LEGACY AT TOWN CREEK
Open-data reference.
LEGACY AT TOWN CREEK is a government - hospital district facility in PALESTINE, TX with 199 certified beds and a 2-star overall CMS rating. The facility has 37 deficiency records on file. Total penalties: $300K.
2212 W REAGAN ST, PALESTINE, TX 75801
Phone: 9037278500
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 675998
- Ownership
- Government - Hospital district
- Provider Type
- Medicare and Medicaid
- Beds
- 199
- Residents
- 88
- In Hospital
- No
- County
- Anderson
- Last Inspection
- Aug 6, 2025
Staffing Data
- RN Hours
- 0.33 (nat'l avg: 0.68)
- LPN Hours
- 0.93
- CNA Hours
- 2.63
- Total Nursing Hours
- 3.89 (nat'l avg: 3.89)
- PT Hours
- 0.01
- Nursing Turnover
- 63.2%
- RN Turnover
- 69.2%
What the CMS Record Reveals About LEGACY AT TOWN CREEK
LEGACY AT TOWN CREEK operates 199 certified beds in PALESTINE, TX with approximately 88 residents currently in care, and carries a CMS overall rating of 2 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (2★), staffing levels (2★), and quality measures (2★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 37 deficiency records from recent surveys, of which 5 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. On the enforcement side, CMS has assessed 2 penalties totaling $300K against this provider, a tangible indicator that regulators moved beyond citation into financial consequence. Staffing is reported at 3.89 total nursing hours per resident day (national average 3.89), with RN coverage at 0.33 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.
Classified as "Government - Hospital district" ownership and operating as a "Medicare and Medicaid" provider, LEGACY AT TOWN CREEK falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 63.2%, above the level where continuity of care typically begins to suffer. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (37 most recent)
Provide safe and appropriate respiratory care for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: Oct 9, 2025
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Sep 10, 2025
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Category: Nutrition and Dietary Deficiencies
Corrected: Sep 10, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Sep 10, 2025
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: Sep 10, 2025
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Category: Environmental Deficiencies
Corrected: Aug 12, 2024
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Aug 12, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Aug 12, 2024
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.
Category: Pharmacy Service Deficiencies
Corrected: Aug 12, 2024
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: Aug 12, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Aug 12, 2024
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Aug 12, 2024
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Jun 7, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 7, 2024
Respond appropriately to all alleged violations.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Jun 7, 2024
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Jun 7, 2024
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Jun 7, 2024
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Jun 7, 2024
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.
Category: Pharmacy Service Deficiencies
Corrected: Feb 14, 2024
Provide safe and appropriate respiratory care for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: Feb 14, 2024
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Aug 9, 2023
Have policies on smoking.
Category: Environmental Deficiencies
Corrected: May 15, 2023
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Category: Environmental Deficiencies
Corrected: May 1, 2023
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: May 27, 2023
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.
Category: Pharmacy Service Deficiencies
Corrected: May 19, 2023
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: May 12, 2023
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Category: Quality of Life and Care Deficiencies
Corrected: May 12, 2023
Provide safe and appropriate respiratory care for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: May 12, 2023
Provide enough food/fluids to maintain a resident's health.
Category: Quality of Life and Care Deficiencies
Corrected: May 19, 2023
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Category: Quality of Life and Care Deficiencies
Corrected: May 15, 2023
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 27, 2023
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: May 19, 2023
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: May 16, 2023
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Category: Resident Assessment and Care Planning Deficiencies
Corrected: May 20, 2023
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.
Category: Resident Rights Deficiencies
Corrected: May 19, 2023
Ensure that residents are fully informed and understand their health status, care and treatments.
Category: Resident Rights Deficiencies
Corrected: May 19, 2023
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category: Resident Rights Deficiencies
Corrected: May 12, 2023
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 21.5% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 4.3% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 3.0% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 0.3% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 0.6% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 6.7% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 99.2% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 87.1% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 0.4% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 37.6% | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 29.9% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 99.1% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 91.5% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 6.7% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 25.7% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 6.8% | Yes |
Penalty History 2 penalties totaling $300K
| Date | Type | Amount |
|---|---|---|
| Oct 8, 2025 | Fine | $16K |
| Jun 6, 2024 | Fine | $284K |
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Frequently Asked Questions
What is the overall CMS rating for LEGACY AT TOWN CREEK?
What are the staffing levels at LEGACY AT TOWN CREEK?
How many beds does LEGACY AT TOWN CREEK have?
Does LEGACY AT TOWN CREEK have any deficiencies on record?
Has LEGACY AT TOWN CREEK received any fines or penalties?
Who owns LEGACY AT TOWN CREEK?
When was LEGACY AT TOWN CREEK last inspected?
What quality measures are tracked for LEGACY AT TOWN CREEK?
Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology — how this data is sourced, computed, and verified.