All citations for Legacy at Town Creek
State inspectors check nursing homes that take Medicare or Medicaid against federal rules, usually about once a year, and also look into complaints. Each rule a home did not meet is a citation.
Last standard health inspection on record
August 6, 2025
Showing 1 to 25 of 25 citations
Immediate jeopardy to resident health or safety
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
The home gave a date the problem would be corrected (June 7, 2024).
Immediate jeopardy to resident health or safety
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
The home gave a date the problem would be corrected (June 7, 2024).
Immediate jeopardy to resident health or safety
Respond appropriately to all alleged violations.
The home gave a date the problem would be corrected (June 7, 2024).
Harm to a resident
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
The home gave a date the problem would be corrected (June 7, 2024).
No harm, with potential for more than minimal harm
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
The home gave a date the problem would be corrected (June 7, 2024).
No harm, with potential for more than minimal harm
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.
The home gave a date the problem would be corrected (February 14, 2024).
No harm, with potential for more than minimal harm
Ensure that residents are fully informed and understand their health status, care and treatments.
The home gave a date the problem would be corrected (May 19, 2023).
No harm, with potential for more than minimal harm
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.
The home gave a date the problem would be corrected (May 19, 2023).
No harm, with potential for more than minimal harm
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
The home gave a date the problem would be corrected (May 20, 2023).
No harm, with potential for more than minimal harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
The home gave a date the problem would be corrected (May 16, 2023).
No harm, with potential for more than minimal harm
Provide care and assistance to perform activities of daily living for any resident who is unable.
The home gave a date the problem would be corrected (April 27, 2023).
No harm, with potential for more than minimal harm
Provide safe and appropriate respiratory care for a resident when needed.
The home gave a date the problem would be corrected (May 12, 2023).
No harm, with potential for more than minimal harm
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.
The home gave a date the problem would be corrected (May 19, 2023).
No harm, with potential for more than minimal harm
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
The home gave a date the problem would be corrected (May 1, 2023).
No harm, with potential for more than minimal harm
Have approved installation, maintenance and testing program for fire alarm systems.
The home gave a date the problem would be corrected (July 14, 2023).
No harm, with potential for more than minimal harm
Provide and implement an infection prevention and control program.
The home gave a date the problem would be corrected (June 7, 2024).
No harm, with potential for more than minimal harm
Provide safe and appropriate respiratory care for a resident when needed.
The home gave a date the problem would be corrected (February 14, 2024).
No harm, with potential for more than minimal harm
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
The home gave a date the problem would be corrected (May 12, 2023).
No harm, with potential for more than minimal harm
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
The home gave a date the problem would be corrected (May 19, 2023).
No harm, with potential for more than minimal harm
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
The home gave a date the problem would be corrected (May 15, 2023).
No harm, with potential for more than minimal harm
Provide enough food/fluids to maintain a resident's health.
The home gave a date the problem would be corrected (May 19, 2023).
No harm, with potential for more than minimal harm
Provide safe, appropriate dialysis care/services for a resident who requires such services.
The home gave a date the problem would be corrected (May 12, 2023).
No harm, with potential for more than minimal harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
The home gave a date the problem would be corrected (May 12, 2023).
No harm, with potential for more than minimal harm
Provide and implement an infection prevention and control program.
The home gave a date the problem would be corrected (May 27, 2023).
No harm, with potential for more than minimal harm
Have policies on smoking.
The home gave a date the problem would be corrected (May 15, 2023).
Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of September 30, 2026. Inspection results describe the home at the time of each inspection.