Legacy At Town Creek
LEGACY AT TOWN CREEK in PALESTINE, TX — inspection on October 8, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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] at 10:53 a.m. indicated Resident #1 was admitted on [DATE] 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] 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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