Timely Mission Nursing Home

In the surveyor’s words

From the most serious findings on record at Timely Mission Nursing Home, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF812Apr 14, 2022

  Based on observations and staff interviews the facility failed to ensure food was labeled with dates after opening, labeled with product after removing from original package, discarded after product expiration date and maintain clean and sanitizable cutting boards for food preparation. The facility identified a census of 24 residents. Findings include: 1. An initial kitchen tour conducted on [DATE] at 10:01 a.m., of the kitchen revealed the following items were stored in the kitchen ready for service: a. gallon of low-fat white milk- open with no open date b. gallon of chocolate milk- open with no open date c. light cranberry juice- open with no open date d. unsweetened tea- open with no open date e. grape juice-open with no open date f. shredded cabbage-open with no open date g. […]

• No harm, potential for more than minimal, isolatedF825Nov 17, 2025

  Based on observation, clinical record review, staff and resident interview, the facility failed to ensure the provision of occupation and physical services for 1 of 3 resident reviewed for therapy services upon admit. (Resident #1). The facility identified a census of 33 residents.Findings include:Resident #1s Minimum Data Set (MDS) assessment dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition with decision making abilities, was able to understand and was understood by others. The resident required staff dependence with mobility and transfers and the use of a walker or wheelchair. […]

• No harm, potential for more than minimal, isolatedF637Aug 1, 2024

  Based on record review, staff interview, and Resident Assessment Instrument (RAI) Manual the facility failed to ensure 2 of 2 residents (Resident #20 and #19) Significant Change Minimum Data Set (MDS) assessments were completed within 14 days of identifying a significant change occurred. The facility reported a census of 30 residents. Findings include: 1. Record review of Resident #20 revealed a Physicians Order documented the resident was discharged from hospice on 11/22/23. Record review of Resident #20 revealed that a Significant Change MDS was not completed when the resident had been discharged from hospice care. During an interview on 7/30/24 at 1:21 PM, the MDS Coordinator reported when a resident goes on or off hospice she has not done anything for MDS completion for it. […]

• No harm, potential for more than minimal, isolatedF686Aug 1, 2024

  Based on clinical record review, staff interviews, resident interview and policy review the facility failed to assure that a resident with a pressure ulcer received treatment and services, consistent with professional standards of practice, to promote healing of two stage two pressure ulcers for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 30 residents. Finding include: The Minimum Data Set (MDS) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. […]

• No harm, potential for more than minimal, isolatedF623Aug 17, 2023

  Based on record review and staff interview, the facility failed to notify the Long Term Care (LTC) Ombudsman of a resident transfer to the hospital for 1 of 2 residents reviewed for hospitalization s (Resident #3). The facility reported a census of 28 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] documented Resident #3 had a re-entry date of 4/12/23 from an acute visit to the hospital. The MDS further documented a Brief Interview for Mental Status (BIMS) of 5 indicating severe cognitive impairment and the resident required extensive physical assistance with bed mobility, toilet use and transfers. […]