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Deficiency Records for Legacy at Town Creek
View the most recent health deficiencies and inspection results for Legacy at Town Creek. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Legacy at Town Creek. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2026-01-07 | 2026-01-08 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2025-10-08 | 2025-10-09 | Y |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2025-08-06 | 2025-09-10 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2025-08-06 | 2025-09-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2025-08-06 | 2025-09-10 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2025-08-06 | 2025-09-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2025-08-06 | 2025-09-10 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2025-08-06 | 2025-09-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-07-31 | 2024-08-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-07-31 | 2024-08-12 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2024-07-31 | 2024-08-12 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-07-31 | 2024-08-12 | N |
| 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. | Health | 2024-07-31 | 2024-08-12 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-07-31 | 2024-08-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-07-31 | 2024-08-12 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2024-07-31 | 2024-08-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-06-06 | 2024-06-07 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-06-06 | 2024-06-07 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-06-06 | 2024-06-07 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-06-06 | 2024-06-07 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-06-06 | 2024-06-07 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-06-06 | 2024-06-07 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-01-22 | 2024-02-14 | Y |
| 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. | Health | 2024-01-22 | 2024-02-14 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-08-08 | 2023-08-09 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-04-26 | 2023-07-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-04-26 | 2023-05-27 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-04-26 | 2023-05-20 | N |
| 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. | Health | 2023-04-26 | 2023-05-19 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-04-26 | 2023-05-19 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-04-26 | 2023-05-19 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-04-26 | 2023-05-19 | N |
| 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. | Health | 2023-04-26 | 2023-05-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-26 | 2023-05-16 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-04-26 | 2023-05-15 | N |
| Have policies on smoking. | Health | 2023-04-26 | 2023-05-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-04-26 | 2023-05-12 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-04-26 | 2023-05-12 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-04-26 | 2023-05-12 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-04-26 | 2023-05-12 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-04-26 | 2023-05-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-04-26 | 2023-04-27 | N |