Timberwood Court Specialty Care Community

Deficiency:stained carpet and strong urine odor.
Plan of correction
1. All community carpets were professionally cleaned with a odor nutralizer specific to urine on 8/28/2025. Areas with stains were treated with an acid wash on 8/28/2025.
2. Carpeting in all common areas on both Oak and Maple sides will be replaced to fully address the staining and odor. The community is currently accepting bids for carpet replacement. Once bid is selected , installation will occur within an estimated 10-12 weeks lead time.
3. Until the carpeting is replaced housekeeping supervisor will complete enviromental rounds to ensure the areas remain clean and odor free, this information will be shared with the Executive Director and any stains or odors will be addressed immediately. Carpets have been scheduled for twice monthly professional cleaning and application of odor nutralizer. These processess will ensure carpets remain clean and odor free and prevent reoccurrance of stain and odor concerns.
4. The Housekeeping Supervisor with oversight by the Executive Director will be responsible for ensuring corrections and completed and monitored.

Deficiency:stained carpet and strong urine odor.
Plan of correction
1. All community carpets were professionally cleaned with a odor nutralizer specific to urine on 8/28/2025. Areas with stains were treated with an acid wash on 8/28/2025.
2. Carpeting in all common areas on both Oak and Maple sides will be replaced to fully address the staining and odor. The community is currently accepting bids for carpet replacement. Once bid is selected , installation will occur within an estimated 10-12 weeks lead time.
3. Until the carpeting is replaced housekeeping supervisor will complete enviromental rounds to ensure the areas remain clean and odor free, this information will be shared with the Executive Director and any stains or odors will be addressed immediately. Carpets have been scheduled for twice monthly professional cleaning and application of odor nutralizer. These processess will ensure carpets remain clean and odor free and prevent reoccurrance of stain and odor concerns.
4. The Housekeeping Supervisor with oversight by the Executive Director will be responsible for ensuring corrections are completed and monitored.

Providers plan of correction for the tag of C240 and memory care tag Z142 is as follows. A. Food debris, splatters, loose food, trash, dirt, dust and or black matter that was visable on the following areas has been cleaned and made in good repair. ~The popcorn machine has been cleaned and stored in an offsight location at this time. ~Maple and Oak kitchenette drawers and cupbaords have been wiped down and food debris removed. This task has been added to the nightly cleaning list for care partners to complete nightly. This will be over seen each night by the supervisor on duty. ~Maple and Oak kitchenette ovens and burners are to have debris removed and cleaned nightly as needed to remove food debris and spills. This task has been added to the nightly cleaning task list and will be over seen nightly by the supervisor on duty. ~Kitchen drains have been cleaned and task added to weekly zonal cleaning for the kitchen cleaning. This will be monitored by the Dining Serviced Director. ~Areas in kitchen ceiling in main kitchen have been cleaned and patched and repainted. Cleaning of kitchen ceiling will be done monthly by maintenance director. ~Kitchen ceiling vents and light fixtures were taken down and cleaned and repainted. Maintenance director will check and clean monthly.~Countertop mixer has been deep cleaned with food debris removed. A plastic dust cover was purchased and is in place while not in use to keep dust off the machine. Cleaning of this item has been added to the weekly zonal cleaning for this item. This will be overseen by the Dining Services Manager. ~Exterior of meal delivery cart was deep cleaned and debris was removed. This task has been added to the daily cleaning task list for the kitchen and will be overseen by the Dining Services Director. B.The following areas were in need of repair. ~Main Kitchen ceiling had peeling and chipped paint. The areas have been cleaned, sealed and repainted. Maintenance Director will observe ceiling monthly and repair any further areas as needed. ~Drawers in units with exposed porus wood and wood shelving under steam table has porus wood. This area has been repainted and a metal overlay has been ordered to prevent continued surface areas from being scraped, scratched and wood exposed as a porus surface. This metal is expected to be in the community 6/25/2024 and will be installed within 2 weeks after the metals arrives. This area will be inspected monhly to look for areas that have non cleanable surfaces by the Dining Services Director. C. Staff person was unable to demonstrate adaquate knowledge of employee illness and symptoms for exclusion. This director has printed the illness policy and each kitchen employee was given a copy and a signed copy was placed in each kitchen persons file. A copy of the illness policy was also made available in the kitchen area to reference. This policy is also available in the community guidebook. D. Multiple cutting boards and cutting surfaces were found heavily stained. New Cutting boards were ordered and are in place in the kitchen. Old stained cutting boards have been removed from the community. Dining Services Manager will inspect items monthly and order new items as these become stained or not have a cleanable surface area. ~Multiple grill spatulas were damaged and no longer had smooth cleanable surfaces. These items were removed from the kitchen and replaced with brand new spatulas. Dining Services Manager will inspect items monthly or as needed and replace or repair items when surface no longer cleanable or become porus. ~utility cart that was storing chemicals was rusted and not a smooth cleanable surface. Cart was removed from the premises and chemicals are now stored in a different location. E. Multiple food items in fridges and freezers did not contain open or use by dates. The task of dating items will be done as items are opened and used. It will be overseen each day by the cook on duty.F. Oak and Maple fridges did not have cold food thermometers where food temps could be monitored daily. Fridge thermometers were purchased for both fridges and are in place in each fridge. The task of monitoring the temps was placed in the ECP system and will be done daily by the med techs. H. Maple kitchenette had single serve spoons and straws that were stored open. Straw and spoon dispensers were purchased and are in place in both kitchenettes. These items will be replaced as needed. I. Staff was observed washing dishes and not washing hands when going between dirty and clean dishes. The staff was also observed using a dish towel to wipe the surface of a sanitized dish after it had been on the waist of a staff member. Kitchen inservice has been scheduled for June 25th and the topic of proper sanitation and dish washing will be taught again. The regional Dining Services Director will oversee this class.

see C 240

Community acknowledges that Facility areas were not maintained in occordance with the Food Sanitation rules and have been addressed as described below., Kitchen cleaning list has been updated and posted for daily, weekly and monthly cleaning duties. Each person will sign off on cleaning duties completed and Executive Chef will audit cleaning schedule weekly. 1. Areas of kitchen food starage, food prep and food service revealed splatters, spills, drips, dust and debris ~Can opener and casing, Can opener was replaced with new equipment. Equipment is scheduled to arrive on 6/10/2023 and will be installled my building maintainence and will be cleaned daily by kitchen staff on duty. 2. small table top mixerMixer cover has been ordered and will be here on or about 5/8/2023 and will be used to cover mixer when not in use. Kitchen staff will ensure that mixer is cleaned as needed and after every use and covered when not in use. 3. Interior drawer next to steam table that holds the hambuger buns.Debris was removed from kitchen drawer on 5/17/2023. Kitchen staff to wipe out drawer after each meal or as needed to prevent crumbs or debris from building up in drawer. This taskadded to daily cleaning schedule by kitchen staff 4.Grill/oven/stove knobs and Vents, Fire sprinklers and parts of ceiling fan with dust accumulation. Kitchen staff to remove items from the stove daily and clean and remove debris and dust per cleaning schedule daily. Vents, ceiling fan and fire system being cleaned by fire company on 6/23/2023 to remove the dust and grease build. Community setup routine cleaning with fire company for 1x each quarter.

5.Corner of steam table area with plastic covering broken and pieces missing as welll as areas of laminate surface chipped and missing exposing wood surface.Broken pieces were removed and replaced with new plastice pieces. Exposed wood was cleaned and repaired with fresh paint 6/12/2023 Cabinets with exposed wood were repainted by 6/12/2023 ensuring clean surfaces with no exposed wood 6.Ceiling around vent in dry storage in need or repairCeiling area and vent was cleaned and repainted on 6/2/2023 by building maintenance. 7.Clock was broken with large plastic piece missing and Multiple vents with rust buildup. Clock was replaced with new clock on 6/2/2023, vents were moved cleaned and replaced with a fresh coat of paint on 6/2/20238. Slicer was observed to be uncovered and was not protected from potential contamination while not in use. Slicer cover was ordered and is scheduled to be here about 6/23/2023. Staff using clean dry palstic bags until new cover gets here. Staff to ensure slicer is santitzed as needed and ensure cover is in place when not in use.9. Cutting board on steam table was observed heavily soiled scored and stained. Community will use bleach solution to wash and sanitize daily and as needed to ensure it is clean.Completed and as needed by 6/1/2023 10.Facility did not have small diameter thermometer to accurately check or monitor temperatures of thin foods. Community ordered and received small thermometers on 05/22/2023 11.Ice machine was found with large amount of mold type substance. Facility was instructed while surveyor was still in the building to empty the ice machine and service. Ice machine was promptly emptied and cleaned and weekly cleaning has been added to cleaning schedule. Kitchen staff will ensure this gets done weekly.Ice machine will also be serviced every 6 months by maintenance director 12.Ware washing machine was not reaching temp of 180 degrees for effective sanitation Machine continued to not temp after maintenance supervisior checked it. Kitchen staff were instructed to do sanitation in the 3 compartment sink until it could be fixed. Machine tech determined thermostat was bad and part has been ordered.Machine is temped daily by kitchen staff and if machine does not temp out to 180, maintenance is called and 3 sink sanitation is implemented. 13.Meal service was observed and kitchen staff were using single service gloves incorrectly. Kitchen staff have a training on 6/26/2023 to be retrained on handling food items with gloves and how to prevent cross contamination

Community acknowledged incomplete investigations and lack of reporting for incidents that met reporting criteria for Resident #2 for the dates in question (11/16/2021, 11/25/2021, 12/6/2021, 12/7/2021, 12/9/2021, 12/22/2021 and 12/31/2021). Community completed required reporting prior to survey exit on 2/8/2022. Community to conduct in-service training with staff on Abuse Reporting and Investigation Guidelines for Providers by March 31, 2022. Executive Director and/or Designee will be responsible for conducting investigations and meeting reporting requirements on an ongoing basis. Random compliance audits will be conducted by regional team (VPO and/or Nurse Consultant) on a bi-annual basis.

1. What actions will be taken to correct the rule violation for each example/resident? Resident #1: Upon further record review resident did have service plan completed in computer system on 12/25/2021 which meets the quarterly requirement; however, was not reviewed signed and completed by responsible party/resident and community and did not contain items listed in citation. Resident #1 will have review of service plan and update to reflect current care needs (such as Anti-coagulant therapy, turning and positioning, oral care and use of lip ointment) and completed by 3/31/2022.Resident #2 will have review of service plan and update to reflect current care needs (such as Dressing with repeated clothing changes, sleep schedule, toileting assistance, incontinent care, and toileting in inappropriate places, use of psychotropic medication, grooming of facial hair, meal assistance, health shakes, fluid needs, fall and safety interventions to include fall mat) and completed by 3/31/2022. Resident #4 will have review of service plan and update to reflect current care needs (such as assistance needed with transfers) and completed by 3/31/2022.All Resident's services plans will be reviewed, with ISP or handwritten changes that are initial and dated implemented for any care needs not addressed in service plan by 4/8/2022. Changes to be fully incorporated into service plan with next comprehensive service plan (quarterly or change in condition). ED, RCC and HSD will be re-educated on completed timely and comprehensive service plans by VPO or Nurse Consultant by 3/1/2022. Staff to be educated on utilization of service plans for providing care by 4/1/2022.ED and/or HSD to review service plans prior to locking to ensure they reflect the Resident current care needs on an ongoing basis. Random SP audits to be conducted by Health Service Department during QA process at least monthly.

Resident #1,2,3 & 4 will have service plans reviewed by Service Plan Team that will consist of the following members at a minimum: Executive Director, Health Service Director, Resident Care Coordinator, Lifestyles Director, Resident/Responsible Party will be invited to attend and participate as part of this team. Other team member will be included on a Resident-by-Resident basis to include: Caseworker, Hospice, and other Third-Party Providers as appropriate. Executive Director and/or HSD will oversee compliance by reviewing Service Plans prior to locking.

idents # 1 & 2 will have outside provide records requested and reviewed. Any recommendations not currently implemented will be initiated and documented within medical record by 3/31/2022. HSD and/or ED will meet with current outside providers to review protocol for exchange of information and coordination of care. Staff will be provided additional education on coordination of care with outside providers by 3/31/2022. Review of outside provider documentation will be conducted weekly during High-Risk Resident Meeting with follow-up by HSD/RCC as needed. Random chart audit for coordination of care will be conducted during QA process by Health Service Team.

Resident #4 order for Sertraline 50 mg was received from the pharmacy prior to survey exit on 2/8/2022. All Resident MARs reviewed and compared to current orders to ensure signed orders are in-house conducted and completed by 3/15/2022. Re-education for medication technicians regarding process for verifying medication orders prior to administration. Verification of order validation process by RCC/HSD and re-education to be completed by Nurse Consultant. All Re-education to be completed by 3/31/2022. Monthly Sample of 5-10% of Resident for MAR to Order audits by Health Service Department and quarterly pharmacy consultant reviews for QA purposes.

Resident # 4 MAR will be updated to reflect need for documentation of non-drug interventions prior to administration of PRN Psychotropic Medications and service plan to address potential side effect monitoring. All Residents all PRN Psychotropic Medications will be reviewed to ensure their MAR reflects non-drug intervention utilization prior to administration and service plans are reflective as side effect monitoring by 4/8/2022. Med Techs will be re-educated on psychotropic medications, non-drug interventions, documentation and EMAR set-up and utilization for these processes. HSD/RCC to oversee the compliance with documentation and implementation of ISPs/Service Plans for side effect monitoring. HSD or Designee to oversee compliance with by MAR audits quarterly.

The following areas have been address as described below: o The floor in the laundry room is being replaced all supplies have been ordered with an estimated delivery date of 4/2/2022. Instillation has not been scheduled pending an exact delivery date. Areas will continue to be cleaned to the best of the communities ability until replacement is finished. o The laundry room had sheetrock replaced and areas re-puttied, re-painted, to repair the walls. Area cleaned and cracks sealed by 4/9/2022 o Top surface of industrial washing machine, as well as connected tubing and venting surfaces were coated in white powder and dust Washing Machine cleaned, tubing replaced, and vent areas cleaned by 4/9/2022 o Ceiling in main laundry room had multiple areas of chipped paint, creating uncleanable surfaces Area repainted and cleaned by 3/15/2022 o Utility sink in main laundry room was coated with speckled black debris, as well as gray, yellow and brown splatters Sink cleaned, and debris and splatters removed by 3/1/2022 o Doors and door jambs throughout Oak and Maple units had chipped paint and black streaks Doors and door jambs throughout Oak and Maple cleaned and repainted as needed by 4/9/2022. o Quarter round floor moldings in Oak dining room were loose and pulled away in multiple spots. Floor molding repaired and where unable to be repaired was replaced by 4/9/2022 o Built-in bookcases in activity areas in Oak and Maple units had splatters, streaks and chipped paint. Built-in bookcases in activity areas in Oak and Maple cleaned with splatters/streaks removed and chipped paint areas touched up. All areas above added to Preventative Maintenance Plan and routine housekeeping schedules. ED and ESD to conduct routine community physical plant inspections at least monthly to check for areas needing repairs/replacements.

Refer to POC for C231 and C513

Refer to POC for C 260, C 262, C 290, C 303 and C 330.

Residents # 1 & #4 will have service plans updated to reflect hydration needs. Residents with specialized hydration needs will have services plans reviewed, with ISP or handwritten changes that are initial and dated implemented for any hydration needs not addressed in service plan by 4/8/2022. Changes to be fully incorporated into service plan with next comprehensive service plan (quarterly or change in condition). Staff to be educated on hydration and inclusion of specialized hydration needs in service plans by 4/1/2022.ED and/or HSD to review service plans prior to locking to ensure they reflect the Specialized Hydration needs (as needed) on an ongoing basis. Random SP audits to be conducted by Health Service Department during QA process at least monthly.

Residents # 1, #2 & #4 will have service plans updated to reflect individualized activity plans. Residents will have the following areas evaluated with each comprehensive evaluation: Current abilities and skills; Emotional and social needs and patterns; Physical abilities and limitations; Adaptations necessary for the resident to participate; and Activities that could be used asbehavioral interventions. Individualized Activity Plans to be developed in the Service Plan for each resident. Current residents will be reviewed and an ISP or handwritten changes that are initial and dated implemented for individualized activity plans not addressed in service plan by 4/8/2022. Changes to be fully incorporated into service plan with next comprehensive service plan (quarterly or change in condition). Staff to be educated on individualized activity plans and utilization of these plans by 4/1/2022.ED and/or HSD to review service plans prior to locking to ensure they reflect the individualized activity plan on an ongoing basis. Random SP audits to be conducted by Lifestyles Director for QA process at least monthly.

Resident #2 Service Plan will be updated to reflect Behaviors to include: anxiety, exit seeking, yelling, hitting staff, disrobing, hallucinations and aggression towards other residents including hitting and grabbing and individualized interventions to minimize or mitigate the potential negative outcome from these behaviors by 3/31/2022. Resident #4 Service Plan will be updated to reflect behaviors to include: anxiety, throwing themselves onto the floor, refusing care, hallucinations, and aggressive behaviors towards other residents and staff including yelling and threats and individualized interventions to minimize or mitigate the potential negative outcome from these behaviors by 3/31/2022.Other Residents with known behaviors will have service plans reviewed and updated as needed to reflect behaviors and individualized interventions to minimize or mitigate the potential negative outcome from these behaviors by 4/8/2022.Staff to be provided education on utilization of service plans for minimizing and/or mitigation strategies for behaviors by 3/31/2022. ED and/or HSD to review service plans prior to locking to ensure they reflect the individualized intervention for behaviors on an ongoing basis. Random SP audits to be conducted by Health Service Team for QA process at least monthly.