Timberlyn Heights Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Timberlyn Heights Nursing and Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF561Sep 15, 2023

  Based on records reviewed and interviews for one of three sampled residents (Resident #1), whose Advanced Directives and Physician's Orders indicated his/her elected code status was Do Not Resuscitate (DNR, medical order written by a physician, which instructs healthcare providers not to do cardiopulmonary resuscitation, in the event of cardiac or respiratory arrest) and Do Not Intubate (DNI, medical order written by a physician, which instructs healthcare providers not to place a tube down the patient's throat or connect to a breathing machine that pumps air into and out of lungs), the Facility failed to ensure nursing staff honored his/her right to self-determination related to his/her choice of Advanced Directives. […]

• Actual harm, isolatedF656Sep 15, 2023

  Based on records reviewed and interviews for one of three sampled residents (Resident #1) whose Comprehensive Person Centered Plan of Care indicated he/she was Do Not Resuscitate (DNR, medical order written by a physician, which instructs healthcare providers not to do cardiopulmonary resuscitation, in the event of cardiac or respiratory arrest) and Do Not Intubate (DNI, medical order written by a physician, which instructs healthcare providers not to place a tube down the patient's throat or connect to a breathing machine that pumps air into and out of lungs) and that staff were to honor his/her wishes, the Facility failed to ensure nursing implemented and followed interventions identified in Resident #1's plan of care related to his/her Advanced Directives. […]

• Actual harm, isolatedF658Sep 15, 2023

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), whose Advanced Directives and Physician's Order indicated his/her elected code status was Do Not Resuscitate (DNR, medical order written by a physician, which instructs healthcare providers not to do cardiopulmonary resuscitation (CPR), in the event of cardiac or respiratory arrest) and Do Not Intubate (DNI, medical order written by a physician, which instructs healthcare providers not to place a tube down the patient's throat or connect to a breathing machine that pumps air into and out of lungs), the Facility failed to ensure services provided by nursing met professional standards of practice, when nursing initiated life saving measures including performing chest compressions on a resident who was… […]

• No harm, potential for more than minimal, patternF755Aug 10, 2021

  Based on policy review, observation and interview, the facility failed to ensure an opened Insulin Emergency Kit (E-Kit) was replaced on one of two units observed. Findings include: Review of the facility Emergency Pharmacy Service and Emergency Kits Policy, dated 9/1/13, included: -The nurse records the medication use from the emergency kit on the medication order/use form and calls the pharmacy for replacement of the kit/dose or flags the kit with a color-coded lock to indicate their need for replacement of kit/dose as soon as possible after the medication has been administered. -If exchanging kits, opened kits are replaced with sealed kits within 72 hours of opening. […]

• No harm, potential for more than minimal, patternF812Aug 10, 2021

  Based on policy review, observations and interviews, the facility failed to A.) Label and/or date food items used for resident meal service, and B.) Failed to ensure food preparation equipment was clean and free of debris. Findings include: Review of facility policy titled Dietary Services, dated [DATE], indicated: -Foods will be properly labeled with name of product and date of production. -Foods will be date marked with the name of the product and the date of the production or opening . […]