Tri-Community Nursing Center

In the surveyor’s words

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

• Immediate jeopardy, patternF689Dec 1, 2022

  Based on observation, record review, and interview, the facility failed to ensure residents' environment were as free of accident hazards by failing to: 1. properly secure wheelchairs in the facility's van for 1 (#3) of 8 (#1-#5, #R1-#R3) sampled residents who utilized wheelchairs during facility transport; and 2. train transportation staff on the correct procedure for utilizing the van's restraint system. This failed practice resulted in an Immediate Jeopardy (IJ) on 08/24/22 at 4:45 p.m. when S4CNADriver placed Resident #3, who utilized a wheelchair, in the facility's transport van with the j-hook of the van strap applied to the wheel instead of the frame of Resident #3's wheelchair. […]

• Immediate jeopardy, patternF835Dec 1, 2022

  Based on record review, and interview; the facility failed to administer its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident by failing to: 1. ensure the safety of Resident #3 during van transport, 2. ensure staff were properly trained and competent to secure wheelchair residents in the van according to manufacturer's instructions for use, and; 3. ensure all transportation staff were retrained on proper wheelchair restraint after Resident #3's incident and develop policies and procedures for safe tranportation to prevent future incidents. This failed practice resulted in an Immediate Jeopardy (IJ) on 08/24/22 at 4:45 p.m. […]

• No harm, potential for more than minimal, widespreadF880Mar 25, 2026

  Based on record reviews and interviews, the facility failed to maintain an effective infection control program. The facility failed to: 1. Analyze the cause of resident's repeat facility acquired infections; and2. Follow its system for identifying potential infections The facility's census was 45 residents.Findings: Record review of the facility's policy titled, Infection Prevention and Control Program with a revision date of 04/28/2025 read in part, The facility has established and maintains an infection prevention and control program.to help prevent the development and transmission of communicable diseases and infections.1. The designated Infection Preventionist (IP) is responsible for oversight of the program.and surveillance.and investigations of exposures of infectious diseases.3. […]

• No harm, potential for more than minimal, widespreadF851Feb 26, 2025

  Based on record review and interview, the facility failed to electronically submit accurate payroll information for direct care staffing as required. This deficient practice had the potential to affect any of the 51 residents residing in the facility. Findings: Review of the PBJ (Payroll Based Journal) Staffing Data Report for Fiscal Year 2024, Quarter 1 (October 1- December 31) revealed the following: -One star staffing rating, triggered. -Excessively low weekend staffing, this metric is suppressed for this facility and quarter. -Failed to have licensed nursing coverage 24 hours/day, triggered. On 02/26/2025 at 9:22 AM, an interview was conducted with S1ADM (Administrator). […]

• No harm, potential for more than minimal, widespreadF812Jan 18, 2024

  Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service by failing to ensure all stored food items in the facility's walk in freezer were labeled and dated. This deficient practice had the potential to affect the 52 residents who consumed meals prepared and/or served from the facility's kitchen. Findings: Review of the facility's policy and procedure titled Food Storage revealed in part: . Food is stored, prepared, and transported at an appropriate temperature and by methods designed to prevent contamination . 16. Frozen foods . c. […]