Transylvania Regional Hospital

In the surveyor’s words

From the most serious findings on record at Transylvania Regional Hospital, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF880Sep 25, 2024

  Based on observations, record review and staff interviews, the facility failed to develop and implement Enhanced Barrier Precautions policy and procedures that included the use of Personal Protective Equipment (PPE) during high-contact care activities for residents with indwelling medical devices and chronic wounds. In addition, nursing staff did not don a gown while providing high-contact care for residents with indwelling medical devices for 2 of 2 nursing staff observed for infection control practices (Nurse #1 and Nurse Aide #1). Findings included: Review of the facility's infection control policy and procedures revealed no policy and procedure for Enhanced Barrier Precautions (EBP). a. […]

• No harm, potential for more than minimal, patternF812Nov 25, 2025

  Based on observations and staff interviews, the facility failed to discard expired food items, label and date food items, and remove food items with signs of spoilage in 1 of 1 walk-in cooler; label and date a food item in 1 of 1 walk-in freezer; and label, date, and cover food items in 1 of 1 reach-in freezer. These failures had the potential to affect food served to residents.Findings included:1. An initial observation of the walk-in cooler on 11/24/25 at 9:47 AM revealed the following:a. a 5-pound bag of peeled garlic with a use by date of 11/20/25 sitting on a shelfb. Seven pints of grape tomatoes that contained scattered shriveled tomatoes and tomatoes with a white fuzzy substance sitting on a shelfc. […]

• No harm, potential for more than minimal, patternF812Sep 25, 2024

  Based on observations and staff interviews, the facility failed to store food items on a clean surface and maintain a clean floor in the dry food storage area and failed to discard thickened fluids as indicated by the expiration date. These deficiencies occurred in the kitchens dry food storage area and had the potential to affect food served to residents at the facility. Findings included: During initial tour of the kitchen on [DATE] at 9:01 AM with the Director of Dining Services revealed the following: a. Crumblike food debris on the plastic shelf covering in the dry food storage area where food items were being stored. b. […]

• No harm, potential for more than minimal, patternF868Jun 20, 2023

  Based on record review and staff interview, the facility failed to ensure the Medical Director (MD) was present for one (1) of the one (1) quarterly Quality Assurance (QA) meetings reviewed. This deficient practice had the potential to impact facility residents as the Medical Director was not involved in identifying and responding to quality deficiencies within the facility. The findings include: Review of the last quarterly QA committee meeting dated 05/18/2023 revealed the MD was not present for the QA committee meeting. On 06/20/2023 at 1:45 PM, the Administrator Director Quality and Safety reported that she was responsible for inviting the MD or his/her designee and she had never invited the MD or his/her designee to attend any of the quarterly QA committee meetings. […]

• No harm, potential for more than minimal, patternF812Nov 24, 2021

  Based on observations, record review, and staff interview the facility failed to remove food ready for use with signs of spoilage and after the use by date for 1 of 1 walk-in cooler and the facility failed to remove foods ready for use by the use by date for 1 of 1 dry food storage area. This practice had the potential to affect food served to residents. The findings included: Initial tour of the kitchen was completed on 11/22/21 at 10:22 AM with the Executive Chef (EC). Observations of the walk-in refrigerator revealed a half full zip lock gallon size bag of sliced pepperoni with a use by date of 9/8/21 with several slices turning gray in color. […]