Timber Springs Transitional Care

In the surveyor’s words

From the most serious findings on record at Timber Springs Transitional Care, in the surveyor’s own words.

• Immediate jeopardy, isolatedF812May 8, 2023

  Based on policy reviews, record review, observations and interviews, it was determined the facility failed to ensure residents were not served foods at high risk for transmission of food borne illness. This was true for 2 of 73 residents (#20 and #53) reviewed, who dined in the facility. This deficient practice placed Resident #20 and Resident #53 in immediate jeopardy of serious harm, impairment, or death related to Salmonellosis, an infection with Salmonella bacteria that causes diarrhea, fever and stomach pains when they consumed undercooked, unpasteurized whole shell eggs. Findings include: The CDC website, last reviewed 3/8/23, and accessed on 5/17/23, stated Salmonella illness can be serious and was more dangerous for some groups of people. […]

• Actual harm, isolatedF600Sep 12, 2025

  Based on policy review, record review, and staff interview, it was determined the facility failed to ensure resident's right were protected to be free from abuse. This was true for 1 of 1 resident (Resident #87) reviewed for abuse. This failure caused harm to Resident #87 and placed all residents at risk for ongoing abuse and potential physical and psychosocial harm. Findings include:The facility's Reporting Reasonable Suspicion of a Crime policy revision date April 2025, documented it was the policy of the facility to protect its residents from abuse, neglect, exploitation, and misappropriate of resident property.Resident #87 was admitted to the facility on [DATE], with the multiple diagnoses including parkinson's and dementia.Review of Resident #87's quarterly MDS, dated [DATE],… […]

• Actual harm, isolatedF600Jun 28, 2024

  Based on policy review, record review, review of the State Agency's Long Term Care Reporting Portal, and staff interview, it was determined the facility failed to ensure residents' rights were protected to be free from sexual abuse. This was true for 1 of 9 residents (Resident #63) reviewed for abuse. Application of the reasonable person concept caused harm to Resident #63 when she was inappropriately touched by Resident #42. Findings include: The Centers for Medicare and Medicaid Services (CMS) Psychosocial Outcome Severity Guide, dated October 2022, states: The following are examples of circumstances in which a resident's psychosocial outcome may not be readily determined through the investigative process and the reasonable person concept should be used: - When a resident may not be… […]

• Actual harm, isolatedF600May 8, 2023

  Based on policy review, record review, review of the State Agency's Long Term Care Reporting Portal, review of facility documents, and staff interview, it was determined the facility failed to ensure residents were free from abuse by other residents and staff. This was true for 4 of 8 residents (Residents #53, #60, #63, and #233) reviewed for abuse and neglect. This failure resulted in the potential for residents to ongoing abuse and potential harm. Findings include: The facility's policy Recognizing Signs and Symptoms of Abuse/Neglect, revised 1/2011, defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. […]

• Actual harm, isolatedF686May 8, 2023

  Based on policy review, record review, and staff interview, it was determined the facility failed to ensure professional standards of practice were followed to prevent the development and worsening of a wound. This was true for 3 of 9 residents (Residents #1, #326, and #329) reviewed for pressure ulcers. This failure resulted in harm when Resident #1, Resident #326, and Resident #329 developed new pressure ulcers, and Resident #326 and Resident #329's pressure ulcers worsened. […]