Timber Ridge Health and Rehabilitation

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and served in a safe and sanitary manner. This practice had the potential to affect 44 of 44 residents residing in the facility. Staff did not store food in a manner to ensure food safety, including proper labeling and dating practices. Staff did not accurately test parts per million (PPM) of the sanitizing solution or accurately complete testing logs. Kitchen equipment and food services areas were not in clean and condition. Staff did not follow safe food cooling protocols. Staff did not appropriately test and maintain dishwasher temperatures. In addition, staff engaged in an unsanitary dishwashing process. Staff did not wear hair restraints consistently throughout the kitchen. Staff did not complete appropriate hand hygiene.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure meals were served at a safe and appetizing temperature and prepared in a way to conserve nutritive value. This practice had the potential to affect more than 4 of the 44 residents residing in the facility. Staff did not follow a recipe when preparing pureed food in order to conserve/ensure the nutritive value of the food. Staff did not appropriately temp meals served to residents. Food was served outside the designated temperature range.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection. This practice had the potential to affect more than 4 of the 44 residents residing in the facility. R3 had open wounds on both feet and had an order for enhanced barrier precautions (EBP). R3's room entrance did not contain an EBP sign or other EBP protocol. R3's care plan did not indicate R3 was on EBP. R8 had open wounds on the buttocks. R8's room entrance did not contain an EBP sign or other EBP protocol. R8 did not have an order for EBP. R8's care plan did not indicate R8 was on EBP. R34 had a surgical wound and drain. R34's room entrance did not contain an EBP sign or other EBP protocol. R34 did not have an order for EBP. [...]

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not provide appropriate care and services to prevent urinary tract infections (UTIs) for 1 resident (R) (R1) of 4 sampled residents. R1 had urinary catheter valve also known as a Flip-Flo (R) that was not reflected in R1's plan of care. R1's care plan did not reflect R1's current care needs and R1's orders were not up to date. In addition, staff did not measure R1's urinary output and did not empy or clean R1's catheter bag.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not provide the necessary respiratory care and services for 2 residents (R) (R16 and R34) of 2 sampled residents. R16 was on continuous oxygen. The nasal cannula and tubing for R16's room concentrator was not changed as ordered. R34 had sleep apnea and expressed the desire to use a continuous positive airway pressure (CPAP) machine. The facility did not obtain an order for the machine or assist R34 with using the machine.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not provide pharmaceutical services to ensure the accurate administration of medication for 1 resident (R) (R6) of 8 sampled residents. R6 had an order for acetaminophen. Staff attempted to administer the medication on 5/5/26 but R6 was unavailable. Staff returned the medication to a stock bottle of acetaminophen.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect all 29 residents residing in the facility. The cooler and dry storage area contained multiple open and undated items. In addition, one item was stored uncovered and open to air. Staff did not consistently document cooked food temperatures. Staff did not follow safe food cooling protocols.

Inspectors wroteBased on staff interview and record review, the facility did not ensure high-risk medications were monitored for 4 residents (R) (R11, R18, R19, and R26) of 5 residents reviewed for unnecessary medications. Staff did not monitor R11 for side effects or adverse reactions of pain medication. Staff did not monitor R18 for side effects or adverse reactions of anticonvulsant, pain, and diuretic medication. Staff did not monitor R19 or R26 for side effects or adverse reactions of pain and diuretic medication.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure medications for 10 residents (R) (R8, R17, R9, R14, R15, R26, R16, R279, R23, and R12) of 29 residents in 1 of 2 medication carts were labeled or dated appropriately. In addition, the facility did not ensure expired medical supplies were removed from storage in 1 of 2 medication storage rooms. The North medication cart contained inhalers, eye drops, and an insulin pen that were not labeled or dated when opened. The North medication storage room contained several expired medical supplies.

Inspectors wroteBased on staff interview and record review, the facility did not notify the physician or court-appointed Guardian of a change in condition for 1 resident (R) (R8) of 1 sampled resident. R8 had a fall with a head injury on 1/14/25. R8's physician and court-appointed Guardian were not notified.

Inspectors wroteBased on staff interview and record review, the facility did not report an allegation of abuse to the State Agency (SA) for 1 resident (R) (R2) of 1 sampled resident. On 12/13/24, R2 complained of arm pain during cares and indicated a staff was bruising R2. Staff discovered 2 round bruises on the back of R2's right arm and a reddened area on R2's right elbow. The facility did not report the potential allegation of abuse and injuries of unknown origin the SA in a timely manner.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a potential allegation of abuse and injuries of unknown origin were thoroughly investigated for 1 resident (R) (R2) of 1 sampled resident. On 12/13/24, R2 complained of arm pain during cares and indicated a staff was bruising R2. Staff discovered 2 round bruises on the back of R2's right arm and a reddened area on R2's right elbow. The facility did not thoroughly investigate the potential allegation of abuse and injuries of unknown origin.

Inspectors wroteBased on staff interview and record review, the facility did not ensure timely transmittal of Resident Assessment Information (RAI)/Minimum Data Set (MDS) information for 1 resident (R) (R279) of 15 sampled residents. The facility did not transmit an RAI/MDS assessment timely for R279. A Quarterly assessment due for R279 on 1/29/25 was not completed.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 2 residents (R) (R19 and R10) of 5 residents observed during the provision of cares. Staff did not ensure enhanced barrier precautions (EBP) were followed for R10 and transmission-based precautions (TBP) were followed for R19. Staff did not ensure medical equipment was sanitized in between resident use for R10.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a physician and resident representative were notified timely of a change in condition for 1 resident (R) (R1) of 3 sampled residents. On 11/10/24, staff observed a suspected burn on R1's skin following use of a hot pack. Staff did not notify R1's Nurse Practitioner (NP) until 11/11/24 and did not notify R1's Power of Attorney for Healthcare (POAHC) until 11/14/24.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure the resident environment remained as free of accident hazards as possible for 1 resident (R) (R1) of 3 sampled residents. R1 developed skin redness with blisters (similar to second degree burn) following the use of a hot pack approximately 15 minutes after Licensed Practical Nurse (LPN)-C applied a topical analgesic (pain reducing) cream.

Inspectors wroteBased on staff interview and record review, the facility did not ensure an allegation of abuse was reported to the State Agency (SA) for 1 resident (R) (R4) of 4 sampled residents. On 9/20/24, R4 alleged Certified Nursing Assistant (CNA)-C was rough during cares and staff reported there were red marks on R4's arms. The facility did not report the allegation of abuse to the SA.

Inspectors wroteBased on staff interview and record review, the facility did not ensure an allegation of abuse was thoroughly investigated for 1 resident (R) (R4) of 4 sampled residents. On 9/20/24, R4 alleged Certified Nursing Assistant (CNA)-C was rough during cares and staff reported there were red marks on R4's arms. The facility did not thoroughly investigate the allegation of abuse.

Inspectors wroteBased on staff interview and record review, the facility did not ensure an allegation of abuse was reported to the State Agency (SA) for 1 Resident (R) (R1) of 4 sampled residents. On 9/3/23, R1's family member alleged verbal/mental abuse by a staff member. The facility did not report the allegation of abuse to the SA.

Inspectors wroteBased on staff interview and record review, the facility did not ensure an allegation of abuse was thoroughly investigated for 1 Resident (R) (R1) of 4 sampled residents. On 9/3/23, R1's family member alleged verbal/mental abuse by a staff member. The facility did not thoroughly investigate the allegation of abuse.