Timberland Ridge Nursing & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Timberland Ridge Nursing & Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF692Oct 29, 2025

  Based on observation, medical record review, policy review, and interview, the facility failed to develop and implement a comprehensive, individualized and effective nutrition/hydration plan to prevent weight loss and dehydration for Resident #12. This affected one resident (#12) of three residents reviewed for significant weight loss. The census was 65. Actual harm occurred on 10/01/25 when Resident #12, who had moderate cognitive impairment, was at moderate risk for malnutrition, required cues and assist with eating, and had a care-planned intervention to monitor and provide hydration as prescribed, was assessed to weigh 189.4 pounds representing a 17.3 pound or 8.3 percent (%) severe weight loss in two weeks. […]

• No harm, potential for more than minimal, widespreadF727Aug 12, 2025

  Based on record review, the CASPER Payroll Based Journal Staffing Data Report for the Second Quarter of 2025 (01/01/25 to 03/31/25), staffing schedules, posted staffing information, and staff interview, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 63 residents residing in the facility.Findings include: Review of facility staffing schedules, posted staffing information, and the CASPER Payroll Based Journal Staffing Data Report for the Second Quarter of 2025 (01/01/25 to 03/31/25) revealed there was no evidence of Registered Nurse (RN) coverage eight hours a day on 01/04/25, 03/16/25, 08/02/25, and 08/03/25.Interview on 08/07/25 at 2:45 P.M. […]

• No harm, potential for more than minimal, widespreadF814Aug 12, 2025

  Based on observation and interview, the facility failed to maintain a sanitary dumpster area. This had the potential to affect all residents residing in the facility. The facility census was 63. Findings include:Observation on 08/04/25 at 8:53 A.M. with Dietary Manager (DM) #825 revealed significant debris including gloves, cardboard, and empty medication packaging on the ground surrounding dumpsters. Interview on 08/04/25 at the time of observation with DM #825 confirmed findings and indicated the maintenance department was responsible for ensuring the area remained clean.

• No harm, potential for more than minimal, widespreadF868Aug 12, 2025

  Based on interview and record review, the facility failed to ensure the required members of the quality assessment and assurance (QAA) committee participated at least quarterly as required. This had the potential to affect all residents residing in the facility. The facility census was 63. Findings include:Review of Infection Preventionist (IP) Training Certificate dated 10/24/24 revealed IP #833 was the facility's IP. Review of the Quality Assurance and Performance Improvement (QAPI) sign in sheets from 10/16/24, 01/22/25, 04/02/25, 06/18/25, and 07/16/25 revealed no evidence of participation by the facility's IP. Review of undated facility QAPI Plan revealed the QAA committee members included the IP. Interview on 08/12/25 at 10:04 A.M. […]

• No harm, potential for more than minimal, widespreadF926Aug 12, 2025

  Based on observation, interview, and facility policy review, the facility failed to ensure a safe smoking environment. This had the potential to affect all residents residing in the facility. The facility census was 63. Findings include: Observation of the resident smoking session on 08/06/25 at 9:09 A.M. revealed Resident #36 and Resident #52 were supervised by Business Office Manager (BOM) #868 in the smoking area at thee back of the building across the parking lot. The two residents began to smoke. There were four cigarette butts in the smoking area. At 9:17 A.M., Dialysis Technician (DT) #921 walked out of the building, stood next to the door, lit a cigarette, and began smoking. DT #921 was observed talking on the phone and flicking her cigarette ashes. […]