Timberwood Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Timberwood Nursing and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Sep 12, 2024

  Based on interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents reviewed for accidents and supervision. (Resident #1) The facility failed to provide adequate supervision for Resident #1 who was assessed as a high risk for elopement. On 01/22/24 he was allowed to sit on the front porch without supervision, and facility was contacted by equipment company next door that resident was there. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 01/22/2024 and ended on 01/22/2024. The facility had corrected the non-compliance before the survey began. […]

• No harm, potential for more than minimal, widespreadF812Jan 14, 2026

  Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food under sanitary conditions in 1 of 1 preparation kitchen. * The facility did not ensure baking sheets did not have brown colored buildup on the outside edges.* The facility did not ensure muffin pans did not have brown colored buildup on the inside and outside edges.* The facility did not ensure skillets did not have brown colored buildup on the inside and outside.* The facility did not ensure skillets did not have the anti-stick coating flaking off. * The facility did not ensure steam table pans did not have brown colored buildup on the corner edges. These failures could place all residents who eat from the kitchen at risk for foodborne illnesses. […]

• No harm, potential for more than minimal, widespreadF908Jan 14, 2026

  Based on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 stove in the kitchen reviewed for essential equipment. * The facility did not ensure the gas stove was in safe operating condition. The front left burner and the left side oven on the stove would not ignite when the knobs were turned. This failure could place the residents at risk of a fire for not having safe operating equipment. Findings included:During an observation and interview on 01/13/26 at 11:45 a.m. left front burner on the stove would not light. The DM said the pilot light was out and she used a multipurpose lighter to light the burner. […]

• No harm, potential for more than minimal, widespreadF812Apr 20, 2021

  Based on observation, interview, and record review, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for 4 of 5 staff (Dietary Manager, Dietary Aide B, Cook D, Dietary Aide C) reviewed for sanitary conditions. The facility failed to ensure staff properly wore hair restraints during meal service. This failure could place residents who consumed food prepared by the kitchen at risk of cross contamination and food-borne illnesses. Findings included: During an observation in the kitchen on 4/18/21 at 11:20 a.m., the Dietary Manager had the hair on the back of her head approximately 2 under her bun not covered in her hair restraint. […]

• No harm, potential for more than minimal, patternF755Jan 14, 2026

  Based on observations, interviews and record reviews, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 2 of 6 (Resident #32 and #75) reviewed for pharmacy services.The facility failed to ensure all of Resident #32's medications were administered as ordered by the Physician resulting in the incorrect dose of Vitamin D administration.The facility failed to hold Resident #75's Clonidine (used to lower blood pressure) medication (for 9 administrations) when the blood pressure was outside the Physician prescribed parameters.This failure could place residents at risk of not receiving medications as ordered by their physicians… […]