Timberlane Health & Rehabilitation

Inspectors wroteBased on observations, interviews, record review, and facility policy review, it was determined that the facility failed to ensure two front locking mechanisms were locked during a wheelchair transport of one (Resident #1) of five residents reviewed for van transportation safety. This failed practice resulted in an injury associated with the death of Resident #1. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to CFR 483.25(d) (Accidents) at a scope and severity of J. The Administrator was informed of the IJ on [DATE] at 2:25 PM, and notified it was considered to be Past Non-Compliance (PNC).

Inspectors wroteBased on observation, interviews, record review and facility policy review , it was determined the facility failed to ensure multi-dosed insulin vials were labeled in accordance with currently accepted professional standards specifically insulin was not labeled with the date the vial was first accessed for five (Residents #1, #6, #7, #8, and #9) of seven residents reviewed.

Inspectors wroteBased on interviews, record review, and facility document review, it was determined the facility failed to ensure staff administered medication according to accepted professional standards and failed to follow physician orders for one (Resident #4) of one resident reviewed

Inspectors wroteThrough observation, interview, and policy reviews, the facility failed to ensure hand hygiene was conducted, that equipment, utensils, plates, cups, and food dome covers were clean and/or properly stored, and that food items had open and expiration dates. These failed practices has the potential to effect 33 sampled residents.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to convey a resident's personal funds to the individual or representative administering the individual's estate within 30 days for 1 (Resident #235) of 1 sampled resident for whom the facility-maintained trust accounts per a list provided by the Administrator on 08/2/2024 at 3:33 PM.

Inspectors wroteBased on observation, record review, interview, and facility policy review, it was determined that the facility failed to properly lift a resident with the legs open on a mechanical lift for 1 (Resident #79) resident to ensure the mechanical lift was balanced to prevent accidents or injuries based on 1 of 1 observation.

Inspectors wroteBased on observation, interviews, record review, and facility document review, the facility failed to have a process in place to identify refrigerated narcotic expiration or use by dates to ensure refrigerated narcotics were returned to the pharmacy in a timely manner affecting 3 (Resident #63, #64, #185) sampled residents, and the facility failed to ensure periodical accounting for all controlled narcotics, antianxiety medication, affecting 1 deceased (Resident #185) sampled resident discharged from the facility on [DATE] to prevent possible loss or misappropriation of resident medications.

Inspectors wroteBased on observations, interviews, document review, and facility policy review, the facility failed to ensure hydrocortisone 1/2% was stored in a locked compartment and not left at the bedside for 1 (Resident #8) to prevent the risk for accidental overdose, or injury. This failed practice had the potential to affect 1 (Resident #8) sampled resident reviewed for storing medication at the bedside without self-administration rights.

Inspectors wroteBased on record review and interview, the facility failed to ensure written notification of transfer/discharge to another facility was provided to the resident and/or resident's representative, and the state Ombudsman, to protect the rights of 1 (Resident #83) of 1 sampled resident who transferred to a different facility in the last 90 days. 1. Review of a NSG/MD Discharge Summary for Resident #83 revealed the resident was discharged from the facility on 06/07/2024. a. On 08/29/2024 at 10:50 AM, the Administrator (AD) was asked who keeps up with the discharges and sends them to the state Ombudsman. The AD indicated that she did. The AD was then asked if a resident is transferred to another facility, is a notification sent to the Ombudsman. The AD indicated that she keeps a list for the month and at the end of the month it is sent to the Ombudsman. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure a comprehensive care plan addressed a high-risk medication, insulin, to ensure planning was completed for individualized and appropriate care and services for 1 (Resident #43) of 18 (Residents #7, #8, #10, #12, #16, #40, #43, #47, #49, #54, #57, #58, #59, #64, #77, #79, #135 and #286) sampled residents whose care plans were reviewed.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents were free from accidents with the use of a stand-up lift; staff were supervised in the use of the stand-up lift and the resident's care plan was followed for 1 (Resident #1) of 3 sampled residents (Residents #1, #2 and #4) per a list of residents who require the use of a stand-up lift provided by Administrator 11-13-23 at 12:24 pm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dented cans were removed from stock; foods were dated when received to assure first in first out usage; scoops used in dry storage bins were stored in a plastic bag, and items stored in the refrigerator were dated and labeled to prevent potential for food bone illness for residents who received meals from 1 of 1 kitchen. This failed practice had the potential to affect 87 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure bilevel positive airway pressure/continuous positive airway pressure (BiPAP/CPAP) masks and/or oxygen tubing were stored in a bag or container when not in use 2 (Residents #26, and #322) of 5 (Residents #1, 26, 36, 48 and 322) sampled residents who received oxygen therapy, updrafts, and/or BiPAP/CPAP therapy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were properly stored on the medication cart; beverages were not stored in the medication refrigerator, and narcotics were surrendered in a timely manner.

Inspectors wroteBased on observation and interview, the facility failed to ensure the Infection Preventionist had completed specialized training in infection prevention and control. This failed practice had the potential to affect all 87 residents.