Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Timberridge Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Failure to Follow Medication Hold Parameters The facility administered multiple BP and pain medications to several residents despite ordered hold parameters not being met. Residents with HTN, HF, atrial fibrillation/flutter, diabetes, and other chronic conditions received meds such as losartan, enalapril, midodrine, sacubitril-valsartan, carvedilol, diltiazem, and oxycodone-acetaminophen when BP or pain scores were outside the prescriber’s limits. Staff stated that MAR check marks meant the meds were given and acknowledged that ordered parameters should have been followed.
The facility failed to coordinate PASRR assessments for a resident with newly evident mental health diagnoses and did not determine whether Level II PASRR services were needed. The resident had schizophrenia on the PASRR, later developed depression, anxiety, and insomnia, and the DON and ADON stated the resident should have been rescreened and the Level 1 PASSR updated to check for Level II PASRR evaluation.
A resident who preferred to speak Spanish had difficulty communicating with staff, and observations showed CNAs interacting with her in Spanish. However, her care plan did not include a communication focus for her Spanish-speaking preference. Staff interviews confirmed she was strictly Spanish-speaking and that translation was sometimes needed, while the MDS Coordinator and DON acknowledged the language preference was not addressed in the care plan.
A facility failed to ensure oxygen therapy was provided as ordered for three residents. One resident with COPD was observed receiving oxygen above the ordered flow rate, another resident was receiving oxygen at a higher rate than the PRN order specified, and a third resident was observed on oxygen at a higher rate than the continuous order directed. Staff stated oxygen flow rates should follow physician orders and be checked each shift.
Incomplete MAR and care documentation were found for a resident with depression and COPD. The MAR was blank for multiple scheduled meds, with no initials, codes, or notes showing whether doses were given, refused, held, or unavailable, and additional documentation was missing for antidepressant monitoring, behavioral monitoring, respiratory support, fortified foods, and a nursing note entry. An RN and the DON stated the record should accurately reflect actual med administration and care.
Staff failed to perform hand hygiene during med pass and meal delivery, and multiple staff entered a resident's contact isolation room without the required gown and gloves. An RN administered meds to several residents without cleaning hands between room entries, and a CNA and an RN/LPN Unit Manager were observed entering a room on contact precautions without PPE while handling meals, care items, and meds. Staff interviews confirmed the missed hand hygiene and PPE use.
A resident was not informed of co-pay obligations after a payor source change. Initially covered by managed care with a specified co-pay, the resident was switched to Medicare without being informed of a $205 daily co-pay. The Business Office Manager claimed to have explained the change, but there was no documentation, violating the facility's policy on Medicare Conversions.
The facility failed to administer medications according to physician orders and professional standards for several residents. A resident received Oxycodone for pain levels below the prescribed threshold, while others received blood pressure medications despite vital signs being outside specified parameters. Additionally, a resident's PICC dressing was not changed despite being soiled, and another resident's medications were not properly mixed with water before administration via a gastrostomy tube, leading to clogging issues.
A facility failed to provide an accurate assessment for a resident's discharge status. The resident was discharged home, but the MDS incorrectly recorded the discharge as a transfer to a hospital. Interviews with the Lead MDS Coordinator and DON confirmed the error, which contradicted the facility's policy on accurate MDS documentation.
A resident with multiple health conditions, including end-stage renal disease and mild protein-calorie malnutrition, did not receive the therapeutic diet as ordered by the physician and recommended by the Registered Dietician. The resident's care plan required double protein portions at each meal, but observations showed insufficient protein was provided during a morning meal. The Registered Dietician confirmed the resident should have received larger protein portions.
The facility failed to document medication administration and vital signs accurately for two residents, leading to a deficiency. One resident's Valsartan was not properly documented in the MAR, lacking progress notes for certain entries. Another resident's Hydralazine administration also lacked necessary documentation. The ADON and DON confirmed the absence of required documentation, highlighting a failure to adhere to the facility's documentation policy.
The facility failed to maintain enhanced barrier precautions and timely dressing changes. A CNA did not wear a gown while inspecting and emptying a urinary catheter, and an LPN administered IV medication without a gown. Additionally, a resident's PICC line dressing was not changed despite being visibly soiled and dated a week prior. Facility policies on PPE and dressing changes were not followed.
Failure to Follow Ordered Medication Hold Parameters
Penalty
Summary
The facility failed to ensure physician-ordered medication parameters were followed for multiple residents whose drug regimens included blood pressure medications and pain medication with specific hold parameters. The report identified 6 of 8 residents reviewed for unnecessary medications: Residents #15, #179, #6, #23, #88, and #94. The deficiency was based on medication administration records showing medications were given when the documented blood pressure or pain scores did not meet the prescriber’s ordered parameters. Resident #15 had diagnoses including sequela of cerebral infarction, major depressive disorder, and essential hypertension. The physician ordered Losartan 25 mg twice daily for HTN with instructions to hold for systolic blood pressure below 130. The MAR showed Losartan was administered multiple times in January 2026 and once in February 2026 when blood pressures were below the ordered threshold, including readings such as 116/53, 123/49, 116/64, 118/66, 127/54, 95/55, and 92/54. An LPN stated that if there was a check mark, the medication was probably administered and that the orders should be followed to hold the medication when parameters were present. Resident #179 had diagnoses including orthopedic aftercare following surgical amputation, diabetes with hyperglycemia, hypertension, hyperlipidemia, polyneuropathy, peripheral vascular disease, and anemia. The physician ordered Oxycodone-Acetaminophen 10-325 mg every 4 hours as needed for non-acute moderate pain 6-10. The MAR showed the medication was administered on several occasions when the documented pain scores were 5, 5, 5, 4, and 5. An LPN stated the pain medication was given and acknowledged the doctor’s ordered parameters should have been followed and the doctor called if the pain score was not within range. Resident #6 had diagnoses including cerebral infarction, major depressive disorder, schizoaffective disorder bipolar type, diabetes, essential hypertension, and generalized anxiety disorder. The physician ordered Enalapril Maleate 20 mg daily for HTN with instructions to hold for systolic blood pressure less than 110. The MAR documented administration on 12/28/2025 with a blood pressure of 108/50, on 1/18/2026 with a blood pressure of 101/55, and on 1/21/2026 with a blood pressure of 102/44, all signed as administered. An LPN stated the check mark on the MAR meant the medication was administered and that it was given outside the physician’s ordered parameters. Resident #23 had diagnoses including essential hypertension, chronic diastolic heart failure, and hypertensive heart disease with heart failure. The physician ordered Midodrine 10 mg three times daily for hypotension with instructions to hold for systolic blood pressure greater than 110. The MAR showed Midodrine was administered repeatedly in December 2025 and January 2026 when systolic blood pressures were above the hold parameter, including readings of 124/59, 144/82, 138/75, 122/51, 115/67, 120/56, 112/59, 120/72, 117/59, 131/73, 122/58, 113/70, 115/63, 120/78, and 121/59. An LPN stated that if there was a check mark, the medication had been given. Resident #88 had diagnoses including essential hypertension, paroxysmal atrial fibrillation, chronic combined systolic and diastolic heart failure, and type 2 diabetes mellitus. The physician ordered Sacubitril-Valsartan 24-28 mg twice daily for HTN with instructions to hold for systolic blood pressure less than 110. The MAR documented administration on multiple dates in December 2025 and January 2026 when blood pressures were below 110, including 101/61, 105/69, 103/67, 106/66, 100/73, 102/64, 106/64, 100/60, 106/60, 101/64, 102/73, 101/64, 104/57, 108/71, and 108/75. Staff stated that a check mark on the MAR meant the medication was given and that parameters were supposed to be followed. Resident #94 had diagnoses including essential hypertension and atrial flutter. The physician ordered Carvedilol 3.125 mg twice daily for HTN and Diltiazem 120 mg twice daily for atrial fibrillation, both with instructions to hold if systolic blood pressure was less than 110. The MAR showed Carvedilol and Diltiazem were administered on multiple occasions in December 2025 and January 2026 when blood pressures were below the ordered threshold, including 105/60, 102/59, 102/70, 109/68, and 100/60. The facility policy stated medications are administered in accordance with written orders of the prescriber.
Failure to Rescreen PASRR for New Mental Health Diagnoses
Penalty
Summary
The facility failed to coordinate assessments with the PASRR program for a resident with newly evident or possible serious mental disorder and did not refer for Level II PASRR services as needed. The resident was admitted and later readmitted with diagnoses including major depressive disorder, other specified anxiety disorders, and schizophrenia. The resident’s PASRR dated 7/22/2025 identified schizophrenia as the only mental illness or suspected mental illness under Section I, PASRR Screen Decision-Making. A psychiatry subsequent note dated 1/12/2026 documented chief complaints of depression, anxiety, and insomnia, with a diagnostic assessment and plan of major depressive disorder recurrent moderate, other specified anxiety disorders, and primary insomnia. During interviews, the DON stated the resident should have been rescreened to determine whether Level II services were required, and the ADON stated the Level 1 PASSR should have been updated to ensure the resident did not require Level II PASRR evaluation.
Failure to Care Plan Spanish Language Communication Needs
Penalty
Summary
The facility failed to develop a comprehensive care plan for Resident #122’s communication needs related to her Spanish-speaking preference. During an interview conducted in Spanish, the resident stated that she preferred to talk in Spanish and had difficulty at times communicating with staff, and she would prefer to speak in Spanish with staff. Observations showed staff members interacting with her in Spanish, including a CNA answering her with a couple of words in Spanish and another CNA speaking to her in Spanish while assisting her in bed. Review of the resident’s care plan did not document a communication focus for her Spanish-speaking preference. During interviews, an RN stated the resident was strictly Spanish-speaking and that staff sometimes needed another staff member to translate to understand what she needed. A CNA stated she did not speak Spanish but could understand a little and would get another staff member to translate if the resident became very agitated. The MDS Coordinator stated she was not aware the resident preferred Spanish and that the care plan did not have a focus for Spanish language communication. The DON stated the resident’s language preferences should be part of the care plan.
Oxygen Therapy Not Provided at Ordered Flow Rates
Penalty
Summary
The facility failed to ensure oxygen therapy was provided as ordered for 3 of 5 residents reviewed for respiratory care. Resident #22 was observed receiving oxygen at 4 liters per minute via nasal cannula, although the physician order dated 6/7/2025 directed oxygen at 3 liters per minute every shift for chronic obstructive pulmonary disease. During interview, an RN stated staff should follow the orders for the amount of oxygen being run and was unsure why the oxygen was not at the ordered amount. Resident #151 was observed in bed with the head of bed elevated and oxygen being administered at 3 liters per minute via nasal cannula, despite a physician order dated 2/2/2026 for oxygen at 2 liters per minute via nasal cannula as needed. The resident stated she did not change her oxygen level. Resident #11 was observed receiving oxygen via nasal cannula through an oxygen concentrator at 3 liters per minute, although the physician order dated 12/31/25 directed oxygen at 2 liters per minute continuous inhalation via nasal cannula every shift for chronic obstructive pulmonary disease. An LPN stated nursing staff are responsible for setting and adjusting oxygen flow rates and that oxygen must be administered strictly according to physician orders.
Incomplete Medication and Care Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident, including documentation of medication administration and related nursing care. On review of the resident’s MAR for January 2026, the scheduled 9:00 AM medication pass on 01/27/2026 was blank with no entries for multiple physician-ordered medications, including citalopram, fluticasone-salmeterol, tamsulosin, thiamine, doxycycline, gabapentin, metoprolol succinate ER with hold parameters, and sennosides. The MAR did not show staff initials, documentation codes, or narrative notes indicating whether the medications were administered, refused, held, or unavailable. Additional record review found missing documentation for antidepressant side effect monitoring on the 7:00 AM to 3:00 PM shift on 01/27/2026, behavioral monitoring on 01/01/2026 at 3:00 PM, nursing care related to respiratory support including encouragement to elevate the head of the bed on 01/01/2026 at 3:00 PM and again during the 7:00 AM to 3:00 PM shift on 01/27/2026, and dietary documentation for fortified foods ordered three times daily on multiple dates and times. There was also no supporting nursing documentation corresponding to a nursing note time-stamped 01/27/2026 at 2:30 PM. Staff interviews confirmed that blank MAR entries were not acceptable and that documentation should accurately reflect actual medication administration.
Hand Hygiene and Contact Precaution Failures
Penalty
Summary
The facility failed to prevent the possible spread of infection when staff did not perform hand hygiene during medication administration. During an observation of medication pass, an RN prepared and administered medications to multiple residents without cleaning hands before entering resident rooms, after leaving resident rooms, or when returning to the medication cart between residents. The RN also unlocked the medication cart and used the computer between resident encounters without hand hygiene. When interviewed, the RN stated hand hygiene should have been done each time the room was exited. The facility also failed to follow transmission-based precautions for a resident on contact isolation for ESBL in urine. During observations, a CNA entered the resident's room without gown or gloves to deliver lunch trays, adjusted the bed and touched the bed linen and bed controller, assisted with meal setup, and left the room without hand hygiene before going to another resident's room. The CNA later returned to the same resident's room again without gown or gloves, removed the meal tray, returned it to the cart without hand hygiene, and entered another resident's room. An RN and an LPN Unit Manager were also observed entering the contact precaution room without gown or gloves while providing care and delivering food or medications. Staff interviews confirmed the observed practices. The RN stated that when a patient is on contact precautions, PPE should always be worn when going into the room and hand hygiene should be performed after care. The LPN Unit Manager stated a gown and gloves should have been worn before entering the room. The CNA stated staff had not been trained to put on a gown and gloves to go into the room, only when having physical contact with the resident, and acknowledged hand hygiene should have been performed between residents. Facility leadership stated staff should follow the posted signage, don and doff PPE as instructed, and perform hand hygiene between residents and after meal tray delivery.
Failure to Inform Resident of Co-Pay Obligations
Penalty
Summary
The facility failed to ensure that a resident was fully informed about their co-pay obligations following a change in their payor source. Resident #512 was initially admitted with a diagnosis of an unspecified fracture of the sacrum. The pre-admission insurance verification form indicated that the resident's primary payor source was a managed care insurance company, with a co-pay of $125.00 per day for days 21-100. However, during an interview, the resident stated that the Business Manager informed her that her insurance would not cover services after 20 days and that she would be switched to Medicare. The resident reported that she was told there would be no co-pay, but upon discharge, she was informed of a co-pay of $205.00 per day. The Managed Medicare Conversion Form and Medicare Part D Enrollment agreement signed by the resident did not specify the daily co-pay cost. The Business Office Manager stated that it was a team decision to switch the resident to Medicare due to the need for more skilled care. Although the Business Office Manager claimed to have explained everything to the resident, there was no documentation of this conversation. The facility's policy on Medicare Conversions requires that the impact of changing coverage, including deductibles and co-pays, be explained verbally and in writing, which was not adhered to in this case.
Medication Administration and Dressing Change Deficiencies
Penalty
Summary
The facility failed to administer medications according to physician orders and professional standards for several residents. Resident #24 received Oxycodone for pain levels below the prescribed threshold, indicating a failure to adhere to the physician's order that specified administration only for pain levels greater than five. The Director of Nursing acknowledged that the medication was given out of parameters, which was not in compliance with the established guidelines. For Residents #42, #110, and #127, blood pressure medications were administered despite vital signs being outside the specified parameters. Resident #42 received Valsartan with heart rates below the prescribed limit, and Resident #110 was given Hydralazine with heart rates below the threshold. Similarly, Resident #127 received Metoprolol Tartrate with a heart rate below the specified parameter. The nursing staff did not follow the physician's orders, and the Assistant Director of Nursing confirmed that medications were given out of parameters, emphasizing the expectation to follow the set guidelines. Additionally, the facility failed to perform dressing changes for a peripherally inserted central catheter (PICC) for Resident #264, whose dressing was visibly soiled and not changed in a timely manner. The policy required dressing changes when the integrity was compromised, yet the dressing remained unchanged despite being soiled. Furthermore, Resident #27's medications were not properly mixed with water before administration via a gastrostomy tube, leading to clogging issues. The Director of Nursing confirmed that medications should be mixed with water prior to administration, highlighting a deviation from the facility's procedures.
Inaccurate Resident Discharge Assessment
Penalty
Summary
The facility failed to ensure that each resident received an accurate assessment, specifically in the case of one resident reviewed for discharge status. The deficiency was identified during a review of the Social Service's progress note and the Minimum Data Set (MDS) for the resident. The progress note dated June 7, 2024, indicated that the resident was discharged home. However, the MDS, signed and dated June 10, 2024, incorrectly recorded the discharge status as a transfer to a short-term general hospital. Interviews conducted on August 27, 2024, with the Lead MDS Coordinator and the Director of Nursing revealed that the MDS should have been coded to reflect the resident's discharge to home, acknowledging the error. The facility's policy on the Resident Assessment Instrument (RAI) emphasizes the importance of accurate documentation and utilization of the MDS to ensure comprehensive assessments. The policy outlines that the assessment must include discharge planning, which was not accurately reflected in this instance.
Failure to Provide Therapeutic Diet as Ordered
Penalty
Summary
The facility failed to provide a therapeutic diet as ordered by the physician and recommended by the Registered Dietician for a resident with multiple health conditions, including unspecified cirrhosis of the liver, end-stage renal disease, and mild protein-calorie malnutrition. The resident's physician's orders specified a Liberal Renal diet with regular texture, thin consistency, double protein portions, and eggs with breakfast when available. Despite these orders, the resident was observed receiving insufficient protein portions during a morning meal, which included only one sausage patty, one 2-ounce scoop of eggs, and an 8-ounce serving of milk. The resident's care plan, revised earlier in the year, highlighted nutritional problems related to non-compliance with dialysis, congestive heart failure, end-stage renal disease, anemia, chronic viral Hepatitis C, and other factors. The care plan included interventions such as double protein at each meal. A nutrition note from July indicated the resident's recent weight loss and preference for more protein portions, specifically eggs for breakfast and meat for lunch/dinner. However, during an interview, the Registered Dietician confirmed that the resident was nutritionally compromised and should have received double protein portions, including two scoops of eggs and two sausage patties, which were not provided.
Deficiency in Medication Administration Documentation
Penalty
Summary
The facility failed to accurately document medication administration and vital signs for two residents, leading to a deficiency in maintaining medical records according to accepted professional standards. For Resident #42, the physician's order required Valsartan to be held if the systolic blood pressure (SBP) was less than 110 or the heart rate (HR) was less than 60. However, the Medication Administration Record (MAR) for August 2024 showed entries coded as 'other/see progress note' and 'hold/see progress notes' without corresponding documentation in the progress notes for specific dates. The Assistant Director of Nursing (ADON) confirmed the absence of additional documentation for these entries. Similarly, for Resident #110, the physician's order for Hydralazine required the medication to be held under the same conditions as Resident #42. The MAR for August 2024 contained entries coded as 'other/see nursing note' and 'hold/see progress notes' without any documentation in the progress notes for certain dates. The ADON acknowledged the lack of documentation, and the Director of Nursing (DON) stated that vital signs should be recorded in the MAR, and any coded entries should be supported by notes in the system. The facility's policy on documentation emphasized the need for accurate reflection of clinical care and services provided to residents.
Failure to Maintain Enhanced Barrier Precautions and Timely Dressing Changes
Penalty
Summary
The facility failed to maintain enhanced barrier precautions during direct catheter care and intravenous medication administration, as well as failed to provide timely intravenous dressing changes for a peripherally inserted central catheter (PICC) line. During an observation, a Certified Nursing Assistant (CNA) entered a resident's room without wearing a gown and inspected and emptied a urinary catheter drainage bag. The CNA also provided incontinent care without wearing a gown, acknowledging the mistake during an interview. In another instance, a Licensed Practical Nurse (LPN) entered a resident's room, which had an enhanced barrier sign posted, and administered intravenous medication without wearing a gown. The LPN admitted to not knowing where to find a gown due to the relocation of personal protective equipment (PPE) and acknowledged the requirement to wear a gown during such procedures. The Director of Nursing confirmed that staff had been educated on enhanced barrier precautions, which require the use of gloves and gowns during high-contact resident care activities. Additionally, a resident with a PICC line had a dressing that was visibly soiled and dated from a week prior. The dressing had not been changed despite its compromised condition, which included a dried dark red substance and a beige-colored substance underneath the transparent dressing. The LPN responsible for the resident's care noted the need for a dressing change but was unable to perform it due to time constraints. Facility policies require dressing changes at specific intervals or when the dressing is compromised, which was not adhered to in this case.
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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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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bridgewater Park Health & Rehabilitation Center | 5.8 mi | ★★★★★ | 9 | 0 |
| Hawthorne Center For Rehabilitation And Healing Of | 8.7 mi | ★★★★★ | 16 | 0 |
| Life Care Center Of Ocala | 8.9 mi | ★★★★★ | 8 | 0 |
| Palm Garden Of Ocala | 9.3 mi | ★★★★★ | 1 | 0 |
| Avante At Ocala, Inc | 11.4 mi | ★★★★★ | 25 | 0 |
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