Timber Springs Rehab and Retirement

In the surveyor’s words

From the most serious findings on record at Timber Springs Rehab and Retirement, in the surveyor’s own words.

• Immediate jeopardy, patternF689Dec 8, 2022

  Based on record review, observations, and interviews, the facility failed to ensure 1 (Resident #3) of 20 (#3, #5, #37, #41, #11, #9, #152, #39, #10, #14, #102, #44, #19, #42, #29, #34, #21, #1, #46, #12) residents reviewed for impaired cognition and/or a diagnosis that may increase their risk of elopement was adequately supervised to prevent elopement from the facility. This deficient practice resulted in an Immediate Jeopardy for Resident #3 on 08/21/2022 at 2:48 a.m. when Resident #3 exited from the facility unsupervised and was found across the street from the facility in front of the police station. Resident #3 had a diagnosis of Schizophrenia, Alzheimer's disease and has severe cognitive impairment with a history of confusion and escalating psychotic behaviors. […]

• Immediate jeopardy, patternF835Dec 8, 2022

  Based on interviews, the facility failed to administer its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident by failing to: 1. Ensure Resident #3 was adequately supervised to prevent repeated elopements from the facility 2. Complete incident reports, investigations, and train staff on supervision of residents to prevent elopements 3. Ensure Resident #3 was reassessed for elopement risk and update his plan of care with additional interventions to prevent repeat elopements. This deficient practice resulted in an Immediate Jeopardy for Resident #3 on 08/21/2022 at 2:48 a.m. […]

• No harm, potential for more than minimal, patternF644Mar 25, 2026

  Based on record review and interview, the facility failed to refer a resident with a newly diagnosed mental disorder to the appropriate state-designated authority for Level II PASARR evaluation and determination for 1 ( #5) of 2 residents reviewed for PASARR. Findings:A review of Resident #5's medical record revealed an admission date of 04/27/2015 with a diagnosis of Generalized Anxiety Disorder on 11/05/2020. Further review revealed Resident #5 was not referred to the appropriate state-designated authority for a Level II PASARR evaluation.During an interview on 03/25/2026 at 2:00 p.m., S3 Social Services acknowledged a Level II PASARR evaluation was not completed for Resident #5 after new diagnosis of generalized anxiety disorder.During an interview on 03/25/2026 at 2:30 p.m., S3… […]

• No harm, potential for more than minimal, patternF656Jan 15, 2025

  Based on record review and interview the facility failed to ensure a comprehensive person-centered care plan was developed for 1 (#50) of 26 sampled residents. The facility failed to ensure an activities care plan had been developed with interventions for Resident #50. Findings: Review of Resident #50's medical record revealed an initial admitted [DATE] with diagnoses that included, in part, anxiety disorder, essential (primary) hypertension, and depression. Review of Resident #50's 12/02/2024 Quarterly MDS (Minimum Data Set) revealed Resident #50 had a BIMS (Brief Interview Mental Status) score of 15, which indicated Resident #50 was cognitively intact. […]

• No harm, potential for more than minimal, patternF700Jan 15, 2025

  Based on record reviews, observations and interviews, the facility failed to ensure correct use and maintenance of bed rails for 7 (#1, #4, #24, #25, #42, #48, #49) of 7 (#1, #4, #24, #25, #42, #48, #49) residents reviewed for the use of bed rails. The facility failed to ensure: 1. Residents #1, #4, #24, #25, #42, #48, and #49 were assessed for the risk of entrapment prior to the use of bed rails, less restrictive approaches were attempted prior to the use of bed rails, ongoing assessments for the risk of entrapment were conducted after bed rail installation, and residents were care planned with specific interventions for the use of bed rails, and; 2. Bed rails were securely attached to the bed for resident # 4, and #25. […]