The Timbers Skilled Nursing And Therapy
The Timbers Skilled Nursing and Therapy in Edmond, OK — inspection on February 27, 2026.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
facility policy titled Notification of Change, dated 07/2012, read in part, The facility will notify the
jeopardy to resident health or there is: 1.A significant change in the residents' physical, mental or psychological status,2. An safety accident involving the resident that results in injury or has the potential for requiring physician intervention,3. A need to alter treatment significantly, and4. A decision to transfer or discharge the
had a BIMS score of 10 which indicated moderate cognitive impairment and they received insulin injections.A Baseline Assessment and Care Plan for Resident #129, dated 11/18/24, showed the resident had diagnoses which included type 2 diabetes mellitus with hyperglycemia.A physician's order for Resident #129, date ordered 11/18/24, showed Glucagon Emergency Injection Kit 1 mg (a medication to treat very low blood sugar), inject one dose intramuscularly (a shot into a muscle) as needed for FSBS less than 71, give cola/orange juice and/or high carb snack, and notify physician.A document titled Injections/Insulin/FSBS for Resident #129, dated 11/27/24 at 8:00 p.m., showed the resident's blood sugar was 64.
The physician was not notified of the FSBS below 71 per physician's order.A Nurses Progress Note for Resident #129, dated 11/28/24 at 9:07 a.m., read in part, Focused assessment r/t need for send out for emergency services.
Upon assessment it was noted pt was unresponsive. Pt not even reacting to sternal rub. VS obtained 130/73, 78, 96%, 12, 97.8.
This nurse called 911, EMS arriving and reporting FSBS was 41. Pt then transported via stretcher to [hospital name withheld].A facility policy titled Blood Glucose Monitoring Guideline, dated 01/2026, read in part, Follow physician orders based on finger stick results. If no follow up orders are in place, notify the physician of noted signs/symptoms of hypo/hyperglycemia.A document titled Quality Assurance and Performance Improvement, dated 02/26/26, showed the facility held a QA meeting to discuss and implement measures related to the failure of notification to physician.An in-service document, dated 02/26/26, showed all staff had been educated on physician and family notifications of changes, what constituted a change in condition, and how a change in condition would be communicated internally.On 02/26/26 at 2:14 p.m., RN #2 stated if a diabetic resident was unresponsive, they called 911 and notified the physician and family.On 02/26/26 at 2:22p.m., RN #1 stated if a diabetic resident was unresponsive, they checked a FSBS and notified the physician. On 02/26/26 at 2:50 p.m., the DON stated if there were orders to notify the physician of blood sugar less than 71, they expected the nurses to follow the order and notify the physician.On 02/26/26 at 2:53p.m., RN#1 was shown the November 2024 Injection/Insulin/FSBS administration record.
They stated their initials indicated the blood sugar was 64. RN #1 stated they did not call the physician per orders.On 02/27/26 at 10:02 a.m., the medical Director stated if a resident blood sugar was below 71 nurses should notify the physician.On 02/27/26 at 11:12 a.m., RN #2 stated they were educated on identifying changes in condition for residents.
They stated they were educated on notifying physicians and representatives of changes in condition. On 02/27/26 at 11:15 a.m., LPN #1 stated they assisted in providing education for all staff regarding changes in condition for residents.
They stated they were a part of the quality assurance meeting.On 02/27/26 at 11:16 a.m., LPN #2 stated they were educated on signs and symptoms of hypoglycemia, identifying changes in condition in residents, and when to notify the physiciany of changes.On 02/27/26 at 11:17 a.m., LPN #3 stated they were educated on changes in condition and when to notify the physician of changes.02/27/26 at 11:20 a.m., the assistant director of nursing stated they were educated on notifications to the physician regarding changes in condition.On 02/27/26 at 11:22 a.m., LPN #4 stated they were educated on identifying changes in condition for residents.
They stated they were educated on when to notify the physician and resident's representative regarding changes in condition.
375158 02/27/2026
The Timbers Skilled Nursing and Therapy 2520 South Rankin Edmond, OK 73013
arriving and reporting FSBS was 41. Pt then transported via stretcher to [hospital name withheld].A
jeopardy to resident health or orders based on finger stick results. If no follow up orders are in place, notify the physician of noted safety signs/symptoms of hypo/hyperglycemia. A facility document titled, Injections/Insulin/FSBS, showed an order for Glucagon Emergency Injection Kit 1mg (a medication to treat very low blood sugar) to
less than 71 give cola/orange juice and or high carb snack and notify physician.A document titled Quality Assurance and Performance Improvement, dated 02/26/26, showed the facility held a QA meeting to discuss and implement measures related to the failure to assess, monitor, and intervene for a resident with hypoglycemia.An in-service document, dated 02/26/26, showed all staff had been educated on assessing, monitoring, and intervening for residents with hypoglycemia.On 02/26/26 at 2:14 p.m., RN #2 stated if a diabetic resident was unresponsive, they called 911 and notified the physician and family.On 02/26/26 at 2:22p.m., RN #1 stated a resident with a blood sugar of 64 depending on how responsive the resident is they would give glucose tablets or fluids or a snack. If the resident can swallow, they are not going to give a shot.On 02/26/26 at 2:50 p.m., the DON stated if there were orders to notify the physician of blood sugar less than 71, they expected the nurses to follow the order and notify the physician.On 02/26/26 at 2:53p.m., RN #1 showed the November Injections/Insulin/FSBS administration record with Resident #129 blood sugar of 64. RN #1 stated their initials which indicated they administered 40 units of (Toujeo SoloStar subcutaneous solution) long-acting insulin to Resident #129.On 02/27/26 at 10:02 a.m., Medical Director stated if a resident had a blood sugar of 64 depending on the status of the resident if awake administer juice if unresponsive give Glucagon injection.
They stated they would not expect the nurse to administer a long-acting insulin.On 02/27/26 at 11:12 a.m., RN #2 stated they were educated on assessing, monitoring, and intervening for residents with hypoglycemia.On 02/27/26 at 11:15 a.m., LPN #1 stated they assisted in providing education for all staff regarding assessing, monitoring, and intervening for residents with hypoglycemia.On 02/27/26 at 11:16 a.m., LPN #2 stated they were educated on signs and symptoms of hypoglycemia and assessing, monitoring, and intervening for residents with hypoglycemia.On 02/27/26 at 11:17 a.m., LPN #3 stated they were educated on assessing, monitoring, and intervening for residents with hypoglycemia.02/27/26 at 11:20 a.m., the assistant director of nursing stated they were educated on assessing, monitoring, and intervening for residents with hypoglycemia.On 02/27/26 at 11:22 a.m., LPN #4 stated they were educated on assessing, monitoring, and intervening for residents with hypoglycemia.