Timber Point Healthcare Center

In the surveyor’s words

From the most serious findings on record at Timber Point Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF697Mar 13, 2024

  Based on observation, interview, and record review the facility failed to administer prescribed opioid medications to keep residents' pain controlled, failed to perform a pain assessment while the residents were not receiving their prescribed opioid medications, and failed to develop a pain plan of care for two of three residents (R1 and R2) reviewed for pain in the sample of three. These findings resulted in R1, who suffers from bone cancer, experiencing uncontrolled lower back pain and resulted in R2, who suffers from Osteomyelitis from a flesh-eating wound caused by a spider bite, experiencing uncontrolled severe continuous and unbearable pain to his right lower leg wound. These failures resulted in an Immediate Jeopardy. […]

• Immediate jeopardy, isolatedF755Mar 13, 2024

  Based on observation, interview, and record review the facility failed to obtain scheduled opioid medications from the pharmacy for two of three residents (R1 and R2) reviewed for pharmacy services in the sample of three. This failure resulted in R1 abruptly stopping and missing her scheduled Fentanyl patch (Opioid Medication) for two weeks resulting in R1 experiencing withdrawal symptoms of a fall, night terrors, drooped eyes with continuous blinking, shallow and quick breaths, non-reactive pupils, garbled speech, and hypertensive. […]

• Immediate jeopardy, isolatedF760Oct 15, 2021

  Based on interview and record review, the facility failed to ensure a resident (R1) was not administered medications prescribed for another resident which affected one of four residents (R1) reviewed for significant medication errors in the sample of six. This failure resulted in R1 receiving another resident's prescribed medications and becoming ill with vomiting, loss of consciousness, decreased blood pressure, slow respirations and a decrease in blood oxygen saturation level and subsequently being transported to a local emergency room . This failure resulted in an Immediate Jeopardy. […]

• Actual harm, isolatedF600Feb 15, 2026

  Based on interview and record review the facility failed to accurately assess a resident's risk of abuse and failed to adequately supervise a resident to prevent resident-to-resident physical abuse for two of three residents (R2 and R3) reviewed for abuse in the sample of four. These findings resulted in R2 and R3 physically assaulting each other and R3 experiencing pain, ongoing increased anxiety, fear, and restlessness.Findings Include:The facility's Abuse and Retaliation Policy Prevention Program Policy dated 1/2026 documents, Policy: The facility affirms the right of our resident to be free from abuse, neglect, exploitation, retaliation, misappropriation or property, deprivation of goods and services by staff, or mistreatment. […]

• Actual harm, isolatedF686Jun 3, 2025

  Based on observation, interview, and record review the facility failed to update the care plan with pressure relieving interventions, implement pressure relieving interventions to prevent facility acquired pressure ulcers, conduct routine skin checks, and perform Braden Scale Assessments (Pressure Risk Assessments) quarterly as directed by the facility's policy for three of five residents (R4, R10, and R32) reviewed for pressure ulcers in the sample of 44. These failures resulted in R4 developing two facility acquired painful stage two pressure ulcers to R4's buttocks, R32 developing a facility acquired unstageable deep tissue pressure injury to R32's right heel that continues to worsen, and R10 developing a facility acquired painful unstageable pressure ulcer to R10's right heel that… […]