Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Legacy At Town Creek during CMS and state inspections, most recent first.
A resident with ESRD, on hemodialysis and dual antiplatelet therapy (aspirin and clopidogrel) for prior MI, sustained an unwitnessed fall while attempting to rise from a wheelchair, resulting in facial/scalp contusions and a forehead hematoma with reported head pain. An LVN found the resident on the floor, assisted him back to the wheelchair, administered Tylenol, applied ice, and initiated neuro checks, which were largely documented as normal, though one assessment noted the resident was not fully oriented. The LVN notified the family promptly but delayed notifying the MD by approximately 81 minutes, despite the head injury and antiplatelet use, and documented on a dialysis communication form that there were no new problems. The resident was later seen at dialysis, where staff and the physician noted significant bruising and a hematoma and arranged for ER evaluation. Interviews showed that the ADON and an RN expected immediate MD notification for falls with head injury in residents on antiplatelet therapy, while the DON considered the delay acceptable, despite a facility policy requiring prompt MD notification after accidents involving a resident.
A resident dependent on continuous oxygen was transported to a medical appointment with an empty oxygen tank, resulting in shortness of breath and hospital admission. Staff interviews revealed that although the charge nurse was responsible for ensuring a full tank, a malfunctioning oxygen refilling station led to tanks appearing full when they were not, contributing to the deficiency.
Kitchen Staff Failed to Wear Beard Cover During Food Prep: A kitchen employee was observed pureeing lunch food with a full beard that was not covered. He said he had never been told he needed a beard net, while the DM later told him to put one on and stated staff with facial hair should wear a beard cover so hair does not get into food. The Interim Administrator confirmed kitchen staff preparing food should wear hair restraints, including beard covers, and the facility policy required beard restraints to prevent hair from contacting food.
Expired insulin Lispro was found in a nurse med cart for a resident with DM2, dementia, and bipolar disorder. The vial had been opened and was past the manufacturer’s allowed use period, yet it remained stored with the resident’s medication. Staff, including LPNs, the DON, and the Administrator, stated charge nurses were responsible for checking med expiration dates and removing expired meds, and the facility policy required outdated medications to be removed from stock.
Expired Yogurt Left in Resident Refrigerator: A resident with Parkinson’s, dementia, major depressive disorder, and osteoporosis had a personal refrigerator that contained multiple containers of yogurt past their use-by dates. The resident said she did not check expiration dates and staff checked the refrigerator, while the HSK Supervisor and Activity Director described different routines for monitoring food and temperatures. The facility policy stated nursing staff would discard perishable foods on or before the use-by date.
Improper Handling of Soiled Linens: A resident who was dependent on staff for all ADLs and incontinent care was observed in bed after a CNA had just changed her. Dirty linens were left on the floor by the trash can instead of being bagged. Another CNA later placed the linens into a plastic bag and removed them. The CNA who left the linens on the floor stated she knew they should have been bagged, and the DON, ADON, and Interim Administrator all stated soiled linens should be bagged and placed in the soiled linen barrel.
The facility failed to maintain food safety and sanitation standards, with staff not wearing hair nets effectively, improper labeling and storage of food items, and unclean kitchen equipment. Observations revealed unlabeled and expired food in storage, and staff interviews confirmed a lack of adherence to food safety protocols. These deficiencies posed a risk of foodborne illnesses.
The facility failed to maintain an effective pest control program, resulting in ants in two halls. A resident with COPD and moderately impaired cognition had ant bites, while another with sarcopenia and severe cognitive impairment was moved due to ants. Despite weekly treatments and monthly pest control services, ants were still present, indicating a failure in the program's effectiveness.
The facility failed to ensure a safe environment by not properly handling Hoyer lift slings, leading to potential accident hazards. Observations showed that two residents dependent on mechanical lift transfers were using slings with faded straps and illegible tags. Staff, including a CNA and the DON, were unaware of the manufacturer's guidelines for removing compromised slings from service. The facility's policy required slings to be laundered and removed if damaged, but this was not effectively implemented.
The facility failed to dispose of expired medications in two medication rooms, affecting two residents. A resident with dementia had expired scopolamine in the refrigerator, and another with heart failure had expired acetaminophen suppositories. Staff interviews revealed confusion over who was responsible for checking expired medications, despite facility policies requiring it.
The facility failed to properly label and store medications, as observed in a medication storage room and for a resident. A refrigerator in the medication room was leaking onto capsules, and medications were improperly stored at a resident's bedside. Staff interviews revealed a lack of clarity in responsibilities for checking expired medications, contributing to the deficiencies.
A facility failed to maintain proper infection control practices when a CNA did not sanitize or wash her hands between glove changes while providing incontinent care to a resident. The resident, who was dependent on staff for personal hygiene, was at risk due to this oversight. Despite being trained and assessed as satisfactory in hand hygiene, the CNA admitted to forgetting to use hand sanitizer. The facility's policy requires hand hygiene before and after glove use, and the administration confirmed the importance of these practices.
A facility failed to transmit a resident's Discharge MDS assessment to the CMS System within the required timeframe, resulting in a delay of over 14 days. The MDS Coordinator responsible for the assessment acknowledged the oversight, and interviews with the DON and VP of Clinical Reimbursement confirmed the requirement to follow the RAI manual for timely transmission. The Administrator noted the absence of a facility policy on MDS transmission, highlighting the risk of inaccurate data.
The facility failed to protect residents from abuse and neglect, resulting in multiple incidents of resident-to-resident aggression. Residents with severe cognitive impairments were involved in physical altercations, including slapping, hitting, and scratching. Despite known aggressive behaviors, the facility did not implement new interventions to prevent further occurrences, leading to a pattern of abuse and neglect.
The facility failed to implement and update policies to prevent abuse, neglect, and exploitation among residents. Several residents with cognitive impairments experienced or perpetrated physical aggression, yet their care plans were not updated with new interventions. Additionally, the facility did not report these incidents to the appropriate authorities, increasing the risk of continued abuse.
The facility failed to investigate multiple incidents of resident-to-resident abuse, involving residents with cognitive impairments and behavioral issues. Despite numerous altercations resulting in injuries, the facility did not conduct thorough investigations or implement necessary interventions. Staff interviews revealed a misunderstanding of reporting requirements, contributing to the deficiency.
A resident with severe cognitive impairment and a care plan requiring two-person transfers was injured when a CNA transferred her with only one staff member, resulting in a 4 cm toe laceration. The CNA had received training but failed to follow the protocol, leading to the incident.
The facility failed to report multiple incidents of resident-to-resident abuse involving residents with cognitive impairments, such as dementia and bipolar disorder. Despite repeated physical altercations, including slapping, flipping wheelchairs, and causing skin tears, these incidents were not reported to the appropriate authorities. The administrator believed these incidents were not reportable due to a lack of willful intent, leading to a significant deficiency in the facility's reporting process.
A CNA in an LTC facility failed to follow proper hand hygiene protocols while providing incontinent care to a resident with severe cognitive impairment. The CNA did not change gloves between cleaning different areas and did not wash hands after removing gloves, contrary to the facility's infection control policies. This lapse was observed during a survey, and interviews with the DON and Administrator confirmed the deficiency.
Delayed Physician Notification After Resident Fall With Head Injury on Dual Antiplatelet Therapy
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify a resident’s physician after an accident that resulted in a head injury. A male resident with end stage renal disease, dependence on dialysis, atherosclerotic heart disease, and intact cognition (BIMS 15) was on dual antiplatelet therapy with aspirin and clopidogrel for a prior myocardial infarction. His care plan included monitoring and reporting changes or increases in bruising. In the early morning, the resident fell while attempting to get up from his wheelchair to get coffee, tripped over the footrest, and struck the right side of his face and head on the floor. He reported head pain to the nurse, who told him it would improve when the swelling went down. The fall was unwitnessed and documented at 3:00 a.m. by an LVN who found the resident on his right side, assisted him back to his wheelchair, noted a bump/hematoma on his forehead, administered Tylenol, applied an ice pack, and initiated neurological checks. The fall report showed that the resident was alert and oriented with a reported pain level of 6/10 and normal vital signs, and that the physician was not notified until 4:21 a.m., an 81‑minute delay. The facility’s neurological assessment sheet documented that at 3:20 a.m. the resident was not fully oriented, with subsequent assessments between 3:00 a.m. and 5:35 a.m. showing no confusion/disorientation and stable vital signs. The LVN stated he texted the physician but was unsure of the time, and reported that the resident was confused and unstable, and that he notified the family at 3:00 a.m. but delayed notifying the physician. A dialysis communication form completed by the same LVN shortly after indicated there were no new problems or concerns. The resident later reported that he was not offered to go to the ER and that he went to dialysis first, after which the doctor there sent him to the ER. Interviews with staff and the physician highlighted inconsistent expectations and practices regarding physician notification. An RN stated that if a resident on antiplatelet medication fell and had a head injury, he would call the physician immediately or as soon as possible due to the risk of brain bleeding, and that any neurological changes should prompt further contact. The ADON stated she expected immediate physician notification after a fall with head injury, especially for residents on antiplatelet therapy, citing increased risk of brain bleeding. The DON, however, stated that as long as neurological checks were normal there was no reason to contact the physician sooner and felt the 81‑minute delay and use of text notification were acceptable. The attending physician reported that standard teaching for a patient on clopidogrel with a head injury is usually to go to the ER, and that he was unaware of the 81‑minute delay. The facility’s policy on change in condition required prompt notification of the attending physician when there has been an accident or incident involving the resident.
Resident Transported with Empty Oxygen Tank Due to Equipment and Process Failures
Penalty
Summary
A deficiency occurred when a resident who required continuous supplemental oxygen due to chronic respiratory failure, congestive heart failure, and a history of pneumonia was transported to a doctor's appointment with an empty oxygen tank. The resident's care plan specified the need for continuous oxygen via nasal cannula at a prescribed flow rate. On the day of the appointment, the responsible party noticed the oxygen tank was empty, and the resident exhibited symptoms of shortness of breath and gasping for air. The resident was subsequently transported to the hospital from the doctor's office and admitted to the emergency room. Interviews with facility staff revealed that the charge nurse was responsible for ensuring residents leaving the facility had a full oxygen tank. The nurse assigned to the resident reported checking and replacing the oxygen tank with a full one prior to departure and again just before leaving, noting it was full. However, the resident arrived at the appointment with an empty tank, and the transportation staff had to return to the facility to retrieve a replacement. The resident's symptoms prompted the doctor's office staff to call emergency medical services. Further investigation indicated that the facility's oxygen refilling station had been intermittently malfunctioning, with reports of tanks appearing full when they were not, and a red warning light being observed. Some staff were aware of these issues, while others were not. The malfunctioning equipment contributed to the failure to provide the resident with an adequate supply of oxygen during transport, as required by professional standards of practice and the resident's care plan.
Kitchen Staff Failed to Wear Beard Cover During Food Preparation
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food safety requirements and kitchen sanitation. During an observation on 8/5/2025 at 10:30 AM, the [NAME] was seen in the kitchen pureeing food for the lunch meal while wearing a full beard that was not covered. During an interview later that morning, the [NAME] said he had worked at the facility for 10 years and had never been told he needed to wear a cover for his beard. He stated he should have a beard net on because of his facial hair and that hair could drop into the food if staff did not wear a covering. The DM later observed the [NAME] in the kitchen and told him to put on a beard cover, stating that staff with facial hair should wear a beard cover so hair does not get into the food. The Interim Administrator stated that kitchen staff who prepared food should wear a hair net or beard cover and that staff without the appropriate hair coverings could contaminate food. The facility policy titled Food Safety Requirements stated dietary staff must wear hair restraints, including a beard restraint, to prevent hair from contacting food.
Expired Insulin Lispro Left in Medication Cart
Penalty
Summary
The facility failed to ensure all drugs were stored properly for 1 of 3 medication carts reviewed. During an observation on 8/5/25 at 8:30 A.M., an insulin Lispro multi-dose vial labeled for Resident #101 was found in the top drawer of a nurse medication cart. The vial had an open date of 6/10/25 printed on it and an expired date of 07/10/25 on the box, and it appeared to be opened with approximately half of the contents missing. Resident #101 was a [AGE]-year-old female with diagnoses including type 2 diabetes mellitus, dementia, and bipolar disorder. Her significant change MDS assessment dated 7/28/25 indicated a BIMS score of 07, dependent assistance with ADLs, and that she was always incontinent of bowel and bladder. Her physician orders dated 8/05/25 included Insulin Lispro solution 100 units per milliliter to be injected subcutaneously before meals and at bedtime according to a sliding scale. During interviews, LVN A, LVN B, LVN C, the Administrator, and the DON stated that charge nurses were responsible for monitoring medication expiration dates and that expired medications should be removed from the cart. They stated insulin multi-dose vials are generally good for 30 days after opening, though manufacturer directions vary, and that expired medications could be less effective. The facility policy, Medication Storage revised 01/2025, stated outdated, contaminated, discontinued, or deteriorated medications are to be immediately removed from stock and disposed of according to medication disposal procedures. The manufacturer of insulin Lispro, Lilly Pharmaceuticals, recommended opened insulin Lispro be kept at room temperature for up to 28 days.
Expired Yogurt Left in Resident Refrigerator
Penalty
Summary
The facility failed to maintain safe and sanitary storage of a resident’s personal food items in accordance with its policy for foods brought by family and visitors. Resident #80, who had Parkinson’s disease, dementia, major depressive disorder, and osteoporosis, had moderate impairment in thinking with a BIMS score of 12 and required setup/cleanup assistance with eating. Her care plan addressed an ADL self-care performance deficit related to Parkinson’s and included setup help for eating, but it did not indicate that she refused staff to clean out her refrigerator. During observation on 8/4/2025 and again on 8/6/2025, Resident #80’s personal refrigerator contained three containers of yogurt that were past their use-by dates, including items expired on March 16, 2025 and May 12, 2025. The resident stated she never looked at expiration dates and that staff checked the refrigerator daily, while the HSK Supervisor said housekeepers checked refrigerators daily for temperature and Activity Directors checked for expired food items weekly. The Activity Director stated she was responsible for checking Resident #80’s refrigerator but was on vacation, and the Interim Administrator stated activities was responsible for weekly checks of personal refrigerators for outdated foods. The facility policy titled Foods Brought by Family/Visitors stated that nursing staff would discard perishable foods on or before the use-by date.
Improper Handling of Soiled Linens
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for Resident #5 and CNA D. Resident #5 was readmitted to the facility, had diagnoses of hemiplegia affecting the right side, Parkinsonism, and depression, and was dependent on staff for all ADLs. Her care plan identified total staff assistance for incontinent care for bowel and bladder incontinence. During observation, Resident #5 was in bed in her room and said the nurse aide had just left after changing her. Dirty linens were observed on the floor by the trash can and were not in a plastic bag. CNA D entered the room with CNA E, and CNA E placed gloves on and put the dirty linens from the floor into a plastic bag and removed them from the room. CNA E stated the linens should not have been placed on the floor and should have been placed in a plastic bag. CNA D stated she had placed the linens on the floor after changing the bed, knew they should have been placed in a bag and not on the floor, and said she made a mistake. The DON, ADON, and Interim Administrator all stated dirty linens should be placed in a bag and then in the soiled linen barrel, and should not be left on the floor.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in their kitchen operations. Staff members did not effectively wear hair nets, leading to exposed hair that could potentially contaminate food. Specifically, one staff member wore a baseball cap over a hair net, which caused the net to be ineffective, while another staff member had hair exposed at the front and sides of her head. These lapses in proper hair covering were acknowledged by the staff during interviews, where they expressed awareness of the potential for hair to contaminate food. The facility also failed to properly label, date, and manage food storage in their refrigerators, freezers, and pantry. Numerous food items were found without labels or expiration dates, and some were past their expiration dates. Observations revealed pre-wrapped pancakes, red onions, lettuce, ribs, ground beef, cheese slices, diced chicken, beef patties, hamburger buns, and various other items improperly stored. Additionally, expired prune juice and Dijon mustard were found in the pantry. Staff interviews confirmed a lack of awareness and adherence to proper food labeling and storage protocols. Sanitation issues were also identified, including unclean ovens and an ice machine with a black, slimy substance. The facility's dietary manager did not wash hands between tasks, further compromising food safety. These deficiencies were recognized by the staff, who admitted to not realizing the extent of the issues. The facility's policies on employee sanitation and food safety were not followed, as evidenced by the observations and staff interviews, which highlighted the risk of foodborne illnesses due to these lapses in food safety and sanitation practices.
Ineffective Pest Control Program Leads to Ant Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of ants in two of the four halls reviewed. Specifically, ants were found in the rooms and beds of two residents, leading to incidents of ant bites. Resident #31, a female with chronic obstructive pulmonary disease and moderately impaired cognition, was noted to have ant bites on her right upper extremity. Her care plan included interventions to identify and eliminate potential causative factors for her skin impairment. Resident #75, a female with sarcopenia, anxiety disorder, and severely impaired cognition, was also affected by ants in her room, although her care plan did not address this issue. Observations and interviews revealed that Resident #31 did not experience itching or discomfort from the bites, and no ants or food were observed in her room at the time of inspection. Resident #75 was moved from her original room due to ant presence, and maintenance had sprayed the room while awaiting pest control services. The maintenance man reported treating the facility for ants weekly and confirmed that pest control services were conducted monthly. Despite these measures, ants were still found in multiple rooms, as noted in the pest control log. The facility's pest control program, as outlined in their policy, aimed to eradicate and contain common household pests. However, the presence of ants in residents' rooms and the resulting bites indicate a failure in the program's effectiveness. The pest control invoices showed treatments for ants using various products, but the continued sightings of ants suggest that these measures were insufficient to prevent infestations in the facility.
Failure to Properly Handle Hoyer Lift Slings
Penalty
Summary
The facility failed to ensure the residents' environment was free from accident hazards by not developing and implementing a policy and procedure for the proper handling of Hoyer lift slings. Observations and interviews revealed that the facility did not inspect the slings for signs of damage before each use, and damaged slings were not removed from service. This deficiency was identified during a review of the care provided to two residents who required mechanical lift transfers. One resident, a female with severe impaired cognition and dependent for all transfers, was observed with a lift sling that had faded straps and illegible care tags. The CNA, who was agency staff, was unaware of the manufacturer's guidelines for removing compromised slings from service. Another resident, who had intact cognition and was also dependent for all transfers, had a sling provided by hospice services that was similarly faded and crinkled. The hospice nurse was not aware of the need to remove such slings from service. Interviews with the laundry staff and the DON revealed a lack of awareness regarding the manufacturer's recommendations for sling maintenance. The laundry staff had been trained to air dry slings and remove those with visible damage, but they were not informed about the importance of removing slings with faded colors or illegible labels. The DON acknowledged the risk of injury if defective slings were used but was not fully aware of the manufacturer's guidelines. The facility's policy for safe resident handling indicated that slings should be laundered according to the manufacturer's instructions and removed from service if damaged, but this was not effectively implemented.
Expired Medications Not Disposed of in Medication Rooms
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not ensuring the proper disposal of expired medications in two medication rooms, affecting two residents. Resident #81, who was admitted with dementia, anxiety disorder, depression, and hypertension, had a scopolamine medication in the refrigerator with a discard date that had passed. The medication aide, who was new to the facility, was unaware of who was responsible for checking expired medications. Similarly, Resident #68, with chronic systolic heart failure, depression, dementia with agitation, and hypertension, had expired acetaminophen suppositories in the medication room refrigerator. The ADON responsible for checking the medication rooms admitted to forgetting to check the refrigerator for expired medications. Interviews with facility staff, including the DON and the Administrator, revealed a lack of clarity and consistency in the responsibility for checking expired medications. The DON stated that the ADONs were responsible for this task, while the Administrator mentioned that charge nurses and medication aides were also responsible, with ADONs as backup. The facility's policies on administering and storing medications emphasized the importance of checking expiration dates and not using outdated drugs, but these procedures were not followed, leading to the presence of expired medications in the facility.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to professional principles, as observed in one of the medication storage rooms and for one resident. In the medication storage room, a refrigerator was found leaking water onto a medicine cup containing white capsules, identified as lactobacillus capsules. The Agency Medication Aide, who was unfamiliar with the facility's procedures, was unaware of the leak and did not know who was responsible for checking for expired medications. For one resident, medications were improperly stored at the bedside, with eleven vials of normal saline found on the nightstand next to a nebulizer. The resident, who had a history of cognitive impairment and other medical conditions, had an order for glycopyrrolate to be mixed with normal saline, but the medication was not administered as ordered. The LVN confirmed that medications should not be left at the bedside due to the risk of overdose or improper use. Interviews with facility staff, including the DON and ADON, revealed that there was a lack of clarity and consistency in the responsibility for checking medication rooms and carts for expired medications. The ADON admitted to forgetting to check the refrigerator for expired medications, and the DON emphasized the risk of medication errors if medications were expired or left at the bedside. The facility's policies on administering and storing medications were not followed, contributing to the deficiencies observed.
Infection Control Deficiency Due to Improper Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of CNA F during the provision of incontinent care to Resident #80. Resident #80, who was admitted to the facility with diagnoses including myopathy, atrial fibrillation, major depressive disorder, and hypertension, was dependent on staff for personal hygiene and frequently incontinent. During an observation, CNA F did not sanitize or wash her hands between glove changes while providing care to the resident, which is a breach of infection control practices. Despite having been trained and assessed as satisfactory in hand hygiene and incontinent care, CNA F admitted to forgetting to use hand sanitizer between glove changes. The facility's policy on hand hygiene, dated 6/13/2024, clearly states that hand hygiene must be performed before donning gloves and immediately after removing them. Interviews with the ADON, DON, and the Administrator confirmed that the expected practice is to sanitize or wash hands before care, during care, after removing gloves, and after care is completed. The failure to adhere to these practices could place residents at risk of exposure to infectious diseases. The incident was acknowledged by the facility's administration, who reiterated the importance of hand hygiene in preventing the spread of infections.
Failure to Timely Transmit MDS Data
Penalty
Summary
The facility failed to transmit encoded, accurate, and complete Minimum Data Set (MDS) data to the CMS System for one resident, identified as Resident #33, reviewed for MDS accuracy and completion. The Discharge MDS assessment for this resident, with a target date of April 11, 2024, was completed on April 18, 2024, but was not transmitted until July 30, 2024, which was more than 14 days after completion. This delay in transmission was identified during a record review of a closed record and confirmed by a MDS Final Validation Report dated July 30, 2024, indicating the late submission. Interviews with facility staff revealed that the MDS Coordinator responsible for the assessment had been employed since March 2024 and acknowledged the failure to transmit the assessment timely. The Director of Nursing (DON) and the Vice President of Clinical Reimbursement both confirmed that the facility should follow the Resident Assessment Instrument (RAI) manual, which requires MDS assessments to be transmitted within 14 days of completion. The Administrator also confirmed the lack of a facility policy on MDS transmission and acknowledged the risk of inaccurate facility data if assessments are not transmitted timely.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect multiple residents from abuse and neglect, resulting in numerous incidents of resident-to-resident aggression. Residents with severe cognitive impairments, such as dementia and schizoaffective disorder, were involved in physical altercations, including slapping, hitting, scratching, and flipping wheelchairs. These incidents occurred over several months and involved residents with known aggressive behaviors, yet the facility did not implement new interventions to prevent further occurrences. Resident #1, a male with severe cognitive impairment and a history of aggressive behavior, was repeatedly involved in altercations with other residents. Despite his care plan indicating a potential for aggression, no new interventions were added following incidents where he was both the aggressor and the victim. Similarly, Resident #2, with a history of bipolar disorder and dementia, exhibited physical aggression on multiple occasions, yet his care plan remained unchanged after several incidents. Other residents, such as Resident #3 and Resident #4, also displayed aggressive behaviors, leading to injuries among themselves and others. The facility's failure to update care plans and implement effective interventions contributed to a pattern of abuse and neglect, placing residents at risk for further harm. The report highlights the facility's inability to maintain a safe environment for its residents, as evidenced by the repeated incidents of aggression and the lack of appropriate response to these events.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to develop and implement written policies and procedures that prohibited and prevented abuse, neglect, and exploitation of residents, as well as the misappropriation of resident property. This deficiency was identified for seven out of ten residents reviewed for abuse policies. The facility did not protect residents from abuse by other residents, failed to implement interventions after multiple incidents of resident-to-resident altercations, and did not report these altercations to the appropriate authorities. Resident #1, a male with dementia and schizoaffective disorder, experienced multiple incidents of physical aggression from other residents. Despite having a care plan that identified his potential for aggression, no new interventions were added following these incidents. Resident #1 was involved in numerous altercations, resulting in injuries such as skin tears and a busted lip. Similarly, Resident #2, with dementia and bipolar disorder, was involved in several aggressive incidents, yet his care plan was not updated with new interventions after these events. Other residents, including Resident #3, Resident #4, and Resident #5, also exhibited aggressive behaviors or were victims of aggression. Their care plans indicated potential for aggression, but interventions were not consistently updated following incidents. The facility's failure to report these altercations to the Health and Human Services Commission (HHSC) further compounded the issue, placing residents at risk of continued abuse and neglect.
Failure to Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate and document incidents of resident-to-resident abuse, as required by their abuse policy. This deficiency was identified for seven out of ten residents reviewed for abuse investigations. The facility did not conduct investigations into multiple incidents involving physical and verbal altercations between residents, which occurred over several months. These incidents included residents being slapped, scratched, pinched, and pushed, resulting in injuries such as skin tears and bruises. The report highlights specific cases where the facility did not follow through with investigations. For instance, Resident #1, who had severe cognitive impairment and a history of aggressive behavior, was involved in numerous altercations with other residents. Despite these incidents, there was no evidence of thorough investigations or implementation of interventions to prevent further occurrences. Similarly, other residents with cognitive impairments and behavioral issues were involved in altercations, yet the facility failed to investigate these incidents as per their policy. Interviews with facility staff, including the Administrator and Director of Nursing, revealed a lack of understanding and adherence to reporting requirements for resident-to-resident altercations. The Administrator believed that incidents involving residents with dementia were not reportable due to the lack of willful intent. This misunderstanding contributed to the facility's failure to investigate and report incidents appropriately, leaving residents at risk of unaddressed abuse and neglect.
Inadequate Supervision and Assistance Leads to Resident Injury
Penalty
Summary
The facility failed to provide adequate supervision and assistance devices to prevent accidents for a resident who required extensive assistance with transfers. The resident, who had severe cognitive impairment and was at risk for falls, was care planned to require the assistance of two staff members for transfers. However, on one occasion, a CNA transferred the resident with only one staff member, resulting in the resident suffering a 4 cm laceration on her toe that required sutures. The incident occurred despite the CNA having received training on gait belt transfers, including proficiency in both one and two-person transfers. The CNA claimed not to have realized that the resident always required a two-person transfer. The facility's documentation system, the Kardex, was expected to be checked by staff to ensure proper care protocols were followed, but this was not adhered to in this instance, leading to the resident's injury.
Failure to Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report alleged violations involving abuse or mistreatment immediately, as required by state law, for seven out of ten residents reviewed. These residents experienced various forms of abuse, including physical aggression and altercations with other residents, over a period of several months. Despite the facility's policy to report all allegations and substantiated occurrences of abuse to the state agency and other required agencies, these incidents were not reported, potentially placing residents at risk for continued harm. Resident #1, a male with severe cognitive impairment due to dementia and schizoaffective disorder, was involved in multiple incidents of abuse from other residents. These incidents included being slapped, flipped out of a wheelchair, and sustaining skin tears from physical altercations. Despite these repeated incidents, the facility did not report them to the appropriate authorities. Similarly, Resident #2, with a history of dementia and bipolar disorder, was involved in several aggressive incidents, including flipping another resident's wheelchair and hitting another resident, which were also not reported. The facility's administrator, who was responsible for reporting these incidents, believed that resident-to-resident altercations involving residents with dementia were not reportable due to a lack of willful intent. This misunderstanding led to a failure to report numerous incidents, as evidenced by the lack of self-reports in the facility's TULIP account. Interviews with staff, including the Director of Nursing and the Social Worker, revealed a lack of clarity and communication regarding the reporting process, contributing to the deficiency.
Inadequate Hand Hygiene During Incontinent Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the improper hand hygiene practices of a CNA during the provision of incontinent care to a resident. The resident, an elderly male with severe cognitive impairment and a history of metabolic encephalopathy, depression, dementia, and hypertension, was observed receiving care from CNA B. During the care, CNA B did not change gloves between cleaning different areas of the resident's body and failed to wash her hands after removing gloves and before exiting the room. The facility's policies on hand hygiene and infection control, which require handwashing before and after direct contact with residents and after removing gloves, were not followed by CNA B. This lapse in protocol was observed during a survey, and interviews with the DON and Administrator confirmed that the CNA did not adhere to expected procedures. The failure to perform proper hand hygiene could potentially expose residents to communicable diseases and infections.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 27 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Palestine
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Trucare Living Centers | 1.7 mi | ★★★★★ | 3 | 0 |
| Avir At Town Creek | 1.7 mi | ★★★★★ | 15 | 0 |
| Greenbrier Nursing & Rehabilitation Center Of Pale | 3.6 mi | ★★★★★ | 8 | 0 |
| Avir At Elkhart | 9.6 mi | ★★★★★ | 1 | 0 |
| Avir At Jacksonville | 26.2 mi | ★★★★★ | 1 | 0 |
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