Above average — CMS composite of the measures below.
The next survey window likely opens 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 Trucare Living Centers during CMS and state inspections, most recent first.
A resident’s comprehensive care plan did not include interventions for indefinite Macrobid use for UTI prophylaxis. The resident had cognitive impairment, was dependent for toileting and personal hygiene, and was receiving a high-risk antibiotic, but the care plan for bowel-bladder incontinence was not updated to reflect the long-term antibiotic regimen. The MDS Coordinator acknowledged the omission, and the DON and Administrator stated care plans were the responsibility of the MDS Coordinator and other staff when needed.
Expired insulin was left on a nurse med cart for a resident with DM and impaired cognition, and an opened PPD vial was found undated in a med room refrigerator. Staff stated insulin and PPD should be dated when opened and discarded after the allowed time, but both items were observed without proper dating or removal.
A facility failed to maintain infection control when a CNA did not perform hand hygiene between glove changes during incontinent care for a resident with dementia who was always incontinent, and when a CNA and an LVN provided high-contact care to a resident on EBP without wearing gowns. The resident on EBP had pneumonia, moderately impaired cognition, total dependence for ADLs, and a pressure ulcer, and staff acknowledged they should have used gown and gloves during repositioning and linen adjustment.
The facility failed to ensure accurate MDS assessments for six residents, leading to potential risks in care planning. A resident was incorrectly coded as receiving insulin, while others had bed rails misclassified as enabler bars, resulting in discrepancies in MDS documentation. Staff acknowledged the importance of accurate assessments for proper care planning.
The facility failed to develop comprehensive care plans for the use of enabler bars and side rails for several residents, leading to potential risks of inappropriate care. Residents with cognitive impairments and mobility issues had these devices in use without corresponding care plans, as the facility referred to side rails as enabler bars, contributing to the oversight.
The facility failed to maintain a safe environment by not removing worn mechanical lift slings from service for two residents, one of whom lacked a physician order for lift transfers. Observations showed faded and damaged slings, and staff interviews revealed inadequate training on sling inspection. This deficiency highlights the facility's failure to adhere to safety protocols and ensure proper equipment maintenance.
The facility failed to use alternatives and obtain informed consent before installing bed rails for four residents, leading to a deficiency. Residents with various medical conditions, including respiratory failure, tracheostomy, and dementia, had bed rails installed without proper assessment or consent. Staff acknowledged the oversight, attributing it to a misunderstanding of bed rail classification.
A resident admitted with bipolar disorder did not receive a required PASSAR evaluation due to an oversight by the MDS Coordinator, who failed to recognize the mental illness diagnosis on admission. The facility lacked a specific PASSAR policy, relying instead on the RAI manual for guidance.
A facility failed to ensure safe storage of a resident's food, as a jar of expired mayonnaise was found in a personal refrigerator. The resident, who required assistance with eating, confirmed that staff checked his refrigerator. However, the responsible staff member did not recall seeing the expired item and did not maintain a log of checks. The facility's policy required nursing staff to discard perishable foods on or before their use-by date, which was not followed, potentially risking foodborne illnesses.
Care Plan Missing Interventions for Long-Term Prophylactic Antibiotic Use
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #58 that reflected the intervention of prophylactic antibiotic use for prevention of urinary tract infection. Record review showed the resident was an older female with diagnoses including atrial fibrillation, malnutrition, and lack of coordination, and a quarterly MDS indicated moderate impairment in thinking with a BIMS score of 9. She was dependent on personal hygiene, including toileting, and the MDS showed she was taking a high-risk antibiotic during the last seven days. Record review showed the resident’s care plan for bowel-bladder incontinence, initiated on 5/02/2023, did not include interventions for long-term prophylactic Macrobid 100 mg every hour of sleep for prevention of UTI. The hospital discharge summary indicated she was discharged with a new prescription for Macrobid 100 mg by mouth every hour of sleep indefinitely for management of UTIs after an acute hospital stay. During interviews, the MDS Coordinator stated she was responsible for revising and updating care plans and acknowledged she failed to update the care plan with interventions appropriate to long-term Macrobid use. The DON and Administrator stated the MDS Coordinator was responsible for updating and revising comprehensive care plans and that if interventions were not included, staff may not know resident needs and changes in care provided.
Expired insulin and undated PPD vial found in medication storage
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident when Resident #26 had Admelog SoloStar insulin left on the nurse medication cart after it had expired. Resident #26 was a female admitted with senile degeneration of the brain and had diabetes mellitus; her care plan directed staff to give diabetes medication as ordered and monitor for side effects and effectiveness. Her order summary showed Admelog SoloStar 100 unit/ml to be given by sliding scale before meals and at bedtime, and during observation of station A's nurse medication cart, the insulin syringe was found in use on the cart and dated with an expired date. An LVN stated insulin should be dated when opened and discarded after 28 days, and the DON stated nurses should date insulin when it is removed from the refrigerator and placed on the cart and check medication carts regularly to ensure medications are within date. The facility also failed to date an opened bottle of tuberculin PPD in medication room B. During observation with the DON, an opened undated bottle of Aplisol was found in the refrigerator. The DON stated the vial should be dated when opened because it is only good for 30 days, and LVN B stated the vial should be dated when opened and discarded after 28 days. The Administrator stated nurses were responsible for proper labeling and storage of multiuse vials and insulin, and the facility policy stated outdated drugs or biologicals shall not be used and must be returned to the pharmacy or destroyed.
Infection Control Failures During Peri-Care and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for two residents reviewed for infection control. One deficiency involved a CNA who provided incontinent care to a resident with dementia, arthritis, and total assistance needs for toileting hygiene, while the resident was always incontinent of bowel and bladder. During observed peri-care, the CNA removed gloves after incontinent care and put on a clean pair of gloves to apply a clean brief without performing hand hygiene between glove changes. The CNA later stated she knew she should have sanitized between the glove change, and the IP, DON, and Administrator all stated staff were expected to perform hand hygiene before and after care and between glove changes. A second deficiency involved a resident with pneumonia, moderately impaired cognition, dependence on staff for all ADLs, and a pressure ulcer who was on enhanced barrier precautions due to pressure ulcers. The resident’s care plan directed use of PPE, including gown and gloves, during high-contact resident care activities that could allow transfer of MDRO. During observation, a CNA and an LVN entered the resident’s room to reposition him, applied gloves but no gown, and provided direct care by adjusting linens, lifting him in bed, and repositioning pillows and linens before removing gloves and performing hand hygiene. Both staff members stated they had been trained on enhanced barrier precautions but became confused about using a gown for positioning and acknowledged that gown and gloves should have been used because they made contact with the resident and his linens. The Infection Preventionist, DON, and Administrator stated that enhanced barrier precautions were required for high-contact care and that staff were expected to follow the infection control program. The record also showed both staff had completed enhanced barrier precautions training earlier in the year, and the facility policy stated that enhanced barrier precautions were to be used per CDC requirements.
Inaccurate MDS Assessments and Misclassification of Bed Rails
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for six residents, leading to potential risks in care planning and service delivery. For Resident #40, the MDS was incorrectly coded to indicate insulin administration, despite the resident only receiving Bydureon BCise, a non-insulin medication. This error was acknowledged by the MDS Coordinator, who misunderstood the medication classification. For Residents #53, #70, #74, and #7, the MDS assessments failed to accurately reflect the use of bed rails, which were present and used by the residents. The facility staff, including the MDS Coordinator, Regional Nurse, and Director of Nursing (DON), referred to these bed rails as enabler bars, which led to their exclusion from the MDS coding. Observations confirmed the presence of 1/4 rails on the beds of these residents, contradicting the MDS documentation. The facility's policy and staff interviews revealed a misunderstanding regarding the classification of bed rails, which were considered enabler bars to assist with mobility. This misclassification was identified during the survey, highlighting discrepancies between the facility's practices and the MDS coding requirements. The Administrator and other staff acknowledged the importance of accurate MDS assessments to ensure appropriate care planning.
Failure to Develop Comprehensive Care Plans for Enabler Bars and Side Rails
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for five residents, which included the use of enabler bars and side rails. These care plans lacked measurable objectives and time frames necessary to meet the residents' medical and nursing needs. Specifically, the care plans did not address the use of side rails for residents who had them in use, potentially placing them at risk of inappropriate care and decreased quality of life. Resident #13, who had diagnoses including congestive heart failure and reduced mobility, was observed to have enabler bars in use without a comprehensive care plan addressing their use. Similarly, Resident #74, with severe cognitive impairment and reduced mobility, was observed with 1/4 rails on both sides of the bed, yet the care plan did not address the use of these side rails. Resident #130, with moderate cognitive impairment and reduced mobility, also had side rails in use without a corresponding care plan. The MDS Coordinator, responsible for care plans and assessments, indicated that the facility referred to side rails as enabler bars, as instructed by corporate staff. This terminology discrepancy contributed to the oversight in care planning. The facility's policy required comprehensive care plans to be developed within seven days of the resident's comprehensive assessment and revised as needed, but this was not adhered to, leading to the deficiencies noted by surveyors.
Failure to Maintain Safe Mechanical Lift Equipment
Penalty
Summary
The facility failed to ensure the residents' environment was free from accident hazards by not removing worn, damaged, and bleached mechanical lift slings from service for two residents. One resident, a female with severe cognitive impairment and total dependency on mechanical lift transfers, was observed using a sling with faded straps. Another resident, a male with a hip fracture and severe cognitive impairment, was also observed using a sling with faded and illegible labels. These observations indicate that the facility did not adequately inspect and maintain the slings used for resident transfers. Additionally, the facility did not obtain physician orders for mechanical lift transfers for one of the residents, which is a necessary step to ensure safe and appropriate care. The lack of physician orders for mechanical lift transfers could lead to improper handling and increased risk of injury during transfers. The facility's failure to follow proper procedures for obtaining physician orders and inspecting equipment contributed to the deficiency. Interviews with staff, including CNAs and the DON, revealed a lack of awareness and training regarding the inspection and maintenance of lift slings. Some staff members were unable to identify signs of wear or understand the importance of inspecting slings before use. The facility's policies did not include specific interventions to ensure slings were examined for potential failure, and the manufacturer's guidelines for sling inspection were not followed. This lack of adherence to safety protocols and inadequate staff training led to the deficiency.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to implement appropriate alternatives before installing bed rails for four residents, leading to a deficiency in care. For Resident #53, the facility did not attempt to use alternatives or complete quarterly side rail assessments. The resident, who had a history of respiratory failure, diabetes, COPD, and osteoarthritis, was independent in bed mobility but had 1/4 rails installed without proper consent or assessment. The resident reported that the rails were already on the bed upon admission, and she was not asked if she wanted them. Similarly, Resident #70, who had a tracheostomy and hypertension, was not offered alternatives before the installation of bed rails. The resident was independent in bed mobility and had signed a consent form electronically, but reported not being informed of the risks associated with bed rails. Observations confirmed the presence of 1/4 rails on the bed, which the resident could operate independently. For Resident #74, who had severely impaired cognition and was dependent on staff for mobility, the facility did not attempt alternatives before using bed rails. The resident's care plan included the use of enabler bars, but there was no evidence of informed consent or risk assessment. Resident #16, with moderate dementia and muscle weakness, also had bed rails installed without quarterly assessments. The facility's staff, including the MDS Coordinator and Maintenance Supervisor, acknowledged the lack of proper assessments and consent, attributing the oversight to a misunderstanding of the classification of bed rails as enabler bars.
Failure to Conduct PASSAR Evaluation for Resident with Bipolar Disorder
Penalty
Summary
The facility failed to refer a resident with a newly evident mental disorder for a Level II resident review upon a significant change of condition. Specifically, Resident #53, who was admitted with a diagnosis of bipolar disorder, did not have a new Level 1 PASSAR completed at the time of admission. This oversight was identified during a survey when the MDS Coordinator acknowledged missing the bipolar diagnosis on the resident's admission orders. The MDS Coordinator, responsible for coordinating PASSAR, admitted to not recognizing the mental illness diagnosis and failing to initiate the necessary evaluation. The resident, who was admitted with multiple diagnoses including acute and chronic respiratory failure, type 2 diabetes, COPD, osteoarthritis, and bipolar disorder, did not receive the required PASSAR services. The MDS Coordinator, who had been employed at the facility for several years, stated that she was unaware of the need for a PASSAR evaluation until questioned by the surveyor. The facility did not have a specific PASSAR policy in place and relied on the RAI manual for guidance, which contributed to the oversight.
Failure to Ensure Safe Storage of Resident's Food
Penalty
Summary
The facility failed to maintain safe and sanitary storage of food items in a resident's personal refrigerator, as per facility policy. Specifically, a jar of mayonnaise with an expired date was found in the refrigerator of Resident #54, who had been admitted to the facility with diagnoses including venous insufficiency, prostate cancer, and dementia. The resident, who required assistance with eating, confirmed that he consumed food from his refrigerator and that staff checked it. However, the responsible staff member, RNA, did not recall seeing the expired mayonnaise and did not maintain a log of the refrigerators checked, only recording temperatures. Interviews with the Director of Nursing (DON) and the Administrator revealed that the responsibility for checking personal refrigerators was assigned to restorative aides, who were expected to check for expired food items and maintain appropriate temperatures. Despite this, the expired mayonnaise was not removed until the Administrator intervened. The facility's policy required nursing staff to discard perishable foods on or before their use-by date, but this was not adhered to, potentially placing residents at risk for foodborne illnesses.
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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.
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Nursing homes near Palestine
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Legacy At Town Creek | 1.7 mi | ★★★★★ | 2 | 0 |
| Avir At Town Creek | 2.9 mi | ★★★★★ | 15 | 0 |
| Greenbrier Nursing & Rehabilitation Center Of Pale | 4 mi | ★★★★★ | 8 | 0 |
| Avir At Elkhart | 8.1 mi | ★★★★★ | 1 | 0 |
| Avir At Jacksonville | 25.6 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.