Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Timberland Ridge Nursing & Rehabilitation during CMS and state inspections, most recent first.
Surveyors found that medications were not securely stored or properly administered. An LPN left an unlocked medication cart unattended in a hallway with multiple labeled medication cups containing pills for several residents, having preset doses in advance rather than preparing and administering them one resident at a time. On the memory care unit, an LPN left a cup with nine medications on a bedside table for a severely cognitively impaired resident to take without supervision, despite the DON’s statement that no residents were authorized to self-administer and that staff were required to remain with residents until medications were taken.
Two cognitively intact, fully incontinent residents who depended on staff for toileting hygiene reported and were observed to experience long delays in incontinence care, including remaining in urine and feces for extended periods. Staff CNAs described checking and changing residents only three to four times in a 12‑hour shift and stated they were not allowed to perform patient care, including changing briefs, during meal service, causing residents to wait through mealtimes. One resident was found with a saturated brief, deep redness of the peri area and buttocks, and pain during cleansing, while another was observed saturated with stool and urine, with redness on the buttocks and thighs, after her call light had been on and her request to be changed was disputed by a CNA. An RN confirmed CNAs were occupied feeding residents, and the DON later stated residents were supposed to be checked and changed every two hours and as needed and that staff were allowed to change residents during meals.
A resident with severe cognitive impairment and a history of pressure ulcers developed extensive skin breakdown, including open wounds and bleeding, due to the facility's failure to consistently perform and document required skin assessments and interventions. Staff did not effectively communicate or report changes in the resident's skin condition, and a malfunctioning low air loss mattress was not promptly addressed, leading to delayed identification and treatment of skin impairments.
A resident at risk for falls, requiring substantial assistance, was not provided with care planned interventions during a transfer using a sit-to-stand lift, resulting in a fall. The CNA did not ensure proper hand placement or secure the safety belt, and the resident's concerns were ignored. After the incident, vital signs and pain assessments were not completed, and documentation was lacking, contrary to facility policy.
A resident with significant care needs was found wearing two saturated incontinence briefs and lying on a wet blanket, with redness noted on the skin. A CNA provided care but failed to follow infection control protocols, including handling soiled items without a plastic bag and touching clean surfaces with soiled gloves. The DON confirmed these lapses and that the use of two briefs was inappropriate.
A resident with diabetes and obesity did not receive a scheduled dose of Zepbound because the medication was not available at the facility when needed. The delay occurred due to insurance prior authorization issues, requiring administrative approval before the pharmacy could dispense the medication. There was a lack of clarity among staff regarding responsibility for ensuring the medication was available for timely administration.
Three medication errors were observed, resulting in a 12% error rate. Errors included an LPN administering insulin without priming the pen as required, and two residents missing scheduled doses of inhaled and topical medications because the medications were not available and needed to be reordered from the pharmacy. These deficiencies were confirmed through observation, record review, and staff interviews.
A resident with Parkinson's Disease and anxiety did not receive prescribed alprazolam for anxiety because the medication order was not processed and the pharmacy never received a valid prescription. Despite multiple attempts by the pharmacy to contact the prescriber and observable signs of anxiety in the resident, the medication was not administered due to communication failures among staff and unclear on-call physician coverage.
A resident with moderate cognitive impairment and multiple chronic conditions experienced significant unplanned weight loss and dehydration due to the facility's failure to monitor weight, record fluid intake, and implement timely interventions for decreased meal intake. Despite care plan requirements for assistance and monitoring, the resident did not consistently receive needed support, leading to hospitalization for dehydration.
A resident with multiple complex medical conditions developed a vascular wound on the left calf, but wound care was not initiated or ordered for three days after identification. During this period, no wound treatments were documented, and the resident later required hospital transfer due to acute medical issues. Facility staff confirmed the lack of timely wound care, which was inconsistent with facility policy.
A resident with severe cognitive impairment and multiple mobility issues was admitted with several pressure ulcers and subsequently developed additional blisters while in the facility. For three days, there were no physician orders or wound care provided for the resident's sacrum, right ankle, or left ankle wounds, as confirmed by record review and staff interview.
A resident with multiple medical conditions was not provided timely podiatry care due to a delay in obtaining consent for auxiliary services and a lack of awareness among staff. The resident was observed with long, thickened, yellow toenails, and staff interviews confirmed there was no specific policy for podiatry services, resulting in the resident missing needed foot care.
Unsanitary dumpster area. During observation, significant debris, including gloves, cardboard, and empty medication packaging, was found on the ground around the dumpsters. The DM confirmed the findings and stated that maintenance was responsible for keeping the area clean. The issue had the potential to affect all residents in the facility.
The facility failed to ensure the required QAA committee members participated at least quarterly. Review of QAPI sign-in sheets showed no evidence that the IP attended multiple QAPI meetings, even though the QAPI Plan listed the IP as a committee member. The Administrator confirmed the IP had not been attending meetings and said the IP, who was also the Receptionist, provided a report to the DON for presentation at QAPI meetings. The IP also confirmed she had not been attending QAPI meetings.
Unsafe smoking practices were observed when two residents smoked in the designated area while a BOM supervised, and a DT was later seen smoking next to the facility exit door, talking on the phone, and flicking ashes. Four cigarette butts were found in the smoking area, and there was no approved cigarette disposal near the door. The facility policy required smoking only in designated areas with noncombustible ashtrays placed away from exits and common spaces.
A resident with impaired cognition and diagnoses including dysphagia, HTN, anxiety, adult failure to thrive, and depression had no smoking care plan despite a smoking assessment and facility policy requiring supervision while smoking. During observation, the BOM lit the resident’s cigarette while the resident held it independently and asked the BOM to dispose of the butt; the DON verified there was no smoking care plan.
A resident with dementia and a history of falls experienced a delay in receiving appropriate care after a fall resulting in a fractured femur. Despite a STAT x-ray order, the x-ray was conducted 17 hours later, delaying the diagnosis and transfer to the hospital. The facility's policy for timely response to changes in condition was not followed.
A resident with SIADH did not receive a physician-ordered urea sodium oral packet due to the medication being consistently unavailable from the pharmacy. Despite multiple notes indicating the medication was on order or out of stock, there was no documentation of the physician being informed. Interviews confirmed the resident never received the treatment, highlighting a failure in medication administration policy adherence.
Unsecured Medications and Improper Self-Administration Practices
Penalty
Summary
The deficiency involves the facility’s failure to securely store and properly administer medications in accordance with professional standards and facility policy. During observation on the west hall, an unlocked medication cart was found unattended with eight medication cups containing pills on top of the cart, each cup labeled with letters corresponding to resident names. LPN #300 acknowledged she had preset 11:00 A.M. medications for multiple residents, written their names on the cups, and left the cart and medications unsupervised in the hallway while she was in a resident’s room. She confirmed the specific number of pills preset for each identified resident. The DON later stated that nurses should not preset medications and that medications were to be prepared and administered at the same time, one resident at a time. A second deficiency was identified on the memory care unit involving a resident with dementia who was assessed as severely cognitively impaired on a recent MDS and resided on the Memory Care Unit. Observation revealed this resident lying in bed with the door open and a bedside table in front of her, on which there was a medication cup containing nine medications of various pill sizes and capsules, with no staff present nearby. LPN #302 confirmed she had completed her medication pass and had left the medications in the resident’s room for the resident to self-administer, stating the resident preferred not to be supervised when taking pills. The DON later confirmed that no residents in the facility were authorized to self-administer medications and that this resident, given her severe cognitive impairment, would not be appropriate for self-administration, and that nursing staff were required to remain with residents until all medications were taken.
Failure to Provide Timely Incontinence Care Due to Meal-Time Restrictions and Inadequate Rounding
Penalty
Summary
The deficiency involves the facility’s failure to provide timely toileting hygiene and incontinence care to residents who were dependent on staff, resulting in residents remaining in urine and feces for extended periods. One resident, admitted with a fracture of the right femur, muscle weakness, and a need for assistance with personal care, was documented as cognitively intact, frequently incontinent of bowel and bladder, and dependent on staff for toileting hygiene. Her care plan identified complete incontinence with an intervention to provide incontinence care as needed. She reported that staff sometimes did not change her when she was incontinent and made her wait long periods. She described an incident where, after she had an accidental bowel movement, a CNA told her it was mealtime and she would have to wait until after the meal to be changed. On a subsequent observation, this resident was found lying in bed and reported she was wet with urine and had not yet been checked or changed that day, despite CNAs starting their shift at 6:00 A.M. Her primary CNA stated she had not yet checked the resident for incontinence and that she typically did her first rounds after breakfast, then again before lunch, for a total of about four checks in a 12‑hour shift. During observed incontinence care, the resident’s brief was saturated with urine, her peri area and buttocks were deep red, and she cried out in pain when the area was cleansed. Another CNA reported she routinely checked and changed residents only three times in a 12‑hour shift. Multiple staff, including CNAs and an LPN, stated they were not allowed to perform patient care, including changing residents, during meal service from the time the meal cart arrived until trays were picked up, and one CNA confirmed she had required a resident to wait to be changed during a prior mealtime because of this rule. A second cognitively intact resident, always incontinent of bowel and bladder and dependent on staff for toileting hygiene, also had a care plan indicating complete incontinence with interventions to provide incontinence care as needed. She reported that she had requested to be changed about an hour earlier after having a bowel movement, and that the CNA told her she would change her before bringing meal trays. Later, she stated she still had not been changed, her call light remained on, and she expressed being upset about having to sit in her bowel movement. The charge nurse confirmed both CNAs were feeding other residents and that it took a long time for staff to provide care. When the CNAs arrived, one CNA denied the earlier request, rolling her eyes, while the resident firmly restated that she had asked to be changed. Observation of peri care revealed the resident was saturated with urine and stool in the peri area, with a large bowel movement present and redness on the buttocks and thighs. The CNA wiped from the buttocks up through the vaginal area, revealing heavy stool with each wipe, and confirmed she only wiped the front twice in this manner. The DON later stated that staff were allowed to change residents during meals and that residents were to be checked and changed every two hours and as needed.
Failure to Implement and Monitor Skin Integrity Interventions
Penalty
Summary
A deficiency occurred when the facility failed to implement care planned interventions and timely identify and treat skin impairments for a resident with severe cognitive impairment, cerebral palsy, and a history of pressure ulcers. The resident was dependent on staff for all activities of daily living, including incontinence care, and had orders for regular skin checks and the application of moisture barrier ointment. Despite these orders, documentation and staff interviews revealed that skin assessments were not consistently performed, and the resident's skin condition was not properly monitored or reported. Observations showed that the resident developed extensive skin breakdown, including large reddened areas, open wounds, and bleeding on the lower back, buttocks, and hips. Multiple staff members, including CNAs and LPNs, either did not notice or did not report the worsening skin condition, and some were unsure if the required interventions had been completed. The low air loss mattress, intended to prevent pressure injuries, was found to be malfunctioning with a low pressure warning, but there was no indication of how long it had been inoperable or if it had been reported or addressed in a timely manner. Interviews with staff revealed a lack of communication and documentation regarding the resident's skin condition. CNAs reported seeing redness and applying barrier cream but often did not inform the nurse, assuming the nurse was already aware. Nurses admitted to checking off treatments and skin checks on the Treatment Administration Record without actually assessing the resident's skin, relying on CNAs to report any issues. The facility's policy required reporting of skin breakdown, but this was not consistently followed, resulting in delayed identification and treatment of the resident's skin impairments.
Failure to Implement Fall Prevention Interventions and Timely Post-Fall Assessment
Penalty
Summary
A deficiency occurred when the facility failed to implement care planned interventions and did not complete a comprehensive fall evaluation in a timely manner for a resident identified as being at risk for falls. The resident, who had diagnoses including sepsis, obesity, and type 2 diabetes with diabetic neuropathy, required substantial to maximal assistance for transfers and personal care. Despite being cognitively intact and having no upper or lower extremity impairment, the resident's care plan included specific interventions such as education on proper hand placement during sit-to-stand transfers, encouragement to use assistive devices properly, and provision of rest periods. However, these interventions were not followed during a transfer using a sit-to-stand lift, resulting in the resident sliding out of the lift and being lowered to the floor by a CNA. Following the incident, the resident reported that the CNA was impatient and did not ensure her hands were correctly placed on the lift, nor was the safety belt properly secured. The resident expressed that she communicated her concerns during the transfer but was ignored, leading to her sliding out of the lift, hitting her knee, and experiencing pain and anxiety. Observations after the fall revealed a reddened area on her right knee and missing artificial fingernails, consistent with her account of the incident. The resident also stated that her vital signs were not checked, she was not asked about pain, and she did not receive prompt attention or medication for her pain and anxiety. A review of the medical record and facility documentation showed no evidence that vital signs were checked at the time of the fall, no comprehensive pain assessment was completed, and no physical assessment was documented in the progress notes. Additionally, the fall investigation lacked staff witness statements and a statement from the resident. The facility's policy required prompt medical attention, assessment for injuries, and documentation of pertinent data following a fall, but these procedures were not followed in this case.
Failure to Provide Timely Incontinence Care and Maintain Infection Control
Penalty
Summary
Staff failed to provide timely and appropriate incontinence care for a resident with a history of urinary tract infection, diabetes mellitus, and hemiplegia. The resident, who required substantial to maximal assistance with toileting and was frequently incontinent, was observed wearing two saturated incontinence briefs and lying on a wet blanket used as a chux pad. The blanket was wet with urine, and dried urine was noted around the edges. During incontinence care, redness was observed on the resident's buttocks and sacral area. The CNA providing care acknowledged that the resident had not been changed in a long time and confirmed the use of two briefs, which was not in accordance with facility policy. Additionally, the CNA failed to follow proper infection control procedures by removing soiled briefs and the wet chux pad and placing them on the floor without a plastic bag. The CNA continued to touch the resident's closet door, clean bed linens, pillow, and door handle while still wearing soiled gloves, only removing the gloves after leaving the room. The DON confirmed these actions and that the resident should not have been wearing two incontinence briefs. Facility policy required proper hand hygiene and glove use after each incontinent episode, which was not followed in this instance.
Failure to Provide Timely Administration of Ordered Medication Due to Ordering and Authorization Delays
Penalty
Summary
The facility failed to ensure that a resident's physician orders for Zepbound, a medication prescribed for diabetes management and weight loss, were followed and that the medication was available for administration as scheduled. The resident, who was cognitively intact and had diagnoses including class III obesity and type 2 diabetes with neuropathy, did not receive her ordered Zepbound injection on the scheduled day. The medication administration record confirmed the dose was missed, and the resident reported to staff that she had not received her shot within the expected timeframe. Staff interviews revealed that the medication was not present in the facility at the time it was due, and it was still on order. Further investigation showed that the delay was due to issues with insurance prior authorization, requiring administrative approval before the pharmacy could dispense the medication. The pharmacy confirmed that a refill request was received, but the medication was not covered by insurance, prompting them to contact the facility for approval. The administrator authorized the medication after being contacted by the pharmacy, but there was a lack of clarity regarding who was responsible for ensuring the medication was available for timely administration. This resulted in the resident missing a scheduled dose of her prescribed medication.
Medication Error Rate Exceeds Five Percent Due to Administration and Availability Failures
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, resulting in a 12% error rate with three errors observed in 25 opportunities. For one resident with diabetes, an LPN administered insulin using a FlexPen without priming it as directed by the manufacturer’s instructions, despite the resident’s care plan and physician order specifying insulin administration per sliding scale. The LPN confirmed not priming the pen, and the DON stated that priming is necessary before dialing the dose. Additionally, two residents missed scheduled doses of their prescribed medications due to unavailability. One resident with COPD and heart failure did not receive a scheduled dose of a bronchodilator inhaler because the medication was not available on the medication cart, and the LPN confirmed it needed to be reordered from the pharmacy. Another resident with Alzheimer’s disease and pain management needs missed a scheduled dose of topical capsaicin cream for pain relief, also due to the medication not being available and requiring reorder. These incidents were observed during medication administration and confirmed by staff interviews and record reviews.
Failure to Administer Ordered Anxiety Medication Due to Communication and Order Processing Breakdown
Penalty
Summary
A deficiency occurred when a resident with Parkinson's Disease and anxiety was admitted to the facility with a physician's order for alprazolam (Xanax) 0.25 mg to be given every 12 hours as needed for anxiety. Despite this order, the medication was never administered during the resident's stay. Review of the Medication Administration Record confirmed that alprazolam was not given, and pharmacy records indicated that the prescription was never filled because the pharmacy did not receive a valid prescription from the physician. The pharmacy attempted to contact the physician multiple times without success, and there were no notes indicating that facility nurses called the pharmacy about the medication. Staff interviews revealed confusion and lack of communication regarding the medication order. The LPN who admitted the resident stated that the night shift nurse was supposed to complete the admission process and was unsure if the medication was ordered or filled. The LPN also noted that during the weekend in question, staff were unable to reach the nurse practitioner or physicians, which was unusual and led to a post-incident meeting. The DON, who was not employed at the time, confirmed that alprazolam was available in the facility's starter supply and could have been administered with proper authorization, but could not explain why the medication was not filled or administered. The facility's policy required medications to be dispensed only upon receipt of a clear, complete order signed by an authorized prescriber. In this case, the lack of a valid prescription and the inability to contact the prescriber resulted in the resident not receiving the ordered medication for anxiety. The situation was further complicated by family involvement, visitor disruptions, and the resident's observable anxiety symptoms, but the core issue remained the failure to ensure the resident was free from significant medication errors due to breakdowns in communication and order processing.
Failure to Implement Effective Nutrition and Hydration Plan Resulting in Harm
Penalty
Summary
The facility failed to develop and implement a comprehensive, individualized, and effective nutrition and hydration plan for a resident with moderate cognitive impairment, resulting in significant weight loss and dehydration. The resident, who had diagnoses including dementia, hemiplegia, diabetes, and other chronic conditions, was at moderate risk for malnutrition and required cues and assistance with eating. Despite care plan interventions to monitor and provide hydration, the facility did not ensure ongoing weight monitoring or implement adequate interventions in response to the resident's decreased meal intake. The resident experienced a severe weight loss of 17.3 pounds (8.3%) in two weeks and was subsequently hospitalized for altered mental status secondary to dehydration, requiring intravenous fluids. Medical record review revealed that the facility did not obtain an admission weight for the resident upon readmission and failed to record fluid intake amounts for the entire month of September. There was no evidence that the diet technician was notified of the resident's decreased meal intake, and no updates or new interventions were made to the care plan during the period of declining intake. Observations showed that fluids were not consistently within the resident's reach, and interviews with staff and family members indicated that the resident's meals were often left on the bedside table without adequate assistance, despite the resident's need for help with feeding. The facility's own weight monitoring policy required weekly weights for four weeks after admission and prompt reporting of significant weight changes, but these protocols were not followed. The resident's significant weight loss and decreased intake were not addressed in a timely manner, and the lack of proper monitoring and intervention led to actual harm, as evidenced by the resident's hospitalization for dehydration. Interviews confirmed that staff were aware of the resident's declining intake but did not take appropriate action to notify the diet technician or update the care plan.
Failure to Provide Timely Wound Care for Resident
Penalty
Summary
A resident with a history of paraplegia, chronic respiratory failure, osteomyelitis, and major depressive disorder was admitted and later readmitted to the facility. The resident developed a vascular wound on the rear left calf, which was first identified during a skin assessment. Despite the care plan indicating that wound treatments should be provided per physician orders, there was no evidence that any wound care was initiated or ordered for three days following the identification of the wound. Medical records, including the Medication Administration Record (MAR) and Treatment Administration Record (TAR), confirmed that no wound care was provided during this period. Subsequently, the resident experienced a significant change in condition, including tachycardia and hypotension, leading to transfer to the emergency room. Hospital documentation noted the presence of the left lower extremity wound with cellulitis, as well as additional pressure injuries acquired during hospitalization. Facility staff interviews confirmed that no wound care orders were placed or treatments completed for the wound during the initial three-day period. The facility's policy required necessary care and treatment to prevent and manage pressure injuries, which was not followed in this instance.
Failure to Obtain Orders and Provide Wound Care for Pressure Ulcers
Penalty
Summary
The facility failed to obtain physician orders and provide wound care for a resident with multiple pressure ulcers. The resident was admitted with several wounds, including a stage one sacrum pressure ulcer, a right ankle deep tissue injury, and a left ankle stage three pressure ulcer. Additionally, two blisters on the plantar surfaces of the feet were identified as acquired in the facility. Review of the resident's medical record, medication administration records, and treatment administration records revealed that there were no physician orders or wound care provided for the sacrum, right ankle, or left ankle wounds for three consecutive days following admission. Interview with the wound nurse confirmed that wound care orders or treatments were not in place for these pressure wounds during the specified period. The facility's skin assessment policy required necessary care to prevent and treat pressure injuries, but this was not followed for the resident in question. The deficiency was identified during a complaint investigation and affected one resident with severe cognitive impairment and multiple mobility-related diagnoses.
Failure to Provide Timely Podiatry Services
Penalty
Summary
A deficiency was identified when a resident did not receive timely podiatry services. The resident, who had diagnoses including muscle weakness, vascular dementia, and epilepsy, was observed to have long, thickened, yellow toenails on both great toes. Review of the medical record showed that although the resident was readmitted to the facility, a consent for auxiliary services, including podiatry, was not obtained until several weeks later. During this period, the resident did not receive podiatry care, and the need for such services was not recognized until a care conference was held. Interviews with facility staff confirmed that there was no specific policy in place for podiatry services, and the social services designee was unaware of the resident's need for podiatry until the care conference. The podiatrist's last visit to the facility occurred prior to the consent being obtained, and the next scheduled visit was after the deficiency was identified. The lack of timely consent and absence of a clear process for arranging podiatry services led to the resident not receiving necessary foot care.
Unsanitary Dumpster Area
Penalty
Summary
The facility failed to maintain a sanitary dumpster area. During observation, significant debris was found on the ground surrounding the dumpsters, including gloves, cardboard, and empty medication packaging. The Dietary Manager confirmed the findings and stated that the maintenance department was responsible for keeping the area clean. The facility census was 63, and the deficiency was identified as affecting all residents residing in the facility.
QAA Committee Lacked Required IP Participation
Penalty
Summary
The facility failed to ensure the required members of the Quality Assessment and Assurance (QAA) committee participated at least quarterly as required. Review of the Infection Preventionist training certificate dated 10/24/24 showed IP #833 was the facility's IP, and review of the QAPI sign-in sheets from 10/16/24, 01/22/25, 04/02/25, 06/18/25, and 07/16/25 showed no evidence that the IP participated in the QAPI meetings. The undated facility QAPI Plan listed the IP as a QAA committee member. During interview on 08/12/25, the Administrator confirmed IP #833 had not been attending QAPI meetings and stated the IP was also the Receptionist and provided a report to the DON for presentation at the QAPI meetings. IP #833 also confirmed during interview that she had not been attending QAPI meetings and stated she had been in the position since obtaining her IP certificate in October 2024.
Unsafe Smoking Practices and Improper Cigarette Disposal
Penalty
Summary
The facility failed to ensure a safe smoking environment. During observation of a resident smoking session, two residents were supervised by the Business Office Manager in the smoking area at the back of the building across the parking lot, and four cigarette butts were observed in that area. Shortly afterward, a Dialysis Technician walked out of the building, stood next to the facility door, lit a cigarette, and smoked while talking on the phone and flicking ashes. Although there was a trash receptacle next to the facility door, there was no approved cigarette disposal. The technician then walked across the parking lot out of view and returned to the building without a cigarette butt, and later stated she had put the cigarette butt in her pocket before saying she put it in the trash can. The Administrator and Business Office Manager later verified the cigarettes on the ground. The facility policy stated smoking is only allowed in designated smoking areas and that safety measures include ashtrays made of noncombustible material and placement away from exits and common spaces used by other residents.
Failure to Develop Smoking Care Plan
Penalty
Summary
The facility failed to develop a person-centered care plan for smoking for Resident #36, who was admitted on 07/03/25 with diagnoses including syncope, dysphagia, difficulty in walking, hypertension, anxiety, adult failure to thrive, and depression. The quarterly MDS assessment indicated the resident had impaired cognition and required staff supervision for activities of daily living. Review of the care plan dated 07/10/25 showed no evidence of a smoking care plan, and the smoking assessment indicated the resident did not require staff assistance or smoking devices while smoking. During an observation on 08/06/25 at 9:09 A.M., the Business Office Manager lit the resident’s cigarette, the resident held the cigarette independently, and asked the BOM to place the cigarette butt in the disposal. The DON later verified that the resident had no care plan for smoking. The facility policy stated that all residents are to be supervised while smoking.
Delayed Response to Resident's Fall and Fracture
Penalty
Summary
The facility failed to provide appropriate and timely care to a resident after a fall that resulted in a fracture. The resident, who was admitted with diagnoses including dementia, repeated falls, and arthritis, was found on the floor by a registered nurse. The resident complained of hip pain and was unable to move her right leg. The nurse notified the nurse practitioner, who ordered a STAT hip x-ray. However, the x-ray was not conducted until approximately 17 hours later, delaying the diagnosis of a fractured femur and the resident's transfer to the hospital for surgery. The delay in obtaining the x-ray and subsequent treatment was a significant oversight, as the facility's policy defines a change of condition to include life-threatening conditions such as broken bones. Interviews with the nurse practitioner and registered nurse revealed a lack of awareness regarding the delay in the x-ray, and the resident was found to be in more pain and soiled the following morning. The deficiency was identified during a complaint investigation, highlighting the facility's failure to adhere to its policy for timely response to a change in a resident's condition.
Failure to Administer Physician-Ordered Medication for SIADH
Penalty
Summary
The facility failed to provide a physician-ordered treatment for a resident diagnosed with Syndrome of Inappropriate Secretion of Antidiuretic Hormone (SIADH). The resident, who had multiple diagnoses including normal pressure hydrocephalus, chronic obstructive pulmonary disease, and depression, was prescribed a urea sodium oral packet to manage low sodium levels associated with SIADH. Despite the order being in place from late May to early July, the medication was never obtained from the pharmacy and thus never administered to the resident. Throughout the period, multiple medication administration notes indicated that the urea sodium oral packet was either on order or out of stock, yet there was no documentation of the physician being notified about the unavailability of the medication. Interviews with the Director of Nursing, the physician, and a nurse practitioner confirmed that the resident did not receive the prescribed treatment and that there was no record of communication with the physician regarding this issue. The facility's policy on medication administration was not adhered to, resulting in a deficiency as investigated under a specific complaint number.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Fairlawn
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Concordia At Sumner | 0.6 mi | ★★★★★ | 10 | 0 |
| Arbors At Fairlawn The | 0.8 mi | ★★★★★ | 0 | 0 |
| Phoenix Of Fairlawn | 1.6 mi | ★★★★★ | 0 | 0 |
| Copley Health Center | 1.7 mi | ★★★★★ | 6 | 0 |
| Wyant Woods Healthcare Center | 1.9 mi | ★★★★★ | 8 | 0 |
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