Transitional Care Unit

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF812Apr 15, 2026

  Based on observation, staff interview, review of the dishwasher sanitation logs, review of the manufacturer instructions and review of facility policy, the facility failed to ensure accurate dishwasher chemical sanitation to prevent foodborne illness. This had the potential to affect all four residents of the facility. The facility census was four. Findings include:Observation on 04/13/26 at 8:53 A.M. of the kitchen dishwasher operation with the Dietary Manager (DM) #114 revealed the dishwasher utilized chemical sanitation. Continued observation revealed the wash cycle water temperature was 120 degrees Fahrenheit (F) and the rinse cycle water temperature was 120 degrees F. […]

• No harm, potential for more than minimal, isolatedF628Apr 15, 2026

  Based on record review and staff interviews the facility failed to provide discharge notification to the Ombudsman. This affected two (#1 and #8) of three residents reviewed for discharge. The facility census was four.Findings include:1. Review of medical record for Resident #1 revealed an admission date of 03/20/26. Diagnoses included wound dehiscence, osteoarthritis of the spine, anxiety, morbid obesity, and peripheral artery disease. Resident #1 discharged to home with home health services on 04/04/26.Review of the electronic medical record (EMR) revealed no evidence the Ombudsman was notified of the 04/04/26 discharge.2. Review of medical record for Resident #8 revealed an admission date of 3/18/26. Diagnoses included acute pancreatitis, depression, pancreatic cyst and obesity. […]

• No harm, potential for more than minimal, isolatedF684Apr 15, 2026

  Based on medical record review, observation, staff interview and review of facility policy, the facility failed to ensure non-pressure ulcer wounds were thoroughly documented and further failed to ensure physician treatment orders were obtained. This affected one (#2) of two residents reviewed for wounds. The facility census was four.Findings include:Review of medical record for Resident #2 revealed an admission date of 03/26/26. Diagnoses included septic bacteremia, atrial fibrillation, hypertension and hyperlipidemia. Review of the admission Minimum Data Set (MDS) assessment, dated 04/08/26, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. […]

• No harm, potential for more than minimal, isolatedF812Aug 1, 2023

  Based on observation, staff interview, and operational requirement review, the facility failed to ensure routine monitoring and record keeping of the wash and rinse cycle requirements for the dishwasher to ensure the dishes were properly sanitized and disinfected. This had the potential to affect the one resident residing in the facility at the time of the survey. The facility census was one. Findings include: Observation on 07/31/23 at 9:05 A.M. of the dishwasher operation revealed the wash cycle was 122 degrees Fahrenheit (F), the rinse cycle was 128 degrees F, and the test strip results were 100 parts per million. Observation on 07/31/23 at 9:09 A.M. […]