8 CMS Surveys
Inspection Report — Mar 16, 2026
Date: Mar 16, 2026
Visit Reason
No health deficiencies were found during the survey.
Findings
The survey conducted on 03/16/2026 found no health deficiencies at Timber Springs Transitional Care.
Inspection Report — Nov 20, 2025
Routine
Date: Nov 20, 2025
Visit Reason
A routine health care licensure survey was conducted to assess compliance with regulatory requirements and identify any deficient practices.
Findings
The facility was found deficient in four areas: failure to allow resident representatives to participate in care planning, failure to act on resident grievances regarding missing personal items, failure to implement a physician's order for symptom management, and failure to ensure drug regimens were free from unnecessary medications.
Deficiencies (4)
F 0553 Allow resident to participate in the development and implementation of his or her person-centered plan of care: the facility failed to ensure residents' representatives were provided the opportunity to participate in the development of the resident's care plan, resulting in a delayed initial care conference beyond regulatory timeframes.
F 0585 Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances: the facility failed to ensure grievances were acted upon when staff were made aware of residents' missing items, including ear amplifiers, socks, underwear, and shoes, and did not replace missing items in a timely manner.
F 0658 Ensure services provided by the nursing facility meet professional standards of quality: the facility failed to implement a physician's order for Haldol prescribed for symptom management during end-of-life care, potentially causing untreated symptoms during the death and dying process.
F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs: the facility administered Keflex beyond the prescribed 10-day duration without documented physician authorization or clinical justification, increasing the risk of adverse outcomes including multi-drug resistant organisms.
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Inspection Report — Sep 12, 2025
Routine
Date: Sep 12, 2025
Visit Reason
A health care licensure and follow-up survey was conducted to assess compliance with regulations and resident care standards.
Findings
The facility was found deficient in multiple areas including environmental conditions, resident abuse prevention, transfer documentation, assessment accuracy, medication administration, dental care, hydration, food safety, staff licensure, and infection control practices. These deficiencies posed potential risks for resident harm and compromised quality of care.
Deficiencies (15)
F 0584 Honor the resident's right to a safe, clean, comfortable and homelike environment: Resident #2's room had persistent foul urine odor and unclean conditions despite increased cleaning frequency.
F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect: Resident #87 was harmed by Resident #113 in a resident-to-resident abuse incident; facility failed to prevent further abuse.
F 0610 Respond appropriately to all alleged violations: Facility failed to implement effective interventions to prevent further resident-to-resident abuse between Residents #87 and #113.
F 0628 Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies: Pertinent medical information was not documented as provided to receiving hospitals for Residents #4 and #79 during transfers.
F 0641 Ensure each resident receives an accurate assessment: Resident #10's Minimum Data Set (MDS) did not include diagnoses of dementia or anxiety despite medical documentation.
F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals: Resident #17's anticoagulant therapy monitoring was incomplete; signs and symptoms of complications were not documented as required.
F 0693 Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube: Resident #72 was administered the incorrect nutritional supplement, contrary to physician orders.
F 0695 Provide safe and appropriate respiratory care for a resident when needed: Resident #29 was not receiving continuous oxygen therapy as ordered, resulting in dangerously low oxygen saturation.
F 0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures: Pharmacy recommendations for discontinuing unnecessary medications for Resident #90 were not acknowledged or acted upon.
F 0760 Ensure that residents are free from significant medication errors: RN failed to assess Resident #50's apical pulse prior to administering digoxin, risking adverse effects.
F 0790 Provide routine and 24-hour emergency dental care for each resident: Resident #68 had a broken tooth causing pain, but no dental appointment was scheduled in a timely manner.
F 0807 Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration: Resident #3 was observed coughing during lunch without a hydration beverage available.
F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards: Facility failed to clean ice machines and pans, ensure proper glove use, and remove expired food and damaged cooking equipment.
F 0839 Employ staff that are licensed, certified, or registered in accordance with state laws: RN #1 worked multiple shifts with an expired nursing license before reassignment.
F 0880 Provide and implement an infection prevention and control program: Facility failed to prevent cross-contamination during medication administration and sterile dressing changes for Residents #2 and #50.
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Inspection Report — Sep 12, 2025
Routine
Date: Sep 12, 2025
Visit Reason
A routine health care licensure and follow-up survey was conducted to assess compliance with state regulations and ensure resident safety and care quality.
Findings
The facility was found deficient in multiple areas including environmental cleanliness, resident abuse prevention, transfer documentation, accurate assessments, medication administration, dental care, hydration, food safety, staff licensure, and infection control practices. These deficiencies posed potential risks of harm, infection, and inadequate care to residents.
Deficiencies (15)
F 0584 Honor the resident's right to a safe, clean, comfortable and homelike environment: Resident #2's room had persistent foul urine odor and unclean conditions despite increased cleaning frequency.
F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody: Resident #87 was harmed by resident-to-resident abuse; facility failed to prevent ongoing abuse and potential harm.
F 0610 Respond appropriately to all alleged violations: Facility failed to implement effective interventions to prevent further resident-to-resident abuse incidents involving Residents #87 and #113.
F 0628 Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies: Pertinent medical information was not provided to receiving hospitals for Residents #4 and #79 during transfers.
F 0641 Ensure each resident receives an accurate assessment: Resident #10's Minimum Data Set (MDS) assessments did not accurately reflect diagnoses of dementia and anxiety or related medication use.
F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals: Resident #17's anticoagulant therapy monitoring was incomplete; signs and symptoms of complications were not consistently documented.
F 0693 Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube: Resident #72 was administered the incorrect nutritional supplement via feeding tube, contrary to physician orders.
F 0695 Provide safe and appropriate respiratory care for a resident when needed: Resident #29 was not receiving continuous oxygen therapy as ordered, resulting in dangerously low oxygen saturation levels.
F 0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures: Pharmacy recommendations to discontinue unnecessary medications for Resident #90 were not acknowledged or acted upon.
F 0760 Ensure that residents are free from significant medication errors: Resident #50 was administered digoxin without prior assessment of apical pulse as required, risking adverse effects.
F 0790 Provide routine and 24-hour emergency dental care for each resident: Resident #68 had a broken tooth causing pain, but the facility failed to schedule timely dental care.
F 0807 Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration: Resident #3 was observed coughing during lunch without a hydration beverage available.
F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards: Facility failed to maintain food safety including expired food, unclean ice machines, improper glove use, and dirty cooking equipment.
F 0839 Employ staff that are licensed, certified, or registered in accordance with state laws: RN #1 worked multiple shifts with an expired nursing license before reassignment.
F 0880 Provide and implement an infection prevention and control program: Facility failed to prevent cross-contamination during medication administration and sterile dressing changes for Residents #2 and #50.
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Inspection Report — Jun 28, 2024
Routine
Date: Jun 28, 2024
Visit Reason
A routine health care licensure and follow-up survey was conducted to assess compliance with state and federal regulations.
Findings
The facility was found deficient in multiple areas including resident dignity during dining, advance directive documentation, physician notification of weight changes, environmental cleanliness, grievance investigation, abuse prevention, transfer documentation, care planning, medication management, respiratory care, bed rail use, staffing census posting, and food safety practices.
Deficiencies (17)
.0550 Honor the resident's right to a dignified existence: residents seated at the same table were served meals at different times, causing potential psychosocial harm.
.0578 Honor the resident's right to request, refuse, and/or discontinue treatment, and to formulate an advance directive: six residents' records lacked documentation of advance directives or assistance to formulate them.
.0580 Immediately tell the resident, doctor, and family of situations affecting the resident: physician was not notified of significant weight changes for two residents as ordered.
.0584 Honor the resident's right to a safe, clean, comfortable and homelike environment: multiple pieces of resident-care equipment were dirty and lacked cleaning documentation.
.0585 Honor the resident's right to voice grievances without discrimination: the facility failed to investigate and resolve a grievance regarding a missing medication for one resident.
.0600 Protect each resident from all types of abuse: a resident was inappropriately touched by another resident; facility took corrective actions and no further incidents were noted.
.0622 Not transfer or discharge a resident without adequate reason and documentation: three residents' transfer records lacked documentation of pertinent medical information provided to receiving hospitals.
.0656 Develop and implement a complete care plan: one resident's dentures and oxygen use were not documented in the care plan.
.0684 Provide appropriate treatment and care according to orders: one resident's physician-ordered bed rails were not in place; another resident's bowel medications were not administered as ordered.
.0695 Provide safe and appropriate respiratory care: oxygen tubing and nasal cannula were observed lying on the floor instead of being stored properly.
.0700 Try different approaches before using a bed rail: two residents had bed rails without documented consent or evidence of alternatives attempted; risk versus benefit discussion was incomplete.
.0732 Post nurse staffing information every day: census information was not accurately posted daily for each shift.
.0756 Ensure a licensed pharmacist perform monthly drug regimen review: pharmacist failed to recognize and report irregularities related to PRN psychotropic medication for one resident.
.0758 Implement gradual dose reductions and limit PRN psychotropic medications to 14 days unless evaluated: one resident received PRN antipsychotic medication without documented stop date or pharmacist review.
.0761 Ensure drugs and biologicals are labeled and stored properly: expired medications found in storage room; insulin pens undated in medication cart.
.0812 Procure food from approved sources and store, prepare, distribute, and serve food safely: multiple food safety violations including improper hand hygiene, food stored on floor, undated opened food containers, unrestrained hair, inadequate cleaning schedules, and unsanitary kitchen conditions.
.0849 Arrange for provision of hospice services or assist resident in transferring to facility that will: failed to delineate responsibilities between facility and hospice agency for one resident.
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Inspection Report — Jun 28, 2024
Routine
Date: Jun 28, 2024
Visit Reason
A health care licensure and follow-up survey was conducted to evaluate compliance with state and federal regulations related to resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including resident dignity during dining, advance directive documentation, physician notification of weight changes, environmental cleanliness, grievance investigation, abuse prevention, transfer documentation, care planning, medication administration, respiratory care, bed rail use, staffing census posting, pharmacy medication review, medication labeling and storage, food safety and sanitation, and hospice care coordination.
Deficiencies (17)
.0550 Honor the resident's right to a dignified existence: residents seated at the same table were served meals at different times, causing potential decrease in dignity and psychosocial wellbeing.
.0578 Honor the resident's right to request, refuse, and/or discontinue treatment: facility failed to ensure residents and representatives received assistance to formulate advance directives; documentation was missing for multiple residents.
.0580 Immediately tell the resident, doctor, and family of situations affecting the resident: physician was not notified of significant weight changes for residents #12 and #48 as ordered, risking complications.
.0584 Honor the resident's right to a safe, clean, comfortable environment: facility failed to maintain cleanliness of equipment including lifts and vital sign machines, risking cross-contamination.
.0585 Honor the resident's right to voice grievances: facility failed to investigate and take prompt corrective action on a grievance regarding missing oxycodone medication for Resident #16.
.0600 Protect each resident from abuse: Resident #42 inappropriately touched Resident #63; facility intervened promptly and took corrective actions; no further incidents noted.
.0622 Not transfer or discharge a resident without adequate reason and documentation: facility failed to provide pertinent medical information to receiving hospitals for residents #8, #42, and #54.
.0656 Develop and implement a complete care plan: Resident #27's dentures and oxygen use were not documented in care plan; oxygen order was missing.
.0684 Provide appropriate treatment and care according to orders: Resident #27's physician order for half side rails was not followed; Resident #53 did not receive bowel medications as ordered.
.0695 Provide safe and appropriate respiratory care: Resident #27's oxygen tubing and nasal cannula were found lying on the floor instead of stored properly, risking infection.
.0700 Try different approaches before using bed rails: Residents #47 and #56 had siderails without documented consent or evidence of alternatives attempted; risk/benefit discussion incomplete.
.0732 Post nurse staffing information daily: census information was not posted daily on the census and staffing form, affecting transparency for residents and visitors.
.0756 Ensure licensed pharmacist performs monthly drug regimen review: pharmacist failed to recognize and report irregularities with PRN psychotropic medication for Resident #16.
.0758 Implement gradual dose reductions and limit PRN psychotropic medications to 14 days: Resident #16's PRN quetiapine was used frequently without documented stop date or pharmacist review.
.0761 Ensure drugs and biologicals are labeled and stored properly: expired medications found in medication storage room; insulin pens undated in medication cart.
.0812 Procure food from approved sources and store, prepare, distribute, and serve food safely: multiple food safety violations including improper hand hygiene by kitchen staff, food stored on floor, undated/opened food items, inadequate cleaning schedules, and unsanitary kitchen conditions.
.0849 Arrange for hospice services or assist resident in transferring to hospice: Resident #56's care plan lacked documentation delineating responsibilities between facility and hospice agency.
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Inspection Report — May 8, 2023
Routine
Date: May 8, 2023
Visit Reason
A routine health care licensure survey was conducted to evaluate compliance with state and federal regulations.
Findings
The facility had multiple deficiencies including failure to assess residents for self-administration of medication, inadequate accommodations for resident needs, failure to notify family members timely of changes in condition, insufficient documentation and follow-up of abuse allegations, incomplete neurological assessments, inadequate dietary services including menu and food preparation issues, insufficient staffing, and failure to ensure safe food handling practices.
Deficiencies (28)
.0554 Self-administration of medication: the facility failed to assess and document self-administration of albuterol inhaler for Resident #20; self-administration was not properly recorded.
.0558 Reasonably accommodate resident needs: Resident #61's light switch was not within reach, causing potential harm due to falls and sleep disruption.
.0565 Resident/family groups: concerns from Food Committee meetings were not documented or addressed, causing resident frustration and decreased self-worth.
.0580 Notification of changes: the facility failed to immediately notify family members of changes in condition for Residents #2, #19, and #231, risking lack of advocacy and support.
.0582 Medicare notices: Residents #58, #66, and #178 were not provided Medicare Advance Beneficiary Notices when discharge was anticipated, risking uninformed financial liability.
.0584 Sanitary environment: Resident #380's room was unsanitary due to a cat litter box with feces in the resident's bathroom, risking cross contamination.
.0600 Abuse prevention: Residents #53, #60, #63, and #233 were subjected to abuse or neglect by staff or other residents, including rough handling, verbal abuse, and aggressive behavior.
.0609 Abuse reporting: the facility failed to timely report and investigate allegations of abuse and injury of unknown origin for Residents #19 and #61, risking ongoing abuse and harm.
.0622 Transfer and discharge: Resident #8 was transferred to hospital without proper documentation and communication to ensure safe and effective transition of care.
.0637 Significant change assessment: Residents #61 and #329 had significant changes in condition that were not timely or properly assessed and documented, risking unmet care needs.
.0657 Care plan revision: Residents #10, #19, #61, and #329 had care plans that were not revised to reflect current needs, including medication use, ADLs, discharge goals, and wound care.
.0677 ADL assistance: Residents #10, #19, #326, and #40 were not consistently provided bathing, nail, oral care, and other ADL assistance as needed, risking skin impairment and decreased quality of life.
.0684 Nursing standards: Residents #2, #19, #61, #66, and #327 did not receive timely or complete neurological assessments after falls or head injuries, risking undetected brain injury.
.0686 Pressure ulcer care: Residents #1, #326, and #329 had pressure ulcers that were not properly assessed, documented, or treated, and repositioning was inconsistently provided, resulting in worsening wounds.
.0690 Urinary care: Residents #3 and #10 did not receive appropriate catheter care and incontinence management, risking urinary tract infections and skin breakdown.
.0692 Nutrition and hydration: Resident #64's tube feeding was disconnected and formula spilled, resulting in inadequate nutrition and hydration.
.0695 Respiratory care: Resident #66 received oxygen at 3.5 liters per minute while order was for 2 liters per minute, risking oxygen toxicity.
.0725 Staffing: The facility failed to ensure sufficient nursing staff and a charge nurse on all shifts, risking delays and inadequate resident care.
.0732 RN coverage: The facility failed to ensure an RN was on duty for eight consecutive hours daily, seven days a week, risking unmet nursing needs.
.0756 Nurse staffing posting: Nurse staffing information was not posted daily or retained for 18 months, limiting transparency for residents and visitors.
.0800 Medication regimen review: Residents #14 and #31 did not have monthly pharmacist medication reviews or physician responses to irregularities, risking medication errors.
.0758 Psychotropic medication monitoring: Residents #10, #12, #19, and #61 had incomplete monitoring of target behaviors and adverse reactions, risking unnecessary medication use.
.0800 Food and nutrition: Residents on mechanical soft, cardiac, and renal diets (#2, #10, #22, #26, #32, #36, #37, #41, #42, #43, #45, #47, #56, #57, #58, #59, #62, #68, #70, #72, #176) were not served diets consistent with orders or menus; menus were not reviewed by dietitian after changes; repetitive and inappropriate foods served.
.0804 Food palatability and temperature: Residents #7, #13, #19, #25, #30, #34, #61, and #66 reported food was often cold, bland, or unpalatable; food temperatures were frequently outside safe ranges.
.0806 Food preferences: Residents #7, #10, #19, #25, #30, #34, #38, #57, #61, #63, and #66 were not assessed for food preferences or dislikes; preferred foods were not consistently served; alternates were delayed or unavailable.
.0808 Therapeutic diets: Residents #22 and #70 on renal diets received regular diets without modifications, risking adverse health effects.
.0812 Food safety: Residents #20 and #53 were served unpasteurized eggs that were not fully cooked, risking foodborne illness; immediate jeopardy was identified and removed after corrective actions.
.0842 Medical records: Resident #20's self-administration of medication was not properly documented after June 14, 2023, risking medication errors.
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Inspection Report — May 8, 2023
Routine
Date: May 8, 2023
Visit Reason
A routine health care licensure and follow-up survey was conducted to evaluate compliance with state and federal regulations.
Findings
The facility was cited for multiple deficiencies including failure to assess residents for self-administration of medication, inadequate accommodations for resident needs, failure to notify family members timely of changes in condition, failure to provide required Medicare notices, unsanitary environment related to pet care, resident abuse and neglect, failure to report and investigate abuse allegations timely and thoroughly, incomplete assessments after significant changes, incomplete and outdated care plans, inadequate bathing and personal care, failure to follow nursing standards including neurological assessments, medication regimen review deficiencies, psychotropic medication monitoring failures, nutritional and dietary deficiencies, insufficient staffing and lack of charge nurse coverage, failure to post nurse staffing information, and serving unpasteurized eggs not fully cooked resulting in immediate jeopardy which was later removed.
Deficiencies (29)
.0554 Self-administration of medication: the facility failed to assess whether residents had the ability to self-administer their medications for 2 of 4 residents reviewed, including Resident #20 and #61; Resident #20 self-administered an Albuterol inhaler without documentation and Resident #20's self-administration was not assessed.
.0558 Reasonably accommodate the needs and preferences of each resident: Resident #61's light switch was not within reach, creating potential for harm due to falls and sleep disruption.
.0565 Honor the resident's right to organize and participate in resident/family groups: the facility failed to document and address concerns raised in Food Committee meetings, placing residents at risk of ongoing frustration and decreased self-worth.
.0580 Immediately tell the resident, the resident's doctor, and a family member of situations that affect the resident: the facility failed to notify family members timely of changes in condition for 3 of 6 residents (#2, #19, #231), including late notification of falls and bruises.
.0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered: the facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (CMS-10055) to 3 residents (#58, #66, #178) with Medicare coverage.
.0584 Honor the resident's right to a safe, clean, comfortable and homelike environment: Resident #380 was observed with a cat and unsanitary litter box in the room, risking cross contamination.
.0600 Protect each resident from all types of abuse: the facility failed to ensure residents (#53, #60, #63, #233) were free from abuse by staff and other residents, including physical and verbal abuse, resulting in potential ongoing harm.
.0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities: the facility failed to report and investigate allegations of abuse and injury of unknown origin timely for Residents #19 and #61, resulting in Resident #61's injury not being investigated and Resident #19's bruises being investigated late.
.0610 Respond appropriately to all alleged violations: the facility failed to investigate and document Resident #61's unknown forehead injury and failed to document neuro checks after the fall as required.
.0622 Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged: the facility failed to ensure information was provided to the receiving hospital for Resident #8 during transfer.
.0637 Assess the resident when there is a significant change in condition: the facility failed to complete timely significant change in status MDS assessments for Residents #61 and #329 after improvements or declines in ADLs and skin integrity.
.0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals: the facility failed to revise care plans to reflect current needs for Residents #10, #19, #61, #329 including ADLs, fall care, discharge goals, and catheter care.
.0677 Provide care and assistance to perform activities of daily living for any resident who is unable: Residents #10, #19, #326, and #40 were not consistently provided bathing, nail care, and oral care as needed, resulting in poor personal hygiene.
.0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals: the facility failed to follow nursing standards for neurological assessments after falls or head injuries for Residents #2, #19, #61, #66, and #327; failed to provide ordered catheter care for Resident #10; and failed to provide oxygen per order for Resident #66.
.0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift: the facility failed to ensure sufficient staffing and failed to identify a charge nurse on all shifts, impacting residents #2, #40, #61, #62, and #69.
.0727 Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis: the facility failed to ensure an RN was on duty for eight consecutive hours per day, seven days a week.
.0732 Post nurse staffing information every day: the facility failed to post nurse staffing information daily and failed to keep records for 18 months.
.0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing: the facility failed to provide consistent pressure ulcer care, including assessments, documentation, repositioning, and treatment for Residents #1, #326, and #329, resulting in new and worsening pressure ulcers.
.0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections: the facility failed to provide catheter care and monitoring for Residents #10 and #3, resulting in risk for UTI and inadequate toileting assistance.
.0692 Provide enough food/fluids to maintain a resident's health: Resident #64 was not provided tube feeding as ordered, with feeding tubing disconnected and formula spilled on clothing and floor.
.0695 Provide safe and appropriate respiratory care for a resident when needed: Resident #66 was provided oxygen at 3.5 liters per minute while order was for 2 liters per minute via nasal cannula when sleeping.
.0800 Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs: the facility failed to provide diets that met nutritional and special dietary needs for 21 residents, including mechanical soft diets with repetitive foods and missing items, cardiac diets with regular foods, and renal diets without modifications.
.0801 Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician: the facility failed to ensure nutritional assessments were completed for Resident #380, risking malnutrition.
.0803 Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident: the facility failed to ensure menus met nutritional needs, were followed, and were reviewed by the dietitian after changes, resulting in residents receiving incorrect foods and repetitive meals.
.0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature: residents reported food was often cold, bland, and unpalatable, with cold salads served on heated plates, and temperatures outside safe ranges.
.0806 Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options: the facility failed to obtain and honor food preferences and dislikes for 11 residents, resulting in residents being served disliked foods, no choices, and delayed alternates.
.0812 Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law: the facility failed to follow physician-ordered renal diets for Residents #22 and #70, serving regular diets instead.
.0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards: Residents #20 and #53 were served unpasteurized eggs that were not fully cooked, placing them in immediate jeopardy of food borne illness; the facility implemented corrective actions and removed the immediacy.
.0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards: the facility failed to maintain documentation of self-administration of medication for Resident #20 after 6/14/23.
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