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Deficiency Records for Legacy at Town Creek
A list of the most recent deficiencies for Legacy at Town Creek. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Legacy at Town Creek. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-08-21 | 2024-08-22 | 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 | 2024-07-31 | 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 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 |
| 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 |
| 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 |
| 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 |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | 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 |
| Respond appropriately to all alleged violations. | Health | 2024-06-06 | 2024-06-07 | Y |
| 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 |
| 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 | 2023-07-13 | 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 |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-04-26 | 2023-05-19 | 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-02-16 | 2022-03-31 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-02-16 | 2022-03-16 | 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 | 2022-02-16 | 2022-03-16 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2022-02-16 | 2022-03-16 | N |
| 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. | Health | 2021-10-27 | 2021-11-15 | Y |
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