Timbercreek Rehab and Health Care Center

In the surveyor’s words

From the most serious findings on record at Timbercreek Rehab and Health Care Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF689Mar 28, 2026

  Based on observation, interview, and record review the facility failed to ensure baseboard heaters were maintained in a safe manner and failed to implement an effective system to monitor heater surface temperatures and resident room arrangements, including bed placement, to prevent burn hazards and potential fire risks. These deficient practices resulted in R1 becoming entrapped between the bed and a baseboard heater, sustaining painful partial-thickness burns with blistering to the left upper arm, left forearm, and left hand that required emergency room treatment. […]

• Immediate jeopardy, patternF689Jul 25, 2024

  Based on observation, interview and record review, the facility failed to prevent a resident with known wandering and exit seeking behaviors from leaving the facility without staff supervision for one of four residents (R1) reviewed for elopement in a sample of four. R1 was last seen by staff in the facility on 7/13/24 at 6:00 pm and was located three days later (7/16/24) on a local park bench, approximately two and a half miles from the facility, in 90-degree Fahrenheit temperature. This failure resulted in R1 requiring transportation to the local hospital for evaluation and treatment. This failure has the potential to affect all Elopement Risk Residents residing in the facility. Findings include: This failure resulted in an Immediate Jeopardy. […]

• Immediate jeopardy, patternF600Jan 14, 2021

  Based on observation, interview and record review, the facility failed to develop and implement interventions to successfully protect a vulnerable resident (R1) from multiple inappropriate sexual advances by R2 and R3. The facility also failed to prevent two male residents (R2 and R3) with a history of sexual abuse from having continued access to R1 and all other residents on the same wing. These failures have the potential to affect five of five residents (R1-R5) reviewed for Abuse in a sample of fourteen. These failures resulted in an Immediate Jeopardy. […]

• Actual harm, isolatedF689Jul 30, 2026

  Based on observation, interview and record review, the facility failed to provide continuous observation for two of two residents (R4, R8) that are at high risk for falls and require continuous monitoring, in a sample of 10. These failures resulted in R4 having an unwitnessed fall which required R4 to be transferred to the hospital emergency room for evaluation and was diagnosed with Acute Cystitis with Hematuria, Urinary Tract Infection, Post Traumatic Contusion, Edema of Left Frontal Scalp (Hematoma) and Left Hip Pain. The following days, R4 was reported to be lethargic, had slurred speech, was leaning left, hallucinating, required more assistance with activities of daily living and went on hospice on 7/17/26, 6 days post fall. […]

• Actual harm, isolatedF825Jul 22, 2026

  Based on observation, interview, and record review, the facility failed to ensure physician-ordered rehabilitation services were implemented and monitored for one (R1) of three residents reviewed for rehabilitation services in the sample list of five. This failure resulted in R1 not receiving ordered rehabilitation services from admission through the time of survey, placing R1 at risk for avoidable functional decline and causing R1 to express fear, anxiety and depression. Findings include:R1's census record documents R1 admitted to the facility on [DATE].R1's Medical Diagnosis list documents R1 was admitted to the facility following a left lower extremity fracture requiring surgery and has diagnoses including Cellulitis of the left lower limb, Type 2 Diabetes Mellitus, Morbid Obesity,… […]