TLC Nursing Center

In the surveyor’s words

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

• No harm, potential for more than minimal, isolatedF602Apr 2, 2026

  Based on interviews, record review, review of facility policies titled, Controlled Substances, Identifying Exploitation, Theft and Misappropriation of Resident Property, and Administering Medications, review of a Facility Reported Incident (FRI) received by the State Agency (SA) and review of the facility's investigative file, the facility failed to ensure Licensed Practical Nurse (LPN) #4 did not misappropriate resident property when she failed to follow facility procedures related to handling, storage, disposal, and documentation of controlled substances designed to prevent drug diversion and protect resident safety. […]

• No harm, potential for more than minimal, isolatedF609Apr 2, 2026

  Based on interviews, record review, review of a facility policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, and review of a Facility Reported Incident (FRI) received by the State Agency (SA) on 10/01/2025 at 1:19 PM, the facility's Administrator (ADM) failed to ensure an allegation of misappropriation of resident property was reported to the SA in the required timeframe of 24 hours, when he was made aware on 09/11/2025 that Licensed Practical Nurse (LPN) #4 was falsifying residents' Controlled Drug Records (CDR) and failing to follow facility procedures related to handling, storage, disposal, and documentation of controlled substances designed to prevent drug diversion and protect resident safety. […]

• No harm, potential for more than minimal, isolatedF684Apr 2, 2026

  Based on interviews, record review, review of Resident Identifier (RI) #81's hospital records, and review of a facility policy titled Medication Therapy, the facility failed to provide RI #81 care and treatment based on RI #81's hospital discharge orders, plan of care, and medications necessary to treat existing conditions and address significant risk. During record review surveyors discovered that on 02/20/2026 RI #81 was discharged from the hospital to the facility with discharge medications to include aspirin, 81 milligrams (mg) to be administered twice a day, recommended upon discharge for six weeks per orthopedic surgical consult following right femoral neck fracture and hemiarthroplasty (partial hip replacement). […]

• No harm, potential for more than minimal, isolatedF710Apr 2, 2026

  Based on interviews, record review and review of facility policies titled Medical Director and Medication Therapy, the facility failed to ensure Resident Identifier (RI) #81's attending physician/MD (Medical Director) provided orders to meet RI #81's medical needs upon discharge from the hospital post arthroplasty with partial hip replacement. On 02/20/2026, the facility's attending physician was notified that RI #81 was allergic to aspirin which had been ordered by the Orthopedic surgeon. The attending physician failed to provide an order for RI #81 to receive alternate anticoagulant therapy or follow-up to ensure the prescribing surgeon was notified of RI #81's allergy to aspirin and the need for alternate therapy. […]

• No harm, potential for more than minimal, isolatedF842Apr 2, 2026

  Based on interviews, record review and review of facility policies titled, Discontinued Medication and Charting and Documentation, the facility failed to maintain Resident Identifier (RI) #81's medical records in a manner to ensure the record was complete and accurately reflected RI #81's condition and consultation of RI #81's attending physician. Licensed Practical Nurse (LPN) #9 failed to document in RI #81's medical record when she notified the attending physician of RI #81's allergy to aspirin after RI #81 was readmitted on [DATE] from the hospital with an order for aspirin to be administered for six weeks. The facility failed to identify in RI #81's medical record what would be provided in place of the aspirin. […]