Deficiency Records for Timbercreek Rehab and Healthcare Center
Updated as of October 01, 2021
This is not the most recent data for Timbercreek Rehab and Healthcare Center. For the most recent information, click here.
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? |
|---|---|---|---|---|
| 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 |
| Respond appropriately to all alleged violations. | Health | 2021-09-03 | 2021-09-23 | 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 | 2021-09-23 | 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 | 2021-09-23 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-09-03 | 2021-09-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-03 | 2021-09-23 | 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 | 2021-09-23 | 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 | 2021-09-23 | N |
| Provide and implement an infection prevention and control program. | Health | 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 |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2020-12-30 | 2021-02-01 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-01-14 | 2021-01-14 | Y |
| Report COVID19 data to residents and families. | Health | 2020-09-10 | 2020-09-30 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2020-09-02 | 2020-09-16 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2020-09-02 | 2020-09-16 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2020-09-02 | 2020-09-16 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2020-08-14 | 2020-09-10 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2020-08-14 | 2020-09-10 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-07-28 | 2020-08-24 | 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 | 2020-07-28 | 2020-08-24 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-07-28 | 2020-08-24 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-02-13 | 2020-03-11 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-02-13 | 2020-03-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-02-03 | 2020-02-18 | Y |
| Keep all essential equipment working safely. | Health | 2020-02-03 | 2020-02-18 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2020-01-29 | 2020-02-14 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-01-29 | 2020-02-14 | Y |
| Respond appropriately to all alleged violations. | Health | 2020-01-29 | 2020-02-14 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-01-29 | 2020-02-14 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-11-27 | 2019-12-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-11-27 | 2019-12-12 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-10-03 | 2019-12-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-03 | 2019-11-01 | N |
| Install proper backup exit lighting. | Fire Safety | 2019-10-03 | 2019-10-25 | 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 | 2019-10-03 | 2019-10-25 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-10-03 | 2019-10-25 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-10-03 | 2019-10-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-10-03 | 2019-10-25 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-10-03 | 2019-10-25 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-10-03 | 2019-10-20 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2019-10-03 | 2019-10-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-09-27 | 2019-10-18 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-09-27 | 2019-10-18 | 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 | 2019-09-27 | 2019-10-18 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-09-27 | 2019-10-18 | 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 | 2019-09-27 | 2019-10-18 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-09-27 | 2019-10-18 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-09-27 | 2019-10-18 | Y |
| Provide and implement an infection prevention and control program. | Health | 2019-09-27 | 2019-10-18 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-07-12 | 2019-08-01 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-07-12 | 2019-08-01 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2019-07-12 | 2019-08-01 | Y |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2019-07-12 | 2019-08-01 | Y |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2019-06-19 | 2019-07-10 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-06-19 | 2019-07-10 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2019-05-30 | 2019-06-21 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-05-30 | 2019-06-21 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-04-11 | 2019-04-24 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2019-03-04 | 2019-03-18 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-03-04 | 2019-03-18 | Y |
| Provide and implement an infection prevention and control program. | Health | 2018-10-25 | 2018-11-13 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2018-08-16 | 2018-11-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-08-16 | 2018-11-13 | 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 | 2018-08-16 | 2018-11-13 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2018-08-16 | 2018-11-13 | N |
| 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 | 2018-08-16 | 2018-10-25 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-08-16 | 2018-10-25 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2018-08-16 | 2018-10-25 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-08-16 | 2018-10-25 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2018-08-16 | 2018-10-25 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2018-08-16 | 2018-10-25 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-08-16 | 2018-10-25 | N |
| 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 | 2018-08-16 | 2018-10-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-08-16 | 2018-10-25 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2018-08-16 | 2018-10-25 | 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 | 2018-08-16 | 2018-10-25 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2018-08-16 | 2018-10-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-08-16 | 2018-10-25 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-08-16 | 2018-10-25 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2018-08-23 | 2018-09-07 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-08-23 | 2018-09-07 | N |
