Inspection Report
Complaint Investigation
Census: 226
Deficiencies: 1
Apr 24, 2025
Visit Reason
The inspection was conducted as a result of a complaint investigation into the facility on 04/24/2025, focusing on compliance with 42 CFR Chapter IV, Part 483, Requirements for Long Term Care Facilities.
Findings
The facility failed to ensure an orthopedic consult was obtained for one of five sampled residents, resulting in a delay in treatment and healing of a fracture. The complaint was substantiated based on observations, interviews, and record reviews.
Complaint Details
One complaint (NV00074086) was investigated and substantiated. The investigation included observations of staff and resident interactions, interviews with multiple staff members, and clinical record review of five residents including the resident of concern.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure an orthopedic consult was obtained as per physician order for one of five sampled residents, causing potential delay in treatment and healing of a fracture. | SS=D |
Report Facts
Census: 226
Sample size: 5
Inspection Report
Complaint Investigation
Census: 231
Capacity: 255
Deficiencies: 12
Feb 9, 2024
Visit Reason
The inspection was conducted as a Medicare Recertification Survey, Complaint and Facility-Reported Incident investigations from 2024-02-06 through 2024-02-09.
Findings
The facility had multiple deficiencies including failure to develop baseline care plans for residents with wounds and contractures, untimely medication administration, inadequate care planning for bed rails, failure to provide restorative nursing services as recommended, unsecured oxygen tanks and medications, improper smoking supervision, lack of social services assessments and follow-up, failure to implement infection control precautions for scabies, and failure to properly handle linens and laundry for infectious cases.
Complaint Details
Complaint #NV00069831 was verified with regulatory deficiencies identified related to infection control and other cited deficiencies.
Deficiencies (12)
| Description |
|---|
| Failure to develop baseline care plans for residents with surgical wounds and contractures. |
| Failure to administer medications timely according to physician orders. |
| Failure to develop care plans for residents with bed rails including assessment, consent, and physician orders. |
| Failure to provide restorative nursing services in accordance with therapy recommendations for multiple residents. |
| Unsecured oxygen tanks and medications in the facility, posing safety risks. |
| Failure to follow smoking policy including supervision and securing smoking materials. |
| Failure to obtain and implement care orders for indwelling catheter including Foley changes and perineal care. |
| Failure to complete social services assessments and follow-up for residents including missing dentures and psychosocial needs. |
| Failure to label and date food items and discard expired foods in the walk-in refrigerator. |
| Failure to implement hospice physician orders for residents including transmission-based precautions for scabies. |
| Failure to implement contact isolation precautions for resident with scabies and failure to prevent cross contamination including improper laundry handling and staff assignment. |
| Failure to secure medication carts and medication storage rooms, and medications left unsecured at bedside. |
Report Facts
Number of residents present: 231
Total licensed capacity: 255
Number of complaints investigated: 4
Number of facility-reported incidents investigated: 5
Number of medication administration delays: 7
Number of residents on transmission-based precautions: 58
Number of residents on contact precautions: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Reported suspected scabies and was under treatment; worked on multiple units against policy |
| Director of Nursing | Director of Nursing | Provided multiple confirmations and statements regarding deficiencies and infection control |
| Licensed Practical Nurse | Licensed Practical Nurse | Observed medication cart unlocked and confirmed it should be locked |
| Social Worker | Licensed Social Worker | Reported difficulty completing social services assessments due to staffing shortage |
| Treatment Nurse | Treatment Nurse | Acknowledged wound care team did not don PPE properly and lacked infection control knowledge |
| Activities Assistant | Activities Assistant | Responsible for supervising smoking residents and securing smoking materials |
Inspection Report
Complaint Investigation
Census: 210
Deficiencies: 7
Nov 1, 2023
Visit Reason
This document is an amended Statement of Deficiencies generated as a result of a Complaint and Facility Reported Incident Investigation conducted from 2023-10-31 to 2023-11-01 at TLC Care Center.
Findings
The investigation included 18 complaints and 11 facility reported incidents. Several deficiencies were identified related to notification of changes, baseline care plans, comprehensive care plans, pressure ulcer treatment, accident hazards, pain management, and pharmacy services. Some complaints were verified with deficiencies, while others were not verified.
Complaint Details
The investigation involved 18 complaints and 11 facility reported incidents. Verified complaints with deficiencies include #NV00069314, #NV00069681, #NV00068794, #NV00067469, and #NV00068753. Other complaints were either verified with no deficiencies or not verified.
Deficiencies (7)
| Description |
|---|
| Failed to promptly notify attending physician of urinary catheter dislodgement causing trauma and hematuria. |
| Failed to develop and implement a baseline care plan for surgical wound care in a timely manner. |
| Failed to develop and implement a comprehensive care plan for pain management in a resident with communication problems. |
| Failed to provide wound treatments per physician orders and conduct weekly wound assessments. |
| Failed to ensure post-fall protocol including neurological checks was implemented following an unwitnessed fall. |
| Failed to accurately assess and manage pain for a resident with communication problems using appropriate pain scales. |
| Failed to account for narcotics signed out on controlled drug record and document administration in medication records. |
Report Facts
Complaints investigated: 18
Facility Reported Incidents (FRIs) investigated: 11
Sample size: 33
Resident census: 210
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named in relation to findings about failure to notify physician and pain management. |
| Lead Treatment Nurse | Treatment Nurse | Named in relation to wound care deficiencies. |
| Registered Nurse | Registered Nurse | Named in relation to pain assessment and catheter care findings. |
Inspection Report
Complaint Investigation
Census: 210
Deficiencies: 8
Nov 1, 2023
Visit Reason
The inspection was conducted as a result of a Complaint and Facility Reported Incident Investigation from 10/31/2023 to 11/01/2023, investigating 18 complaints and 11 facility reported incidents.
Findings
Multiple deficiencies were identified including failure to notify physicians of significant changes, inadequate baseline and comprehensive care plans, failure to provide timely wound care and assessments, inadequate pain management, failure to implement post-fall protocols, and issues with pharmacy controlled substance records.
Complaint Details
The investigation included 18 complaints and 11 facility reported incidents. Verified complaints with deficiencies included #NV00069314, #NV00069681, #NV00068794, #NV00067469, and #NV00068753. Multiple unverified complaints and FRIs were also investigated with no deficiencies found.
Severity Breakdown
SS=D: 8
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to promptly notify attending physician of urinary catheter dislodgement resulting in urethral trauma and hematuria for Resident #1. | SS=D |
| Failure to develop a baseline care plan for surgical wound care for Resident #1. | SS=D |
| Failure to develop and implement a comprehensive care plan to manage pain for ventilator-dependent Resident #32. | SS=D |
| Failure to perform initial wound assessment, obtain physician orders, and provide timely wound care for surgical wounds for Resident #1. | SS=D |
| Failure to provide wound treatments per physician orders and conduct weekly wound assessments for Resident #6 with pressure ulcer. | SS=D |
| Failure to implement post-fall protocol including neuro checks after an unwitnessed fall for Resident #22. | SS=D |
| Failure to accurately assess pain and document non-pharmacological interventions for ventilator-dependent Resident #33. | SS=D |
| Failure to account for narcotics signed out on controlled drug record and document administration for Resident #29. | SS=D |
Report Facts
Sample size: 33
Number of complaints investigated: 18
Number of facility reported incidents investigated: 11
Missed wound care treatments: 13
Pressure ulcer measurement: 11
Pressure ulcer measurement: 4.5
Inspection Report
Complaint Investigation
Census: 224
Deficiencies: 0
Aug 17, 2023
Visit Reason
The inspection was conducted as a result of complaints and a Facility Reported Incident (FRI) investigation at the facility.
Findings
Three investigations were conducted: two complaints and one FRI. Two complaints and the FRI could not be verified with no regulatory deficiencies identified. One complaint was verified but also found no regulatory deficiencies. Overall, no regulatory deficiencies were identified and no further action was necessary.
Complaint Details
Two complaints (#NV00064997 and #NV00066234) and one Facility Reported Incident (#NV00063883) were investigated. The first complaint and the FRI were unverified with no deficiencies. The second complaint was verified but with no regulatory deficiencies.
Report Facts
Sample size: 2
Inspection Report
Complaint Investigation
Census: 205
Deficiencies: 0
Jun 28, 2023
Visit Reason
The inspection was conducted as a result of a complaint investigation survey triggered by Complaint #NV00068863.
Findings
The complaint could not be verified and no regulatory deficiencies were identified. The investigation included observations, interviews, clinical record reviews, and document reviews.
Complaint Details
Complaint #NV00068863 was unverified and no regulatory deficiencies were found.
Report Facts
Sample size: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed during the complaint investigation | |
| Administrator | Interviewed during the complaint investigation |
Inspection Report
Complaint Investigation
Census: 179
Deficiencies: 2
Jun 10, 2021
Visit Reason
The inspection was conducted as a result of a complaint investigation initiated on June 4, 2021, regarding allegations of a cockroach infestation in the kitchen and related sanitation issues.
Findings
The facility was found to have an infestation of German cockroaches throughout the kitchen, poor kitchen sanitation, and poor equipment and facility maintenance, which posed an immediate jeopardy to residents. The kitchen was closed and meals were catered off-site until the issues were corrected. The facility failed to maintain sanitary conditions and adequate pest control despite ongoing awareness and multiple pest control treatments over 15 months. The quality assurance program failed to develop and implement effective corrective actions to address the infestation and sanitation problems.
Complaint Details
Complaint NV00064069 was substantiated. The allegation that the kitchen was infested with cockroaches was substantiated. An allegation that a cockroach was found in a resident's ice cream could not be substantiated due to inability to identify the resident.
Severity Breakdown
Immediate Jeopardy: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure food procurement, storage, preparation, and service in a sanitary manner due to infestation of German cockroaches and poor kitchen sanitation. | Immediate Jeopardy |
| Failure of the quality assessment and assurance committee to develop and implement appropriate plans of action to correct identified quality deficiencies related to kitchen sanitation and pest control. | — |
Report Facts
Census: 179
Date of inspection: Jun 10, 2021
Date of complaint initiation: Jun 4, 2021
Date of kitchen closure: Jun 4, 2021
Date of kitchen re-opening: Jun 15, 2021
Date of compliance: Jul 26, 2021
Duration of pest control contract: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Environmental Services Director | Named in relation to findings about pest control and sanitation oversight. | |
| Dietary Manager | Named in relation to findings about kitchen sanitation and pest control issues. | |
| Administrator | Named in relation to oversight and responsibility for kitchen sanitation and pest control. | |
| District Manager of contracted kitchen service | Named in relation to cleaning schedules and pest control coordination. | |
| Director of Nursing | Named in relation to quality assurance committee and oversight. |
Report
File
4V1J21
Report
File
4V1J21
Report
File
EP_poc.pdf
Report
File
LSC_poc.pdf
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