Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Timberlane Health & Rehabilitation during CMS and state inspections, most recent first.
An LPN found a resident’s insulin vial missing the opened date during administration, and a second vial was also unlabeled. A check of the medication cart found multiple residents’ multi-dose insulin vials without opened dates, while MARs showed the vials had been used repeatedly after pharmacy delivery dates. Staff, including the pharmacist, DON, ADON, and MD, stated the opened date should be on the vial and that opened insulin is limited to 28 days unless the manufacturer states otherwise.
A resident with HTN, ESRD on dialysis, CKD, DM2, and depression returned from the hospital with an order for an antihypotensive medication to be given TID and held if SBP was greater than 120. Facility staff entered and administered the medication incorrectly, giving it multiple times when SBP was above the ordered parameter and missing doses when SBP was below it. The family questioned the order during a care plan meeting, and the DON acknowledged the issue was a med error; the MD stated staff were expected to follow the order.
The facility's dietary department failed to maintain proper hygiene and food safety standards, potentially affecting 33 residents. Observations included uncovered food items, improper storage of kitchen equipment, and inadequate hand hygiene by staff. Additionally, food items lacked open and expiration dates, raising concerns about cross-contamination and sanitation. The dietary manager confirmed these issues, acknowledging the risk of serving expired food and the need for proper storage.
A facility failed to convey a resident's personal funds within the required 30-day period after discharge. A resident transferred to a different facility, but their trust account still held a balance months later. The Business Office Manager and Administrator confirmed the 30-day requirement, yet the facility's policy did not address the return of funds upon discharge, leading to the delay.
A resident requiring a mechanical lift with two-person assistance was improperly lifted with the lift's legs in a closed position, contrary to facility policy. Despite being trained, a CNA was unaware of the importance of keeping the legs open for balance. The DON confirmed the correct procedure, but a user manual was not provided.
The facility failed to identify expiration dates for refrigerated narcotics, affecting three residents, and did not account for controlled narcotics for a deceased resident, risking potential misappropriation. An LPN was observed with undated medication bottles, and the ADON and Nurse Consultant could not determine expiration dates due to label coverage. The facility's policy requires proper storage and timely return of expired drugs.
A facility failed to store hydrocortisone cream securely, leaving it at a resident's bedside without self-administration rights, risking accidental overdose. Additionally, improperly labeled narcotic bottles were found in the medication room refrigerator, contrary to the facility's policy requiring proper labeling and return of outdated drugs.
A resident with a standing order for two cups of tea to ensure hydration did not receive their preferred amount during a meal, as confirmed by the ADON. The DON indicated that dietary staff and CNAs are responsible for ensuring meal preferences are met, but the facility's policy did not address resident food preferences, leading to this deficiency.
The facility did not provide timely written notification of a resident's transfer to the state Ombudsman, as required. The Administrator admitted the resident was omitted from the monthly transfer log sent to the Ombudsman. The facility's policy also lacked guidance on notifying the Ombudsman.
A facility failed to include insulin management in a comprehensive care plan for a resident with diabetes. Despite a diagnosis of inadequate blood sugar control and an order for Glargine insulin, the care plan did not address insulin use or monitoring for adverse reactions. The Director of Nursing confirmed the omission, acknowledging that insulin, a high-risk medication, should have been included in the care plan.
Unlabeled Multi-Dose Insulin Vials
Penalty
Summary
The facility failed to ensure multi-dose insulin vials were labeled with the date they were first accessed. During an observation of insulin administration, an LPN identified that a resident’s fast-acting insulin vial did not have an opened date and stated she could not access it because it was not properly labeled. She stopped the administration process, reported the unlabeled vial to the DON, and the vial was discarded and replaced. A second resident’s rapid-acting insulin vial was then observed to also be missing the opened date. When the remaining insulin in the medication cart was checked, five of seven residents’ multi-dose insulin vials were found without an opened date. These included vials for residents receiving second rapid-acting, fast-acting, rapid-acting, and long-acting insulin. Facility MARs showed that the vials had been administered multiple times after the pharmacy delivery dates, including 31 administrations for one resident’s second rapid-acting insulin, six administrations for another resident’s fast-acting insulin, 31 and 25 administrations for two different vials used by one resident, 11 administrations for another resident’s second rapid-acting insulin, four administrations for another resident’s long-acting insulin, and 13 administrations for another resident’s long-acting insulin. The pharmacist stated the delivery date on the vial was not the opened date and that it was the facility’s responsibility to write the opened date on the vial. Staff interviews reflected that nurses expected the opened date to be on the vial, not only on the bag, and that insulin should not be used past 28 days. The facility policy titled Medication Labeling and Storage stated opened multi-dose vials are to be discarded within 28 days unless the manufacturer specifies otherwise.
Medication Administered Contrary to BP Parameters
Penalty
Summary
The facility failed to ensure medication was administered according to accepted professional standards and failed to follow physician orders for one resident who had multiple chronic conditions, including type 2 diabetes mellitus, morbid obesity, hypertension, peripheral vascular disease, chronic kidney disease, dependence on renal dialysis, and depression. The resident was admitted with a care plan noting hypertension, depression, use of an antidepressant, and dependence on hemodialysis for ESRD. After a hospital discharge, the resident returned to the facility with an order for an antihypotensive medication to be given three times daily and held if systolic blood pressure was greater than 120. The medication order summary initially showed the antihypotensive medication was entered with a note that changed the order to give it when the blood pressure was greater than 120, and that order remained until it was discontinued and replaced with the correct hold parameter. Review of the June 2026 MAR showed the medication was administered nine times when the resident's systolic blood pressure was greater than 120 and was not administered two times when the systolic blood pressure was less than 120, for a total of eleven medication errors. The medication was intended for symptomatic orthostatic hypotension and could cause marked elevation of supine blood pressure. During interviews, the resident's family stated they questioned why the medication was being given when the order was to hold it if systolic blood pressure was greater than 120, and the DON acknowledged it was a medication error. The APRN stated the medication should always be given with a blood pressure check before administration, and the MD stated staff were expected to follow orders and should have held the medication when systolic blood pressure was greater than 120. The DON stated the error was identified by staff, the on-call physician was notified, and the facility completed an internal investigation documenting disciplinary action and an in-service, but the report shows the medication had already been administered incorrectly multiple times before the error was identified.
Deficiencies in Dietary Department Hygiene and Food Safety
Penalty
Summary
The facility failed to maintain proper hand hygiene and cleanliness standards in the dietary department, which could potentially affect 33 sampled residents. Observations revealed that a dietary aide left an orange whip dessert uncovered, allowing for possible contamination by flies or other elements. Additionally, coffee carafes and various kitchen items, including plates, pitchers, and deep fryers, were found uncovered or improperly stored, with some equipment showing signs of accumulated grime and unknown substances. Further inspection showed that the dishwasher area was not maintained properly, with chunks of unknown substances present, and clean items such as bowls and utensils were not stored inverted or covered. Staff members, including a dietary aide and a cook, were observed touching food surfaces and dome covers with their fingers, without washing their hands after handling non-food items or leaving the serving line. This lack of hand hygiene and improper handling of food items raised concerns about cross-contamination and sanitation. The facility also failed to ensure that food items were labeled with open and expiration dates. Items such as tuna, orange whip, chicken dishes, and various bulk food items lacked proper dating, and some were improperly stored, such as eggs left unrefrigerated and a dented tomato juice can. The dietary manager confirmed these lapses, acknowledging the risk of serving expired food and the need for proper storage to prevent contamination. Training records indicated incomplete adherence to cleaning schedules and food safety protocols, further highlighting the deficiencies in maintaining sanitary conditions.
Failure to Convey Resident Funds Timely
Penalty
Summary
The facility failed to convey a resident's personal funds to the individual or representative administering the individual's estate within the required 30-day period. Resident #235 was documented as having transferred to a different facility on 05/01/2024. However, as of 08/27/2024, the trust account for this resident still contained a closing balance of $120.00. During an interview on 08/29/2024, the Business Office Manager confirmed the discharge date and acknowledged the 30-day requirement for conveying residual funds. The Administrator also confirmed this 30-day requirement. Despite this, the facility's policy titled 'Policy & Procedure Patient Trust' did not address the return of resident funds upon discharge or death, contributing to the oversight in conveying the funds in a timely manner.
Improper Use of Mechanical Lift Poses Accident Hazard
Penalty
Summary
The facility failed to ensure the proper use of a mechanical lift, leading to a potential accident hazard for Resident #79. The resident, who requires a mechanical lift with two-person assistance due to impaired mobility, was observed being lifted by CNA #8 and CNA #3 with the legs of the mechanical lift in a closed position. This action was contrary to the facility's policy and training, which stipulates that the legs should be in an open position to maintain balance and prevent the lift from tipping over. CNA #8, despite having been in-serviced on the correct use of the mechanical lift, confirmed during an interview that she did not know why the legs should be open. The Director of Nursing (DON) also confirmed that staff are trained to use the lift with the legs open to ensure safety. The facility's policy on safe lifting and movement of residents, revised in December 2007, emphasizes the importance of staff competency in lifting techniques to protect both residents and staff from accidents or injuries. However, a user manual for the mechanical lift was not provided during the survey.
Failure to Manage Narcotic Expiration and Accountability
Penalty
Summary
The facility failed to implement a process to identify the expiration or use-by dates of refrigerated narcotics, affecting three residents. During an observation, an LPN was seen removing undated bottles of antianxiety and opioid pain medications from the medication room. The LPNs confirmed they could not determine when the medications were opened, and the fill dates ranged over several months. The Assistant Director of Nursing (ADON) and a Nurse Consultant were unable to ascertain the expiration dates due to labels covering the information. The Nurse Consultant later stated that antianxiety medications expire 90 days after opening, while opioid pain medications could expire in as little as 7 days, depending on storage conditions. Additionally, the facility failed to account for controlled narcotics for a deceased resident, which could lead to potential loss or misappropriation. An LPN confirmed that the deceased resident's antianxiety medication was not being counted during narcotic checks. The ADON and Nurse Consultant acknowledged that the medication should have been returned to the Director of Nursing to prevent diversion. A review of the facility's policy indicated that nursing staff are responsible for ensuring medications are stored properly and that expired drugs should be returned to the pharmacy or destroyed.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that hydrocortisone 1/2% cream was stored in a locked compartment and not left at the bedside for a resident, which could lead to accidental overdose or injury. The facility's policy on self-administration of medications, revised in December 2016, requires an assessment by the IDT team to determine if a resident is safe for self-administration rights. It was observed that the resident had the cream on their over-the-bed table, and there was no order for the steroid cream for this resident. The LPN confirmed that no residents had self-administration rights, as it was deemed unsafe. Additionally, the facility failed to properly label and store narcotic medications. Four loose narcotic bottles were found in a double-locked drawer of the medication room refrigerator. The LPN had difficulty identifying the medications due to faded labels, and it was confirmed that one of the bottles should have been returned to the pharmacy. The facility's policy on medication storage, revised in April 2007, states that drug containers with improper labels should be returned to the pharmacy for proper labeling, and discontinued or outdated drugs should be returned or destroyed.
Failure to Honor Resident Meal Preferences
Penalty
Summary
The facility failed to honor the meal preferences of a resident, identified as Resident #52, who had a standing order for two 8-ounce cups of tea to ensure proper hydration. On the specified date, Resident #52 was observed coughing strongly in the dining room and expressed a need for more tea, with only about 1/2 inch of tea-colored fluid and ice remaining in their cup. The meal slip confirmed the standing order for two cups of tea, which was not fulfilled. The Assistant Director of Nursing (ADON) verified the discrepancy and acknowledged that the resident's preference was not met. Further investigation revealed that the Director of Nursing (DON) stated that dietary staff are responsible for discussing preferences with residents, and CNAs or staff should verify the meal trays and address any discrepancies with the kitchen. However, the facility's policy titled 'Food and Nutrition Services Staff' did not address the food preferences of residents. This oversight in policy and practice led to the failure to meet the resident's hydration needs as per their preference, potentially affecting other residents observed for dining.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to provide timely written notification of transfer or discharge to the resident, the resident's representative, and the state Ombudsman, as required by regulations. This deficiency was identified in the case of a resident who was discharged to another facility. The Administrator acknowledged that the resident was not included in the transfer log for the month, which is typically sent to the Ombudsman at the end of each month. Additionally, the facility's policy on transfer or discharge documentation did not address the requirement for notifications to the Ombudsman.
Deficiency in Comprehensive Care Plan for Insulin Management
Penalty
Summary
The facility failed to ensure a comprehensive care plan for a resident, identified as Resident #43, who was receiving insulin, a high-risk medication, for diabetes management. The resident's medical records indicated a diagnosis of diabetes with inadequate blood sugar control, and an order for Glargine insulin was documented. However, the care plan did not address the use of insulin or include any measures for monitoring potential adverse reactions or symptoms related to insulin use. This oversight was identified during a review of the resident's care plan, which only mentioned potential skin integrity and vision issues related to diabetes, but omitted any specific care measures for insulin management. During an interview, the Director of Nursing confirmed that the resident's care plan lacked documentation for insulin usage and monitoring. The facility's policy on comprehensive person-centered care plans, which was revised in December 2016, requires that care plans include measurable objectives and timetables to meet residents' needs, incorporating identified problem areas and risk factors. The Director of Nursing acknowledged that the MDS assessment should drive the care plan and that insulin, being a high-risk medication, should have been included in the care plan. The absence of a care plan for insulin use was a deficiency identified by the surveyors.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near El Dorado
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hudson Memorial Nursing Home | 0.6 mi | ★★★★★ | 1 | 0 |
| The Springs Of El Dorado | 1.4 mi | ★★★★★ | 2 | 0 |
| Oak Ridge Health And Rehabilitation | 1.4 mi | ★★★★★ | 2 | 0 |
| Courtyard Rehabilitation And Health Center, Llc | 1.9 mi | ★★★★★ | 4 | 0 |
| Silver Oaks Health And Rehabilitation | 25.9 mi | ★★★★★ | 0 | 0 |
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