United Transitional Care Center

Based on observations, record review and staff interviews, the facility failed to ensure residents were given the choice to eat their meals in a communal setting rather than in their room all the time. This was a random opportunity for discovery during the Long-Term Care Survey. This deficiency can affect more than an isolated number of residents. Resident identifier: #24, #25, #72, #76, #86, and #24. Facility Census: 28 a) Findings included: Observations made during lunch on 08/05/25 revealed the residents were all eating their meal in their room. Further observations revealed an area on the unit marked as an activity room. On the blueprint (facility layout) that was submitted during construction of the unit this room was marked dining/activities. However, observation on 08/05/25 of the sign outside the door to this room revealed the sign said Activities. On 08/06/25 a review of a policy titled Meal Passage and Nutritional Intake revised on 02/2025 revealed the following statement, In order to encourage a homelike atmosphere and to promote a social interaction between our…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to provide ongoing resident-centered group activity programming that met the expressed interests of residents, including a variety of facility-sponsored activities and weekend group activities. This failed practice had the potential to affect more than an isloated number of residents in the facility. Resident identifier: #84. Facility Census: 28.Findings included:a) A review of the admission Minimum Data Set (MDS) for Residents #84, #24, #76, #25, #83, #82, #86, #85, #78, #75, #74, #4, and #72 completed on 08/05/25 at approximately 10:00 AM, revealed each had marked it was very important for them to do things with groups of people. A review of the facility's posted activity calendars for April, May, June, July, and August 2025 revealed the only scheduled group activity was Activities in the Dayroom on Thursdays at 2:00 PM. No group activities were scheduled on weekends during this review period. On 08/05/25 at 8:20 AM, Resident #84 stated the facility handed out puzzles and she watched TV, but she did not think group…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure food items were stored and discarded in accordance with facility policy to prevent the potential for foodborne illness. This deficient practice was observed for one of the food items in the kitchen and had the potential to affect all residents who consume food prepared by the facility. Facility Census: 28Findings include:On 08/04/2025 at 12:27 PM, during the initial tour of the kitchen, a tray of biscuits was observed on a rack with a discard date of 08/03/2025.Review of the facility policy titled Food Dating (Effective Date 4/08; Revised 09/24) revealed, in part: Date items for the last day to be used. Disposal should be that night after dinner or early the next morning before breakfast.During an interview on 08/04/2025 at 12:30 PM with the Dietary Manager (DM) the DM stated, Yes, they should have been thrown out this morning or last night.

Based on record review and staff interview, the facility failed to manage pain in accordance with current professional standards of practice. Pain assessments were not consistently performed before and after as needed (PRN) pain medication was given. This deficient practice had the potential to affect one (1) of three (3) residents reviewed for the care area of pain. Resident identifier: #16. Facility census: 26. Findings include: a) Resident #16 Review of Resident #16's medical records showed a physician's order written on 06/17/24 for oxycodone (Roxicodone) 5 mg, every six (6) hours as needed for pain. Further medical record review showed three (3) occasions when oxycodone was administered for pain, but no premedication pain assessment was performed. Additionally, the resident was not assessed for effectiveness of the pain medication. These three (3) occasions were as follows: - 06/26/24 at 12:54 PM - 06/29/24 at 10:37 PM - 07/30/24 at 9:59 PM Additionally, on 06/29/24 at 3:31 AM, pain effectiveness was assessed after medication administration, but premedication pain assessment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interview and record review, the facility failed to provide the required beneficiary notification for Resident #189. This was true from one (1) of three (3) residents reviewed for beneficiary notcies during the long term care survey. Finding include: On 07/02/24 the required Notice of Medicare Non Coverage was requested from the facility for Resident #189 when her most recent medicare stay was ending. On 07/02/24 at 1:30 PM an interview was completed with the Administrator who acknowledged, he could not find a copy of the Beneficiary Notification for Resident #189.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on medical record review and staff interview the facility failed to provide the State Ombudsman with notification of a hospitalization. This was discovered for one (1) of three (3) residents reviewed for hospitalizations during the Long Term Care Survey Process. Resident #13 was hospitalized and the State Ombudsman was not notified of the hospital discharge. Resident identifier: #13. Facility census: 27. Findings included: a) Resident #13 A medical record review on 10/04/22, revealed Resident #13 was discharged to the hospital on [DATE] and there was no hospitalization notice sent to the State Ombudsman. During an interview with the Director of Nursing on 10/04/22 at 10:45 AM, the DON confirmed the State Ombudsman had not been notified of the hospitalization for Resident #13 on 08/30/22. She also reported it was their procedure to send the State Ombudsman notice of hospital transfers. .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview the facility failed to complete a discharge assessment for Resident #1. This was true for one (1) of three (3) residents reviewed for discharges. This failed practice had the opportunity to affect only a limited number of residents. Resident identifier: #1. Facility census: 27. Findings included: a) Resident #1 Record review showed a Discharge summary dated [DATE] indicating Resident #1 was to be discharged to home effective 04/28/22. A progress note dated 04/28/22 indicated that the Resident was taken off the unit and discharged home via personal vehicle at 12:17 PM. Review of Resident #1's Minimum Data Set (MDS) assessment indicated only an admission assessment was completed. The five-day scheduled assessment in section A0310 was completed on 04/28/22 for the resident's admission on [DATE]. No additional MDS assessment was completed for the discharge. Section A2000, discharge date , was blank on the MDS assessment. On 10/04/22 at 2:00 PM Registered Nurse (RN) #27…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review and staff interview the facility failed to revise an interim care plan for an indwelling Foley catheter. This was discovered for one (1) of one (1) residents reviewed for the care area of urinary catheter. The interim care plan for Resident #67 was not revised for placement and care of a urinary Foley catheter. Resident identifier: #67. Facility census: 27. Findings included: a) Resident #67 A medical record review for Resident #67 on 10/04/22, revealed the interim care plan was not revised to include an order for insertion and maintenance of an indwelling Foley catheter for Resident #67. In an interview with the Director of Nursing (DON) on 10/04/22 at 3:18 PM, reported the Foley catheter was placed on 09/29/22 for Resident #67. The DON also verified the interim care plan was not revised to show placement and care of the indwelling Foley catheter for Resident #67. .

Based on medical record review, observation, and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. This was discovered for one (1) of two (2) residents reviewed for the care area of position and mobility. The physician's order for Resident #67 was not followed for the application of heel lift boots. Resident identifier: #67. Facility census: 27. Findings included: a) Resident #67 A medical record review for Resident #67 on 10/04/22, revealed a physician's order for heel lift boots to be worn continuously with a start date of 09/22/22. During an observation on 10/04/22 at 8:15 AM, it was discovered Resident #67 was not wearing the bilateral heel lift boots. An interview with the Director of Nursing (DON) on 0/04/22 at 8:20 AM, verified Resident #67 was not wearing the bilateral heel lift boots. .