Timber Springs Rehab and Retirement

Based on record review and interview, the facility failed to refer a resident with a newly diagnosed mental disorder to the appropriate state-designated authority for Level II PASARR evaluation and determination for 1 ( #5) of 2 residents reviewed for PASARR. Findings:A review of Resident #5's medical record revealed an admission date of 04/27/2015 with a diagnosis of Generalized Anxiety Disorder on 11/05/2020. Further review revealed Resident #5 was not referred to the appropriate state-designated authority for a Level II PASARR evaluation.During an interview on 03/25/2026 at 2:00 p.m., S3 Social Services acknowledged a Level II PASARR evaluation was not completed for Resident #5 after new diagnosis of generalized anxiety disorder.During an interview on 03/25/2026 at 2:30 p.m., S3 Corporate Nurse confirmed a Level II PASARR was not completed after a new diagnosis of generalized anxiety disorder for Resident #5 and should have been.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to revise the care plan to reflect changes of a resident's falls for 1 (#50) of 3 residents reviewed for accidents. Findings:Review of Resident #50's medical record revealed a readmission date of 06/03/2025 with the following diagnoses which included but not limited to: Bilateral primary osteoarthritis of knee, muscle weakness, muscle wasting and atrophy multiple sites, abnormalities of gait and mobility, dementia, and unsteadiness on feet.Review of Resident #50's Annual MDS assessment dated [DATE] revealed a BIMS score of 06 indicating severely impaired cognition.Review of the facility's Incident Log revealed Resident #50 had falls on 02/18/2026 and 02/21/2026.Review of the medical record revealed Resident #50 was care planned for risk of falls with the most current intervention date of 01/07/2026. Further review failed to reveal the care plan was revised to reflect the falls on 02/18/2026 and 02/21/2026.During an interview on 03/25/2026 at 1:13 p.m. S1…

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 person-centered care plan was developed for 1 (#50) of 26 sampled residents. The facility failed to ensure an activities care plan had been developed with interventions for Resident #50. Findings: Review of Resident #50's medical record revealed an initial admission date of 09/02/2024 with diagnoses that included, in part, anxiety disorder, essential (primary) hypertension, and depression. Review of Resident #50's 12/02/2024 Quarterly MDS (Minimum Data Set) revealed Resident #50 had a BIMS (Brief Interview Mental Status) score of 15, which indicated Resident #50 was cognitively intact. Review of Resident #50's 09/09/2024 admission MDS, Section F-Preferences for Customary Routine and Activities revealed, in part: -It was very important to listen to music Resident #50 likes. -It was somewhat important for Resident #50 to have books, newspapers, and magazines to read. -It was somewhat important for Resident #50 to go outside and get fresh air when the weather is good. Review of Resident #50's care plan…

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 record reviews, observations and interviews, the facility failed to ensure correct use and maintenance of bed rails for 7 (#1, #4, #24, #25, #42, #48, #49) of 7 (#1, #4, #24, #25, #42, #48, #49) residents reviewed for the use of bed rails. The facility failed to ensure: 1. Residents #1, #4, #24, #25, #42, #48, and #49 were assessed for the risk of entrapment prior to the use of bed rails, less restrictive approaches were attempted prior to the use of bed rails, ongoing assessments for the risk of entrapment were conducted after bed rail installation, and residents were care planned with specific interventions for the use of bed rails, and; 2. Bed rails were securely attached to the bed for resident # 4, and #25. Findings: Review of the facility's Bed Rails policy (undated) revealed in part: Policy Explanation and Compliance Guidelines: 1. The facility will use appropriate alternatives prior to installing a side or bed rail. 2. If a bed or side rail is used, the facility must ensure correct installation,…

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 record review and interviews the facility failed to ensure MDS (Minimum Data Set) assessments were completed and transmitted within the specified time frames for 3 (#1, #5, #12) of 26 sampled residents. The facility failed to ensure: 1. An annual assessment had been completed for Resident #1. 2. A discharge assessment had been completed for Resident #5. 3. An entry assessment had been transmitted for Resident #12. Findings: 1. Review of Resident #1's medical record revealed an admission date of 12/12/2023 with diagnoses that included, in part, cerebral infarction unspecified, metabolic encephalopathy, acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure, schizophreniform disorder, bipolar disorder, generalized anxiety disorder, and depression. Review of Resident #1's medical record revealed the following Accepted MDS assessments, in part: 12/19/2023 Admission/Medicare-5 day MDS 12/12/2023 Entry MDS Further review failed to reveal an annual MDS assessment had been…

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, observation, and interviews, the facility failed to ensure a resident received proper treatment to maintain and/or improve hearing for 1 (#12) of 1 (#12) residents reviewed for communication and sensory problems. Findings: Review of Resident #12's record revealed an inital admit date of 03/30/2022 and diagnoses including: unspecified abnormalities of gait and mobility; unspecified glaucoma; and impacted cerumen (earwax), unspecified ear. Review of Resident #12's physician order dated 11/04/2024 revealed an order for a referral by the ENT (Ear, Nose, and Throat doctor) for an audiogram (a hearing test). Review of Resident #12's care plan failed to reveal a care plan for hearing impairment. Review of Resident #12's medical record failed to reveal an appointment was scheduled for an audiogram. During an interview on 01/13/2025 at 02:12 p.m. Resident #12 reported she had increased hearing loss. Resident #12 further reported she was supposed to see a doctor about her hearing loss, but did not believe an appointment was ever made. Resident #12 reported in Novembere…

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, and record review, the facility failed to ensure a resident's environment remained free of accident hazards. The facility failed to ensure a resident's TV (television) was positioned in a secure manner for 1 (#12) of 4 (#4, #12, #23, #25) residents reviewed for accidents. Findings: Review of Resident #12's record revealed an admit date of 03/30/2022 and diagnoses including: Unspecified abnormalities of gait and mobility, muscle weakness, unspecified glaucoma, repeated falls and lack of coordination. Review of Resident #12's Quarterly MDS (Minimum Data Set) dated 12/24/2024 revealed the resident had severe impaired vision. An observation on 01/13/2025 at 1:56 p.m. revealed Resident #12's TV was positioned in a manner of which not all 4 legs were positioned on the nightstand. An observation on 01/15/2025 at 10:55 a.m. with S6 CNA (Certified Nursing Assistant) revealed Resident #12's TV was positioned on the nightstand with one of the 4 legs hanging off of the nightstand and another leg only halfway on the nightstand. During an interview on 01/15/2025…

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 record reviews and interviews, the facility failed to ensure documentation of resident rights regarding Advance Directives for 7 (#3, #8, #23, #24, #27, #45, #301) of 11 (#3, #8, #14, #20, #23, #24, #27, #40, #41, #45, #301) residents reviewed for Advanced directives by failing to: 1) Ensure each residents or resident's representative was provided with written information concerning advance directives and/or the option to formulate an advance directive. for Resident #3, #8, #23, #24, #27, and #301. 2) Ensure a copy of the resident's Advance Directives was in the medical record and accessible to all staff for Resident #45. Findings: 1) Review of Resident #3's medical record revealed Resident #3 was admitted to the facility on [DATE]. Further review of Resident #3's medical record failed to reveal resident or resident's representative was provided with written information concerning advance directives and/or the option to formulate an advance directive. Review of Resident #8's medical record revealed…

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 baseline care plan was completed within 48 hours of admission for 1 (#301) of 15 (#3, #8, #10, #14, #20, #23, #24, #27, #29, #40, #41, #45, #49, #50, #301) residents reviewed for care plans Findings: Review of record revealed Resident #301 had an admission date of 11/28/2023. Further review of Resident #301's clinical record failed to reveal a baseline care plan had been completed within 48 hours of admission date. During an interview on 12/05/2023 at 2:00 p.m. S3 Business Office Manager/Human Resources/Minimum Data Sets reported a baseline care plan for resident #301 had not been completed and should have been completed within 48 hours of admission date.

Based on record review, observation, and interview the provider failed to ensure an oxygen concentrator filter was placed appropriately in the intake port of the concentrator for 1 (Resident #29) of 1 (Resident #29) residents reviewed for respiratory care. Record review of Resident # 29's physician orders for December 2023 revealed the following, in part: Oxygen at two liters per minute per nasal cannula at night time. (09/18/2023) Change the oxygen cannula, sterile water, and tubing every seven days and as needed. Wash filters from oxygen concentrators every seven days with soap and water. Rinse and squeeze dry. (09/18/2023) Record review of Resident # 29's comprehensive care plans revealed the following, in part: Description- I have history of shortness of breath. I get oxygen saturations checked each shift. Interventions- Administer oxygen per physician order; assess lung sounds as needed; monitor oxygen saturations per facility policy, position upright when possible . Record review of Resident # 29's MDS (minimum data set) revealed the following, in part: Section C showed a BIMS…

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 provider failed to ensure a resident received appropriate monitoring when receiving antidepressant medications for 1 (Resident #20) of 5 (Residents #3, #20, #24, #29, #301) residents reviewed for unnecessary medications, psychotrpic medications, and medication regimen review. Record review of Resident #20's diagnosis revealed the following, in part: Heart failure Constipation Depressive episodes Record review of Resident #20's physician orders for December 2023 revealed the following, in part: Duloxetine 30mg (milligrams) by mouth every morning with start date of 10/01/2023. Fluoxetine 40mg by mouth every morning with start date of 10/01/2023. Record review of Resident #20's comprehensive care plans revealed the following, in part: Descripton- Antidepressant medication use: At risk for side effects. I have diagnosis of depression. Interventions- monitor patterns of target behaviors, assess for adverse side effects and report, monitor of signs of extrapyramidal symptoms and document . Record review of Resident #20's MDS (minimum data set)…

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 and record reviews, the facility failed to protect the residents' right to be free from verbal abuse by staff. The facility failed to ensure residents were free from verbal abuse by staff for 1 (#1) of 6 (#1, #2, #3, #4, #5, #6) sampled residents. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be Past Noncompliance. Findings: Review of the facility's Abuse Prevention Program (revised December 2016) revealed in part: our residents have the right to be free from abuse .this includes but is not limited to verbal abuse .as part of the resident abuse prevention, the administration will protect our residents from abuse by anyone including, but not necessarily limited to facility staff . Review of the facility's Self-Reported Incident Report initiated 8/13/2023 revealed in part: Victim: Resident #1 Accused: S4, Cook Allegation: Verbal Abuse-substantiated Employee S4 [NAME] was suspended immediately pending…

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.