Resident #115 was admitted on September 3rd with multiple diagnoses including mild cognitive impairment, cancer of multiple lymph sites, and adult failure to thrive. His care conference wasn't held until September 16th.
The facility had signed a hospice agency delineation of care form on September 3rd that specifically documented Timber Springs was responsible for providing the date and time of interdisciplinary team meetings. But the social worker assigned to coordinate the meeting said she never read that agreement.
"She confirmed she had not read the delineation of care and was not informed the facility was responsible for coordinating the care conference," federal inspectors wrote after interviewing the social worker on November 19th.
The delay violated the facility's own policies. The Clinical Resource Nurse told inspectors that initial care conferences were to be conducted within 72 hours of admission. The social worker gave inspectors an even tighter timeline, stating care conferences were to be conducted within 24-48 hours.
Neither timeframe was met.
When inspectors asked for documentation showing the facility had worked with the hospice agency to schedule the conference, administrators couldn't produce any records. The social worker stated the next day that she did not have documentation indicating collaboration with the hospice agency.
The breakdown in communication left a dying patient without a coordinated care plan for nearly two weeks. Federal regulations require nursing homes to involve residents and their representatives in developing personalized care plans, particularly crucial for hospice patients whose complex medical needs require careful coordination between multiple care providers.
The inspection found that staff didn't understand their responsibilities under the hospice agreement. While the facility had signed paperwork making them responsible for scheduling interdisciplinary team meetings, the person tasked with organizing those meetings was never told about that obligation.
This communication failure created what inspectors called "the potential for miscommunication and unmet care needs" for a resident dealing with terminal cancer and cognitive decline.
The violation occurred despite the facility having clear policies about care conference timing. Staff gave inspectors conflicting information about those policies, with the Clinical Resource Nurse citing a 72-hour requirement while the social worker mentioned 24-48 hours. Neither standard was followed.
For hospice patients like Resident #115, timely care conferences are essential for coordinating pain management, comfort measures, and end-of-life preferences between nursing home staff, hospice workers, and family members. The 13-day delay meant crucial decisions about his care were postponed during a critical period.
The inspection was triggered by a complaint and completed on November 20th. Inspectors found the facility failed to ensure residents' representatives were provided the opportunity to participate in care plan development, reviewing records for three residents and finding problems with Resident #115's case.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents. But for Resident #115, the delay represented nearly two weeks without the coordinated hospice care plan that his terminal diagnosis required.
The facility's failure to read its own hospice agreements and communicate responsibilities to staff created a gap in care for a vulnerable patient whose complex medical needs demanded immediate attention and careful coordination between multiple healthcare providers.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Timber Springs Transitional Care from 2025-11-20 including all violations, facility responses, and corrective action plans.
Additional Resources
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