Legacy At Town Creek

Penalties

• Oct 8, 2025 — Fine ($10,358)
• Jun 6, 2024 — Fine ($284,250)

Inspection findings

1. Jan 7, 2026 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0580 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.

     Corrected Jan 8, 2026 · CMS health inspection

2. Oct 8, 2025 Health · 1 finding
   • Serious Scope/severity G Complaint

     F0695 Quality of Life and Care Deficiencies

     Provide safe and appropriate respiratory care for a resident when needed.

     Corrected Oct 9, 2025 · CMS health inspection

3. Aug 6, 2025 Health · 6 findings
   • Not serious Scope/severity D

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Sep 10, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Sep 10, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0813 Nutrition and Dietary Deficiencies

     Have a policy regarding use and storage of foods brought to residents by family and other visitors.

     Corrected Sep 10, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Sep 10, 2025 · CMS health inspection

   • Not serious Scope/severity E

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Sep 10, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected Sep 10, 2025 · CMS fire safety

4. Jul 31, 2024 Health · 8 findings
   • Not serious Scope/severity B

     F0640 Resident Assessment and Care Planning Deficiencies

     Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

     Corrected Aug 12, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Aug 12, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Aug 12, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0761 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.

     Corrected Aug 12, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Aug 12, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Aug 12, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0925 Environmental Deficiencies

     Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

     Corrected Aug 12, 2024 · CMS health inspection

   • Not serious Scope/severity E

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Aug 22, 2024 · CMS fire safety

5. Jun 6, 2024 Health · 6 findings
   • Serious Scope/severity K Complaint

     F0600 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.

     Corrected Jun 7, 2024 · CMS health inspection

   • Serious Scope/severity K Complaint

     F0607 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Develop and implement policies and procedures to prevent abuse, neglect, and theft.

     Corrected Jun 7, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Jun 7, 2024 · CMS health inspection

   • Serious Scope/severity K Complaint

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected Jun 7, 2024 · CMS health inspection

   • Serious Scope/severity G Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Jun 7, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Jun 7, 2024 · CMS health inspection

6. Jan 22, 2024 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0695 Quality of Life and Care Deficiencies

     Provide safe and appropriate respiratory care for a resident when needed.

     Corrected Feb 14, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0761 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.

     Corrected Feb 14, 2024 · CMS health inspection

7. Aug 8, 2023 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0607 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Develop and implement policies and procedures to prevent abuse, neglect, and theft.

     Corrected Aug 9, 2023 · CMS health inspection

8. Apr 26, 2023 Health · 17 findings
   • Not serious Scope/severity D

     F0550 Resident Rights Deficiencies

     Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

     Corrected May 12, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0552 Resident Rights Deficiencies

     Ensure that residents are fully informed and understand their health status, care and treatments.

     Corrected May 19, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0584 Resident Rights Deficiencies

     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 May 19, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0655 Resident Assessment and Care Planning Deficiencies

     Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

     Corrected May 20, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected May 16, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0657 Resident Assessment and Care Planning Deficiencies

     Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

     Corrected May 19, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0677 Quality of Life and Care Deficiencies

     Provide care and assistance to perform activities of daily living for any resident who is unable.

     Corrected Apr 27, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0690 Quality of Life and Care Deficiencies

     Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

     Corrected May 15, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0692 Quality of Life and Care Deficiencies

     Provide enough food/fluids to maintain a resident's health.

     Corrected May 19, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0695 Quality of Life and Care Deficiencies

     Provide safe and appropriate respiratory care for a resident when needed.

     Corrected May 12, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0698 Quality of Life and Care Deficiencies

     Provide safe, appropriate dialysis care/services for a resident who requires such services.

     Corrected May 12, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected May 12, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0758 Pharmacy Service Deficiencies

     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.

     Corrected May 19, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected May 27, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0921 Environmental Deficiencies

     Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

     Corrected May 1, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0926 Environmental Deficiencies

     Have policies on smoking.

     Corrected May 15, 2023 · CMS health inspection

   • Not serious Scope/severity E

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected Jul 14, 2023 · CMS fire safety

Owners and managers (as published by CMS)

• ADEWALE, ADEBAYO — adp of the snf, NOT APPLICABLE, since 10/01/2025
• ADEWALE, ADEBAYO — operational/managerial control, NOT APPLICABLE, since 10/01/2025
• BAUDER, KELLY — adp of the snf, NOT APPLICABLE, since 10/01/2025
• BAUDER, MADISON — adp of the snf, NOT APPLICABLE, since 10/01/2025
• BAUDER, PARKER — adp of the snf, NOT APPLICABLE, since 10/01/2025
• BAUDER, WILLIAM — adp of the snf, NOT APPLICABLE, since 10/01/2025
• BOULWARE, DOUGLAS — individual is an owner, partner or trustee of any adp of the snf, NOT APPLICABLE, since 03/24/2026
• BOULWARE, SANDRA — individual is an owner, partner or trustee of any adp of the snf, NOT APPLICABLE, since 03/24/2026
• BOULWARE, STEVEN — adp of the snf, NOT APPLICABLE, since 10/01/2025
• BOULWARE, THOMAS — adp of the snf, NOT APPLICABLE, since 10/01/2025
• FRANKLIN, BRADLEY — adp of the snf, NOT APPLICABLE, since 10/01/2025
• FRANKLIN, BRADLEY — operational/managerial control, NOT APPLICABLE, since 10/01/2025
• STRATTON, CHARLES — corporate officer, NOT APPLICABLE, since 04/01/2018
• WALKER, KATIE — adp of the snf, NOT APPLICABLE, since 10/01/2025
• BAUDER FAMILY INVESTMENTS, LLC — adp of the snf, NOT APPLICABLE, since 10/01/2025
• BOULWARE ST JAMES LLC — adp of the snf, NOT APPLICABLE, since 10/01/2025
• LIBERTY COUNTY HOSPITAL DISTRICT NO 1 — 5% or greater direct ownership interest, 100%, since 04/01/2018
• PMG OPCO- PALESTINE LLC — operational/managerial control, NOT APPLICABLE, since 10/01/2025
• PMG REALCO- PALESTINE LLC — adp of the snf, NOT APPLICABLE, since 10/01/2025
• STEVEN BOULWARE FAMILY INVESTMENTS LLC — adp of the snf, NOT APPLICABLE, since 10/01/2025