Legacy at Town Creek

Inspectors wroteBased on observation, interview, and record review the facility failed to immediately consult with the resident's physician when there was an accident involving the resident which resulted in injury and had the potential for requiring physician intervention for 1 of 4 residents (Resident #1) reviewed for notification of changes. The facility failed to notify Resident #1's physician immediately on 12/11/25 at 3:00 a.m. when he fell in the dining room resulting in facial/scalp contusions and a hematoma to his forehead. Resident #1 was on dual antiplatelet therapy of Clopidogrel and Aspirin which increased the risk of intracranial bleeding and the physician was not notified of the fall with head injury until 4:21 a.m., a delay of 81 minutes. This failure could place all residents at risk of delayed medical care, pain, and hospitalization.

Inspectors wroteBased on observations, interviews, and records review the facility failed to ensure respiratory care was provided, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 5 residents (Resident #1) reviewed for Respiratory Care. The facility failed to ensure appropriate respiratory care was provided to Resident #1 on 10/1/25 when the facility transported her to a doctor's appointment with an empty oxygen tank. This failure could place residents who require supplemental oxygen at risk of hospitalization and diminished quality of life.

Inspectors wroteBased on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food safety requirements and kitchen sanitation. The facility failed to ensure the [NAME] wore a beard covering on 8/5/2025 when he prepared food. These failures could place residents at risk of foodborne illness and food contamination.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure all drugs were stored properly, for 1 of 3 medication carts reviewed for medication storage. The facility failed to ensure Resident #101's insulin Lispro multi-dose vial with an expired date of 7/10/2025 was disposed of. This failure could place residents at risk of not receiving the therapeutic benefit of medications prescribed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items, per facility policy for 1 of 4 resident's (Resident #80) personal refrigerators reviewed for food safety. The facility failed to ensure the refrigerator for Resident #80 did not contain three containers of yogurt that were past their use by dates from 8/4/2025-8/6/2025. This failure could place residents at risk for food borne illnesses.

Inspectors wroteBased on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Resident #5) and 1 of 6 staff (CNA D) reviewed for infection control. The facility failed to ensure CNA D did not store dirty linens on the floor on 8/5/2025. These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices.

Inspectors wroteBased on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food safety requirements and kitchen sanitation. 1. The facility failed to ensure [NAME] wore a hair net effectively to cover all his hair on 7/30/2024. 2. The facility failed to ensure DA wore a hair net effectively and did not have hair out on the front and side of her head not covered by her hair covering on 7/31/24. 3. The facility failed to ensure all foods stored in the refrigerators, freezers, and dry pantry were labeled, dated, and not kept past their expiration dates. 4. The facility failed to ensure proper hand washing between tasks. 5. The facility failed to ensure ovens were clean and free of debris. 6. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as possible for 1 of 1 facility reviewed for accident hazards. The facility failed to develop and implement a policy and procedure to properly handle the care of Hoyer lift slings including interventions to inspect the Hoyer sling for signs of damage before each use and not removing damaged slings from service. This deficient practice could result in falls and injuries if damaged lift sling broke during mechanical lift transfers.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of medications for 2 of 24 residents (Resident #81, and Resident #68) and 2 of 5 medication rooms (Medication room [ROOM NUMBER] and #2) reviewed for medication administration. The facility failed to dispose of expired medications from Medication Rooms #1 and #2 on 7/29/2024 These failures could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications, decreased quality of life, and hospitalization.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles for 1 of 5 medication storage rooms (Medication room [ROOM NUMBER]) and 1 of 24 residents (Resident #30) reviewed for medication administration. The facility did not ensure medications were not stored at the bedside for Resident #30 on 7/29/2024. The facility failed to ensure Medication room [ROOM NUMBER]'s refrigerator was free of contaminants on 7/29/2024 when it was observed leaking water inside and had a medicine cup of white capsules that water was dripping on. This failure could place all residents at an increased risk of receiving contaminated medications/supplements resulting in adverse health consequences.

Inspectors wroteBased on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #80) and 1 of 8 staff (CNA F) reviewed for infection control. CNA F did not sanitize or wash her hands between glove changes when providing incontinent care to Resident #80 on 7/30/2024. These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an effective pest control program and ensure it was free of pests for 2 of 4 halls ([NAME] Lane and [NAME] Center) reviewed for incidents and accidents related to pests. The facility failed to ensure ants were kept out of the rooms and beds for Resident #31 and Resident #75. This failure could place residents at risk for injury due to an ineffective pest control program at the facility.

Inspectors wroteBased on interviews and record review, the facility failed to transmit encoded, accurate, and complete MDS data to the CMS System for 1 of 6 residents (Resident #33) reviewed for MDS accuracy and completion. Resident #33's Discharge MDS assessment dated [DATE] was not transmitted within 14 days of completion to CMS. This deficient practice could result in MDS inaccuracies.

Inspectors wroteBased on interview and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 7 of 10 residents (Residents #1, #4, #3, #9, #6, #7 and #10) reviewed for abuse and neglect. 1. The facility failed to protect Resident #1 from abuse from Resident #2, Resident #3, Resident #4, Resident #6, and Resident #10 between 5/8/23-1/11/24. on 1/11/24 Resident #6 slapped Resident #1 on his helmet. on 11/13/23 Resident #3 grabbed Resident #1's arm causing 2 skin tears. On 10/29/23 Resident #1 was in the lobby hollering and Resident #2 went over and flipped Resident #1 out of his wheelchair causing him to fall on the floor. On 10/29/23 Resident #3 grabbed Resident #1's right arm causing skin tears to right arm. [...]

Inspectors wroteBased on interview and record review the facility failed to develop and implement written policies and procedures that prohibited and prevented abuse, neglect, and exploitation of residents and misappropriation of resident property for 7 of 10 residents (Resident #1, Resident #4, Resident #3, Resident #9, Resident #6, Resident #7 and Resident #10) reviewed for abuse policies. 1. The facility failed to implement the abuse policy by failing to protect Resident #1 from abuse from Resident #2, Resident #3, Resident #4, Resident #6, and Resident #10 between 5/8/23-1/11/24. 2. The facility failed to implement interventions after multiple incidents of resident-to-resident altercations. 3. The facility failed to implement the abuse policy by failing to protect Resident #4 from abuse from Resident #1, and Resident #3 between 7/25/23- 3/8/24. 4. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to have evidence violations were thoroughly investigated to prevent further abuse for 7 of 10 residents (Resident #1, Resident #4, Resident #3, Resident #9, Resident #6, Resident #7, and Resident #10) reviewed for investigating abuse. The facility failed to ensure a thorough investigation of allegations of resident-to-resident abuse in that: 1. The facility failed to implement the abuse policy by failing to investigate the incidents involving Resident #1 receiving abuse from Resident #2, Resident #3, Resident #4, Resident #6, and Resident #10 between 5/8/23-1/11/24. 2. The facility failed to investigate multiple incidents of resident-to-resident altercations. 3. [...]

Inspectors wroteBased on interview, and record review, the facility failed to provide adequate supervision and assistance devices to prevent accidents for 1 of 10 residents reviewed for accidents. (Resident #27). On [DATE] CNA A failed to ensure a safe transfer for Resident #27 by transferring with only 1 staff member when she required 2 staff members for transfers which led to Resident #27 suffering a 4 cm toe laceration requiring sutures. The noncompliance was identified as PNC (past non-compliance). The non-compliance began on [DATE] and ended [DATE]. The facility had corrected the noncompliance before the survey began. This failure could place residents who required supervision at risk of injury or accidents and hospitalization.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that all alleged violations involving abuse or mistreatment were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse, to the administrator of the facility and to other officials (including to the State Survey Agency where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 7 of 10 residents (Resident #1, Resident #4, Resident #3, Resident #9, Resident #6, Resident #7, and Resident #10) reviewed for reporting abuse. The facility failed to ensure that allegations of resident-to-resident abuse were reported to appropriate State Agency in that: 1. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 residents (Resident #31) reviewed for infection control. The facility failed to ensure CNA B performed proper hand hygiene when providing incontinent care to Resident #31 on 6/3/2024. This failure could place residents at risk of exposure to communicable diseases and infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were secured on 1 of 3 medication carts reviewed for pharmacy services. (Unit-RR Medication Aide Cart) -Medication Aide Cart for Unit-RR was left unlocked, unsecured, and unattended near the nurse station. -Seven medications were stored a bedside of Resident #2 . These failures could affect the residents, who resided on Unit-RR and received medications from these carts, by placing them at risk of drug diversions or misuse of medications.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for 2 of 2 residents (Resident #1 and #2) reviewed for oxygen. -The facility failed to ensure Resident #1 portable tank of oxygen had air. -The facility failed to properly store empty portable oxygen tank located in the medication room on Unit-RR. -The facility failed to properly remove all potentially flammable items from immediate area in Resident #2's room where the oxygen was to be administered. These failures could affect the residents, receiving respiratory care at risk of shortness of breath and a decline in heath.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure the resident's had the right to be informed of the risks, and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred, for 3 of 26 residents ( Resident #52, Resident #104 and Resident #327) reviewed for resident rights . The facility failed to obtain a signed informed consent based on information of the benefits, risks, and options available from Resident #52 prior to administering Quetiapine (antipsychotic). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment 3 of 26 residents reviewed for environment. (Resident #73, Resident #52, Resident #10). The facility failed to properly make the bed of Resident #73. The facility failed to ensure Resident #52 did not have a water leak in their bedroom. The facility failed to ensure Resident #10 did not have a water leak and a strong odor in her bedroom. These failures could place residents at risk of an unsafe or uncomfortable environment and a decrease in quality of life and self-worth.

Inspectors wroteBased on interview and record review, the facility failed to ensure the baseline care plan that included the instructions for resident care needed to provide effective and person-centered care was completed and provided to the resident and/or their representative for 6 of 24 residents reviewed for new admissions (Resident #52, Resident #104, Resident #327, Resident #275, Resident #277, and Resident #121). 1. The facility failed to complete a baseline care plan for Resident #52, Resident #104, and Resident #327. 2. The facility did not provide a summary of the baseline care plan to Resident #275, Resident #277, and Resident #121 and/or their representatives. These failures could place residents at risk of not receiving care and services to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet residents' mental and psychosocial needs; and, services that were to be furnished to attain or maintain the residents highest practicable physical, mental and psychosocial well-being for 13 (Residents #121, #69, #39, #34, #52,#104, #108, #111, #06, #26,#89, and #99) of 24 residents reviewed for care plans. * The facility failed to develop a care plan for the care areas assessments triggered on the admission MDS for Resident #121, Resident #69, and Resident #39. * The facility failed to develop and implement a care plan for Resident #34's scooped mattress and fall mat in place while in bed, ordered by the physician. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary services to maintain personal hygiene for 5 of 24 residents reviewed for ADLs (Residents #17, #121, #51, #80, #89) The facility did not shave Resident #17, #121, #51, #80, and #89' s facial hair. This failure could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care, feelings of poor self-esteem, lack of dignity and health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents requiring respiratory care are provided such care, consistent with professional standards of practice for 4 of 10 residents reviewed for respiratory care (Residents #23, #121, #69 and #37 ). The facility failed to change Resident #23's oxygen tubing every week on Sundays as ordered by the physician. The facility failed to ensure Resident #121 and #69's oxygen concentrator filters were free of dust and debris. The facility failed to change humification bottle for Resident #69 weekly. The facility failed to ensure Resident #37 had an oxygen concentrator filter in place. The facility failed to ensure Resident #37's portable oxygen tank had a sufficient level of oxygen. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure, based on the comprehensive assessment of a resident, residents who had not used psychotropic drugs were not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 6 of 24 residents (Resident #6, Resident #34, Resident #52, Resident #93, Resident #104, Resident #327) reviewed for psychotropic medications. The facility failed to have an appropriate diagnosis or indication of use for Resident #6, Resident #52, and Resident #93's Quetiapine (antipsychotic). The facility failed to have an appropriate diagnosis or indication of use for Resident #34's Trazadone (anti-depressant). [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, for 5 of 12 dining room chairs reviewed for environment. 1. The facility failed to ensure resident on the secured unit had clean, safe dining room chairs. This failure could place residents at risk for diminished quality of life due to lack of personal hygiene along with a safe, functional, sanitary, or comfortable environment.

Inspectors wroteBased on observations, interviews, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promotes maintenance or enhancement of his or her quality of life for 2 of 26 residents (Resident #100 and Resident #275) reviewed for resident rights in that: The facility did not ensure Resident #100's catheter bag (urine collection bag) had a privacy bag over it. Resident #275 was not informed of the puree menu served to him or the alternate puree menu. This failure could place residents at risk for diminished quality of life, loss of dignity and self-worth.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to review and revise by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessment for 1 resident (Resident #52) of 24 residents reviewed for comprehensive person-centered care plans in that: The facility failed to revise Resident #52's care planned swallowing problem coded on the MDS.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 4 residents (Resident #100) reviewed appropriate treatment and services related to indwelling catheters. The facility failed to ensure Resident #100 indwelling catheter had a catheter secure device in place. The facility failed to ensure Resident #100's catheter tubing was free of dependent loops (a configuration of catheter tubing where the drainage tubing dips below the entry point into the catheter bag). This failure could place residents at risk for urethral injury and urinary tract infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an acceptable parameter of nutritional status was maintained for 1 of 24 residents (Resident #121) who was reviewed for nutritional status, in that: 1. Resident #121 had a significant weight loss of 26 pounds, a 21.13% loss, in less than 30 days. The facility did not provide nutritional supplements as ordered, did not notify the physician, did not notify the RD, and did not notify the family of the significant weight loss. This failure could place residents at risk for further weight loss and decline in health due to nutritional needs not being met.

Inspectors wroteBased on interviews and record review, the facility failed to ensure dialysis service were provided consistently with professional standards of practice for 1 of 3 residents reviewed for dialysis services. (Residents #84) The facility failed to keep ongoing communication with the dialysis facility for Resident #84. The facility failed to complete ongoing assessment of Resident #84's condition before, during and after dialysis. This failure could place residents who received dialysis at risk for complications and not receiving proper care and treatment to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate administering of all drugs and biologicals, to meet the needs of 2 of 24 residents reviewed for pharmacy services. (Resident # 73 and Resident #23) The facility failed to keep in stock all medications for Resident #73 and #23. This failure could place residents at risk for inaccurate drug administration and cause Resident #73 increased pain. This failure could place resident at risk for inaccurate drug adminsitration and cause Resident #23 to have bradycardia.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents reviewed for incontinent care. (Resident #23) The facility failed to ensure CNA C changed her gloves and performed hand hygiene appropriately while providing incontinent care to Resident #23. The facility failed to ensure CNA C secured her hair to prevent contact with the resident's female perineum area between her upper inner thighs while providing incontinent care. This failure could place residents and staff at risk for cross-contamination and the spread of infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their established smoking policy for 1 or 1 residents reviewed for smoking. The facility failed to follow their smoking policy and allowed Resident #78 to smoke on their smoke-free facility premises and keep his cigarettes and lighter in his room.