Timberidge Nursing And Rehabilitation Center

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the facility's only kitchen observed for kitchen sanitation.The facility failed to ensure:- the dish machine was not sanitizing- the ice machine ice chute and air intake vent were not clean- in the reach in cooler chocolate milk pints were out of date - 2 packages of dry pasta were no re-closed after opening- freezer #1 had a package of frozen fried eggs open and not secured closed- the pan rack had 8 pans stacked wet, 1 with food debris present and 1 greasy full size baking sheet- the deep fryer had cornmeal-like debris floating on the surface of the oil, stuck to both fry baskets, and covering the drain tray.- the spice rack had brown sugar and powdered sugar packages opened and not re-sealed.- the 3 compartment sink was not sanitizing and the QA test strips were out of date.These failures could place residents who ate food from the kitchen at risk of foodborne illness. Findings included:During observations, interviews and record reviews…

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 interview and record review, the facility failed to ensure an encoded, accurate, and complete MDS assessment was electronically transmitted to the CMS System within 14 days after completion for 1 of 4 residents (Resident #22) reviewed for encoding/transmitting assessments. The facility failed to transmit a death record assessment for Resident #22 within 14 days of completion. This failure could place residents at risk of not having records completed and submitted in a timely manner as required. Findings include:Record review of a face sheet dated [DATE] indicated Resident #22 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included cirrhosis of the liver (chronic liver damage leading to scarring and liver failure), hepatitis (inflammation of the liver), and hepatomegaly (enlarged liver). Record review of progress notes dated [DATE] indicated Resident #22 expired on the evening of [DATE] while a resident in the facility. Record review of Resident #22's electronic…

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 observations, interviews, and record review, the facility failed to provide the necessary services to maintain personal hygiene for 1 of 12 residents reviewed for ADLs (Residents #1.) The facility did not apply moisturizer on the cracked and dry lips of Resident #1. This failure could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity, and health. The findings were: Review of Resident #1's Electronic Face Sheet dated 07/24/24 revealed she was admitted to the facility on [DATE] with diagnoses including hypertension (high blood pressure), constipation (passing fewer than three stools a week or having a difficult time passing stool), and hypothyroidism (deficiency of thyroid hormones can disrupt such things as heart rate, body temperature, and all aspects of metabolism). Record review of Resident #1's Significant Change MDS dated…

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 observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 2 of 4 (Resident's #6 and #38) reviewed for infection control. 1. CNA B did not change her gloves when going from dirty to clean after performing incontinent care. CNA B did not sanitize or wash her hands after performing incontinent care when she applied Resident #6's clean brief. 2. LVN A did not change her gloves when going from dirty to clean when providing indwelling urinary catheter care. LVN A did not sanitize or wash her hands after performing Resident #38's indwelling urinary catheter care when she changed her gloves. These failures could place residents at risk of exposure to communicable diseases, cross-contamination, and infections. Findings included: 1. Record review of Resident #6's undated face…

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, interviews and record review, 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 kitchen sanitation in that: 1. Hairnets were not worn or were worn unproperly. 2. Food was not labeled or dated. 3. Expired food was not thrown away. These deficient practices could place residents who received meals from the main kitchen at risk for food borne illness. The findings were: During an observation on 05/22/23 at 8:40 a.m., it was observed that hairnets were not worn by [NAME] L while preparing lunch service. Hardboiled eggs were in a one-gallon sized zip lock bag that were not labeled or dated nor had an expiration date stored in the refrigerator. Whole buttermilk was past its expiration date of 05/04/23 stored in the refrigerator. Cabbage stored in a plastic bag inside the refrigerator was past its expiration date of 03/18/23. It was observed that [NAME] L and the Dietary Manager were not properly wearing their hairnets as they had their hair coming out 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 observation, interview, and record review, the facility failed to provide the necessary services to maintain personal hygiene for 2 of 15 residents reviewed for ADLs (Residents #27 and Resident #1) The facility did not shave Resident #27's facial hair. The facility did not trim Resident #1's long nails. This failure could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health. The findings are: 1.Review of Resident #27's undated electronic face sheet revealed she was admitted to the facility on [DATE] with diagnoses of: Need for assistance with personal care Urinary tract infection, Alzheimer's disease with late onset, Other seasonal allergic rhinitis, Hyperlipidemia (too many lipids (fats) in your blood), Pectoris (chest pain or discomfort due to coronary heart disease) Essential (primary) hypertension, Gastro-esophageal…

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 that residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise when the facility failed to implement significant interventions for three (Residents #16, #28, and #39) of nineteen residents reviewed for significant weight loss. There were residents with significant weight variances (both for weight loss and weight gains) that were not identified until after surveyor intervention. This system failure allowed significant weight loss and weight gains to go undetected and untreated. 1. Resident #16 had an unexplained fifteen-pound weight loss (8.57%) in 11 days from 05/12/2023 to 05/23/2023 that was not identified until after surveyor entrance on 05/22/2023. 2. Resident #28 had an unexplained twenty-four-pound weight gain…

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 that respiratory care was provided consistent with professional standards of practice for 1 of 15 residents reviewed for respiratory care. (Resident #205). The facility failed to ensure Resident #205 received continuous oxygen per physician's orders. These failures could place residents at an increased risk of respiratory complications. Findings included: Record review of Resident #205's face sheet dated 5/25/23 revealed she was a [AGE] year-old female, who admitted to the facility on [DATE]. Resident #205 had diagnoses of chronic obstructive pulmonary disease (lung disease that damages lung tissue and causes difficulty or discomfort in breathing), end stage renal disease (permanent cease of function of the kidneys), dependence on oxygen, and heart failure. Record review of Resident #205's MDS revealed it had not been completed. Record review of Resident #205's Care Plan dated 5/24/23 revealed Resident #205 was receiving oxygen…

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 maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 15 residents (Residents #26 and Resident #35) reviewed for infection control practices. CNA O failed to remove her dirty gloves and perform hand hygiene (general term referring to any action of hand cleansing) before touching multiple clean items in the Resident's environment during incontinent care for Resident #26. CNA P failed to remove her dirty gloves and perform hand hygiene before touching clean items in the Resident's environment during incontinent care for Resident #35. These failures could place residents at risk for cross contamination and infections. Findings included: 1.Record review of the face sheet dated 5/23/23 for Resident #26 indicated she was [AGE] years old and admitted to the facility on [DATE] with…

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 follow established policy regarding smoking areas, and smoking safety for 1 of 1 smoking area reviewed. The facility failed to keep trash out of the red metal trash cans designated for cigarette butts in the smoking area and failed to implement their smoking safety policy. This failure could place residents who smoke at risk of physical harm and lead to an unsafe smoking environment. The Findings Included: Record review of List of smokers undated revealed there were 2 residents listed as smokers. During an observation on 05/23/23 at 09:45 AM revealed in the smoking area 2 red metal trashcans with automatic closing lids. Observed in the trashcan on the right side of the smoking area red trashcan #1 was filled to the top with multiple empty cigarette packs, napkins, straws, chip bags and soda cans. Observed on the left of the smoking area in red trashcan #2 was 3/4 of the way full of cigarette butts with a Styrofoam cup on top. Observed all the smoking area with no fire extinguisher available. On 05/23/23 at…

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.