Deficiencies (last 3 years)
Deficiencies (over 3 years)
5.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
2% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Routine
Deficiencies: 7
Date: Aug 29, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident funds, transfer notifications, care planning, accident prevention, pharmaceutical services, medication storage, and food safety at Timberlane Health & Rehabilitation.
Findings
The facility was found deficient in multiple areas including failure to convey resident funds timely upon discharge, failure to notify the Ombudsman of resident transfers, incomplete care plans for high-risk medications, improper use of mechanical lifts, inadequate pharmaceutical controls including narcotic accounting and medication storage, and multiple food safety and sanitation violations.
Deficiencies (7)
Failed to convey a resident's personal funds to the individual or representative within 30 days after discharge.
Failed to provide timely notification of resident transfer/discharge to resident, representative, and Ombudsman.
Failed to develop and implement a comprehensive care plan addressing high-risk medication insulin for a resident.
Failed to properly use mechanical lift with legs open to prevent accidents or injuries.
Failed to have a process to identify refrigerated narcotic expiration or use by dates and ensure periodical accounting for controlled narcotics.
Failed to ensure hydrocortisone cream was stored in a locked compartment and not left at bedside without self-administration rights.
Failed to ensure food safety practices including hand hygiene, proper storage, covering of food items, and sanitation of equipment.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 33
Trust account balance: 120
Insulin dose: 64
Narcotic balance: 29.5
Number of food dome lids open: 68
Number of plates stacked: 43
Number of eggs left out: 14
Number of yogurts: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #9 | LPN | Observed handling narcotics and confirmed lack of expiration dates |
| Licensed Practical Nurse #10 | LPN | Assisted in narcotic identification and confirmed lack of expiration dates |
| Assistant Director of Nursing #6 | ADON | Interviewed regarding narcotic return procedures and medication accounting |
| Director of Nursing | DON | Interviewed regarding mechanical lift use, medication storage, and self-administration policies |
| Administrator | AD | Interviewed regarding resident discharge notification and fund conveyance policies |
| Certified Nursing Assistant #8 | CNA | Observed improperly using mechanical lift with legs closed |
| Licensed Practical Nurse #7 | LPN | Observed removing steroid cream from resident bedside |
| Dietary Aide #1 | Dietary Aide | Observed failing to follow food safety and hand hygiene practices |
| Dietary Manager | Dietary Manager | Confirmed food safety violations and sanitation concerns |
| Nurse Consultant | Nurse Consultant | Provided policies and confirmed medication expiration concerns |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 14, 2023
Visit Reason
The inspection was conducted due to a complaint regarding improper use of a stand-up lift by staff, specifically an incident where a resident was lifted by only one CNA instead of the required two, potentially causing harm.
Complaint Details
The complaint investigation found that on 10-19-2023, a CNA used the stand-up lift alone on Resident #1, hooking only one side of the sling initially and lifting the resident without the required two-person assistance. The resident reported pain and was diagnosed with a rib contusion. The facility acknowledged the incident and confirmed the CNA was trained but did not follow the two-person lift policy.
Findings
The facility failed to ensure residents were free from accidents related to the use of a stand-up lift, with inadequate supervision and failure to follow the resident's care plan for one sampled resident. The investigation confirmed that a CNA used the lift alone contrary to policy, causing potential harm.
Deficiencies (1)
Failure to ensure residents were free from accidents with the use of a stand-up lift; staff did not follow care plan requiring two-person assistance for transfers.
Report Facts
Residents sampled: 3
Date of incident: Oct 19, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Involved in improper use of stand-up lift on Resident #1 |
| CNA #2 | Restorative Aide | Observed using stand-up lift properly with two-person assistance |
| CNA #3 | Assisted with stand-up lift use during survey observation | |
| Assistant Director of Nursing | ADON | Interviewed regarding standing lift use policy and incident |
| Licensed Practical Nurse #1 | LPN | Interviewed about care plan updates and supervision responsibility |
| CNA #4 | Certified Nursing Assistant | Interviewed about proper standing lift procedures |
| Director of Nursing | DON | Interviewed about transfer information and incident awareness |
Inspection Report
Routine
Deficiencies: 4
Date: Sep 29, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to respiratory care, medication storage, food safety, and infection prevention at Timberlane Health & Rehabilitation.
Findings
The facility was found deficient in multiple areas including improper storage of respiratory equipment, medication storage issues including unsecured medication carts and expired medications, food safety violations such as undated and improperly stored food items, and failure to have a certified infection preventionist. All deficiencies were cited with minimal harm or potential for actual harm.
Deficiencies (4)
Failed to ensure BiPAP/CPAP masks and oxygen tubing were stored in a bag or container when not in use.
Medications were improperly stored on medication cart; beverages stored in medication refrigerator; narcotics not surrendered timely.
Food safety violations including dented cans used, undated food items, improperly stored scoops, and unlabeled refrigerated food.
Infection Preventionist had not completed required specialized training and certification.
Report Facts
Residents affected: 87
Medications identified on cart: 3
Medication volumes in narcotic bags: 26.5
Medication volumes in narcotic bags: 24.75
Medication volumes in narcotic bags: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Identified medications on medication cart and stated masks should be stored in bags | |
| Licensed Practical Nurse (LPN) #2 | Responsible for medication cart and identified expired medications; described medication handling | |
| Director of Nursing (DON) | Provided policy information on storage of respiratory equipment and medication surrender process | |
| Assistant Director of Nursing (ADON) #1 | Identified medications in narcotic bags and discussed medication surrender | |
| Dietary Manager | Described food storage practices and issues with dented cans and undated food | |
| Dietary Supervisor | Confirmed unlabeled gravy container in refrigerator | |
| Administrator | Confirmed Infection Preventionist certification status |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 29, 2023
Visit Reason
The inspection was conducted following a complaint investigation into the misappropriation of residents' personal funds held in trust accounts by the facility.
Complaint Details
The complaint investigation found substantiated misappropriation of funds from residents' trust accounts. The facility reimbursed the affected residents with interest and took corrective actions including suspension of the Business Office Manager and reporting to OLTC.
Findings
The facility failed to ensure personal funds were not misappropriated for 3 sampled residents, resulting in past noncompliance. The facility reimbursed affected residents with interest and implemented corrective actions, including suspension of the Business Office Manager and new checkpoints to prevent recurrence.
Deficiencies (1)
Failure to protect residents from wrongful use of their belongings or money, specifically misappropriation of funds from trust accounts of 3 residents.
Report Facts
Amount misappropriated from Resident #1: 2104
Amount misappropriated from Resident #2: 1894.4
Withdrawal correction for Resident #3: 1823.59
Check amount cashed without endorsement: 3629.61
Check amount for roof repairs: 1475
Unauthorized deduction: 574
Deduction from Resident #2 trust account: 285.22
Check amount made out to another individual: 1000
Check amount made out to another individual: 894.4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Named as responsible for misappropriation and suspended immediately | |
| Administrator | Interviewed regarding the misappropriation incident and corrective actions |
Inspection Report
Routine
Deficiencies: 3
Date: Jun 16, 2022
Visit Reason
The inspection was conducted to assess compliance with food safety and hygiene standards in the dietary department of the nursing home.
Findings
The facility failed to ensure food items stored in the freezer were properly covered or sealed, and dietary staff did not consistently wash their hands before handling clean equipment or food items, posing a potential risk of foodborne illness to residents.
Deficiencies (3)
Food items stored in the freezer were not covered or sealed properly.
Dietary staff failed to wash hands before handling clean equipment or food items.
Accumulation of grease below the deep fryer and on pallets.
Report Facts
Date of observations: Jun 15, 2022
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