Trucare Living Centers - Selma
Inspection history, citations, penalties and survey trends for this long-term care facility in Selma, Texas.
- Location
- 16550 Retama Parkway, Selma, Texas 78154
- CMS Provider Number
- 676406
- Inspections on file
- 44
- Latest survey
- April 26, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Trucare Living Centers - Selma during CMS and state inspections, most recent first.
The facility failed to ensure that a physician consistently documented required visit notes, including review of the total program of care, for four residents under one physician’s care. Over extended periods, the EHR contained only sporadic or no physician progress notes for these residents, despite the physician reporting that he visited them every other month and was in the building weekly. During the same time, multiple visits by an NP and a PA were documented. In interviews, the DON confirmed the physician’s regular presence but could not explain the missing notes, and the physician acknowledged that his notes were not in the records and stated he must not have entered them. The Administrator reported there was no policy addressing clinical record accuracy or ensuring that physicians documented a note after each visit.
A resident with severe cognitive impairment was allegedly slapped in the face by a family member during a transfer, as witnessed by a CNA. The incident was reported internally to nursing leadership and the Administrator, but was not reported to the State Survey Agency or law enforcement as required. The facility's incident log did not document the event, and the internal investigation was not completed at the time of survey. Staff interviews confirmed knowledge of the event and the regulatory requirement to report abuse allegations.
A resident with a Foley catheter was observed without a privacy cover, compromising their dignity and privacy. Despite facility protocols requiring privacy covers, staff interviews revealed confusion over responsibility for ensuring covers were in place. The resident's care plan and MAR indicated the need for privacy covers, but this was not adhered to, highlighting a lapse in maintaining resident dignity.
A resident with multiple health issues experienced a change in condition, including diarrhea and fever, but the facility failed to notify the family member promptly. The resident's condition worsened, leading to a hospital transfer. Despite staff training on notification protocols, the responsible party was not informed in a timely manner.
A facility failed to specify the frequency for changing the formula bottle or tubing for a resident receiving enteral nutrition, leading to potential risks of expired formula and clogged tubing. The resident, with a history of pneumonia and dysphagia, had orders lacking clarity on when to change the feeding components, which should have been done every 24 hours. Observations and interviews confirmed the oversight, highlighting a lapse in protocol adherence.
A facility failed to maintain accurate medical records for a resident, resulting in confusion over fluid restriction orders. The resident's care plan and MAR contained inconsistent and duplicate entries, leading to staff uncertainty about the correct fluid restriction. Interviews revealed a lack of awareness and understanding among staff, including CNAs, LVNs, and dietary personnel. The resident's physician and NP were unaware of the restriction, and the facility lacked a policy for fluid restrictions, contributing to the deficiency.
The facility failed to maintain proper infection control practices, as a CNA did not follow correct perineal care procedures, risking contamination of a surgical wound, and an LVN neglected to wear a gown while administering g-tube medication, despite EBP requirements. Both staff members had received training but did not adhere to protocols during these incidents.
The facility failed to properly label and store medications, as an expired medication was found in the medication room, and medications for two discharged residents were not disposed of correctly. The DON confirmed that expired and discharged residents' medications should be removed and stored in a locked disposal box. The medication aide responsible for the medication room admitted to missing the expired medication and was unsure how the discharged residents' medications ended up there.
A resident with moderate cognitive impairment was discharged from a facility without the required written notification to their representatives and the State Long-Term Care Ombudsman. The family was verbally informed of the discharge due to wandering behaviors and felt they had no choice but to agree. The facility's Administrator did not provide written notice, believing it unnecessary since the family agreed, and the facility lacked a policy for such notifications.
Two residents' care plans were not updated to reflect their current needs and conditions. One resident's care plan lacked documentation for bedrails, CPAP use, and OSA diagnosis, despite these being in use. Another resident's care plan still included hospice services and diuretic therapy, which were discontinued. Staff interviews confirmed these oversights, highlighting a failure to adhere to the facility's policy for revising care plans as needed.
A resident with multiple diagnoses, including OSA, did not have necessary orders for bedrails and a CPAP machine, despite using both devices. The facility failed to obtain these orders, leading to potential risks due to inaccurate records. Staff interviews revealed confusion and lack of responsibility in ensuring proper equipment orders, which could negatively impact the resident's care.
The facility failed to provide appropriate CPAP treatment for two residents. One resident with OSA was not assessed for CPAP use, and no orders were obtained, leading to the resident using a CPAP device without staff assistance. Another resident with Pulmonary Fibrosis had an order for CPAP treatment, but the device was missing pieces and not included in the care plan, preventing its use. The facility's policy did not address the need for physician orders for treatments/devices, contributing to these deficiencies.
A facility failed to obtain medication orders for diuretics for a resident with Congestive Heart Failure, despite the resident providing a hospital discharge report listing Lasix. The LVN did not add the diuretic to the resident's orders as the FNP did not check it off, and the DON was unaware of the discrepancy. The facility's policy did not address orders for treatments/devices, contributing to the oversight.
The facility failed to maintain complete and accurate medical records for a resident, particularly regarding incontinent care documentation. Despite the resident being generally clean and groomed, multiple days in March 2024 lacked proper documentation, leading to concerns about the accuracy of care records.
Failure to Ensure Physician Visit Documentation in Clinical Records
Penalty
Summary
The facility failed to ensure that a physician reviewed residents’ total programs of care and documented visit notes, including progress notes and orders, at each required visit for four of five sampled residents under the care of one physician. For one resident with hypertension encephalopathy, stroke, anxiety disorder, and other conditions, the electronic record showed only two visit notes from the primary physician over an approximately ten‑month period, despite the physician reporting that he saw the resident every other month. During that same timeframe, multiple visit notes were documented by NPs and a PA, but there were no additional physician notes between early June 2025 and late April 2026. For a second resident with pneumonia, dysphagia, anemia, atrial fibrillation, hypertension, diabetes, and severely impaired cognition, record review from mid‑January to late April 2026 revealed no physician visit notes from the primary physician, although numerous visit notes were entered by a PA. A third resident with lymphedema, hypertension, hyperlipidemia, COPD, cellulitis, and moderately impaired cognition had no physician visit notes from admission through late April 2026, while NPs and a PA documented several visits during that period. A fourth resident with anxiety disorder, hyperlipidemia, bipolar disorder, neuromuscular bladder dysfunction, and fibromyalgia likewise had no physician visit notes from admission through late April 2026, despite multiple NP and PA visit notes. In interviews, the DON stated that the physician was in the facility weekly to see his residents and could not explain the absence of physician progress notes for the affected residents. The physician confirmed he was in the facility weekly, that he alternated visits with his NP and PA, and that he believed he had seen all four residents numerous times, including in February 2026, but acknowledged that his notes were not present in the electronic records and stated he “must not have put a note” in the records. The Administrator reported that she checked the electronic records after physician visits but noted that providers often delayed entering notes and also stated there was no facility policy on accuracy of clinical records or ensuring that physicians wrote a note after each visit. The report states that this deficient practice could place residents at risk for physician‑identified concerns, inadequate monitoring of medical conditions, and miscommunication with other health care providers.
Failure to Timely Report Alleged Physical Abuse by Family Member
Penalty
Summary
The facility failed to ensure that an allegation of physical abuse involving a resident and her responsible party (RP) was reported to the State Survey Agency within the required timeframe. On 3/29/25, a certified nursing assistant (CNA) witnessed the RP slap the resident in the face during a transfer while the resident was agitated and combative. The CNA immediately reported the incident to a licensed vocational nurse (LVN), who then notified the Director of Nursing (DON) and the Administrator. Despite this, the incident was not documented in the facility's incident log for March 2025, nor was it reported to the State Survey Agency (HHSC) or law enforcement as required by regulation. The resident involved was an 81-year-old female with severe cognitive impairment (BIMS score of zero), dementia, and a history of incontinence and limited mobility, requiring maximum assistance for transfers and care. Skin assessments and vital signs following the incident showed no physical injuries or abnormalities, and the resident did not express pain or psychosocial harm during subsequent interviews. However, the resident was unable to clearly recall or respond to questions about the incident due to her cognitive status. Multiple staff interviews confirmed knowledge of the abuse allegation and awareness of mandatory reporting requirements. The social worker, LVN, DON, and Administrator all acknowledged that the incident was reportable to the State Survey Agency and potentially to law enforcement. Despite this, the facility did not report the allegation within the required two-hour window, and the internal investigation remained incomplete as of the survey date. The facility's own policy also required immediate reporting of such incidents, which was not followed in this case.
Failure to Ensure Privacy for Resident with Foley Catheter
Penalty
Summary
The facility failed to uphold the dignity and privacy of a resident by not ensuring that a privacy cover was placed over the resident's Foley catheter bag. The resident, a male with a history of pneumonia, acute respiratory failure with hypoxia, and reflux uropathy, was observed with his catheter bag exposed and visible to anyone passing by his open door. This observation was made despite the care plan and medication administration record (MAR) indicating that a privacy cover should be verified as in place every shift. Interviews with facility staff, including a CNA, an LVN, and the DON, revealed a lack of clarity and responsibility regarding the placement of privacy covers. The CNA stated that she did not have access to the covers and believed it was the nurses' responsibility, while the LVN acknowledged the importance of the covers but did not ensure they were used. The DON confirmed that all staff were responsible for ensuring privacy covers were in place, but was unsure about the training provided to staff on this matter. The facility's document on Resident's Rights emphasized the importance of privacy and dignity, which was not upheld in this instance.
Failure to Notify Family of Resident's Condition Change
Penalty
Summary
The facility failed to notify the resident's representative when a resident experienced a change in physical condition. The resident, a female with multiple diagnoses including kidney failure, dementia, and diabetes, was admitted to the facility in June 2023. On a particular day, the resident exhibited symptoms such as diarrhea, a slight fever, and increased lethargy. Despite these changes, the responsible party was not informed in a timely manner. The resident's condition was noted by LVN H, who recorded the symptoms and notified the Nurse Practitioner (NP) around noon. However, the resident's family member was not informed of the change in condition until they arrived at the facility later in the afternoon. By that time, the resident's condition had deteriorated significantly, prompting the family member to insist on transferring the resident to the hospital for further evaluation. Interviews with facility staff, including LVN H and the Director of Nursing (DON), revealed that there was a lapse in communication regarding the resident's condition. Although the staff had received training on the importance of notifying the responsible party during a change in condition, this protocol was not followed in this instance. The failure to notify the family member promptly could have delayed necessary medical interventions for the resident.
Failure to Specify Enteral Feeding Change Frequency
Penalty
Summary
The facility failed to provide adequate care and services to prevent complications for a resident receiving enteral nutrition. The resident, a male with a history of pneumonia, acute respiratory failure with hypoxia, and reflux uropathy, required tube feeding due to dysphagia. However, the enteral feeding order for this resident did not specify the frequency for changing the formula bottle or tubing, which is crucial to prevent complications such as expired formula and clogged tubing. Observations revealed that the resident's feeding pump was running at a rate of 20ml/hr with a Jevity 1.2 formula bottle that was not changed as per the facility's policy. Interviews with the LVN and the facility dietician confirmed that the orders lacked clarity on when to change the tubing and formula, which should have been done every 24 hours. The dietician noted that the original order was not clarified upon the resident's admission from the hospital, leading to the potential risk of the resident receiving expired nutritional formula. The Director of Nursing (DON) stated that tube feeding orders from the hospital are entered by the admitting nurse and reviewed for accuracy in clinical meetings. The facility policy mandates changing the tube feeding tubing every 24 hours, and staff are required to sign off on this in the MAR. The failure to adhere to these protocols could result in the resident becoming sick or contracting an infection, as the formula could expire if not changed timely.
Inaccurate Fluid Restriction Orders Lead to Deficiency
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, leading to confusion and inconsistency regarding the resident's fluid restriction orders. The resident, who had a history of kidney failure, dementia, edema, and other health conditions, was documented to be on a fluid restriction in the care plan and MAR. However, there were discrepancies in the fluid restriction orders, with duplicate entries and varying amounts noted, leading to uncertainty among staff about the correct fluid restriction. Interviews with various staff members, including CNAs, LVNs, the dietician, and the dietary manager, revealed a lack of awareness and understanding of the resident's fluid restriction. Some staff members were unaware of any fluid restriction, while others recalled different amounts, such as 1200cc or 1500cc, but could not confirm the exact order. The dietician and dietary manager expressed confusion over the 300cc order, which they found unusual and did not align with standard practices. The resident's physician and NP were also unaware of the fluid restriction, and the physician noted that the 300cc order was likely incorrect. The deficiency was further compounded by the lack of communication and coordination between nursing and dietary staff. The dietary manager relied on communication forms from nursing to update diet orders, but inconsistencies in these forms led to incorrect fluid amounts being provided to the resident. The DON acknowledged the oversight and noted that the fluid restriction order should have been discontinued long ago. The facility lacked a policy for fluid restrictions, contributing to the ongoing confusion and failure to provide accurate care for the resident.
Infection Control Lapses in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two specific incidents involving residents. In the first incident, a Certified Nursing Assistant (CNA) did not follow proper infection control practices while providing perineal care to a resident. The CNA wiped from back to front, which is against the recommended front-to-back direction, potentially contaminating a surgical wound dressing on the resident's scrotum. Additionally, the CNA did not change gloves or wash hands after cleaning the buttocks area before placing a clean brief and repositioning the resident. This resident had a history of surgical aftercare and was dependent on staff for toileting hygiene, with a care plan focused on preventing infections due to incontinence and catheter use. In the second incident, a Licensed Vocational Nurse (LVN) failed to adhere to Enhanced Barrier Precautions (EBP) while administering medication via a gastrostomy tube to another resident. The LVN did not wear a gown, although gloves were used, despite the presence of an EBP sign and PPE supplies readily available. This resident had severe cognitive impairment and required enteral feeding due to dysphagia and cerebrovascular insufficiency. The care plan for this resident included the use of proper PPE during high-contact care activities to prevent the transfer of multidrug-resistant organisms (MDROs). Both staff members involved in these incidents had received training and passed competency reviews in their respective areas of infection control. However, their failure to adhere to established protocols during these specific instances could lead to cross-contamination and the spread of infections among residents. The Director of Nursing (DON) confirmed the expected procedures and expressed surprise at the lapses, given the staff's training and previous performance.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were labeled and stored according to professional standards in the medication room. During an observation, an over-the-counter medication, Feosol, was found with an expiration date of 06/2024, indicating it was not removed from the medication room after its expiration. This oversight was acknowledged by the Director of Nursing (DON), who stated that expired medications should be removed from stock to prevent the risk of being ineffective. Additionally, medications belonging to two discharged residents were found in the medication room, not properly disposed of as per facility policy. The medications included Diclofenac Topical 1% cream, Probiotic Culturelle, Lidocaine 4% ointment, Simvastatin, and Midodrin. The DON confirmed that medications for discharged residents should be stored in a locked disposal box for proper disposal by the pharmacist. The medication aide responsible for maintaining the medication room admitted to missing the expired Feosol and was unsure how the discharged residents' medications ended up in the medication room, suggesting that other staff might have placed them there without her knowledge.
Failure to Provide Written Discharge Notification
Penalty
Summary
The facility failed to provide timely written notification to a resident's representative and the State Long-Term Care Ombudsman before discharging the resident. The resident, an elderly male with moderate cognitive impairment, unspecified dementia, major depressive disorder, and unspecified pulmonary fibrosis, was discharged without the required written notice. The facility's records indicated that the resident was expected to remain in the facility on a long-term basis, as discussed with the resident and family. Family members, who were the resident's representatives, reported that they were informed verbally by the facility's social worker and Administrator about the discharge due to the resident's wandering behaviors. They felt compelled to agree to the discharge without receiving any written notice. The facility's social worker and Administrator confirmed that no written notice was provided, with the Administrator stating that she did not believe it was necessary since the family had agreed to the discharge. The facility lacked a policy requiring written notification for discharge decisions.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to ensure that the comprehensive care plans for two residents were updated to reflect their current needs and conditions. For the first resident, the care plan was not revised to include the use of bedrails, a CPAP machine, or the diagnosis of obstructive sleep apnea (OSA). Despite the resident's intact cognition and the presence of a CPAP machine in the room, the care plan did not reflect these critical elements. Interviews with the resident and staff revealed that the resident used the CPAP every night and had signed a consent for bedrails, yet these were not documented in the care plan. The second resident's care plan was not updated to reflect the discontinuation of hospice services and diuretic medications. The resident had revoked hospice services to seek aggressive treatment and was not receiving diuretics upon readmission to the facility. However, the care plan still included hospice services and diuretic therapy, which were no longer applicable. Interviews with staff indicated that the care plan should have been updated following the resident's change in condition and medication orders. The Director of Nursing (DON) and other staff acknowledged the discrepancies in the care plans and the importance of maintaining accurate documentation for continuity of care. The facility's policy required care plans to be revised as changes in the resident's condition dictated, yet this was not adhered to in these cases. The failure to update the care plans could potentially place residents at risk of their current needs not being met.
Failure to Obtain Necessary Device Orders for Resident
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices. Specifically, the facility did not obtain necessary device orders for a resident on two occasions, which could lead to improper care due to inaccurate records. The resident, who was admitted with multiple diagnoses including obstructive sleep apnea (OSA), did not have orders for the use of bedrails or a CPAP machine, despite using both devices. The resident had signed a consent for the use of bedrails to assist with mobility, and the use of these rails was observed. However, there was no corresponding physician order for the bedrails, which is necessary to ensure they are used appropriately as an assistive device rather than a restraint. Additionally, the resident brought a CPAP machine from home and used it nightly, but the facility did not have an order for its use. The lack of orders meant that staff were not assisting the resident with the CPAP, and there was no verification of the device's settings or appropriateness for the resident's condition. Interviews with facility staff revealed a lack of clarity and responsibility regarding obtaining and verifying orders for the resident's devices. The admitting nurse was responsible for ensuring the resident had the proper equipment orders, but this was not completed. The Director of Nursing (DON) and other staff members acknowledged the oversight but did not take steps to rectify the situation. The absence of orders for the bedrails and CPAP could potentially lead to negative outcomes for the resident, as the devices were used without proper authorization or verification of their necessity and safety.
Failure to Provide Appropriate CPAP Treatment
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents who required CPAP treatment. Resident #1, diagnosed with Obstructive Sleep Apnea (OSA), was not assessed for the use of a CPAP upon admission, and no orders were obtained for its use. Despite having a CPAP device brought from home, it was not included in the resident's care plan, and the nursing staff refused to assist with its application due to the lack of a physician's order. Interviews with the resident and staff revealed that the CPAP was used nightly by the resident, but the Director of Nursing (DON) was unaware of its presence in the resident's room. Resident #2, who had a diagnosis of Pulmonary Fibrosis and other chronic conditions, had an order for CPAP treatment at bedtime or while sleeping. However, the CPAP was not included in the resident's care plan, and the device was reportedly missing pieces, preventing its use. The DON confirmed that the CPAP was put away due to missing parts and that the resident had never used it, despite having an order for its application. The facility's policy on physician orders for treatments and devices did not address the need for such orders, contributing to the oversight. These deficiencies in respiratory care for both residents highlight a failure to adhere to professional standards of practice and the residents' comprehensive person-centered care plans. The lack of proper assessment, documentation, and adherence to physician orders for CPAP treatment placed the residents at risk of not receiving the full therapeutic benefits of their prescribed respiratory care.
Failure to Obtain Medication Orders for Diuretics
Penalty
Summary
The facility failed to provide pharmacological services to meet the needs of a resident, identified as Resident #4, by not obtaining medication orders for diuretics, specifically Lasix or Bumex, which were necessary for the resident's condition. Resident #4 had been admitted with several diagnoses, including Congestive Heart Failure, and was supposed to receive diuretics as per the hospital discharge reconciliation report. However, the facility's records showed that the resident was not receiving any diuretics. During an interview, the resident confirmed that she had provided the facility with a copy of her hospital medication list, which included Lasix, but she did not receive it at the facility. The deficiency was further highlighted during interviews with facility staff. An LVN acknowledged seeing the diuretic on the hospital medication list but stated that the FNP did not check it off to be added to the resident's orders. The LVN admitted to not reviewing the FNP's progress note, which mentioned continuing Bumex. The DON was unaware of why the FNP included Bumex in her note if it was not on the medication reconciliation. The Administrator emphasized the importance of having accurate orders for medications and treatments, stating that the nurse management team was responsible for ensuring this accuracy. The facility's policy on physician medication orders did not address orders for treatments or devices, which may have contributed to the oversight.
Failure to Maintain Accurate Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, specifically regarding the documentation of incontinent care. The resident, who had diagnoses including dementia, stroke, and major depressive disorder, was found to have multiple days in March 2024 where incontinent care was not documented by CNA A. This lack of documentation was observed across various shifts, leading to concerns that the resident's care was not properly recorded, which could result in assumptions that the resident did not receive necessary care and potentially develop skin issues and infections. Interviews with the resident and staff revealed that the resident was generally clean and groomed, and there were no immediate signs of neglect such as skin tears or bruises. However, the resident did report delays in staff responding to call lights for incontinent care. CNA B admitted to providing care but failing to document it due to not having a POC log-in and was subsequently terminated for unrelated attendance issues. LVN A and the Corporate RN acknowledged the missing documentation and emphasized the importance of accurate record-keeping to avoid false allegations of neglect. The Medical Director and other CNAs confirmed that the resident sometimes refused care or soiled briefs intentionally, but there was no evidence that the resident was left in a soiled state. Despite this, the lack of documentation persisted, highlighting a systemic issue in ensuring that all care activities were properly recorded. The facility had conducted in-service training on POC documentation, but the deficiency in maintaining accurate records remained evident.
Latest citations in Texas
Surveyors found that kitchen staff failed to follow facility policy and professional standards for food storage, leaving dry items such as spaghetti noodles, garlic powder, and salt unsealed, and refrigerated items such as a prepared drink, salad, and turkey lunch meat uncovered or undated. The DM and ADM both stated that all food should be sealed, labeled, and dated, that all staff are responsible for these tasks, and that staff had been trained, but observations showed food in both dry and refrigerated storage was not properly sealed or dated as required by the facility’s food receiving and storage policy.
The facility failed to enforce its smoking policy and safe smoking assessments for three residents who used tobacco. One resident with mild cognitive impairment and two residents without cognitive impairment were assessed as smokers who required the facility to store their cigarettes and lighters, yet they reported keeping these items in their rooms, and surveyors observed cigarettes and lighters in bedside furniture. An LVN and the housekeeping supervisor stated that all smoking was to be supervised and that supplies were to be kept at the nurse’s station, and the DON and ADM confirmed that residents were not supposed to keep smoking articles in their rooms. However, residents reported they had not been told they could not keep smoking supplies in their rooms, and the facility’s written policy stated residents may not have or keep smoking articles except under direct supervision.
A resident with dementia, severe cognitive impairment, limited lower extremity range of motion, and a need for assistance with ADLs was twice observed lying in bed without an accessible call light, which was either hanging under the head of the bed or tucked between the mattress and bedframe. An LVN confirmed the resident could use the call light if available, and a CNA, another LVN, the DON, and the ADM all stated that call lights should always be within reach, that all staff are responsible for ensuring access, and that they were unaware this resident’s call light was not in reach. This was inconsistent with the facility’s policy requiring each resident to have a means to call staff directly for assistance from the bed and other areas.
A resident reported that bedroom hand sinks did not provide warm water, requiring handwashing with cold water and causing discomfort. Surveyors observed that in two rooms, the hot water remained cold despite running for several minutes, and thermometer readings at shared hand sinks showed temperatures in the 70°F range on the hot side, below the facility’s stated 100–110°F expectation. Further observation with the MD revealed that in one room the hot and cold valves were transposed, with hot water only available from the cold side. The MD, ADM, and DON each stated the MD was responsible for monitoring and maintaining water temperatures, but none were aware of recent issues, and the DON did not know the required temperature range. The facility’s maintenance request policy was requested twice but was not provided.
A resident with documented Major Depressive Disorder (MDD), including recurrent severe and mild forms, was identified in multiple records such as the face sheet, MDS, care plan, physician orders, and diagnosis report, and was receiving Cymbalta for MDD. However, the resident’s PASRR Level I screening indicated no mental illness. The ADM stated the MDS nurse was responsible for PASRR accuracy and updates when mental illness diagnoses were made, and acknowledged the resident’s active MDD should have been reflected on the PASRR, but he was unaware of the inaccuracy. This resulted in an inaccurate and non-updated PASRR Level I for a resident with a mental illness diagnosis.
Two residents’ care plans were not accurately updated to reflect their assessed needs and physician orders. One resident with dementia, diabetes, and malnutrition had an active MD order and meal tickets for a large-portion, double-portion diet and was observed receiving double portions at meals, yet the care plan continued to list only a regular diet with thin liquids and did not specify the ordered double portions. Another resident with schizophrenia and schizoaffective disorder had a positive PASRR Level 1 for mental illness and a completed PASRR Level 2 evaluation, but the care plan, while listing the psychiatric diagnoses, contained no focus areas addressing the PASRR findings or related services. The ADM and DON acknowledged that care plans should have been updated to reflect these orders and PASRR results and were unaware that this had not occurred.
A resident with severe dementia, psychiatric comorbidities, and protein-calorie malnutrition had a physician order for weekly weights, but the facility failed to consistently obtain and document these weights over several months. Although the resident appeared adequately nourished and was observed eating most of a meal, multiple ordered weekly weights were missing from the treatment records. Facility leadership, including the DON and ADON, were unaware that the weekly weight order had not been followed, despite policies requiring adherence to physician orders and documentation of weights in the EHR.
A resident with severe cognitive impairment and COPD, receiving oxygen therapy via nasal cannula, was observed twice with the cannula lying on the floor beside the bed instead of stored in the bag on the oxygen concentrator as required. A CNA later picked up the cannula from the floor, wiped it with a non-disinfectant incontinent wipe, and reapplied it to the resident, despite having been trained that a cannula found on the floor should be replaced. An LVN, the DON, and the Administrator all confirmed that oxygen cannulas must be stored properly, replaced if found on the floor, and that incontinent wipes are not disinfectants, indicating a failure to follow the facility’s infection prevention and control policy.
Surveyors found loose pills in drawers on two medication carts, indicating medications were not stored in their original packaging or assigned resident-specific areas as required by facility policy. On one cart, two loose tablets later identified as Carbidopa-Levodopa and Zofran were discovered with a medication aide who stated she was responsible for checking the cart at the start of her shift. On the second cart, four loose tablets identified as Allopurinol, Metoprolol, Lasix, and Amlodipine were found with another medication aide, who also reported routinely checking the cart for cleanliness and loose medications. The DON and ADM both reported they were unaware of the loose medications and stated that medication aides, nurses, and charge nurses were responsible for proper medication storage, monitored through administrative and pharmacy cart audits.
A resident with CHF, COPD, morbid obesity, chronic wounds, and total bowel/bladder incontinence was discharged home by stretcher despite being a mechanical-lift resident who could not walk or toilet independently. Home health was not in place, the family reported difficulty reaching SW, and the resident was discharged without an AMA notice or Ombudsman notice. She soiled herself at home, could not clean up, and was hospitalized shortly after for CHF exacerbation and fluid overload.
Improper Sealing, Dating, and Storage of Dry and Refrigerated Foods
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the kitchen, based on observations, interviews, and record review. During a kitchen tour, they observed multiple instances of improperly stored food in dry storage and refrigerated areas. In dry storage, spaghetti noodles were kept in an unsealed zip lock bag, garlic powder was stored with its lid open, and salt was stored with its spout open. In refrigerated storage, a prepared drink was placed on a metal sheet pan without a cover, a plate of salad had no date, and a package of turkey breast lunch meat was undated and not sealed. In interviews, the Dietary Manager (DM) stated that all food in the refrigerator should be sealed and dated, and all dry storage food should be sealed and closed, explaining that sealing stored food keeps it fresh and prevents contaminants from entering. The DM also stated that all staff were responsible for dating and sealing stored food and that all staff had been trained in food storage. The Administrator (ADM) reported he was not aware that food was not properly stored, and stated that dating and sealing stored food was to maintain sanitary conditions, with everyone responsible for this task and all staff trained in food storage. Review of the facility’s “Food Receiving and Storage” policy, revised November 2022, showed that dry foods stored in bins must be removed from original packaging, labeled, and dated with a use-by date, and that all refrigerated and frozen foods must be covered, labeled, dated, and monitored so they are used, frozen, or discarded by their use-by date.
Failure to Enforce Smoking Policy and Control Resident Smoking Supplies
Penalty
Summary
The facility failed to follow its established smoking policy for three residents who used tobacco. Record review showed that one resident with hepatic encephalopathy, anxiety, depression, and hypertension had an annual MDS indicating tobacco use and a BIMS score of 09 (mild cognitive impairment), but there was no smoking care plan in her care plan report. Her safe smoking assessment indicated she required the facility to store her lighter and cigarettes and that she was safe to smoke without supervision. Two other residents, one with heart failure, diabetes, anxiety, and hypertension, and another with a history of cerebral infarction, depression, and hypertension, had MDS assessments indicating tobacco use and BIMS scores of 14 and 13 respectively (no cognitive impairment). Their care plans identified them as smokers, and their safe smoking assessments also indicated the facility should store their lighters and cigarettes and that they were safe to smoke without supervision. Staff interviews and observations revealed inconsistencies between the facility’s smoking policy and actual practice. An LVN stated that all resident smoking was to be supervised, that smoking supplies were kept in a box at the nurse’s station, and that staff supervised residents according to a smoking schedule, with the housekeeping supervisor assigned to supervise at a specific time. Observation confirmed the housekeeping supervisor was outside observing residents while they smoked. The housekeeping supervisor reported she was scheduled to supervise smoking, that all residents had their own cigarettes and lighters, and that she did not hand out smoking supplies, believing residents obtained them from the nurse’s station. Both the LVN and housekeeping supervisor stated they had been trained on the facility’s smoking policy. Resident interviews and room observations showed that residents were keeping smoking supplies in their rooms despite the policy and safe smoking assessments requiring facility storage. One resident reported keeping cigarettes in his nightstand and a lighter in his pants pocket and stated he had not been told he could not keep smoking supplies in his room. Another resident stated he kept cigarettes and a lighter in his nightstand, and the surveyor observed cigarettes and a lighter in the top drawer of the nightstand; he also stated he had not been told he could not keep supplies in his room. A third resident stated she kept her cigarettes and lighter in her room and that if you gave the nurses your cigarettes and lighter they would take them; she did not remember being told she could not have supplies in her room. The DON and ADM both stated that the policy required all residents to be supervised while smoking and that smoking supplies were to be kept at the nurse’s station, and they were not aware that residents had smoking supplies in their rooms. The written smoking policy stated that residents may not have or keep any smoking articles except when under direct supervision.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach, as required by facility policy and staff training. An elderly female resident with dementia, severe cognitive impairment (BIMS score of 03), limited range of motion in both lower extremities, and a need for partial/moderate assistance with ADLs was observed on two separate occasions without accessible call light access. On one observation, the resident was lying in bed with the call light hanging on the bed frame under the head of the bed; on another, the call light was tucked between the mattress and bedframe at the head of the bed, making it unavailable for use. Multiple staff interviews confirmed that the call light should always be within reach of residents and that there was no reason this resident should not have had access to it. An LVN stated the resident was able to use the call light if it was available and that it should always be in reach. A CNA, another LVN, the DON, and the ADM each stated that the purpose of the call light was for residents to call for assistance, that all staff had been trained on call light placement, and that all staff were responsible for ensuring residents had access to the call light. None of them were aware that this resident’s call light was not within reach. The facility’s written policy on the resident call system stated that each resident is to be provided with a means to call staff directly for assistance from the bed and toileting/bathing areas, which was not followed in this case.
Failure to Maintain Adequate Hot Water Temperatures at Resident Hand Sinks
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents had access to safe, functional, sanitary, and comfortable handwashing facilities in their rooms. A resident reported that there was no warm water in the hand sinks in residents’ bedrooms and that they often had to wash their hands with cold water, which made their hands feel cold. The resident also stated they felt the facility did not take the cold water issues seriously and expressed a desire to have warm water available to wash their hands and face. Surveyor observations confirmed that the hot water in two resident rooms remained cold even after running the water for several minutes. Subsequent temperature checks with a thermometer at the shared hand sinks in these rooms showed water temperatures of 73.6°F and 70.5°F on the hot water side, which were below the facility’s stated expected range of 100–110°F for resident room sinks. During a later observation with the Maintenance Director (MD), the hot water at one shared hand sink again measured 70°F on the hot side, and when the cold side was turned on, the water became warm, with a measured temperature of 100°F, indicating the hot and cold valves had been transposed after a plumbing repair. In interviews, the MD stated he was responsible for ensuring adequate water temperatures and that he conducted weekly spot checks of shared hand sinks, maintaining temperature logs, but he was not aware of any recent issues or reports regarding water temperatures. The Administrator (ADM) confirmed that the MD was responsible for water temperatures and that the expected range was 100–110°F, and acknowledged that a recent toilet repair in one of the rooms could have resulted in the hot and cold valves being transposed. The DON stated the MD was responsible for regular water temperature checks and repairs, was not aware of any concerns about hot water temperatures, and was unsure of the required temperature range. When the facility’s maintenance request policy was requested from the ADM on two occasions, it was not provided.
Failure to Maintain Accurate PASRR Level I for Resident With Mental Illness
Penalty
Summary
The facility failed to ensure an accurate and updated PASRR Level I assessment for a resident with a diagnosed mental illness. The resident, a female with hemiplegia following a cerebral infarction, had documented diagnoses of Major Depressive Disorder (MDD), recurrent, severe without psychotic features, and MDD, recurrent, mild, as reflected on her electronic face sheet, MDS, care plan, physician orders, and diagnosis report. Her Annual MDS identified active psychotic/mood disorders of anxiety and depression, and her care plan and physician orders both documented active MDD diagnoses and treatment with Cymbalta (duloxetine) for MDD. The diagnosis report showed onset dates for MDD recurrent severe without psychotic features and MDD recurrent mild well before the survey. Despite these documented mental health diagnoses, the resident’s PASRR Level I screening dated 07/28/2024 indicated "NO" for both primary diagnosis of dementia and mental illness. During an interview, the Administrator stated that the MDS nurse was responsible for ensuring PASRR Level I screenings were accurate upon admission and for requesting updates when new mental illness diagnoses were made, and acknowledged that the resident did have an active MDD diagnosis that should have been reflected as a mental illness on the PASRR. The Administrator reported he was unaware that the PASRR Level I was inaccurate and noted that PASRR screenings were supposed to be reviewed during the admission process and updated with any changes. The report states that this failure could place residents with inaccurate PASRR Level I screenings and no PASRR Level II evaluation at risk for not receiving needed care and services.
Failure to Maintain Accurate Care Plans for Dietary and PASRR-Related Needs
Penalty
Summary
Surveyors identified a deficiency in the facility’s development and implementation of comprehensive, person-centered care plans with measurable objectives and timeframes for residents’ identified needs. For one male resident with dementia, type 2 diabetes, malnutrition, and vitamin deficiency, the admission MDS showed moderate cognitive impairment and independence in eating, with no diet restrictions or weight loss documented in Section K. His care plan included focus areas for diabetes management and potential nutritional problems, with goals to avoid complications related to diabetes and malnutrition and to maintain weight. Interventions listed included dietary consults, monitoring meal intake percentages, providing a regular diet with thin liquids, monitoring for signs and symptoms of malnutrition, and having the RD evaluate and recommend diet changes as needed. Record review showed that this resident had an active physician order for a “Large Portions diet Regular texture, Regular consistency, Double Portions” starting in early February, and his weights increased from 132 lbs to 158 lbs over several months. His lunch meal ticket reflected a regular diet with double portions, and observations confirmed he was receiving double portions at meals, sometimes requesting additional items such as a salad when still hungry. However, the resident’s care plan did not reflect the physician’s order for large/double portions; it continued to reference a regular diet and thin liquids without specifying the ordered double portions. During interviews, the resident reported he sometimes asked for more food because he was hungry but was able to get second portions and felt full after meals. The ADM and DON both stated that the MDS nurse was responsible for updating care plans when diet orders changed, acknowledged that the care plan should have reflected the double-portion order, and were unaware that it had not been updated. For a female resident with hypertensive emergency, schizophrenia, and schizoaffective disorder, bipolar type, the annual MDS documented moderate cognitive impairment and active diagnoses of anxiety disorder, schizophrenia, and schizoaffective disorder, bipolar type. Her active physician orders also listed schizophrenia and schizoaffective disorder, bipolar type. PASRR Level 1 screening indicated no primary diagnosis of dementia and a positive finding for mental illness, and a PASRR Level 2 evaluation had been completed, documenting that she was not interested in enrollment in a community-based program. Despite these PASRR findings and active mental health diagnoses, the resident’s current care plan, while listing schizophrenia and schizoaffective disorder as active diagnoses, contained no focus areas addressing the PASRR Level 1 screening or the PASRR Level 2 evaluation. In interviews, the ADM and DON both stated that the resident’s positive PASRR findings should have been reflected in the care plan and did not know why they were not. The facility’s policy on interdisciplinary care planning stated that resident care plans are to be developed according to the timeframes and criteria established by §483.21, but the care plans for these two residents were not accurate, consistent, or complete with respect to their dietary and PASRR-related needs.
Failure to Follow Physician Orders for Weekly Weights
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document weekly weights as ordered by the physician for one resident with significant nutritional risk factors. The resident was an elderly female with severe dementia with agitation, depression, schizoaffective disorder–bipolar type, and protein-calorie malnutrition. Her Quarterly MDS showed a BIMS score of 0, indicating severe cognitive impairment, and documented a weight of 120 pounds. A physician order dated 05/14/26 directed that weekly weights be obtained every Wednesday starting 01/21/26. Record review showed that, despite this standing order, multiple weekly weights were not obtained or recorded over several months. The Treatment Administration Records from 01/01/26 through 05/13/26 reflected missing weekly weight assessments on at least six ordered dates: 01/28/26, 02/11/26, 03/11/26, 03/25/26, 04/08/26, and 04/22/26. Progress notes documented weights on some dates (01/19/26, 01/21/26, 02/23/26, and 03/18/26), but these did not fulfill the requirement for consistent weekly weights as ordered. The facility’s own policy on Physician Orders stated that such orders are essential for comprehensive care, and the Weight Assessment and Intervention policy required that weights be recorded in the electronic health record. During observations, the resident appeared well-groomed, did not appear underweight or emaciated, and was seen consuming approximately 75% of a meal with staff assistance. However, interviews with the DON, ADON, and Administrator confirmed that they were not aware that the weekly weight orders had not been consistently followed for this resident. The ADON reported that the resident had significant cognitive impairment and often refused to be weighed, but there was no documentation in the report that these refusals were linked to the missed ordered weight dates or that alternative measures were taken to comply with the physician’s order. The deficiency centers on the facility’s failure to follow the physician’s weekly weight order and to ensure weights were consistently obtained and recorded in accordance with professional standards, the care plan, and facility policy.
Improper Handling and Storage of Oxygen Nasal Cannula
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control program related to oxygen therapy equipment for one resident. The resident was an elderly female with dementia, COPD, depression, atrial fibrillation, hypertension, and hyperlipidemia, who had a comprehensive MDS indicating severe cognitive impairment and use of oxygen therapy. Her care plan identified risk for respiratory infections/distress related to COPD with an intervention to administer oxygen as ordered, and physician orders directed oxygen at 2–3 liters via nasal cannula to maintain oxygen saturation above 90% as needed for shortness of breath. On two separate observations, the resident’s nasal cannula was seen lying on the floor beside the bed instead of being stored in the bag on the oxygen concentrator when not in use, as required by facility practice. During interviews, an LVN, a CNA, the DON, and the Administrator all stated that oxygen nasal cannulas should be stored in a bag on the oxygen concentrator when not in use and that if a cannula is found on the floor it should be replaced. The CNA reported that she was unaware the tubing was on the floor until she entered the room to assist with the noon meal, then picked up the nasal cannula, wiped it with an incontinent wipe that did not contain disinfectant, and placed it back on the resident. She acknowledged she had been trained on oxygen tubing storage and should have replaced the cannula. The LVN, DON, and Administrator confirmed that incontinent wipes are for skin use and are not disinfectant wipes, and that staff had been trained on oxygen use and storage. The facility’s Infection Prevention and Control Program policy stated that the program is to help prevent the development and transmission of communicable diseases and infections, including instituting measures to avoid complications or dissemination, which was not followed in this instance.
Loose Medications Found on Two Medication Carts
Penalty
Summary
The deficiency involves the facility’s failure to ensure that drugs and biologicals were stored properly on two medication carts. During an observation of the Station 1 medication cart with a medication aide, surveyors found two loose pills in a drawer. The medication aide acknowledged that the cart should not contain loose pills and stated she was responsible for the cart once she received the keys, usually checking it at the beginning of her shift for loose or expired medications and cleaning it prior to medication pass. The Director of Nursing (DON) later identified the loose pills as Carbidopa-Levodopa 25-100 and Zofran 4 mg. The facility’s policy on Medication Labeling and Storage, revised February 2023, states that medications and biologicals are to be stored in the packaging or dispensing systems in which they are received, and that medications are to be stored in an orderly manner with each resident’s medications assigned to an individual cubicle or drawer to prevent mixing. A similar issue was identified on the Station 2 medication cart, where four loose pills were found in the drawers during an observation with another medication aide. The DON identified these pills as Allopurinol 100 mg, Metoprolol 25 mg, Lasix 20 mg, and Amlodipine 5 mg. The second medication aide also stated that the cart should not contain loose pills and that she was responsible for checking the cart for cleanliness and loose medications at the beginning of each shift. In interviews, the DON and the Administrator both stated they were not aware that there were loose medications on the carts, and each indicated that medication aides and nurses or the charge nurse were responsible for proper storage of medications on the carts. Both referenced that nursing administration and the pharmacy consultant conducted periodic or monthly cart audits, and the DON and Administrator described potential negative outcomes such as residents missing medications or inventory control issues. These findings demonstrate that medications were not consistently stored in accordance with the facility’s policy and accepted professional principles.
Unsafe discharge without needed supports
Penalty
Summary
The facility failed to provide and document sufficient preparation and orientation for the discharge of a resident with significant functional and medical needs. The resident had diagnoses including acute on chronic diastolic CHF, acute pulmonary edema, obesity, COPD, chronic lower-leg ulcer, and bowel and bladder incontinence. Her admission assessment showed a BIMS score of 15, but her functional status was highly limited: bed mobility required dependent to maximal assistance, transfers were not attempted due to medical/safety concerns, walking 10 feet was not attempted, and she was always incontinent of bowel and bladder. Therapy documentation identified her as a mechanical lift resident, and progress notes described persistent debility, high fall risk, and ongoing counseling about unsafe home discharge. Despite these limitations, the resident was discharged home by stretcher with no home health services in place. The discharge summary listed home care and durable medical equipment, including a wheelchair, hospital bed, and 3-in-1 commode, but the home health agency later reported that the referral was declined because of insurance denial. Facility staff and the resident’s family reported that the resident could not walk and could not get to the bathroom by herself. The resident’s family also reported difficulty reaching social services and stated they did not know who would care for her at home. The resident was discharged without an AMA discharge notice and without notice to the Ombudsman, despite facility policy describing requirements for facility-initiated discharge and resident notification. After discharge, the resident arrived home by EMS on a stretcher and was unable to ambulate. Within less than 24 hours, she urinated and defecated on herself and was unable to change her clothing or clean her body. She was then hospitalized for CHF exacerbation and fluid overload. Interviews with facility staff showed conflicting accounts about the discharge process, the availability of home health, and whether the discharge was safe. The attending MD stated she did not recommend the resident go home and recommended long-term care, while other staff stated the resident wanted to go home and that the discharge was insurance driven.
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