Timberlane Health & Rehabilitation

Based 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. The findings include: During an observation of insulins and concurrent interview on 06/30/2026 at 11:05 AM, Licensed Practical Nurse (LPN)#1 indicated Resident #9's multi-dose [fast-acting insulin] vial was not labeled with the opened date. She stated with the vial not being properly labeled, she could not access it. LPN #1 stopped with the administration process and took the unlabeled insulin bottle to the Director of Nursing (DON) to report it. LPN #1 and the DON went to dispose of the insulin vial and obtained a new vial of insulin. LPN #1 labeled the new vial and withdrew four units to administer to Resident #9. During a concurrent observation and interview on 06/30/2026 at 11:42 AM, LPN #1 indicated Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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 The findings include: Review of Resident #4's admission Record, revealed Resident #4was admitted on [DATE] with medical diagnoses that included: disorder of circulatory system, type-2 diabetes mellitus, morbid obesity, essential hypertension, peripheral vascular disease, chronic kidney disease, dependence on renal dialysis, and depression. Review of Resident #4's Care Plan initiated on 04/17/2026, revealed Resident #4 had hypertension, depression, used an antidepressant, and was dependent for hemodialysis for End Stage Renal Disease (ESRD). Review of [the local hospital] After Visit Summary, dated 06/05/2026, revealed Resident #4 was discharged from the hospital and back to the facility with a prescription for an antihypotensive medication to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Through 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. The findings: On 8/26/2024 at 9:37 AM, Dietary Aide #1 confirmed an orange whip dessert, uncovered on counter, should had been covered prior to walking away because flies or anything could have gotten in it. On 8/27/2024 at 7:06 AM, the surveyor observed three coffee carafes were neither inverted nor had a cover. On 8/27/2024 at 7:07 AM, the following was observed: 43 plates stacked upon each other leaned left without a cover; a pitcher of water for thinning cooked cereals was on the bottom shelf uncovered; a double basket deep fryer had unknown particles atop the grease, adhered to the baskets and ledge, with a built up brown sticky unknown substance in the outside top crease of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. The findings are: l. Resident #235 was documented as having transferred to a different facility according to resident's Discharge Summary on 05/01/2024. 2. A document titled Timberlane Health and Rehabilitation Trust-Current Account Balance As of 08/27/2027 documented that a trust account for Resident #235 contained a closing balance of $120.00. 3. On 08/29/24 at 10:29 AM, the Surveyor asked the Business Office Manager (BOM) to identify the date Resident #235 had discharged . The BOM verified that Resident #235 was discharged on 05/01/2024. The Surveyor asked the BOM how long the facility was permitted to convey residual funds in trust accounts. The BOM indicated 30 days. 4. On 08/29/2024 at 11:01 AM, the Surveyor asked the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. The findings are: 1. A review of an in-service topic Skills Fair: Mechanical Lift Use, (Dated, 06/27/2024) revealed that Certified Nursing Assistant (CNA) #8 had been in-serviced on how to use a mechanical lift. 2. A review of resident 79's Care Plan, (Revised, 08/19/2024) revealed that Resident #79 requires a mechanical lift with 2-person assistance due to impaired mobility. 3. On 08/26/2024 at 10:05 AM, CNA #8 and CNA #3 entered Resident #79's room with a mechanical lift. CNA #8 rolled the mechanical lift under the bed with the legs in a closed position. The Surveyor observed CNA #8 raise Resident #79 from the bed and rolled the resident to the center of the room with the legs in the closed position. 4. On 08/26/2024 at 10:12 AM, CNA #8 was asked what process was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: 1.a. On [DATE] at 02:36 PM, Licensed Practical Nurse (LPN) #9 was observed removing 3 bottles of antianxiety medication belonging to Resident #63, #64, and #185 and 1 bottle of opioid pain medication belonging to Resident #63 from the refrigerated, permanently affixed medication drawer located in the [DATE]/700 Hall medication room. LPN #9 confirmed the 4 opened bottles of medication were undated. LPN #9…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: a. A review of a policy titled Self-Administration of Medications, (Revised, December 2016) revealed the IDT team must assess a resident to see if they are safe for self-administration rights. Resident rooms are not considered a safe place for medication storage, and medications must be stored in a safe and secure area. Medications can be stored in the med carts, or in the medication room, but not in a residents room. b. 08/27/2024 08:50 AM, Resident #8 was observed eating from the resident ' s over the bed table with hydrocortisone cream 1/2% resting on the right side of the over the bed table. c. Licensed Practical Nurse (LPN) #7 checked…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. The AD was asked if Resident #83 should be on the transfer log for June? The AD indicated that Resident #83 should be but was left off. b. A Policy titled Transfer or Discharge Documentation provided by the Administrator on 08/29/2024, did…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. The findings are: Resident #43's Medical Diagnosis section of the electronic health record, not dated, was reviewed and indicated a diagnosis of inadequate controls of levels of sugar in the blood (diabetes). The Order Summary dated 08/29/2024 was reviewed and indicated an order for Glargine insulin (a long acting, synthetic form of insulin) 100 units/milliliter (Unit/ML) and was dated 01/14/2024. The instructions were to inject 64 units subcutaneously (under the skin=SQ) one time a day for diabetes. A Care Plan dated 08/22/2024 was reviewed and indicated Resident #43 could have skin integrity issues and had issues with vision, both related to diabetes. The care plan did not indicate…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. The findings are: 1. On 11-13-23 at 11:50 am, review of Resident #1's file revealed the resident's last re-admission date was 3-31-23 for CVA (cerebral vascular accident) effects, Chronic Kidney Disease, Hypertension, Schizophrenia, and Rheumatoid Arthritis. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9-23-2023 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS), and documented the resident required extensive assistance of 2 persons with transfers. a. On 11-13-23 at 11:50 am, review of Resident #1's Progress Notes revealed. Note dated 10-15-23 documented Resident #1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. The findings are: 1. On 09/25/23 at 10:46 AM, observed a 1 can of Cream of Chicken soup with a dented rim. The Surveyor asked the Dietary Manager what was done with dented cans. The Dietary Manager stated, If the can is not dented too bad, they use it, if it is too bad, they put it in the bottom shelf and try and return it. 2. On 09/25/23 at 10:48 AM, observed 11 bags of mini marshmallows not dated on a shelf in the pantry. The Surveyor asked the Dietary Manager if food items should be dated when they are received in the kitchen. The Dietary Manager stated, Yes. 3. On 09/25/23 at 10:49 AM, observed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. The findings are: 1. On 09/25/23 at 12:00 PM, observed a CPAP mask resting on Resident #26's bedside dresser. The mask was not in a closed bag or container. a. On 09/25/23 at 2:27 PM, Resident #26 said, Nobody has given me a bag to store my mask in. I put it on and off myself, but no . I do not have a bag to put it in. I did not know. c. On 09/26/23 at 1:56 PM, observed Resident #26's CPAP mask resting on top of the CPAP machine. The mask was not in a closed bag or container. d. On 09/26/23 at 2:22 PM LPN #1 said mask are supposed to be stored in a bag. e. A Physicians Order dated 09/20/23 noted Resident #26 was to use an overnight pulse ox with Bi-Pap for 7 days. 2. On 09/25/23 at 10:59 AM,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings are: 1. On 09/26/23 at 10:20 AM, observed on the 300 Hall an unsupervised medication cart pushed against the wall with medications cards containing medications on top. The Surveyor asked Licensed Practical Nurse (LPN) #1 to identify the medications and count the pills. LPN #1 identified the following medications: i) Pantoprazole (stomach acid reducer) DR (delayed release) 40 milligrams - 1 tablet. ii) Potassium Cl (Chloride) (a potassium supplement) ER (extended release) 10 milliequivalent - 6 tablets. iii) Myrbetriq (overactive bladder treatment) ER 25 milligram - 5 tablets. a. On 09/26/23 at 10:23 AM, LPN #1 said, I did not realize there were still some pills in those. The Pantoprazole DR and Potassium CL ED was out for reorder, and I think the Myrbetriq…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. The findings are: 1. On 09/28/23 at 9:10 AM, the Administrator confirmed she was aware the Infection Preventionist requires a certification and confirmed two people are in training for the Infection Preventionist certification but are not currently certified.