Tsali Care Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF867Feb 4, 2022

  Based on observation, record review, and staff interviews, the facility Quality Assurance and Performance Improvements (QAPI) committee failed to self-identify and [MEDICATION(S)] to ensure one (1) of four (4) unvaccinated residents did not remain in the same room on a COVID-19 unit, with a COVID-19 positive resident (Resident #4). The QAPI committee was unaware Resident #4 had been on the COVID hall (A) since the resident's admission on 01/07/22. In addition, the QAPI committee failed to ensure the facility sustained compliance related to infection control practices previously identified on the past two surveys. […]

• Immediate jeopardy, isolatedF880Feb 4, 2022

  Based on observations, record review, staff interviews, and review of the facility's policy entitled Coronavirus Disease 2019 (COVID-19) Plan and Protocols, the facility failed to ensure one (1) of four (4) unvaccinated residents did not remain in the same room on a COVID-19 unit, with a COVID-19 positive resident (Resident #4). The facility also failed to conduct a root-cause-analysis (RCA) at the onset of the COVID-19 outbreak to prevent the transmission and spread of COVID-19. The facility confirmed there were empty rooms in the facility that were not located on the COVID unit. The facility also acknowledged there was facility capability to house the unvaccinated resident in a room that was not on the COVID unit or with a COVID positive resident. […]

• Actual harm, isolatedF689Apr 10, 2025

  Based on interviews, record review, and review of facility documents, the facility failed to ensure one (1) of three (3) residents (Resident #1) was safely transferred from the facility van. The findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses that included: Complete Traumatic Amputation to Left Lower Leg and Type 1 Diabetes Mellitus. He was cognitively intact. During an interview on 4/8/25 at 9:00 AM, Resident #1 stated on 12/27/24 he was returning to the facility from an appointment in Asheville for suture removal to his stump (amputated leg). He arrived back to the facility via Tsali's van with facility's staff driver #1. While she was getting him out of the van, and on the ramp down, I slid out of the chair and landed on my stump. […]

• Actual harm, isolatedF697Aug 22, 2024

  Based on observations, medical record review, staff, resident and physician interviews, and facility policy titled Pain Management Protocol Policy, the facility failed to manage pain for one (1) of five (5) residents (Resident #159). The findings include: Resident #159 was admitted to the facility on [DATE]. The resident's diagnoses included hemiplegia, personal history of transient ischemic attack (TIA), cerebral infarction without residual deficits, anxiety disorder, depression, adjustment disorder with mixed anxiety and depressed mood, psychoactive substance, other psychoactive substance dependence, and disorder of the kidney and ureter. […]

• Actual harm, isolatedF689Jul 31, 2024

  Based on record review and staff interview the facility failed to complete a thorough fall investigation to identify root cause(s) and appropriate interventions to prevent future falls for one (1) of three (3) residents (Resident #3). This failure resulted in the resident sustaining a right femoral neck fracture, a type 4 fracture of the sacrum and a rib fracture. The findings include: Resident #3 was admitted on [DATE] and most recently readmitted [DATE] with diagnoses including: unspecified fracture of right femur, dysphasia, type 4 fracture of sacrum, muscle weakness, unspecified dementia and anxiety disorder. […]