Timberridge Nursing & Rehabilitation Center

Inspectors wroteBased on interview and record review the facility failed to ensure physician ordered parameters were followed for 6 of 8 residents, Residents #15, #88, #23, #6, #94 and #179, reviewed for unnecessary medications.

Inspectors wroteBased on record review and interview, the facility failed to coordinate assessments for the residents with newly evident or possible serious mental disorder for Level II PASRR (Pre-admission Screening and Resident Review) for 1 of 3 residents reviewed for PASRR, Resident #2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive care plan for residents who had language preferences for 1 of 3 residents reviewed for communication services, Resident #122.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents received oxygen therapy as ordered by the physician for 3 of 5 residents reviewed for respiratory care, Residents #22, #151, and #11.

Inspectors wroteBased on record review and staff interview, the facility failed to maintain complete and accurate medical records for 1 of 8 residents, Resident #11, reviewed for documentation. Findings Include: Review of Resident #11's Medication Administration Record (MAR) for January 2026, on 01/27/2026 for the scheduled 9:00 AM medication pass, the MAR was blank, no entries, for the physician ordered medications: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent the possible spread of infection when failing to perform hand hygiene during medication administration and dining observations and failing to follow transmission-based precautions.

Inspectors wroteBased on record review and interview the facility failed to ensure pain medication was administered within parameters for 1 of 10 residents, Resident #24, failed to ensure blood pressure medication was administered within parameters for 3 of 10 residents, Residents #42, #110, and #127, reviewed for medication administration, failed to administer medications in accordance with professional standards of practice when administering crushed medications via gastrostomy tube for 1 of 1 resident, Resident #27, and failed to ensure dressing changes were completed for peripherally inserted central catheters for 1 of 4 residents, Resident #264.

Inspectors wroteBased on record review and interview, the facility failed to ensure each resident was provided an assessment which accurately reflects the resident's status for 1 of 3 residents, Resident #159, reviewed for discharge status.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 1 of 6 residents, Resident #136, reviewed for nutrition was offered a therapeutic diet as ordered by the physician and recommended by the Registered Dietician.

Inspectors wroteBased on record review and interview the facility failed to accurately document blood pressure medication administration and vital signs for 2 of 10 residents, Residents #42 and #110 reviewed for medication administration.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain enhance barrier precautions to prevent the possible spread of infection during direct catheter care and intravenous medication administration and failed to prevent the possible spread of infection in failing to provide intravenous dressing change for peripherally inserted central catheter line (PICC). Findings Include: 1) During an observation on 8/26/2024 at 9:40 AM Staff C, Certified Nursing Assistant (CNA), entered Resident #127's room without gowning and inspected the urinary catheter drainage bag to see if it was leaking. Staff C exited Resident #127's room and came back with towels to place on the wet floor. Staff C without wearing a gown emptied the urinary catheter drainage bag. [...]

Inspectors wroteBased on record review and interview the facility failed to ensure 1 resident, Resident #512, of 3 residents reviewed for insurance and payor source change was informed of co-pay obligations following a payor source change.

Inspectors wroteBased on interviews, record reviews, and policy and procedure reviews, the facility failed to ensure residents were free from medical neglect by failing to implement policies and procedures for neglect, resident change in condition or status, and resident transportation safety for facility operated vehicles when the facility transportation driver failed to notify the facility licensed medical staff of a resident change in condition. Resident #1, while being transported to the facility in the facility transport van after attending a physician appointment, stated she was out of oxygen, that she needed oxygen, was short of breath, and experiencing chest pain. The facility transportation driver pulled off the interstate, did not notify the facility licensed medical staff, asked Resident #1 if she wanted to return to the hospital/health facility, the resident declined, stating she was okay. [...]

Inspectors wroteBased on interviews, resident record reviews, and review of the policies and procedures, the facility administration failed to administer the facility in a manner that enables it to use its resources effectively and efficiently to attain and maintain the highest practicable physical well-being of each resident and to prevent medical neglect when the facility failed to implement policies and procedures for neglect, resident change in condition or status, and resident transportation safety for facility operated vehicles; the facility transportation driver failed to notify the facility licensed medical staff of a resident change in condition. Resident #1, while being transported to the facility in the facility transport van after attending a physician appointment, stated she was out of oxygen, that she needed oxygen, was short of breath, and experiencing chest pain. [...]

Inspectors wroteBased on interviews, resident record reviews, and review of policies and procedures, the facility failed to utilize the Quality Assessment and Performance Improvement (QAPI) process to investigate, develop and implement an effective performance improvement plan (PIP) when the facility transportation driver failed to notify the facility licensed medical staff of a resident change in condition. Resident #1, while being transported to the facility in the facility transport van after attending a physician appointment, stated she was out of oxygen, that she needed oxygen, was short of breath, and experiencing chest pain. The facility transportation driver pulled off the interstate, did not notify the facility licensed medical staff, asked Resident #1 if she wanted to return to the hospital/health facility, the resident declined, stating she was okay. [...]

Inspectors wroteBased on record review and interview, the facility failed to notify the resident representative when there was a change in condition for 1 of 3 residents reviewed for wound care, Resident #2.

Inspectors wroteBased on record review and interview, the facility failed to develop a comprehensive person-centered care plan for 1 of 3 residents reviewed for diabetes, Resident #1.

Inspectors wroteBased on record review and interview, the facility failed to ensure the medical records were accurate for blood sugar levels for 1 of 3 residents reviewed for diabetes, Resident #1.

Inspectors wrote3. Review of Resident #309's admission record revealed the resident was admitted to the facility on [DATE] with diagnoses including essential (primary) hypertension, dementia, chronic obstructive pulmonary disease, and adult failure to thrive. Review of Resident #309's physician order dated 4/5/2023 reads. Oxygen @ [at] 2 L/Min [liters/minute] via NC [nasal cannula] CONT [continuous] every shift. During an observation on 4/24/2023 at 11:16 AM, Resident #309 was resting in bed and was being administered oxygen at 3 liters per minute via nasal cannula. During an observation on 4/25/2023 at 12:52 PM, Resident #309 was in bed and was being administered oxygen at 3 liters per minute via nasal cannula. During an interview on 4/25/2023 at 12:54 PM, Staff G, License Practical Nurse (LPN), verified the oxygen was being administered at 3 liters per minute via nasal cannula. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the drugs and biologicals used in the facility were labeled and stored in accordance with currently accepted professional principles. (Photographic evidence obtained).

Inspectors wroteBased on record review and interview, the facility failed to ensure a written bed-hold notice that included all required information was provided to the resident and their representative for 1 of 3 residents reviewed for transfers, Resident #67.

Inspectors wroteBased on record review and interview, the facility failed to ensure each resident received an accurate assessment of the resident's status for 1 of 3 residents, Resident #157.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene during wound care to prevent the possible spread of infection for 1 of 2 residents observed for wound care, Resident #16.

Inspectors wroteBased on record review and interview, the facility failed to ensure nurse staffing information was posted daily. (Photographic evidence obtained)