Trucare Living Centers

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 4 residents (Resident #58) reviewed for care plans. The facility failed to ensure Resident #58's care plan reflected intervention of prophylaxis antibiotic indefinitely for prevention of urinary tract infection. This failure could place residents at risk of not receiving appropriate care to meet their current needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 12 residents and 1 of 1 medication rooms (Resident #26 and medication room B) reviewed for pharmacy services. 1. The facility failed to remove Resident #26's insulin that had expired on [DATE] from the nurse medication cart. 2. The facility failed to date when tuberculin PPD was opened. These failures could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications, decreased quality of life, and hospitalization.

Inspectors wroteBased on observations, interviews, and record reviews, 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 2 of 8 residents (Residents #49 and #53) reviewed for infection control. 1. The facility failed to ensure CNA C performed hand hygiene between glove changes during peri-care on 12/15/25 with Resident #49. 2. The facility failed to ensure CNA A and LVN B followed enhanced barrier precautions and wore a gown and gloves when providing direct care to Resident #53 on 12/15/2025. These failures could place residents at risk for cross contamination and infection.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure an accurate MDS was completed for 6 of 15 residents (Residents #40, #53, #70, #74, #17, and #7) reviewed for MDS assessment accuracy. 1. The facility incorrectly coded Resident #40 as having received Insulin in previous 14 days while a resident on his MDS Assessment. 2. The facility failed to accurately code on the MDS assessments for Resident's #53 on 8/10/2024, #70 on 7/20/2024, #74 on 8/29/2024 and #7 on 8/7/2024 who had side rails on their bed. This failure could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to develop and implement comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 5 of 18 residents (Residents #53, #70, #13, #74, and #130) reviewed for care plans in that: The facility failed to develop a comprehensive care plan for the use of enabler bars for Resident #13 that were put into use on 4/3/21. The facility failed to develop a comprehensive care plan for the use of side rails for Resident #74 that were put into use on 5/29/24. The facility failed to develop a comprehensive care plan for the use of a side rails for Resident #130 that was put into use on 7/30/24. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents' environment remains as free of accident hazards as possible for 2 of 11 residents reviewed for quality of care, (Resident #6 and #281) in that: The facility failed to remove worn, damaged and bleached mechanical lift slings from service for Residents #6 and #281. The facility failed to obtain physician orders for mechanical lift transfers for Resident #6. This deficient practice could result in a loss of quality of life due to injuries.

Inspectors wroteBased on observation, interview, and record review the facility failed to attempt to use appropriate alternatives prior to installing a side or bed rail, assess the resident for risk of entrapment from bed rails prior to installation, and review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for 4 of 24 residents (Resident #53, #70, #74,and #16) reviewed for bed rails. 1. The facility failed to attempt to use an alternative for the use of bedrails and complete quarterly side rail assessments for Resident #53 who re-admitted to the facility on [DATE] and a order with a start date of 12/7/2023 for use of enabler bars to turn and reposition in bed. 2. [...]

Inspectors wroteBased on interviews and record review, the facility failed to refer all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change of condition for 1 of 6 Residents (Resident #53) reviewed for PASSAR (Preadmission Screening and Resident Review Services). The facility failed to ensure Resident #53 had a new level 1 PASSAR completed with a diagnosis of bipolar disorder on admission [DATE]. These failures could place residents at risk of not receiving the needed PASSAR services to meet their individual needs and could result in a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items, per facility policy, for 1 of 11 resident's (Resident #54) personal refrigerators reviewed for food and nutrition services. The facility failed to ensure a personal refrigerator on 09/16/2024 for Resident #54 did not contain a jar of mayonnaise with an expiration date of 8/25/2024. These failures could place residents at risk for food borne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assures the accurate acquiring, receiving, dispensing, and administering of medications for 1 of 4 residents (Resident #39) reviewed for pharmacy services. The facility did not ensure medications were properly administered to Resident #39. This failure could place residents at risk for the unsafe administration of medications and not receiving prescribed doses of ordered medications.