Treyburn Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews with staff and resident, the facility failed to get the resident out of bed for 3 consecutive days which caused the resident to feel frustrated because he was stuck in bed. The deficient practice affected 1 of 2 residents reviewed for choices (Resident #100).Findings included:Resident #100 was admitted to the facility on [DATE] with diagnoses of diabetes and neuropathy.The quarterly Minimum Data Set, dated [DATE] for Resident #100 documented he had an intact cognition. The resident was dependent for all activities of daily living including transfers.The care plan last updated on 5/14/26 with his assessment documented Resident #100 required assistance with all his activities of daily living. Transfer was by mechanical lift by 2 staff. On 6/23/2026 at 10:18 am Resident #100 was observed and interviewed. The Resident stated he was not assisted out of bed on 6/19/26, 6/20/26, and 6/21/26 and indicated he asked Nursing Assistant (NA) #3 to get him up as usual every…

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, staff, Responsible Party, Cancer Clinic Supervisor, Physician, and Oncologist interviews the facility failed to ensure that Resident #93 with metastatic prostate cancer received the medically necessary recommended six-month oncology follow-up appointment for 1 of 1 sampled resident reviewed for medically necessary oncology follow-up services.The findings included:Resident #93 was admitted to the facility on [DATE] with diagnoses that included communication deficit, dementia, and metastatic prostate cancer involving the lymph nodes.The quarterly Minimum Data Assessment (MDS) assessment dated [DATE] revealed Resident #93 was severely cognitively impaired and had a diagnosis of cancer.Review of the cancer clinic visit dated 6/13/25 revealed Resident #93's documented diagnoses were prostate cancer with intrapelvic lymph node involvement. The recommendations included Resident #93's continuation of maintenance injection therapy and follow-up every six months to monitor the resident's condition,…

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 staff interviews, the facility failed to follow a pharmacy recommendation to discontinue a medication for 1 of 5 residents reviewed for unnecessary medication (Resident #100). Findings included:Resident #100 was admitted to the facility on [DATE] with diagnoses of diabetes and neuropathy.The quarterly Minimum Data Set, dated [DATE] for Resident #100 documented he had an intact cognition. The monthly medication pharmacy review dated 5/21/26 for Resident #100 revealed a documented recommendation to discontinue the Zinc Sulfate 220 milligrams each day. The pharmacist documented that the resident's skin was intact, and the zinc was no longer needed. The recommendation was signed and approved by the Nurse Practitioner (NP) dated 6/1/26.A review of Resident #100's medication orders revealed there was not an order to discontinue Zinc Sulfate 220 milligrams each day. A review of Resident #100's Medication Administration Record (MAR) revealed the resident had documented nursing initials for…

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 with staff and residents, the facility failed to protect the right of a resident (Resident # 2) to be free of abuse when another resident (Resident # 3), who was experiencing an increase in agitated behaviors while diagnosed with a urinary tract infection, hit Resident # 2 in the head with a reacher. (A reacher is a metal assistive device used to grab items that are out of reach). This was for one of three residents reviewed for abuse and neglect. The findings included: Record review revealed Resident # 3 resided at the facility from 10/29/19 until his final discharge on [DATE]. Although not inclusive of all diagnoses, Resident # 3 had a history of hip fracture, vascular dementia, and insomnia. Review of Resident # 3's 10/9/24 quarterly Minimum Data Set (MDS) assessment revealed Resident # 3 was moderately cognitively impaired. He was not assessed to have behavioral problems during the assessment period. The resident was coded as using a wheelchair for mobility. On 11/19/24…

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 staff interviews, the facility failed to maintain a complete and accurate medical record by not obtaining a Physician order to hold Intravenous fluids, incomplete oral intake records and inaccurate medication administration times on 5/28/24 that did not match the times Nurse #8 reported administering the medications for Resident #6. This was for 1 of 12 residents reviewed for complete and accurate medical records. The findings included: Based on record review and staff interviews, the facility failed to maintain a complete and accurate medical record by not obtaining a Physician order to hold Intravenous fluids, incomplete oral intake records and inaccurate medication administration times on 5/28/24 that did not match the times Nurse #8 reported administering the medications for Resident #6. This was for of 1 of 12 residents reviewed for complete and accurate medical records. The findings included: 1a. Resident # 6 was admitted to the facility on [DATE]. Nurse # 1 documented a nursing…

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, record review and interviews the facility failed to discard expired food from the walk-in refrigerator, label and date thickened liquids in reach-in refrigerator and maintain the kitchen equipment and bin holding scoops and ladles clean. The facility failed to label, and date opened dietary supplements and thickened liquids, and discard expired food from 2 of 2 nourishment refrigerator (Nourishment refrigerator in Kitchenette #2 and Kitchenette #1). These practices had the potential to affect food served to the residents. Finding included: 1. An observation of the walk-in refrigerator on 2/26/24 at 9:17 AM revealed an aluminum pan containing multiple individual cups of yogurt and nutritional supplements on ice. Observation revealed ten, 4-ounce cups of yogurt with an expiration date 2/25/24. During an interview with the Dietary Manager on 2/26/24 at 9:20 AM, she indicated the aluminum pan contained yogurt and supplements for lunch meal. She stated the expired dates for the yogurt cups were overlooked. She indicated the expired yogurt cups would be discarded.…

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, record reviews, resident and staff interviews, the facility's Quality's Assessment and Performance Improvement (QAPI) Committee failed to maintain implemented procedures and monitor the interventions that were put in place following the annual recertification and complaint survey conducted on 3/30/23. This was for recited deficiencies in the areas of Food Procurement/Prepare/serve-Sanitary (F812) and Care Plan Timing and Revision(F657). These deficiencies were recited during an annual recertification and complaint survey conducted on 2/29/24. The continued failure of the facility during two federal surveys of record showed a pattern of the facility's inability to sustain an effective QAPI program. Findings included: This tag is cross-referenced to: F812: Based on observations, record review and interviews the facility failed to discard expired food from the walk-in refrigerator, label and date thickened liquids in reach-in refrigerator and failed to maintain the kitchen equipment clean. The facility failed to label, and date opened dietary supplements and…

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 records review, and staff interviews, the facility failed to have Advance Directives (code status) in the residents' records for 1 of 1 resident reviewed for Advance Directives (Resident #41). Findings included: Resident #41 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #41 was assessed as severely cognitively impaired. Resident #41's comprehensive care plan dated 1/4/24 did not contain information regarding code status or Advance Directives. At the time of physician's orders review on 2/26/24, there was no active order for code status in Resident #41's medical record in neither the Electronic Health Record (EHR) nor hard copy chart. An interview was conducted with Nurse #1 on 2/27/24 at 12:15 PM. Nurse #1 stated the code status was usually displayed in EHR, next to the resident's picture, in the physician's orders or hard copy chart for Advance Directives. Nurse #1 confirmed that there was no documentation to indicate the code status for…

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, resident, and staff interviews, the facility failed to complete a thorough investigation for an allegation of physical abuse for 1 of 3 residents (Resident # 68) investigated for abuse. The findings included: Review of the abuse neglect policy dated 1/3/24, read in part: revealed the facility protocol included an investigation checklist which included a review of the staff schedule, interview(s) of employees directly involved and witness(es) who observed or had knowledge of the alleged incident or injury and complete statements of the event, interview the resident, other residents, visitors, vendors, and complete witness(es) statements of the event. Resident # 68 was admitted to the facility on [DATE]. The quarterly Minimum Data Set(MDS) dated [DATE], revealed Resident #68's cognition was intact. The facility 24- hour incident report dated 10/3/23 at 11:00 AM, revealed the facility was made aware by Resident #68 that Nurse Aide #2 had pulled her hair and stuck a finger in her ear. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff interview the facility failed to conduct a baseline care plan within 72 hours of admission for 2 of 2 residents reviewed for base line care plan. (Resident #91 and Resident #252). Findings included: 1. Resident #91 was admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #91 was admitted on [DATE]. The resident was assessed as cognitively intact. Review of the discharge return anticipated MDS dated [DATE] revealed the resident was discharged to hospital. The resident was readmitted to the facility on [DATE]. Review of the Social Worker (SW) note dated 2/26/24 indicated the interdisciplinary team completed a 72-hour meeting for readmission. The code status and resident discharge plan to return home were discussed. During an interview on 2/26/24 at 10:42 AM, Resident #91 stated she does not recollect having a base line care plan meeting and a summary of baseline care plan provided to her. Resident further…

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, resident and staff interviews the facility failed to involve residents and/or resident's representatives in the care planning process for 1 of 1 sampled resident reviewed for care plan participation (Residents # 41). The findings included: Resident #41 was readmitted on [DATE] with diagnoses in part, end stage renal disease, dependence on renal dialysis, and dementia. A record review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #41 was assessed as severely cognitively impaired and was dependent on staff for most of the activity of daily living. Review of the resident's comprehensive care plan revealed it was reviewed by staff on 1/4/24 but there was no indication that the resident and/or resident's representative participated in the care plan meeting or in the development of Resident #41's plan of care. During an interview on 2/26/24 at 12:31 PM, Resident #41 indicated he or his family had not participated in his care plan meeting and did not receive…

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, resident interview, staff interview, Psychiatric Nurse Practitioner, and Psychologist interview the facility failed to assure the providers of psychiatric services were aware of altercations and behaviors for residents for whom the psychiatric providers were treating. This was for three (Residents # 5, # 6, an #8) of three residents reviewed for behavioral problems. The findings included. 1. Review of Resident # 5's record revealed Resident # 5 was admitted to the facility on [DATE]. The resident had a diagnosis of depression and a diagnosis of cognitive social or emotional deficit following a stroke. Resident # 5's annual Minimum Data Set Assessment (MDS), dated [DATE], coded Resident # 5 as cognitively intact and as independent in his locomotion within the facility. Resident # 5 was not coded to have behavior problems during the MDS assessment period. Resident # 5's care plan noted Resident # 5 had behaviors related to inappropriate sexual advances and sexually inappropriate language…

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, resident interview, and staff interview the facility failed to implement their abuse policy to 1) assure an abuse allegation was reported to facility administration immediately in order that administration take further actions per their policy and 2) to assure the investigation was thorough enough to identify and talk with a witness who had been present. This was for one (Resident # 6) of four residents reviewed for abuse. The findings included: The facility's abuse policy, last revised on 8/30/2022, included the following information. The center will investigate any alleged abuse/neglect or misappropriation of resident property in accordance with state or federal law. The center will report such allegations to the state, as per state/federal regulation. The center will report immediately but no later than 2 hours after forming the suspicion if the events that cause the allegation involve abuse or result in serious bodily injury. Resident # 6 was admitted to the facility on [DATE].…

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.