Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Timberwood Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that food preparation equipment, including muffin pans, baking sheets, skillets, and steam table pans, had significant debris buildup and flaking anti-stick coating. The Dietary Manager acknowledged that these conditions could contribute to foodborne illness, and facility policies require all food-contact surfaces to be clean and sanitized after each use.
A gas stove in the kitchen was found to have a non-functioning front left burner and left side oven, both of which required manual ignition with a lighter due to a failed pilot light. The dietary manager confirmed that the stove should ignite automatically and no policy on equipment maintenance was provided when requested.
Two residents did not receive medications as ordered by their physicians: one received an incorrect dose of vitamin D, and another was given Clonidine outside of prescribed blood pressure parameters. Medication aides acknowledged the errors, which were attributed to oversight and not following physician orders as documented in the medication administration records.
Two residents received medications without proper adherence to physician orders: one was given a blood thinner without an appropriate diagnosis documented, and another received multiple doses of an antihypertensive medication outside of the prescribed blood pressure parameters. Staff interviews confirmed that medications were administered without following the required indications and parameters.
A resident with hypertension received Clonidine outside of physician-ordered blood pressure parameters on multiple occasions. Medication aides administered the drug when the resident's systolic BP was below the specified threshold, contrary to the written order. Staff interviews and documentation confirmed the medication was given in error, and facility policy required adherence to physician instructions.
A medication aide left a blister pack of allopurinol tablets and a souffle cup with assorted pills unattended on top of a locked medication cart while stepping away multiple times, including to wash hands and retrieve supplies. The medications were out of the aide's line of sight, and at one point, a resident in a wheelchair was observed near the unattended cart. Both the DON and Administrator confirmed that facility policy requires medications to be secured and in view at all times, and the aide acknowledged the lapse in following these procedures.
A resident was discharged without documentation of the basis for discharge, a physician's order, or proper communication with the family and ombudsman. The discharge occurred after an incident of inappropriate behavior, but staff did not follow facility policy, including providing discharge instructions or documenting the discharge in the medical record.
The facility failed to change PICC line dressings as ordered for two residents, leading to a deficiency in care. One resident with cellulitis and diabetes had a dressing unchanged for over two weeks, while another with severe cognitive impairment had a dressing unchanged for over a week. The DON and Administrator acknowledged the oversight, which placed residents at risk of infection, and the facility lacked a policy on IV management.
A Dietary Assistant failed to follow food safety standards by handling food with bare hands during meal preparation for residents on a pureed diet. The Dietary Manager observed the incident and acknowledged the risk of food-borne illness due to improper sanitation practices. The facility's policy prohibits bare-hand contact with food, requiring gloves to be worn and changed between tasks.
A long-term care facility failed to maintain proper infection control practices, as staff reused gowns for residents on enhanced barrier precautions and did not follow hand hygiene protocols during catheter care. This led to potential cross-contamination and increased infection risk.
A CNA in an LTC facility was observed standing while feeding a resident with severe cognitive impairment, contrary to training and facility policy. The resident required substantial assistance with eating due to dementia and other conditions. Staff interviews confirmed that sitting while feeding is a standard practice to ensure resident dignity.
A cognitively intact resident with an indwelling catheter due to obstructive uropathy did not have a physician's order for the catheter or for changing the catheter bag and tubing. This oversight was confirmed through record reviews and interviews with the DON and Administrator, who acknowledged the risk of infections due to the lack of proper orders. The facility also lacked a policy for indwelling catheter management.
Two CNAs at a facility failed to perform proper perineal and catheter care for two residents, risking infection. One CNA did not clean a resident's penis during incontinent care, while another did not adequately clean or dry a resident's penis during catheter care. Both CNAs had prior skills check-offs but lacked recent competency evaluations.
A resident with a history of methamphetamine abuse and severely impaired cognition, assessed as high risk for elopement, was allowed to sit unsupervised on the front porch. This led to the resident leaving the facility and walking to a nearby business to ask for a ride to the bank. The facility was unaware of the resident's absence until contacted by the local business.
Unsanitary Food Equipment and Surfaces in Kitchen
Penalty
Summary
Surveyors observed that the facility failed to maintain sanitary conditions in the kitchen, specifically regarding the cleanliness and condition of food preparation equipment. During inspections, multiple muffin pans, baking sheets, and skillets were found with dark brown or black debris baked onto both the inside and outside surfaces. Additionally, one skillet was noted to have its anti-stick coating flaking off, and several steam table pans had brown debris buildup on the top corners. These items were stacked together and used in food preparation and service. Interviews with the Dietary Manager confirmed that pans should be clean and free of debris buildup, and that such buildup could contribute to foodborne illness. Review of the facility's Infection Control Policy and the FDA Food Code indicated that food-contact surfaces and equipment should be kept free of encrusted grease deposits and other soil accumulations, and that dirty equipment should not come into contact with food. The facility's failure to adhere to these standards was directly observed during meal preparation and kitchen inspections.
Failure to Maintain Kitchen Stove in Safe Operating Condition
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe operating condition, specifically the gas stove in the kitchen. During an observation, it was found that the front left burner and the left side oven of the stove would not ignite when the knobs were turned. The dietary manager (DM) reported that the pilot light was out and used a multipurpose lighter to manually ignite both the burner and the oven. The DM acknowledged that the stove should ignite without the use of a lighter and expressed concern that lighting the stove in this manner could be hazardous. No facility policy regarding equipment maintenance and operation was provided when requested by the surveyor. Record review referenced the FDA Food Code 2022, which requires equipment to be maintained in good repair and proper adjustment.
Failure to Administer Medications as Ordered by Physicians
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of medications as ordered by physicians for two residents. For one resident with a history of protein-calorie malnutrition, hypertension, and chronic ischemic heart disease, the medication aide administered only 1,000 units of vitamin D instead of the physician-ordered 2,000 units. The medication aide acknowledged the error, stating it was a mistake and that she believed she was following the order at the time. The resident's care plan included interventions to give medications as ordered, but the full prescribed dose was not administered. For another resident with hypertension and hypertension urgency, staff failed to follow physician-prescribed parameters for administering Clonidine, a medication used to lower blood pressure. The physician's order specified that Clonidine should be given only when the systolic blood pressure (SBP) was greater than 160. However, the medication was administered on multiple occasions when the resident's SBP was below this threshold. Medication aides involved in these incidents admitted to not holding the medication as required and attributed the errors to oversight and not reading the order carefully. Interviews with staff, including medication aides and the Director of Nursing, confirmed that medications were not always administered according to physician orders and established parameters. The facility's policy required medications to be administered in accordance with written physician orders, but this was not consistently followed, resulting in medication errors for both residents.
Failure to Ensure Drug Regimens Free from Unnecessary Medications
Penalty
Summary
The facility failed to ensure that each resident’s drug regimen was free from unnecessary medications, as evidenced by two separate incidents involving two residents. One resident, a male with a history of heart valve replacement, pacemaker, and congestive heart failure (CHF), was administered Eliquis, a blood thinner, without an appropriate diagnosis documented in the facility records. The hospital records indicated Eliquis was given for a pacemaker, while the facility’s physician orders listed CHF as the indication. During interviews, staff were unable to confirm the correct diagnosis for the medication, and the Director of Nursing (DON) clarified that Eliquis should be indicated for atrial fibrillation or pacemaker, not CHF. Another resident, a female with diagnoses of hypertension urgency and essential hypertension, received Clonidine, an antihypertensive medication, outside of the prescribed parameters. The physician’s order specified that Clonidine should be administered only if the systolic blood pressure (SBP) was greater than 160. However, medication administration records showed that the medication was given on multiple occasions when the resident’s SBP was below this threshold. Medication aides involved acknowledged during interviews that the medication should have been held according to the parameters and attributed the errors to oversight and not reading the order carefully. Facility policy required medications to be administered in accordance with written physician orders. Despite this, the staff failed to follow the specified parameters for medication administration and did not ensure that medications were given only with appropriate indications. These actions resulted in the administration of unnecessary medications and doses, as documented in the residents’ records and confirmed by staff interviews.
Failure to Follow Physician-Ordered Parameters for Blood Pressure Medication
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not adhering to physician-ordered parameters for administering Clonidine, a blood pressure medication. Specifically, the medication was given nine times in January 2026 when the resident's systolic blood pressure was below the ordered threshold of 160, contrary to the physician's instructions. Documentation on the medication administration record (MAR) confirmed that the medication was administered outside the prescribed parameters, and interviews with medication aides and nursing staff acknowledged the oversight and failure to follow the order as written. The resident involved was an older female with diagnoses of hypertension urgency and essential hypertension, who was cognitively intact according to her most recent assessment. Her care plan and physician orders clearly specified the conditions under which Clonidine should be administered. Despite this, medication aides administered the drug when the resident's blood pressure readings did not meet the required criteria. Staff interviews revealed that the medication should have been withheld in these instances, and the facility's policy required medications to be given in accordance with physician orders.
Unattended Medications Left on Medication Cart
Penalty
Summary
A medication aide (MA) failed to properly secure medications during a medication pass on Hall 600. The aide left a blister pack containing 10 white oval pills and a souffle cup with 4 assorted pills on top of a locked medication cart while stepping away to wash hands and later to retrieve additional medication supplies. During these times, the medications were unattended and out of the aide's line of sight, with no staff or residents immediately present at first, but later a resident in a wheelchair was observed near the unattended cart. Multiple staff members also walked past the unattended cart during this period. The aide acknowledged during interviews that the medications should not have been left unattended on top of the cart and confirmed that she had been trained on proper medication storage and cart security. She explained that she left the medications out because she had a question about them and did not want to forget, but admitted this was not in accordance with her training. The medications included allopurinol tablets intended for a single resident, and the aide recognized the potential for someone else to take the medication while it was left unsecured. Facility policy, as reviewed, requires that medication carts be locked when not in use and that medications remain in the clear view and reach of the person administering them. Both the DON and the Administrator confirmed in interviews that staff are expected to maintain visual contact with medication carts at all times and never leave medications unattended on top of the cart. The incident was observed and confirmed by surveyors, and the facility's policies were found to be consistent with accepted professional principles for medication security.
Failure to Document Basis for Discharge and Follow Discharge Procedures
Penalty
Summary
The facility failed to ensure that the basis for discharge was documented in the medical record for a resident who was discharged following an incident involving inappropriate behavior. The resident, who was cognitively intact and had no prior history of behavioral issues, was discharged after allegedly inappropriately touching another resident. There was no documentation in the clinical record regarding the basis for the discharge, nor was there a physician or nurse practitioner order for the discharge. The resident's care plan and progress notes did not reflect any consideration of the caregiver's ability to provide care post-discharge, and there were no discharge notes from the social worker. Interviews with facility staff revealed that the decision to discharge the resident was made jointly by the Administrator and the DON, who instructed the ADON to contact the resident's family member for immediate pick-up. The family member was not provided with discharge instructions, documents, or asked to sign any paperwork, and was not contacted by the facility after the discharge. The ombudsman was not notified of the discharge, and the social worker did not provide post-discharge resources or document the discharge in the medical record. Facility policy requires that the basis for transfer or discharge be documented in the resident's medical record and that appropriate information be communicated to the receiving party. Staff interviews confirmed that the facility did not follow its own discharge policy and procedures, including obtaining a physician's order, notifying the ombudsman, and documenting the basis for discharge. The lack of documentation and communication placed the resident at risk for an improper and unsafe discharge.
Failure to Change PICC Line Dressings as Ordered
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of IV fluids for two residents, leading to a deficiency in care. Resident #49, a cognitively intact male with cellulitis, diabetes, and hyperlipidemia, was observed with a PICC line dressing that had not been changed since 9/29/24, despite a physician's order to change it every seven days. The resident reported not recalling any dressing changes during his stay, which had been approximately 10 days to 2 weeks. Similarly, Resident #75, a female with severely impaired cognition and multiple diagnoses including extradural and subdural abscess, was observed with a PICC line dressing dated 10/3/24, also not changed as per the physician's order. The Director of Nursing (DON) and the Administrator acknowledged that the nurses were responsible for changing the PICC line dressings and admitted that the oversight placed residents at risk of infection. The facility lacked a policy on IV management, contributing to the failure to adhere to professional standards and physician orders for the administration of parenteral fluids. This deficiency was identified through observations, interviews, and record reviews conducted by the surveyors.
Failure to Follow Food Safety Standards in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety during meal preparation in the kitchen. Dietary Assistant A, who was responsible for preparing pureed meals for five residents, did not follow proper sanitation procedures. After using a grinder to puree chicken breasts, she discarded her gloves and proceeded to handle food items, such as bread and beans, with her bare hands without washing her hands or donning new gloves. This action was observed by the Dietary Manager, who acknowledged that the failure to wash hands and use gloves could lead to food-borne illnesses. The Dietary Manager confirmed that she was responsible for training dietary staff on kitchen sanitation, which includes avoiding bare-hand contact with food and changing gloves between tasks. The facility's policy, dated July 2014, explicitly prohibits bare-hand contact with food and mandates the use of gloves, which must be changed after each use. Despite this policy, the Dietary Assistant's actions during meal preparation did not comply with these standards, posing a risk of contamination and illness to residents consuming the pureed diet.
Inadequate Infection Control Practices in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper use of personal protective equipment (PPE) and inadequate hand hygiene practices. Specifically, staff members reused gowns for residents on enhanced barrier precautions, which is against the facility's infection control policy. Observations revealed that two blue gowns were reused in the rooms of two residents who required enhanced barrier precautions due to infections resistant to many antibiotics. Staff admitted to reusing gowns despite knowing the risk of cross-contamination. Additionally, during catheter care for a resident, two CNAs failed to wear gowns and did not sanitize their hands between glove changes. They also touched clean items with dirty gloves, which could lead to contamination. The CNAs acknowledged their failure to follow proper procedures, including not sanitizing hands after glove removal and not wearing gowns during care, despite the resident being on enhanced barrier precautions. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and Director of Nursing (DON), confirmed that staff were aware of the infection control policies but did not consistently adhere to them. The facility had experienced a shortage of PPE, which may have contributed to the improper practices. The facility's policies on catheter care and hand hygiene were not followed, increasing the risk of infection and cross-contamination among residents.
Failure to Maintain Resident Dignity During Feeding
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity during feeding. A CNA was observed standing while feeding a resident who required substantial assistance with eating due to severe cognitive impairment. The resident, who had been diagnosed with dementia, BPH, and generalized anxiety disorder, was seated in a wheelchair by the nurse station during the feeding. The CNA acknowledged that she should have been sitting while feeding the resident, as per her training, but mentioned that chairs had been recently moved, which contributed to her standing. Interviews with facility staff, including the Staffing Coordinator, ADON, DON, and Administrator, confirmed that staff were trained to sit while feeding residents to maintain their dignity. The CNA had completed a skills checklist that included proper feeding techniques, and the facility's policy emphasized treating residents with dignity and respect. Despite this, the CNA's actions did not align with the facility's standards, leading to a deficiency in maintaining the resident's dignity during care.
Failure to Ensure Physician's Order for Indwelling Catheter
Penalty
Summary
The facility failed to provide appropriate care for a resident who was incontinent of bladder, specifically in ensuring the resident received necessary treatment and services to prevent urinary tract infections. The resident, a cognitively intact female with a BIMS score of 15, had an indwelling catheter due to obstructive uropathy. However, there was no physician's order for the indwelling catheter or for changing the catheter bag and tubing, as noted in the physician's order summary report. This oversight was observed during a record review and confirmed through interviews with the Director of Nursing (DON) and the Administrator. The deficiency was further highlighted during an observation where the resident was seen with a Foley bag hanging on the bedside with a privacy cover in place. The DON acknowledged that the Assistant Director of Nursing (ADON) was responsible for ensuring indwelling catheter orders were entered, but was unsure how this particular order was missed. The Administrator also confirmed that nursing staff were responsible for entering orders and acknowledged the risk of infections due to the lack of proper orders. Additionally, the facility did not have a policy in place for indwelling catheter management, which contributed to the oversight.
Deficient Perineal and Catheter Care by CNAs
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate competencies and skill sets to provide adequate care for residents, specifically in the area of perineal and catheter care. Two certified nursing assistants (CNAs) were observed not performing proper cleaning techniques during incontinent and catheter care for two residents. CNA D did not clean the penis of a resident during incontinent care, which is a necessary step to prevent infections. Despite having a skills check-off for perineal care, CNA D admitted to not performing the task correctly. Similarly, CNA B did not properly clean another resident's penis during catheter care. The CNA failed to pull the foreskin back adequately and did not clean in a circular motion or dry the area afterward, which are essential steps to prevent contamination and infection. This CNA also had a skills check-off for perineal care but had not been re-evaluated since starting on the floor. The facility's staffing coordinator and assistant director of nursing (ADON) acknowledged the deficiencies in training and competency checks. The staffing coordinator mentioned that training was conducted every six months, but the CNAs involved had not been adequately checked off for their skills. The facility's policies on nursing staff competency and indwelling urinary catheter care were not adhered to, leading to potential risks for the residents involved.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision for a resident who was assessed as a high risk for elopement. The resident, who had a history of methamphetamine abuse and severely impaired cognition, was allowed to sit on the front porch without supervision. This lack of supervision led to the resident leaving the facility and walking to a nearby business to ask for a ride to the bank. The facility was only made aware of the resident's absence when contacted by the local business. The resident's medical history included congestive heart failure, respiratory failure, hypertension, atrial fibrillation, and cerebral infarction. An Elopement/Wandering Evaluation conducted prior to the incident had identified the resident as high risk for elopement. Despite this assessment, the resident was not adequately monitored, resulting in the elopement incident. The resident had been at the nurses' station multiple times on the day of the incident, expressing a desire to leave the facility to go to the bank. The incident occurred when the resident, after being told by a nurse that he could leave if he signed out and had a ride, walked towards the front of the facility. The resident was later found at a local business, having left the facility without the required supervision. The facility's failure to provide adequate supervision and follow its own elopement policy led to the resident's unsupervised departure.
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What surveyors actually found near you
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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 Livingston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Bradford At Brookside | 5.4 mi | ★★★★★ | 12 | 0 |
| Woodland Park Nursing & Rehab | 12.4 mi | ★★★★★ | 0 | 0 |
| Pine Ridge Health Care Llp | 16.4 mi | ★★★★★ | 0 | 0 |
| Cleveland Health Care Center | 23.1 mi | ★★★★★ | 1 | 0 |
| Corrigan Ltc Nursing & Rehabilitation | 24.9 mi | ★★★★★ | 12 | 0 |
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