Timberwood Nursing and Rehabilitation Center

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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 and exacerbation of their medical conditions.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary medications (is a medication used: without adequate indication for its use) for 1 of 5 residents (Residents #6) or excessive administration doses for 1 of 6 residents (Resident #75) reviewed for unnecessary medications. * The facility did not have appropriate diagnoses for Eliquis (blood thinner) medication for Residents #6. * 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 prescribed parameters. These failures could place residents at risk for toxic ingestion and unintended, harmful events attributed to the use of a medication without the appropriate indication or dosage.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 6 residents (Resident #75) reviewed for significant medication errors. The facility failed to ensure Clonidine (a blood pressure (BP) medication given to lower high blood pressure) was not administered 9 times in January 2026 to Resident #75 as ordered by the physician. This failure could place residents at risk of not receiving desired therapeutic outcomes, increased side effects, or a decline in health.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure all medications were properly secured and stored in locked compartments for 1 of 4 medication carts (Hall 600) reviewed for medication storage. The facility failed to keep unattended medications secured by leaving it on top of a medication cart. This failure could put residents at risk for adverse reactions to medications and misappropriation of medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure the basis for discharge was documented in the residents medical record for 1 out of 4 residents (Resident #1) reviewed for inappropriate discharges. The facility failed to document the basis for Resident #1's discharge prior to discharge. This failure could place residents at risk of diminished continuity of care and unsafe and/or improper discharges.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents received parenteral fluids administered consistent with professional standards of practice and in accordance with physician orders for 2 of 3 residents (Resident #49 and Resident #75) reviewed for parenteral fluids. The facility failed to manage Resident #49's and Resident #75's PICC line dressing per professional standards and per the physician's order. This failure placed residents at risk of developing an infection.

Inspectors wroteBased on observations, interviews, and record review the facility failed to store and distribute food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. Dietary Assistant A failed to follow policy when she discarded her gloves and bare-handed foods during lunch meal preparation for 5 residents receiving a pureed diet. This failure could place residents who ate a pureed diet from the kitchen at risk for food-borne illness and/or transmission-based infections.

Inspectors wroteBased on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 6 residents (Resident #55, #20, and #78) and 2 of 8 staff (CNA B, and CNA E) reviewed for infection control. The facility failed to ensure staff did not reuse gowns for Resident's #55 and #20 who were on enhanced barrier precautions on 10/14/2024. CNA B and CNA E failed to wear a gown while providing catheter care for Resident #78, did not sanitize or wash their hands between glove changes, and touched clean items with dirty gloves on 10/15/2024. These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure each resident was treated with respect, dignity, and care for 1 of 12 residents (Resident # 78) observed for care. CNA B failed to sit while feeding Resident #78 by the nurse station on 10/14/2024. This failure could place residents at risk of not being treated with dignity and respect.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 3 residents (Resident #74) reviewed for quality of care. The facility failed to ensure Residents #74 had a physician's order for an indwelling urinary catheter (drains urine from your bladder into a bag outside your body). This failure could place residents at risk for urinary tract infections and catheter related injuries.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable, physical, mental, and psychosocial well-being for 2 of 8 staff (CNA B and CNA D) reviewed for competent nursing care. 1. CNA D failed to clean Resident #64's penis during incontinent care provided on 10/15/2024. 2. CNA B failed to clean Resident #78's penis properly during catheter and incontinent care provided on 10/15/2024. These deficient practices affect residents who depend on nursing care and could place residents at risk for infection and harm.

Inspectors wroteBased 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. This failure could prevent residents from receiving appropriate supervision which could lead to resident sustaining serious injury or harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 5 of 6 (CNA A, CNA C, CNA D, CNA I and the Treatment nurse) staff and 4 of 4 residents (Residents #54, #12, #64 and #34) reviewed for infection control in that: CNA I did not wash or sanitize her hands in between glove changes when going from dirty to clean while performing incontinent care to Resident #54. CNA C and CNA D did not change gloves while providing incontinent care to Resident #12 when going from dirty to clean. CNA A did not wash or sanitize her hands in between glove changes while performing incontinent care to Resident #64. [...]