Timothy Daniels House

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who had severe cognitive impairment, required constant supervision and a wander guard bracelet for safety, the Facility failed to ensure he/she was provided with an adequate level of staff supervision and that assistive devices such as wander guard safety alarm system /exit doors were functioning properly in order to prevent an incident of elopement, when on 10/18/25 during the evening shift, Resident #1 exited the facility undetected by staff, and was later found by Police in the surrounding neighborhood.

Inspectors wroteBased on nursing staff schedule review, nursing staff time sheet review, and interviews, the facility failed to ensure staffing included the services of a Registered Nurse (RN) for a minimum of eight consecutive hours per day, seven days a week as required. Specifically, the facility failed to ensure RN coverage for eight hours per day seven days a week as follows: 7/1/24 through 9/30/24 there was no RN coverage in a 24-hour period for 6 of 92 days and 12/4/24 through 3/4/24 there was no RN coverage in a 24-hour period for 6 of 91 days.

Inspectors wroteBased on records reviewed, policy review and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment. Specifically, the facility failed to: 1. Perform surveillance activities to monitor and investigate causes of infections and the manner of spread throughout the facility; and 2. For Resident #21, ensure Gastrostomy tube (G-tube: a tube that is placed directly into the stomach through an abdominal incision for administration of nutrition, fluids, and medication) equipment was maintained in a clean and sanitary manner to decrease the risk of potential contamination and infection.

Inspectors wroteBased on a resident group meeting, staff interviews, and document review, the facility failed to ensure concerns from the Resident Council were thoroughly documented to ensure the residents felt their concerns were acted upon timely and included the facility response to the group.

Inspectors wroteBased on observations and interviews, the facility failed to ensure the residents' environment was clean, comfortable, and homelike.

Inspectors wroteBased on observation, interviews, and document review, the facility failed to ensure that residents had access to grievance forms and were aware they could formulate grievances anonymously, should they choose not to alert a staff member of their concern(s).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one Resident (#9), out of a total sample of 12 residents, was assessed for on-going use of a trunk restraint based on his/her medical status and needs.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure all drugs and biologicals were stored in a safe and secure manner as required. Specifically, the facility failed to: 1. Ensure medication carts were locked and secured when not in direct supervision of the licensed nurse on two of two units; 2. Ensure treatment carts were locked and secured when not in direct supervision of the licensed nurse on one of two units; 3. Ensure a refrigerator containing medications on one of two units was locked and secured when not in direct supervision of the licensed nurse; 4. Ensure two of two medication carts were clean and free of loose pills and debris; 5. Ensure multi-dose vials of medications were labeled with a date opened and a use by date per manufacturer's guidelines; and 6. [...]

Inspectors wroteBased on record review and interview, the facility failed to establish and maintain an infection prevention and control program that included an antibiotic stewardship program with antibiotic use protocols and a system to monitor antibiotic use.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure reasonable accommodations were made for one Resident (#5), out of a total sample of 12 residents. Specifically, the facility failed to ensure the call system button was accessible for Resident #5 to call for assistance.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete a Level I Pre-admission Screening and Resident Review (PASARR) for one Resident (#9), out of a total sample of 12 residents, resulting in Resident #9 being admitted to the facility without the determination of whether he/she screened positive for intellectual disability (ID)/developmental disability (DD) or serious mental illness (SMI) requiring further evaluation.

Inspectors wroteBased on record review and interview, the facility failed to develop and implement an individualized baseline care plan within the required 48 hours of admission for one Resident (#33), out of a total sample of 12 residents.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure a comprehensive care plan was developed and/or implemented for one Resident (#3), out of a total sample of 12 residents. Specifically, for Resident #33, the facility failed to develop a comprehensive care plan related to anticoagulant usage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow professional standards of practice for one Resident (#33), out of a total sample of 12 residents. Specifically, the facility failed to ensure Resident #33's physician order for a psychiatric consultation was implemented and completed.

Inspectors wroteBased on record review and interview, the facility failed to monitor adverse consequences (side effects) of anticoagulant medications (used to prevent the blood from clotting; a blood thinner) for one Resident (#21), out of a total sample of 12 residents.

Inspectors wroteBased on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential of foodborne illness to residents who are at high risk. Specifically, the facility failed to properly label and date food products in one of one nourishment refrigerators for residents and ensure staff food items were stored separately from resident food items.

Inspectors wroteBased on interview and record review, the facility failed to ensure that Minimum Data Set (MDS) assessments were transmitted within 14 days after a resident assessment was completed for three Residents (#12, #27, and #31), out of a total sample of three residents. Specifically, the facility failed: 1. For Residents #12 and #27, to ensure their MDS assessments were transmitted into iQIES within 14 calendar days of completion; and 2. For Resident #31, to ensure his/her MDS discharge assessment was completed within the required timeframe.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment. Specifically, the facility failed to perform surveillance activities to monitor and investigate causes of infections and the manner of spread.

Inspectors wroteBased on observation, interview, policy review, and record review, the facility failed for three Residents (#11, #25, and #20) to develop and implement comprehensive care plans to reflect the individual needs of the Residents, out of a total sample of 13 residents. Specifically, the facility failed: 1. For Resident #11, to develop and implement a care plan for oxygen use; 2. For Resident #25, to ensure a care plan was in place to address fall risk and potentially prevent falls; and 3. For Resident #20, to ensure a communication care plan was developed and implemented to address his/her impaired hearing.

Inspectors wroteBased on staffing time sheets and interviews, the facility failed to ensure staffing included the services of a Registered Nurse (RN) for a minimum of eight consecutive hours per day, seven days a week as required. Specifically for the following quarters: July 1, 2023 through September 30, 2023 there was no RN coverage in a 24-hour period for 13 out of 92 days, October 1, 2023 through December 31, 2023 there was no RN coverage in a 24-hour period for 21 out of 92 days, and January 1, 2024 through February 13, 2024 there was no RN coverage in a 24-hour period for 2 out of 25 days.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to establish and maintain an infection prevention and control program that included an antibiotic stewardship program with antibiotic use protocols and a system to monitor antibiotic use.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to develop and implement policies and procedures to ensure residents/resident representatives were educated on benefits and potential side effects of immunizations, documented consent or refusal of the immunization, and offered and administered the pneumococcal immunization in a timely manner for 4 out of 5 residents sampled. Specifically, the facility failed: 1. For Residents #22 and #12, to educate on benefits and potential side effects, offer the immunization, and document in the medical record consent/refusal; and 2. For Residents #24 and #2, to administer the Prevnar 20 (PCV20) pneumococcal vaccine after obtaining informed consent.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to develop and implement policies and procedures to ensure residents/resident representatives were educated on benefits and potential side effects, documented consent or refusal of the immunization and offered and administered the COVID-19 immunization and/or booster in a timely manner for four out of five residents sampled. Specifically, the facility failed for four Residents (#22, #12, #2, and #20) to educate, offer and administer the immunization, and document in the medical record consent/refusal.

Inspectors wroteBased on observation, interview, policy review, and record review, the facility failed to initiate and implement approaches to prevent future falls and provide adequate supervision and oversight to one Resident (#25), out of 13 sampled residents, resulting in further falls.

Inspectors wroteBased on observation, policy review, and interview, the facility failed to store drugs and biologicals used in the facility in accordance with currently accepted professional principles. Specifically, the facility failed to store drugs and biologicals in accordance with accepted professional standards until time of administration, including the appropriate accessory and cautionary instructions, and the expiration date when applicable on one of two units.

Inspectors wroteBased on observation, record review, and interview, the facility failed to complete a Minimum Data Set (MDS) assessment that accurately reflected the status of two Residents (#11 and #25), out of a total sample of 13 residents.