Timber Ridge / Neurorestorative Timber Ridge

Buildings & grounds conducted for PRTF building from 9Am-10:30Am. Client/Staff ratio: 8:12. School observed to have staff/Client ratio 7:12. All sleeping areas furnished, safe, clean and in good repair except room 7, had one pair of pants with tie strings in them, room 8 had 3 pairs of pants with tie strings in them. The gaming area had a toy bag with a long string in it. The items were immediately given to the PRTF supervisor. They stated that all staff will inventory clothing for strings today. They stated that weekly checks will start being conducted to inventory for strings in clothing. All 6 bathrooms functioning, clean and sanitary with good working sinks and toilets.

MAR checked for: [Redacted]. All initialed and up to date. Americana building observed to be furnished, clean and in good repair. Bathrooms clean and sanitary. No grounds safety concerns. Client ratio residing in Americana: 5, staff present 2. Clients were at the pediatric school today. Regulations out of compliance: 911.15.F – at PRTF building room 7, one pair of pants with strings, room 8 had 3 pairs of pants with tie strings in them. Licensing Specialist: Clayton DeBoer.

• Licensing Specialist: Clayton DeBoer.
• Facility visited from 1:00pm – 2:00pm for PRTF building. Census: 11. MARs checked for 5 residents. No licensing concerns noted during visit.

• Licensing Specialist: Clayton DeBoer.
• Census: 12. Buildings and grounds conducted from 1:30pm – 3:00pm and MARs checked for 5 clients; No concerns noted.

Facility visited and records reviewed for 10 clients and 10 personnel.

Walkthrough conducted of Americana and Cabin 6 (visit cut short due to immediate notification of quarantine); MARs checked for 5 residents. No concerns noted.

• Census 13; Reviewed 7 medication logs. Most children were at school during the visit.
• Regs out of compliance –
  • R908.8 – All evening dosages were pre-signed on the medication log. Ensure medication is only logged as dispensed and training is provided to nurses.
  • R406.3 – Nurse came back to sign a noon and PRN dose while reviewing logs; Ensure medications are only logged as dispensed and training is provided to nurses.
  • R406.5 – Prescription cream was left in child’s room. Corrected 11/10/21.
• TA –
  • R911.6 – Hole in wall appeared to be in process of being repaired in room 9.

• Specialist conducted building and grounds inspection; Reviewed medication logs for 8 residents. Initials were missing from the logs on the date of 8/10/21 for all 3 residents. Found multiple items of clothing during walkthrough that contained drawstrings.
• Regs out of compliance –
  • R911.15.f – Ensure all shoelaces, drawstrings, and cords are removed from belongings and are not accessible to residents. This was corrected on site at the time of visit.
  • R406.4.d – Ensure initials of the person giving meds are on the med log. The nurse that was on duty advised that she normally fills these out at the end of the shift. Nurse agreed to fill them out when the meds are given. The Compliance Officer advised the Nurse Manager would re-train all staff on this procedure.

• Reviewed 10 personnel records. No regs noted out of compliance.

• Specialist viewed new building that will be in use in next couple of weeks, Extension of cabin 6. Also viewed cabin 6 and Americana.
• Regs out of compliance:
  • R911.15.f – One clothing item found in room with drawstring. Correction date 12/7/20.
• Regs not correctable:
  • R908.8 – Meds not logged for Sunday, 12/6/20 for 2 children at 5:30am.