Deficiency Records for Timbercreek Rehab and Healthcare Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Timbercreek Rehab and Healthcare Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-04 | 2024-01-16 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-11-29 | 2023-12-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-17 | 2023-12-01 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-21 | 2023-10-06 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-09-21 | 2023-10-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-21 | 2023-10-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-21 | 2023-10-06 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-09-21 | 2023-10-06 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-09-21 | 2023-10-06 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-09-21 | 2023-10-06 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-09-21 | 2023-10-06 | N |
| Post nurse staffing information every day. | Health | 2023-09-21 | 2023-10-06 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-09-21 | 2023-10-06 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-09-21 | 2023-10-06 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-09-21 | 2023-10-06 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-09-21 | 2023-10-06 | N |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2023-09-21 | 2023-10-06 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-09-21 | 2023-10-06 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-09-21 | 2023-10-06 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-09-21 | 2023-10-06 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-09-25 | 2023-10-06 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-09-25 | 2023-10-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-09-25 | 2023-10-06 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-09-25 | 2023-10-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-09-25 | 2023-10-06 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-09-25 | 2023-10-06 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-09-25 | 2023-10-06 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-08-17 | 2023-09-05 | Y |
| Implement a program that monitors antibiotic use. | Health | 2023-08-17 | 2023-09-05 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-08-17 | 2023-09-05 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-08-17 | 2023-09-01 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-08-17 | 2023-09-01 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-08-17 | 2023-09-01 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-17 | 2023-09-01 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-08-17 | 2023-09-01 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-08-17 | 2023-09-01 | Y |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2023-08-17 | 2023-09-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-08-17 | 2023-09-01 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-03-28 | 2023-04-07 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-28 | 2023-04-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-28 | 2023-04-07 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-03-28 | 2023-04-07 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-01-17 | 2023-01-27 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-01-17 | 2023-01-27 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-01-17 | 2023-01-27 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-01-17 | 2023-01-27 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-01-17 | 2023-01-27 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-01-17 | 2023-01-27 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-06 | 2022-11-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-10-06 | 2022-11-05 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-10-06 | 2022-10-24 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-10-06 | 2022-10-21 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-10-06 | 2022-10-21 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-10-06 | 2022-10-21 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-10-06 | 2022-10-21 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-10-06 | 2022-10-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-10-06 | 2022-10-21 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-10-06 | 2022-10-21 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-10-06 | 2022-10-21 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-05 | 2022-10-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-05 | 2022-10-19 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-10-05 | 2022-10-19 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-06-07 | 2022-06-14 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-09-03 | 2021-09-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-09-03 | 2021-09-24 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-09-03 | 2021-09-24 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-09-03 | 2021-09-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-03 | 2021-09-24 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-09-03 | 2021-09-24 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-09-03 | 2021-09-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-09-03 | 2021-09-24 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-09-03 | 2021-09-24 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-09-03 | 2021-09-23 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-09-03 | 2021-09-23 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2021-09-03 | 2021-09-23 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-09-03 | 2021-09-23 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2021-09-03 | 2021-09-23 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2021-09-03 | 2021-09-23 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2021-09-03 | 2021-09-23 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2021-09-03 | 2021-09-23 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2021-09-03 | 2021-09-23 | N |
| Develop a communication plan. | Fire Safety | 2021-09-03 | 2021-09-23 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-09-03 | 2021-09-23 | N |
| Provide emergency officials' contact information. | Fire Safety | 2021-09-03 | 2021-09-23 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2021-09-03 | 2021-09-23 | N |
| Establish methods for sharing information. | Fire Safety | 2021-09-03 | 2021-09-23 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2021-09-03 | 2021-09-23 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2021-09-03 | 2021-09-23 | N |
| Establish emergency prep training and testing. | Fire Safety | 2021-09-03 | 2021-09-23 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-09-03 | 2021-09-23 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-09-03 | 2021-09-23 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-09-03 | 2021-09-23 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-09-03 | 2021-09-23 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-09-03 | 2021-09-23 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2021-09-03 | 2021-09-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-09-03 | 2021-09-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-09-03 | 2021-09-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-06-29 | 2021-07-22 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-03-17 | 2021-04-05 | Y |
