TLC Care Center

In the surveyor’s words

From the most serious findings on record at TLC Care Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF812Jun 10, 2021

  Based on observation, interview and document review, the facility failed to ensure it stored, prepared, distributed, and served food in a sanitary manner as evidenced by an infestation of German cockroaches, poor kitchen sanitation and poor equipment and facility maintenance. The failure of the facility to maintain the kitchen in a clean and sanitary manner had the potential to impact 179 residents who received meals from the kitchen. Findings include: On 06/04/2021 at 10:15 AM, an Environmental Health Inspector (EHI) initiated a state licensure complaint investigation and conducted a walk-through inspection of the kitchen with the contracted Dietary Manager and Administrator. The following was observed by the EHI: An infestation of German cockroaches was observed throughout the kitchen. […]

• Actual harm, isolatedF689Mar 28, 2025

  Based on observation, interview, record review and document review, the facility failed to ensure: 1. The plan of care was followed regarding transfers and the staff was provided with transfer training after a resident fall for 1 of 35 sampled residents (Resident 25) and, 2. An Oxygen tank was secured for 1 of 35 sampled residents (Resident 98). The deficient practice led to a resident's fall with injury and had the potential to cause a resident injury due to an unsecured Oxygen tank. […]

• No harm, potential for more than minimal, widespreadF882Dec 6, 2024

  Based on interview and document review the facility failed to ensure 1.) the Infection Preventionist had specialized training in infection control prior to appointment to the position; 2.) a COVID-19 outbreak was reported to the appropriate state agency; and 3.) N-95 respirator fit testing was completed, documented and staff training was provided per facility policy. The deficient practice had the potential for the facility's infection prevention program to be ineffective. Findings include: 1.) On 12/03/2024 at 3:08 PM, the RN Staff Development Coordinator/Infection Prevention RN (E3), explained had been appointed in their current position at the end of September 2024. […]

• No harm, potential for more than minimal, widespreadF867Jun 10, 2021

  Based on document review and interview, the facility's Quality team failed to develop and implement a plan of action to correct an identified problem of roach infestation and sanitation in the kitchen over a period of 15 months. Findings include: The facility quality committee meetings lacked documented evidence the Kitchen Manager had attended any quality meeting between March 2020 and June 2021. On 06/04/2021 in the afternoon, the Kitchen Manager verbalized had never attended a quality committee meeting since being hired in the fall of 2020. The Environmental Services Director did not attend seven of eight quality committee meetings from August 2020 through February 2021. […]

• No harm, potential for more than minimal, patternF865Mar 28, 2025

  Based on interview and document review, the facility failed to maintain documentation and demonstrate evidence of its ongoing Quality Assurance and Performance Improvement (QAPI) program. This deficient practice has the potential to negatively affect the outcomes of resident care and the quality of each resident's life. Findings include: On 03/28/2025 in the afternoon, the administrator acknowledged the facility was not able to produce documentation providing evidence the facility had developed, implemented, and maintained an effective, comprehensive QAPI program. The Administrator provided evidence the facility had a QAPI meeting on 02/27/2025, 09/24/2024, and 07/30/2024. […]