Legacy at Town Creek

In the surveyor’s words

From the most serious findings on record at Legacy at Town Creek, in the surveyor’s own words.

• Immediate jeopardy, patternF600Jun 6, 2024

  Based on interview and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 7 of 10 residents (Residents #1, #4, #3, #9, #6, #7 and #10) reviewed for abuse and neglect. 1. The facility failed to protect Resident #1 from abuse from Resident #2, Resident #3, Resident #4, Resident #6, and Resident #10 between 5/8/23-1/11/24. on 1/11/24 Resident #6 slapped Resident #1 on his helmet. on 11/13/23 Resident #3 grabbed Resident #1's arm causing 2 skin tears. On 10/29/23 Resident #1 was in the lobby hollering and Resident #2 went over and flipped Resident #1 out of his wheelchair causing him to fall on the floor. […]

• Immediate jeopardy, patternF607Jun 6, 2024

  Based on interview and record review the facility failed to develop and implement written policies and procedures that prohibited and prevented abuse, neglect, and exploitation of residents and misappropriation of resident property for 7 of 10 residents (Resident #1, Resident #4, Resident #3, Resident #9, Resident #6, Resident #7 and Resident #10) reviewed for abuse policies. 1. The facility failed to implement the abuse policy by failing to protect Resident #1 from abuse from Resident #2, Resident #3, Resident #4, Resident #6, and Resident #10 between 5/8/23-1/11/24. 2. The facility failed to implement interventions after multiple incidents of resident-to-resident altercations. 3. […]

• Immediate jeopardy, patternF610Jun 6, 2024

  Based on observation, interview, and record review the facility failed to have evidence violations were thoroughly investigated to prevent further abuse for 7 of 10 residents (Resident #1, Resident #4, Resident #3, Resident #9, Resident #6, Resident #7, and Resident #10) reviewed for investigating abuse. The facility failed to ensure a thorough investigation of allegations of resident-to-resident abuse in that: 1. The facility failed to implement the abuse policy by failing to investigate the incidents involving Resident #1 receiving abuse from Resident #2, Resident #3, Resident #4, Resident #6, and Resident #10 between 5/8/23-1/11/24. 2. The facility failed to investigate multiple incidents of resident-to-resident altercations. 3. […]

• Actual harm, isolatedF695Oct 8, 2025

  Based on observations, interviews, and records review the facility failed to ensure respiratory care was provided, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 5 residents (Resident #1) reviewed for Respiratory Care. The facility failed to ensure appropriate respiratory care was provided to Resident #1 on 10/1/25 when the facility transported her to a doctor's appointment with an empty oxygen tank. […]

• Actual harm, isolatedF689Jun 6, 2024

  Based on interview, and record review, the facility failed to provide adequate supervision and assistance devices to prevent accidents for 1 of 10 residents reviewed for accidents. (Resident #27). On [DATE] CNA A failed to ensure a safe transfer for Resident #27 by transferring with only 1 staff member when she required 2 staff members for transfers which led to Resident #27 suffering a 4 cm toe laceration requiring sutures. The noncompliance was identified as PNC (past non-compliance). The non-compliance began on [DATE] and ended [DATE]. The facility had corrected the noncompliance before the survey began. […]