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Deficiency Records for Transylvania Regional Hospital

A list of the most recent deficiencies for Transylvania Regional Hospital. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.

A list of the most recent deficiencies for Transylvania Regional Hospital. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.

Deficiency Type of Deficiency Deficiency Date Date Corrected Resulted from a Complaint?
Install corridor and hallway doors that block smoke. Fire Safety 2023-07-20 2023-08-31 N
Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. Fire Safety 2023-07-20 2023-08-31 N
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Health 2023-06-20 2023-08-22 N
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Health 2021-11-24 2021-12-22 N
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Health 2021-11-24 2021-12-22 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2021-11-24 2021-12-22 N
Perform COVID19 testing on residents and staff. Health 2021-11-24 2021-12-22 N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Fire Safety 2019-06-11 2019-06-12 N
Ensure operating rooms are properly protected and written records are maintained and available for inspection. Fire Safety 2019-06-11 2019-06-12 N
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Health 2019-05-01 2019-05-29 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2019-05-01 2019-05-29 N
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Health 2019-05-01 2019-05-29 N
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. Health 2019-05-01 2019-05-29 N

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