Tyler's Retreat at Iron Bridge

In the surveyor’s words

From the most serious findings on record at Tyler's Retreat at Iron Bridge, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF700Aug 13, 2025

  Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to implement bed rail requirements for four of 36 residents in the survey sample, Residents #6, #100, #101, and #102. The findings include: 1. For Resident #6 (R6), the facility staff failed to assess the resident for risk of entrapment and failed to attempt appropriate alternatives prior to the resident's use of bed rails (grab bars).On 8/11/25 at 12:44 p.m., R6 was observed lying in bed with bilateral grab bars in the upright position.A review of R6's clinical record (including an enabler-restraint observation form dated 7/3/25) failed to reveal documentation that the facility staff assessed the resident for risk of entrapment or attempted appropriate alternatives.On… […]

• No harm, potential for more than minimal, patternF623Jan 19, 2023

  Based on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to provide written notice of a hospital transfer to the Resident Representative and/or State Long Term Care Ombudsman office for four of 30 residents in the survey sample; Residents #1, #8, #35, and #72. The findings include: 1. For Resident #1, the facility staff failed to evidence a written notification of a hospital transfer was provided to the resident representative and to the State Long Term Care Ombudsman office for a hospital transfer on 10/19/22; and failed to evidence a written notification of a hospital transfer was provided to the resident representative for a hospital transfer on 12/8/22. A. […]

• No harm, potential for more than minimal, patternF656Jan 19, 2023

  Based on observation, staff interview, facility document review, clinical record review, and in the course of a complaint investigation, it was determined the facility staff failed to develop and/or implement a comprehensive care plan for five of 30 residents in the survey sample, Residents #123, #23, #1, #21 and #68. The findings include: 1. For R123, the facility staff failed to implement the comprehensive care plan for the administration of medications per the physician order. On the most recent MDS (minimum data set) assessment, a Medicare five-day assessment, with an assessment reference date of 9/8/2022, the resident scored a 7 on the BIMS (brief interview for mental status) score, indicating the resident was severely impaired for making daily decisions. […]

• No harm, potential for more than minimal, patternF656Aug 5, 2021

  Based on observation, resident interviews, staff interviews, clinical record reviews and facility document reviews it was determined that the facility staff failed to develop and/or implement the comprehensive care plan for eight of 37 residents in the survey sample, (Residents #58, #6, #17, #48, #67, #28, #53 and #29). The findings include: 1. The facility staff failed to implement Resident #58's comprehensive pain care plan for the use of non-pharmacological interventions prior to the administration of as needed pain medication. […]

• No harm, potential for more than minimal, patternF657Aug 5, 2021

  Based on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to review and revise the comprehensive care plan for four of 37 residents in the survey sample, Residents #31, #25, #37 and #21. The findings include: 1. The facility staff failed to review and revise Resident #31's comprehensive care plan for the use of bed rails. Resident #31 was admitted to the facility on [DATE]. Resident #31's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]