Timber Ridge Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Timber Ridge Health and Rehabilitation, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812May 6, 2026

  Based on observation, staff interview, and record review, the facility did not ensure food was stored and served in a safe and sanitary manner. This practice had the potential to affect 44 of 44 residents residing in the facility. Staff did not store food in a manner to ensure food safety, including proper labeling and dating practices. Staff did not accurately test parts per million (PPM) of the sanitizing solution or accurately complete testing logs. Kitchen equipment and food services areas were not in clean and condition. Staff did not follow safe food cooling protocols. Staff did not appropriately test and maintain dishwasher temperatures. In addition, staff engaged in an unsanitary dishwashing process. Staff did not wear hair restraints consistently throughout the kitchen. […]

• No harm, potential for more than minimal, widespreadF812Feb 12, 2025

  Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect all 29 residents residing in the facility. The cooler and dry storage area contained multiple open and undated items. In addition, one item was stored uncovered and open to air. Staff did not consistently document cooked food temperatures. Staff did not follow safe food cooling protocols. Findings include: During an initial kitchen tour that began at 9:10 AM on 2/10/25, Dietary Manager (DM)-G confirmed the facility employs contracted kitchen staff and follows the contracted company's procedures for food preparation and storage. […]

• No harm, potential for more than minimal, patternF804May 6, 2026

  Based on observation, staff interview, and record review, the facility did not ensure meals were served at a safe and appetizing temperature and prepared in a way to conserve nutritive value. This practice had the potential to affect more than 4 of the 44 residents residing in the facility. Staff did not follow a recipe when preparing pureed food in order to conserve/ensure the nutritive value of the food. Staff did not appropriately temp meals served to residents. Food was served outside the designated temperature range. Findings include: The facility's Puree Food Preparation policy, revised 3/1/26, indicates: It is the policy of this facility to provide pureed food that has been prepared in a manner to conserve nutritive value, palatable flavor, and attractive appearance .1. […]

• No harm, potential for more than minimal, patternF880May 6, 2026

  Based on observation, staff and resident interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection. This practice had the potential to affect more than 4 of the 44 residents residing in the facility. R3 had open wounds on both feet and had an order for enhanced barrier precautions (EBP). R3's room entrance did not contain an EBP sign or other EBP protocol. R3's care plan did not indicate R3 was on EBP. R8 had open wounds on the buttocks. R8's room entrance did not contain an EBP sign or other EBP protocol. R8 did not have an order for EBP. R8's care plan did not indicate R8 was on EBP. R34 had a surgical wound and drain. […]

• No harm, potential for more than minimal, patternF757Feb 12, 2025

  Based on staff interview and record review, the facility did not ensure high-risk medications were monitored for 4 residents (R) (R11, R18, R19, and R26) of 5 residents reviewed for unnecessary medications. Staff did not monitor R11 for side effects or adverse reactions of pain medication. Staff did not monitor R18 for side effects or adverse reactions of anticonvulsant, pain, and diuretic medication. Staff did not monitor R19 or R26 for side effects or adverse reactions of pain and diuretic medication. Findings include: The Facility's Medication Utilization and Prescribing-Clinical Protocol (Policy), revised April 2018, indicates: 1. […]