Treasure Hills Healthcare and Rehabilitation Cente

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 1 of 6 resident rooms (Resident #2), reviewed for environment. The facility failed to ensure Resident #2's room was free of food crumbs on the bed linens and floor. This deficient practice could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care was provided with such care consistent with professional standards, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 (Resident #1) of 3 residents reviewed for respiratory care. The facility failed to ensure Resident #1's oxygen was administered on 6/09/2026 as ordered by the physician. This deficient practice could place residents who receive respiratory care at an increased risk of developing complications and decreased quality of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to treat each resident with respect and dignity, and care for each resident in a manner, and in an environment that promotes maintenance or enhancement of his or her quality of life recognizing each resident's individuality for one (Resident #2) of three residents reviewed for facial hair. The facility failed to remove Resident #2's facial hair. This failure could affect the residents who require assistance with care from facility staff, by placing them at risk for social isolation, loss of dignity, and self-worth. Record review of Resident #2's Face Sheet, dated 12/08/2025, revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including; need for assistance with personal care, muscle weakness, lack of coordination, and reduced mobility. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 5 residents (Resident #13) reviewed for assessments:Resident #13's quarterly MDS assessment, dated 9/29/2025, did not include a diagnosis of Displaced Unspecified Fracture of Right Great Toe. Initial Encounter for Closed Fracture. This failure could place residents at risk for inadequate care due to inadequate assessments.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial need that were identified in the comprehensive assessment for 2 of 4 residents (Resident #1, Resident #91) reviewed for comprehensive person-centered care plans. 1. The facility failed to ensure Resident #1's care plan included his code status. 2. The facility failed to ensure Resident #91's care plan had the correct interventions for her DNR code status. This deficient practice could place residents at risk of not being provided with the necessary care or services and not having personalized plans developed to address their specific needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 4 (Resident #47) residents reviewed for respiratory care. The facility failed to ensure Resident #47's oxygen was administered at the correct setting of 3 liters per minute on 12/8/2025 as ordered by the physician. This deficient practice could place residents at an increased risk of developing respiratory complications and a decreased quality of care.

Inspectors wroteBased on interviews and record reviews, the facility failed to maintain medical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 4 residents (Resident #51) reviewed for accuracy of records. The facility failed to ensure LVN D documented Resident #51's change of condition on 12/01/25. This failure could place residents at risk of not receiving appropriate care through inadequate documentation resulting in deterioration in condition, exacerbation of disease process, overmedication, and increased risk of harm or injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of disease and infection for 1 (Resident #100) of 3 residents reviewed for isolation precautions. Resident #100's RP did not don PPE on 12/8/2025 before entering Resident #100's room. Resident #100 was under contact isolations per physician orders. This failure could place residents who resided in the facility, as well as employees and visitors, at risk of communicable diseases.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure all alleged violations including abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (which included to the State Survey Agency) in accordance with State law through established procedures for 2 of 4 residents (Resident #2, #3) reviewed for reporting alleged allegation of abuse. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to incorporate the recommendations from the PASRR Level II determination and the PASRR evaluation report for 1 of 12 residents (Resident #1) reviewed for PASRR. The facility failed to initiate an NFSS within 20 business days following the date the services were agreed upon in the IDT meeting for Resident #1. This failure could affect residents by placing them at risk of their specialized needs not being met.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles for 1 (Cart 1) of 5 medication carts. The facility failed to ensure that the nurses medication cart for 100 hall was secured by a lock when it was left unattended by RN A. These failures could place residents at risk of injury if medication left unsecured were consumed.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents had the right to be free from abuse, neglect and misappropriation of property for 4 of 9 residents (Residents #1, #2, #3 and #4) reviewed for abuse, in that: 1. Resident #1 and Resident #2 had a resident to resident altercation when Resident #1 struck Resident #2 on her upper shoulder and neck. 2. Resident #3 and Resident #4 had a resident to resident altercation that resulted in a skin tear with scant bleeding to Resident #3's hand. These deficient practices could affect residents and place them at risk for abuse, trauma, psychosocial harm, injuries, or hospitalization.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (which included to the State Survey Agency) in accordance with State law through established procedures for 4 of 9 residents (Resident #1, #2, #3, #4) reviewed for reporting alleged allegation of abuse. 1. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the meals served reflected the nutritional needs of residents in accordance with established national guidelines for all residents when the facility failed to ensure menus were followed for all residents for 2 of 2 meals observed. The facility failed to follow the posted menus for two lunch services served at the facility on Wednesday, 09/17/24 and Thursday, 09/18/24. These failures could place residents that eat food from the kitchen at risk of poor intake, chemical imbalance, and/or weight loss.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for storage, preparation and sanitation. The facility failed to ensure equipment was kept clean. The facility failed to ensure food holding pans were not dented. The facility failed to ensure spice in the dry storage area was sealed tightly. The facility failed to ensure there were no expired can goods in the dry storage area. The facility failed to ensure plastic dishes were clean on the clean rack. The facility failed to ensure personal items were kept out of the kitchen. The facility failed to ensure the floors were free of standing water. These failures could place residents at risk for complications from food contamination.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice for 1 of 6 (Resident #293) residents reviewed for oxygen. Resident #293's oxygen was administered at 3 Lpm and the physician's order was written for 2 Lpm. This failure could place Residents, who received oxygen, at risk of developing respiratory complications and a decreased quality of care.

Inspectors wroteBased on interviews and record review the facility failed to ensure residents who have not used psychotropic drugs were not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 (Resident #68) of 3 residents whose records were reviewed for pharmacy services. The facility failed to ensure Resident #68 was not prescribed Zyprexa (an antipsychotic) without appropriate diagnosis for its use. This deficient practice could place residents without a diagnosis for taking psychotropic medications at risk for receiving unnecessary medications.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure all drugs and biologicals were stored and labeled in accordance with currently accepted professional principles and included the appropriate accessory and cautionary instructions, and the expiration date when applicable in 1 of 3 medication carts (medication cart located in A wing hallway) reviewed for medication storage and labeling. The facility failed to ensure that all insulin in medication cart A wing hallway were not past their expiration date. The facility's failure could result in residents receiving expired insulin not being maintained at their best therapeutic level.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide residents with food that was at an appetizing temperature by failing to ensure meal trays were served with food at a preferred temperature to 2 of 5 residents (Resident #83 and Resident #85). checked for appropriate temperatures. The facility failed to ensure food was palatable and at an appetizing temperature for Resident #83 and Resident #85 on 09/17/2024 for the lunch meal. This failure could affect the residents who received oral nutrition, by placing them at risk for weight loss and/or altered nutritional status.

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preference for one (Resident #10) of three residents reviewed for call light. The facility failed to ensure Resident #10's call light was within reach and functioning properly. This failure could place residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.

Inspectors wroteBased on observations and interview, the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a centralized staff work area for of one (Resident #10) of three residents reviewed for physical environment. The facility failed to ensure Resident #10 had a working call light in the room. This failure could place residents at risk of being unable to obtain assistance or help when needed and in the event of an emergency.

Inspectors wroteBased on interview and record review, the facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, for 1 of 5 residents (Resident#1) reviewed for abuse and neglect, in that: The facility did not implement their abuse policy related to reporting when Resident #1 slid off of his wheelchair during transport due to not being properly secured. This failure could place residents at risk of abuse and neglect.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (which included to the State Survey Agency) in accordance with State law through established procedures for 1 of 5 residents (Resident #3) reviewed for reporting alleged allegation of abuse. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for accidents and hazards. The facility failed to ensure staff properly secured Resident #1 during transportation. Driver A did not secure Resident #1 with a lap belt and shoulder belt during transport resulting in Resident #1 sliding off wheelchair during transport. This deficient practice could place the residents at risk for harm or serious injury.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 15 of 77 days reviewed for RN coverage in that: -The facility failed to maintain registered nurse coverage for 8 hours a day, 7 days a week on Thursday 04/06/23, Friday 04/07/23, Sunday 04/09/23, Wednesday 04/12/23, Thursday 04/13/23, Tuesday 04/18/23, Wednesday 04/19/23, Sunday 0423/23, Monday 04/24/23, Tuesday 04/25/23, Sunday 04/30/23, Tuesday 05/09/23, Sunday 0521/23, Sunday 05/28/23, and Wednesday 06/14/23 This failure could place residents at risk by leaving staff without supervisory coverage for RN-specific nursing activities or for adverse events and not having staff to attend to adverse events.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food by professional standards for food service safety for 1 of 1 kitchen reviewed, in that: -There was an unlabeled and undated 12 oz. [...]