TIMBERLYN HEIGHTS NURSING AND REHABILITATION

Nursing Home Inspector

320 MAPLE AVENUE
GREAT BARRINGTON, MA 01230
Berkshire County
Phone: 413-528-2650
Provider Number: 225495
Last Inspection: 08/15/2016

About the Nursing Home

Number of Beds: 71
Number of Residents: 61
Beds Available: 10
Percent Occupancy: 86%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: For profit - Partnership
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

16

Facility
14

County
16

MA
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

16

2016
24

2015
7

2014

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

8/15/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Assess in a timely manner the resident when the resident enters the nursing home. Isolated : Minimal 3 9/23/2016
 
Failed To: Assure that each resident’s assessment is updated at least once every 3 months. Isolated : Minimal 3 9/23/2016
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 9/23/2016
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Isolated : Minimal 3 9/23/2016
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Pattern : Minimal 4 9/23/2016
 

5/12/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Let residents refuse treatment, refuse to take part in an experiment, or formulate advance directives. Isolated : Minimal 3 6/26/2015
 
Failed To: Provide medically-related social services to help each resident achieve the highest possible quality of life. Isolated : Minimal 3 6/26/2015
 
Failed To: Assess in a timely manner the resident when the resident enters the nursing home. Isolated : Minimal 3 6/26/2015
 
Failed To: Review or revise the resident's care plan after any major change in physical or mental health. Isolated : Minimal 3 6/26/2015
 
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Isolated : Minimal 3 6/26/2015
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 6/26/2015
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 6/26/2015
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Isolated : Minimal 3 6/26/2015
 

4/28/2014 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide medically-related social services to help each resident achieve the highest possible quality of life. Isolated : Minimal 3 5/16/2014
 
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Pattern : Minimal 4 5/16/2014
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

3/21/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Isolated : Minimal 3 4/30/2017
 
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Isolated : Minimal 3 4/30/2017
 
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Isolated : Minimal 3 4/30/2017
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated : Minimal 3 4/30/2017
 

2/9/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Isolated : Minimal 3 3/4/2016
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg MA State Avg
Number of Residents 61 94.47 96.79
Registered Nurses 0.76 0.77 0.89
Licensed Practical / Vocational Nurses 0.79 0.84 0.84
Certified Nursing Assistants 2.71 2.12 2.30
Total Staff Hours 4.26 3.72 4.03

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% MA State Avg%
of high risk long-stay residents with pressure ulcers 4 4 4
of long-stay residents assessed and appropriately given the pneumococcal vaccine 85 94 92
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 100 95 95
of long-stay residents experiencing one or more falls with major injury 3 3 3
of long-stay residents who have depressive symptoms 1 3 2
of long-stay residents who lose too much weight 1 4 5
of long-stay residents who received an antianxiety or hypnotic medication 44 28 20
of long-stay residents who received an antipsychotic medication 56 20 18
of long-stay residents who self-report moderate to severe pain 0 2 4
of long-stay residents who were physically restrained 0 1 0
of long-stay residents whose ability to move independently worsened 22 18 18
of long-stay residents whose need for help with daily activities has increased 10 14 14
of long-stay residents with a catheter inserted and left in their bladder 0 0 1
of long-stay residents with a urinary tract infection 0 1 3
of low risk long-stay residents who lose control of their bowels or bladder 5 43 54
of short-stay residents assessed and appropriately given the pneumococcal vaccine 53 82 79
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 65 11 11
of short-stay residents with pressure ulcers that are new or worsened 6 74 60