Timberlane Health & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Timberlane Health & Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jul 30, 2026

  Based on observations, interviews, record review, and facility policy review, it was determined that the facility failed to ensure two front locking mechanisms were locked during a wheelchair transport of one (Resident #1) of five residents reviewed for van transportation safety. This failed practice resulted in an injury associated with the death of Resident #1. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. […]

• No harm, potential for more than minimal, widespreadF812Aug 29, 2024

  Through observation, interview, and policy reviews, the facility failed to ensure hand hygiene was conducted, that equipment, utensils, plates, cups, and food dome covers were clean and/or properly stored, and that food items had open and expiration dates. These failed practices has the potential to effect 33 sampled residents. The findings: On [DATE] at 9:37 AM, Dietary Aide #1 confirmed an orange whip dessert, uncovered on counter, should had been covered prior to walking away because flies or anything could have gotten in it. […]

• No harm, potential for more than minimal, widespreadF812Sep 29, 2023

  Based on observation, interview, and record review, the facility failed to ensure dented cans were removed from stock; foods were dated when received to assure first in first out usage; scoops used in dry storage bins were stored in a plastic bag, and items stored in the refrigerator were dated and labeled to prevent potential for food bone illness for residents who received meals from 1 of 1 kitchen. This failed practice had the potential to affect 87 residents residing in the facility. The findings are: 1. On [DATE] at 10:46 AM, observed a 1 can of Cream of Chicken soup with a dented rim. The Surveyor asked the Dietary Manager what was done with dented cans. […]

• No harm, potential for more than minimal, widespreadF812Jun 16, 2022

  Based on observation, record review and interview, the facility failed to ensure food items stored in the freezer were covered or sealed and dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen according to the list provided by the Dietary Supervisor dated 6/16/2022 The findings are: 1. On 6/15/2022 at 1:27 PM, the following observations were made in the walk-in freezer: a. An opened zip lock bag that contained slices of cheese was stored on a shelf in the refrigerator. The bag was not sealed. b. A box of diced potatoes was on a shelf in the refrigerator with an expiration date of 6/13/2022. c. Two opened boxes of biscuits were stored on a shelf in the walk-in freezer. […]

• No harm, potential for more than minimal, patternF761Jul 1, 2026

  Based on observation, interviews, record review and facility policy review , it was determined the facility failed to ensure multi-dosed insulin vials were labeled in accordance with currently accepted professional standards specifically insulin was not labeled with the date the vial was first accessed for five (Residents #1, #6, #7, #8, and #9) of seven residents reviewed. The findings include: During an observation of insulins and concurrent interview on 06/30/2026 at 11:05 AM, Licensed Practical Nurse (LPN)#1 indicated Resident #9's multi-dose [fast-acting insulin] vial was not labeled with the opened date. She stated with the vial not being properly labeled, she could not access it. […]