Legacy At Town Creek
Inspection Findings
F-Tag F0695
F 0695 Level of Harm - Actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
got a new oxygen tank and returned to the doctor's office. CNA A said the doctor's office called an ambulance due to Resident #1 being short of breath and she was transported to the emergency room. CNA
A said it was the nurse's responsibility to inspect oxygen tanks and replace the tanks if they are low or empty. During an interview on 10/8/25 at 8:45 a.m., the ADM said on 10/1/25 it was reported to him that Resident #1 was transported to a doctor's appointment with an empty oxygen tank. ADM said it was the nurse's responsibility to ensure oxygen tanks were full prior to a resident leaving the facility. ADM said the DON was actively working on improving the system of checking oxygen tanks to include the transportation driver in the process.During an interview on 10/8/25 at 9:00 a.m., the DON said it was the charge nurse's responsibility to ensure residents leaving the unit had a full oxygen tank. The DON said LVN B reported she checked Resident #1's oxygen tank prior to her leaving the facility and noted it to be full. The DON said she was working on improving the system of checking oxygen tanks to include the transportation driver checking before leaving the facility and again upon arriving at the destination. The DON said she also printed and hung new, brightly colored, signs denoting empty oxygen tank storage from full oxygen tank storage. The DON said nursing staff had reported intermittently seeing a red light on the oxygen refilling station and oxygen tanks were not being filled. The DON said she tested the oxygen tank filling station on 10/1/25 and it functioned properly, but she had it replaced on 10/1/25 with a new unit to be safe.During a telephone interview on 10/8/25 at 10:45 a.m., LVN B said the day of Resident #1's appointment she swapped out her oxygen tank with a full tank at approximately 8:00 a.m., after breakfast. LVN B said she checked Resident #1's oxygen tank again just prior to her leaving the facility and noted it was still full. LVN B said the oxygen refilling station had been malfunctioning and oxygen tanks were showing to be full when
they were not. LVN B said the facility had a service technician out recently to repair/replace the oxygen filling station. During an interview on 10/8/25 at 10:55 a.m., LVN C said she was not aware of any problems with the oxygen filling station. LVN C said it was the charge nurse's responsibility to ensure residents leaving the facility had an adequate supply of oxygen.During an interview on 10/8/25 at 11:00 a.m., RN D said the oxygen filling station had been intermittently displaying a red light and failing to fill oxygen tanks.
RN D said the tanks never showed to be full; they were not refilling at all. RN D said the oxygen refilling unit was replaced on 10/1/25. RN D said it was the unit nurse's responsibility to ensure residents leaving the facility had a full oxygen tank.Review of an undated appointment reminder from an oncology office indicated Resident #1 had an appointment on 10/1/25 at 9:50 a.m.Review of a hospital Discharge summary dated [DATE REDACTED] at 10:53 a.m. indicated Resident #1 was admitted on [DATE REDACTED] from a doctor's office after her RP noticed her oxygen tank was empty. Resident #1's chest x-ray showed moderate bilateral pleural effusion (fluid in the space between lungs and chest well) with adjacent atelectasis/consolidation (partial collapse of lung tissue). Resident #1 was discharged back to the facility on [DATE REDACTED] with new orders for breathing treatments daily and an oral antibiotic. Review of facility policy titled Oxygen Administration dated February 2025 indicated .Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered.
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LEGACY AT TOWN CREEK in PALESTINE, TX inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in PALESTINE, TX, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from LEGACY AT TOWN CREEK or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.