Inspection Results » Timbercreek Rehab & Healthcare Center

Health Inspection on August 16, 2018 ^[1]

1. Isolated: Actual harm that is not immediate jeopardy

   • 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. (Corrected 2018-10-25)
   • Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (Corrected 2018-10-25)

2. Widespread: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Implement a program that monitors antibiotic use. (Corrected 2018-10-25)

3. Pattern: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (Corrected 2018-11-13)
   • Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (Corrected 2018-11-13)

4. Isolated: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Provide appropriate pressure ulcer care and prevent new ulcers from developing. (Corrected 2018-10-25)
   • 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 ne (Corrected 2018-10-25)
   • Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. (Corrected 2018-10-25)
   • Encode each residentÂ’s assessment data and transmit these data to the State within 7 days of assessment. (Corrected 2018-10-25)
   • Notify the resident or the residentÂ’s representative in writing how long the nursing home will hold the residentÂ’s bed in cases of transfer to a hospital or therapeutic leave. (Corrected 2018-10-25)
   • Provide and implement an infection prevention and control program. (Corrected 2018-10-25)
   • Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted (Corrected 2018-10-25)
   • Provide care by qualified persons according to each resident's written plan of care. (Corrected 2018-11-13)
   • Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. (Corrected 2018-10-25)
   • Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. (Corrected 2018-10-25)
   • Plan the resident's discharge to meet the resident's goals and needs. (Corrected 2018-10-25)
   • Ensure each resident receives an accurate assessment. (Corrected 2018-11-13)

5. Widespread: No actual harm with potential for minimal harm

   • Have the Quality Assessment and Assurance group have the required members and meet at least quarterly (Corrected 2018-10-25)