Legacy At Town Creek
Inspection History Overview
Detailed Inspection Reports
Notice: These are official CMS inspection narratives containing detailed regulatory findings. This information is not available in searchable format anywhere else online.
Fines and Penalties by Year
2019 2 penalties totaling $21,578
Fine
Fine
Health Violations by Year
2024 15 violations
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Provide and implement an infection prevention and control program.
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Respond appropriately to all alleged violations.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide and implement an infection prevention and control program.
Provide safe and appropriate respiratory care for a resident when needed.
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.
2023 18 violations
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Ensure that residents are fully informed and understand their health status, care and treatments.
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.
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Provide enough food/fluids to maintain a resident's health.
Provide enough food/fluids to maintain a resident's health.
Provide safe and appropriate respiratory care for a resident when needed.
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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.
Provide and implement an infection prevention and control program.
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Have policies on smoking.
2022 3 violations
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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.
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
2021 6 violations
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Provide and implement an infection prevention and control program.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Provide and implement an infection prevention and control program.
2020 2 violations
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Provide timely, quality laboratory services/tests to meet the needs of residents.
2019 10 violations
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Provide and implement an infection prevention and control program.
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Respond appropriately to all alleged violations.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Ensure that residents are free from significant medication errors.
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
2018 15 violations
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Ensure each resident receives an accurate assessment.
PASARR screening for Mental disorders or Intellectual Disabilities
Provide care by qualified persons according to each resident's written plan of care.
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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.
Ensure that residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Provide and implement an infection prevention and control program.
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Ensure that paid feeding assistants have the training they need.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
2017 10 violations
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property.
Provide care by qualified persons according to each resident's written plan of care.
Provide necessary care and services to maintain or improve the highest well being of each resident .
Store, cook, and serve food in a safe and clean way.
Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse.
Have a program that investigates, controls and keeps infection from spreading.
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs.
Train all employees on what to do in an emergency, and carry out unannounced staff drills.
LEGACY AT TOWN CREEK is a 2-star nursing home in PALESTINE, TX with 199 beds.
Most recent inspection: Data not available. No current violations on record.
📍 2212 W REAGAN ST, PALESTINE, TX
💵 Accepts Medicare and Medicaid