22 · HEALTHF0695Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Correction field: Deficient, Provider has date of correction · 2024-02-14 · complaint2024-01-22 · HEALTHF0761Severity E · pattern; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2024-02-14 · complaint03 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2025-10-08 | Fine | $10,358 | 0 |
| 2024-06-06 | Fine | $284,250 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- LIBERTY COUNTY HOSPITAL DISTRICT NO 1Organization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 04/01/2018
- STRATTON, CHARLESIndividual · CORPORATE OFFICERNOT APPLICABLE · since 04/01/2018
- PMG OPCO- PALESTINE LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 10/01/2025
- ADEWALE, ADEBAYOIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 10/01/2025
- FRANKLIN, BRADLEYIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 10/01/2025
- BOULWARE, DOUGLASIndividual · INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFNOT APPLICABLE · since 03/24/2026
- BOULWARE, SANDRAIndividual · INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFNOT APPLICABLE · since 03/24/2026
- BAUDER FAMILY INVESTMENTS, LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 10/01/2025
- BOULWARE ST JAMES LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 10/01/2025
- PMG REALCO- PALESTINE LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 10/01/2025
- STEVEN BOULWARE FAMILY INVESTMENTS LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 10/01/2025
- ADEWALE, ADEBAYOIndividual · ADP OF THE SNFNOT APPLICABLE · since 10/01/2025
- BAUDER, KELLYIndividual · ADP OF THE SNFNOT APPLICABLE · since 10/01/2025
- BAUDER, MADISONIndividual · ADP OF THE SNFNOT APPLICABLE · since 10/01/2025
- BAUDER, PARKERIndividual · ADP OF THE SNFNOT APPLICABLE · since 10/01/2025
- BAUDER, WILLIAMIndividual · ADP OF THE SNFNOT APPLICABLE · since 10/01/2025
- BOULWARE, STEVENIndividual · ADP OF THE SNFNOT APPLICABLE · since 10/01/2025
- BOULWARE, THOMASIndividual · ADP OF THE SNFNOT APPLICABLE · since 10/01/2025
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.37per resident day
RN hours0.27per resident day
Weekend nurse hours3.06per resident day
Staff turnover53.8%CMS reported field