Deficiency Records for Timbercrest Church of The Brethren Home
Updated as of April 01, 2024
A list of the most recent deficiencies for Timbercrest Church of The Brethren Home. 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? |
|---|---|---|---|---|
| Conduct testing and exercise requirements. | Fire Safety | 2023-09-05 | 2023-10-20 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-09-05 | 2023-10-20 | N |
| Meet other general requirements. | Fire Safety | 2023-09-05 | 2023-10-20 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-09-05 | 2023-10-20 | 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 | 2023-09-05 | 2023-10-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-09-05 | 2023-10-20 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-09-05 | 2023-10-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-09-05 | 2023-10-20 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-09-05 | 2023-10-20 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2023-09-05 | 2023-10-20 | 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 | 2023-08-14 | 2023-09-01 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2022-08-08 | 2022-09-09 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-08-08 | 2022-09-09 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-08-08 | 2022-09-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-08 | 2022-09-09 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-08-08 | 2022-09-09 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-08-08 | 2022-09-09 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-08-08 | 2022-09-09 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-08-08 | 2022-09-09 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-08-08 | 2022-09-09 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-06-27 | 2022-07-17 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-06-27 | 2022-07-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-27 | 2022-07-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-27 | 2022-07-17 | 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 | 2022-06-27 | 2022-07-17 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-06-09 | 2022-06-27 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-14 | 2022-02-05 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-08-04 | 2021-09-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-08-04 | 2021-09-05 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-08-04 | 2021-09-05 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2021-08-04 | 2021-09-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-08-04 | 2021-09-05 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-08-04 | 2021-09-05 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-07-16 | 2021-08-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-16 | 2021-08-15 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-07-16 | 2021-08-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-16 | 2021-08-15 | 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 | 2021-07-16 | 2021-08-15 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-05-24 | 2021-06-03 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-05-24 | 2021-06-03 | Y |
