Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
LEGACY AT TOWN CREEK
PALESTINE, TX · 199 certified beds · Last Life Safety survey August 6, 2025
CMS Certification Number 675998 · first certified January 2004
Also on this campus
The same campus holds a state-licensed assisted living facility, with its own state record on the Assisted Living Index: Windermere at Cartmell (30 Variah St). Matched by the telephone number the two records share. The records are separate and are never added together.
Ownership
Operated by SOUTHWEST LTC · Government - Hospital district
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within TX
4 citations — more than 20% of the 1,177 certified nursing homes in TX. Compared within TX rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 2 citations; the earlier surveys in the window averaged 1. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window is open now: September 2026 to October 2026. This facility’s last Life Safety survey was August 2025. Facilities in TX are typically surveyed 13–14 months after the last one (median 14), measured over 1,905 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
Get an email about LEGACY AT TOWN CREEK
One email when it happens. No account; stop it any time with one click.
Physical environment (health survey)
10 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 4 Life Safety citations above. The Physical Environment Index
- F-0880 Provide and implement an infection prevention and control program.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
- F-0584 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.
- F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- F-0926 Have policies on smoking.
How that compares
Compared with the median facility in TX, and nationally. Surveyors differ markedly between states, so the TX figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 4 |
| Median facility in TX | 7 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| April 26, 2023 | 1 |
| July 31, 2024 | 1 |
| August 6, 2025 | 2 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 1 | 2024-07-31 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 1 | 2023-04-26 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 1 | 2025-08-06 |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 1 | 2025-08-06 |
What the citations cover
- Smoke Deficiencies 4
| Category | Citations |
|---|---|
| Smoke Deficiencies | 4 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
August 6, 2025 — 2 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (September 10, 2025) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (September 10, 2025) |
July 31, 2024 — 1 citation
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (August 22, 2024) |
April 26, 2023 — 1 citation
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (July 14, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.