LEGACY AT TOWN CREEK
Owned by: Government - Hospital district
Safety Pulse
AI-GENERATED FAMILY INSIGHTS
**Resident Safety (Red Flag):** Multiple violations indicate potential neglect, including failure to protect residents from abuse and inadequate infection control programs.
**Quality of Care (Red Flag):** Concerns regarding pharmaceutical services and food handling/storage raise serious questions about the consistent delivery of essential care needs.
**Environment (Red Flag):** Lack of a clear policy on food brought in by visitors suggests a disorganized and potentially unsafe environment regarding dietary control and infection risk.
Note: This summary is generated from recently documented safety inspections and citations.
Regional Context
256% more violations than city average
Source: 3-year federal inspection history (CMS.gov)
Quick Stats
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Violation History
Provide safe and appropriate respiratory care for a resident when needed.
Provide safe and appropriate respiratory care for a resident when needed.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
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.
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.
Provide and implement an infection prevention and control program.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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.
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.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Respond appropriately to all alleged violations.
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 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 and implement an infection prevention and control program.
Provide safe and appropriate respiratory care for a resident when needed.
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.
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.
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
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.
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.
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.
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.
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.
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.
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
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.
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.
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.
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
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 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.
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 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 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 and appropriate respiratory care for a resident when needed.
Provide safe, appropriate dialysis care/services for a resident who requires such services.
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.
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.
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.
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.
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.
Have policies on smoking.
Regional Safety Benchmarking
256% more citations than local average
"Comparative analysis is essential for identifying systemic neglect. Our benchmarks are updated monthly using raw CMS files."
Full Evidence Dossier
Documented history of neglect citations, staffing failures, and ownership risk profiles. Perfect for families, legal preparation, or professional due diligence.
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