Below 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 The Timbers Skilled Nursing And Therapy during CMS and state inspections, most recent first.
A resident with diabetes and moderate cognitive impairment had a physician order requiring use of a Glucagon kit, provision of a high-carb snack, and physician notification for FSBS <71. One evening, the resident’s FSBS was documented as 64 and 40 units of long-acting insulin were administered, but the physician was not notified as ordered. The next morning, the resident was found unresponsive, EMS was called, and EMS reported the resident’s blood sugar was 41. Staff and leadership later confirmed that facility policy and the medical director’s expectations required physician notification for blood sugars below the specified threshold, which did not occur in this case.
A resident with type 2 DM and an FSBS of 64 had existing physician orders for Glucagon, oral carbohydrates, and physician notification for blood sugars below 71, but nursing staff did not administer the ordered Glucagon or notify the physician and instead gave 40 units of long-acting insulin. The facility’s policy required following physician orders based on FSBS results, and the medical director later stated they would not expect long-acting insulin to be given in this situation. The next morning the resident was found unresponsive, EMS documented an FSBS of 41, and the resident was sent to the hospital, leading surveyors to cite a deficiency for failure to assess, monitor, and intervene for hypoglycemia.
Survey results were not posted in a readily accessible location for residents, family members, or legal representatives. Staff could not identify where the updated binder was located, and the binder found at the front desk contained only older survey results. Several residents stated they did not know where the survey results were or that they could view them, and the DON/administrator acknowledged the binder should have been available without asking.
A resident’s discharge MDS assessment was completed but not transmitted within the required timeframe. The MDS Consultant acknowledged the assessment was sent late and not in accordance with the RAI manual, while the corporate nurse consultant stated the facility policy was to follow the RAI manual and the DON stated completed assessments are required to be transmitted within 14 days.
Laundry Dryer Lint Trap Not Maintained: A dryer in the laundry room was observed with lint hanging off the lint trap and nearly touching the floor. A laundry attendant stated the lint traps were supposed to be cleaned every 2 hours, but they had not yet been cleaned during the shift. The DON/administrator stated there was no written policy for lint traps and that the process was to clean them 3 times a day.
A resident with dementia and high fall risk eloped from the facility due to inadequate supervision. The resident, who was independent with ambulation but had severely impaired cognition, was found missing after being last seen 30 minutes prior. Despite a search, the resident was located hours later by police. The incident occurred when a family member of another resident mistakenly escorted the resident out, highlighting a lapse in monitoring. The facility's signage and supervision were insufficient to prevent this elopement.
The facility did not post staffing information with the required components in an accessible location for residents and visitors. The staffing details were kept in a binder at the nurse's station, which was not compliant with the requirement to have it posted on the wall. This issue was identified during a survey, affecting a facility with 118 residents.
Failure to Notify Physician of Low Blood Glucose in Insulin-Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of a resident’s low blood sugar as required by existing medical orders and facility policy. Resident #129 had an admission MDS dated 11/24/24 showing a BIMS score of 10, indicating moderate cognitive impairment, and that they received insulin injections. The resident’s baseline assessment and care plan documented a diagnosis of type 2 diabetes mellitus with hyperglycemia. A physician’s order dated 11/18/24 directed staff to use a Glucagon Emergency Injection Kit as needed for finger-stick blood sugar (FSBS) less than 71, to give cola/orange juice and/or a high carbohydrate snack, and to notify the physician when FSBS was below 71. On 11/27/24 at 8:00 p.m., documentation on the Injections/Insulin/FSBS record for Resident #129 showed a blood sugar of 64. Despite this result being below the ordered threshold of 71, the physician was not notified as required by the physician’s order. The same record showed that the resident was administered 40 units of long-acting insulin (Toujeo SoloStar subcutaneous solution). RN #1 later confirmed that their initials on the November 2024 Injection/Insulin/FSBS administration record indicated the blood sugar was 64 and acknowledged they did not call the physician per the existing orders. On 11/28/24 at 9:07 a.m., a nurse’s progress note documented that Resident #129 was assessed as unresponsive and not reacting even to a sternal rub. Vital signs were recorded as 130/73, 78, 96%, 12, and 97.8. The nurse called 911, and emergency medical services arrived and reported the resident’s FSBS was 41 before transporting the resident to the hospital. Interviews with nursing staff and the DON confirmed that the expectation, consistent with facility policy and the medical director’s statement, was that nurses notify the physician when a resident’s blood sugar is below 71, and that this did not occur for Resident #129 on the evening the FSBS of 64 was recorded.
Removal Plan
- In-service all licensed nursing staff on signs and symptoms of hypoglycemia and when to notify physician.
- Audit all residents with hypoglycemia parameters ensuring notification order is in place.
- Add monitoring orders for appropriate residents for signs and symptoms of hypoglycemia with notification order attached.
- Place parameter and notification orders for all residents with hypoglycemia below 70 and notify.
- Conduct root cause analysis.
- Review all residents with hypoglycemia and/or diabetes to ensure parameters are in place to notify physician.
Failure to Follow Hypoglycemia Orders and Inappropriate Insulin Administration
Penalty
Summary
The deficiency involves the facility’s failure to assess, monitor, and intervene according to physician orders for a resident with hypoglycemia. Resident #129 had a diagnosis that included type 2 diabetes mellitus with hyperglycemia. Facility records showed that on 11/27/24 at 8:00 p.m., the resident’s finger stick blood sugar (FSBS) was 64. The resident had a physician order for a Glucagon Emergency Injection Kit 1 mg to be given intramuscularly as needed for FSBS less than 71, along with cola/orange juice and/or a high carbohydrate snack, and to notify the physician. Despite this order, the resident was not given Glucagon or the ordered treatments, and the physician was not notified of the low blood sugar. Instead of following the hypoglycemia treatment orders, RN #1 documented administering 40 units of Toujeo SoloStar, a long-acting insulin, to Resident #129 after the FSBS of 64 was obtained. The facility’s Blood Glucose Monitoring Guideline, dated 01/2026, directed staff to follow physician orders based on finger stick results and to notify the physician if no follow-up orders were in place and signs or symptoms of hypo/hyperglycemia were noted. The medical director later stated that for a blood sugar of 64, depending on the resident’s status, they would expect juice to be given if the resident was awake or a Glucagon injection if unresponsive, and that they would not expect a nurse to administer a long-acting insulin in that situation. On 11/28/24 at 9:07 a.m., a nurse’s progress note documented that Resident #129 was assessed as unresponsive and not reacting even to a sternal rub. Vital signs were obtained, and 911 was called. Emergency medical services arrived and reported the resident’s FSBS was 41, and the resident was transported to the hospital. The facility’s investigation and survey findings concluded that the facility failed to assess, monitor, and intervene appropriately for hypoglycemia for this resident, despite existing physician orders and facility policy, and this failure led to the determination of an Immediate Jeopardy situation.
Removal Plan
- In-service all licensed nursing staff on signs and symptoms of hypoglycemia and treatment within the physician's orders with staff acknowledgment and verbalized understanding of parameters, treatments, and following physician orders for hypoglycemia.
- Audit all residents with hypoglycemia or diabetes to ensure physician treatment orders with parameters are in place.
- Add monitoring orders for appropriate residents for signs and symptoms of hypoglycemia.
- Place parameter orders for all residents with hypoglycemia below 70.
- Initiate compliance rounds to ensure licensed nursing staff understand signs and symptoms of hypoglycemia and provide treatment following physician orders.
- Complete a root cause analysis of the event.
Survey Results Not Readily Accessible
Penalty
Summary
The facility failed to post the most recent state survey results in a place readily accessible to residents, family members, and legal representatives. During observation, no state survey results were seen in any common area of the facility, and there were no postings indicating where the results were located. A state survey binder was later found at the front desk in a bin tucked behind another binder, and the binder contained survey results from 2019, 2020, and 2021. During a resident council meeting, several residents stated they did not know where the state survey results were located or that they could view them. The administrator stated they were not aware the updated binder was not accessible, was not sure where the new binder was located, and later stated the updated survey results binder had been in their office and was available to residents upon request, while acknowledging it should have been available without asking.
Late Transmission of MDS Assessment Data
Penalty
Summary
The facility failed to transmit MDS assessment data to CMS within the required timeframe for Resident #119. The resident was admitted to the facility on [DATE], and the discharge assessment dated 11/07/25 was completed on 11/11/25 but was not submitted until 02/26/26. During interview on 02/26/26, the MDS Consultant stated the facility followed the RAI manual for transmitting assessments and acknowledged that the assessment was completed on 11/11/25 and transmitted on 02/26/26, which was not in accordance with the RAI manual guidelines. The corporate nurse consultant stated the facility policy was to follow the RAI manual, and the Director of Long Term MDS services stated that completed assessments are required to be transmitted in 14 days.
Laundry Dryer Lint Trap Not Maintained
Penalty
Summary
The facility failed to ensure a dryer in the laundry room was maintained in safe operating condition because the lint trap was not cleaned. During a tour of the laundry room, the dryer on the left was observed with lint hanging off the lint trap and almost touching the ground underneath. Laundry attendant #1 stated the lint traps were supposed to be cleaned every two hours and that their shift had started at 7:00 a.m., but the lint traps had not yet been cleaned. The administrator later stated the facility did not have a written policy for lint traps and that the process was to clean them three times a day, which they said was their policy but not in writing.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to adequately supervise and prevent a resident from eloping, which led to a situation of Immediate Jeopardy. The resident, who was admitted with a diagnosis of dementia and was a high fall risk, was found to have severely impaired cognition but was independent with ambulation. The resident was at significant risk of wandering to potentially dangerous areas outside the facility. On the evening of the incident, the resident was last seen approximately 30 minutes before being reported missing. Despite a thorough search of the facility and surrounding areas, the resident could not be located initially. The incident report documented that the resident was eventually found at approximately 2:30 a.m. the following day. The resident was returned to the facility by a police officer and underwent a head-to-toe assessment, which revealed no injuries or dehydration. The resident had walked a long distance, resulting in some redness and edema in the lower extremities. The report noted that a family member of another resident had mistakenly escorted the resident out of the facility, highlighting a lapse in monitoring and supervision. The facility's failure to prevent the resident's elopement was further evidenced by the observation of a staff member allowing visitors in and out of the facility without adequate supervision. The regional director of operations acknowledged that previous signage was insufficient, as a family member of another resident mistakenly thought the resident was part of their party and escorted them out. This incident underscores the need for improved monitoring and supervision to prevent similar occurrences in the future.
Failure to Post Required Staffing Information
Penalty
Summary
The facility failed to ensure that staffing information was posted with the required components and was accessible to all residents and visitors. During the survey conducted from June 17 to June 20, 2024, it was observed that there was no staffing information posted in a manner that was accessible to residents and visitors. When questioned, the Corporate Nurse Consultant acknowledged that the staffing information was kept in a binder at the nurse's station and was not posted on the wall as required. This deficiency affected the facility, which housed 118 residents at the time of the survey.
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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 Edmond
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Edmond Health Care Center | 0.7 mi | ★★★★★ | 10 | 0 |
| Ignite Medical Resort Edmond, Llc | 1.6 mi | ★★★★★ | 19 | 0 |
| Epworth Villa Health Services | 4.4 mi | ★★★★★ | 0 | 0 |
| Bradford Village Healthcare Center | 5.2 mi | ★★★★★ | 0 | 0 |
| The Wilshire Skilled Nursing And Therapy | 5.7 mi | ★★★★★ | 0 | 0 |
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