Above average — CMS composite of the measures below.
The next survey window likely opens around April 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 Timber Ridge Health And Rehabilitation during CMS and state inspections, most recent first.
Unsafe food storage, sanitation, and hand hygiene practices were observed throughout the kitchen. Staff left food unlabeled, unsealed, or past use-by dates; sanitizer testing and dish machine temps were not maintained correctly; the kitchen was dirty; cooling logs showed foods not cooled to safe temps; and staff were observed moving between dirty and clean dishes, changing gloves without hand hygiene, and working without proper hair/beard restraints.
Pureed food was prepared without following recipes and meals were served without proper temperature checks. A cook used Simply Thick and a breadcrumb-and-water mixture without measuring or using a recipe, placed pureed food in a cold oven, and served it without reheating to 135°F or higher. Staff also failed to temp beverages and several foods during meal service, and a test tray showed soup, coffee, juice, and milk outside the required temperature range.
Infection prevention and control was not maintained when residents with wounds and a drain did not consistently have EBP identified in their records or at their room entrances. A resident with bilateral foot wounds had an EBP order but no sign or PPE disposal receptacle at the door and no EBP in the care plan; another resident with buttock wounds had no EBP order, sign, or care plan notation; and a third resident with a surgical wound and drain had no EBP order or resident-specific care plan. Staff were also observed carrying soiled linens against clothing and bare skin.
A resident with urinary retention and a catheter device used a Flip Flo valve independently, but the care plan did not reflect the device, catheter care, output monitoring, or EBP. Staff were unaware the resident had switched from a traditional Foley to a Flip Flo, yet documentation still showed Foley output monitoring. The resident reported managing the valve and bag independently, while staff did not empty, clean, or measure the catheter system as documented.
Failure to Provide Ordered Respiratory Care: Two residents did not receive needed respiratory services. One resident on continuous O2 had tubing for the room concentrator that was not changed as ordered, while another resident with OSA wanted to use a CPAP machine but the machine was unplugged, parts were stored in a bag, and staff had not obtained an order or assisted with setup. The DON confirmed oxygen tubing should be changed weekly and that CPAP use should be ordered and care planned.
Improper Return of Undeliverable Acetaminophen to Stock Bottle: A resident with an order for acetaminophen was unavailable when a nurse tech attempted administration, and the tablets were poured back into the stock bottle. The nurse tech said she had been told stock meds can be returned if they do not enter the resident's room, while the RN and DON stated undeliverable medications should be wasted per facility policy.
A resident with moderate cognitive impairment reported arm pain and bruising, suggesting potential abuse by staff. The facility delayed reporting the incident to the State Agency, missing the required timeframe. The Nursing Home Administrator initially treated the incident as a grievance, later deciding to notify the SA after further review. No abuse or reporting education was provided following the incident.
A resident with moderate cognitive impairment reported arm pain and was found with bruises, suggesting potential abuse. The facility did not thoroughly investigate the incident or remove the involved staff member from resident care, contrary to its policy. The resident had a history of COPD, esophageal ulcer, and falls.
A resident with multiple health conditions experienced a delay in notification to their NP and POAHC after a suspected burn from a hot pack was observed. The facility's policy requires immediate notification of any injury, but the NP was informed the next day, and the POAHC was notified four days later. Miscommunication among staff and lack of documentation on notification procedures contributed to the delay.
A resident with a history of endocarditis and renal disease developed skin redness and blisters after an LPN applied a hot pack following a topical analgesic cream. The LPN did not adhere to facility policies, failing to check the skin every five minutes and leaving the hot pack within the resident's reach. The incident was compounded by inadequate documentation and lack of staff education on using Muscle Rub with hot packs, resulting in a deficiency in maintaining a safe environment.
A resident with moderate cognitive impairment alleged rough treatment by a CNA, with red marks observed on their arms. Despite facility policy requiring immediate reporting of such allegations, the incident was not reported to the State Agency. In contrast, a similar allegation involving another resident was reported. The Nursing Home Administrator confirmed the oversight but could not explain the discrepancy.
A resident with moderate cognitive impairment alleged rough care by a CNA, resulting in red marks on their arms. The facility failed to thoroughly investigate the abuse allegation, did not document follow-up assessments, and did not remove the CNA from care areas. The facility also did not interview other residents or notify the resident's physician, contrary to its policy.
Unsafe Food Storage, Sanitation, and Hand Hygiene Practices
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional standards. During the initial kitchen tour, surveyors observed multiple food storage problems, including open or unsealed dry goods, unlabeled bulk containers, and refrigerated and frozen items without proper date marking or with use-by dates that had passed. Examples included pasta, bread crumbs, oats, flour, hot dogs, fruit, mushrooms, macaroni salad, marinara, ciabatta bread, and pepperoni that were either unlabeled, unsealed, or past the documented use-by date. The kitchen manager acknowledged that food should be sealed, labeled, and dated, but also stated the kitchen did not have enough containers and that some guidance sheets were inaccurate. Sanitizing solution testing and dishwashing practices were not completed correctly. The sanitizer log had missing entries, no space to record solution temperature, and every recorded PPM entry was 400. When the sanitizer was tested during the survey, the kitchen manager was not aware of the temperature requirement and measured the solution at 80.4 degrees F, outside the stated range. The dishwasher temperatures were also below the facility’s posted and policy-required levels, with surveyors observing wash and rinse temperatures that did not consistently meet the required standards. Staff stated the machine had been running low for weeks, that repair attempts had not corrected the problem, and that the temperature testing puck showed a maximum temperature below the required level. The kitchen was observed in an unclean condition, with caked food and debris on stovetop burners, food and debris on transport carts, debris on prep counters and shelves, stains and spilled food on the floor, crumbs in the toaster, and debris on storage shelving. Cleaning logs and opening checklists were marked complete even though staff confirmed the listed tasks had not been done. Surveyors also observed unsafe cooling practices, with several cooked foods still above 40 degrees F on the cooling log, and unsanitary dishwashing practices, including a staff member moving from dirty dishes to clean dishes without cleansing hands or removing a soiled apron. Hair restraints were not used consistently, as staff were observed working in the kitchen without beard restraints or with hair exposed from under hats, and a housekeeper entered the kitchen without a hairnet. Hand hygiene was also not followed consistently, including glove changes without hand cleansing while serving food.
Pureed Food Preparation and Meal Temperature Deficiencies
Penalty
Summary
The facility did not ensure pureed foods were prepared according to recipe directions that conserve nutritive value, flavor, and appearance, and staff did not serve meals at safe and appetizing temperatures. The facility’s policy stated pureed food must be prepared in a manner to conserve nutritive value, palatable flavor, and attractive appearance, and that water should not be used as an additive. The dietary policy also stated mechanically altered hot foods must stay above 135°F during preparation. The report identified that the practice had the potential to affect more than 4 of the 44 residents in the facility. On 5/5/26, a surveyor observed a cook pureeing carrots and seasoned ground beef for two residents who received pureed diets. The cook stated no recipe was followed for the carrots or the ground beef and that approximately 4 pumps of Simply Thick were added. The cook also showed a container of breadcrumbs mixed with water for the two residents and stated the water amount was not measured and no recipe was followed. The cook then placed two plates of pureed meat and carrots into an unheated oven and later added an undetermined amount of the breadcrumb mixture. The surveyor observed that the two residents did not receive refried beans, a tortilla, or taco toppings such as cheese and sour cream. One resident had diagnoses including dysphagia, dementia with psychotic disturbance, anarthria, and paralysis after a stroke, and had an order for a regular diet with pureed texture and honey thick consistency. The other resident had diagnoses including dysphagia, quadriplegia, dementia, and Bell’s palsy, and had an order for a no salt added diet with pureed texture and nectar thick consistency. The surveyor also observed lunch service and found that staff did not consistently check temperatures of food and beverages before service. Staff did not temp beverages, and beverage logs had missing entries for multiple meals. During meal service, staff did not temp food on the steamtable, and hamburger patties were served at 122°F. The pureed food for the two residents was removed from a cold oven and served without being reheated to 135°F or higher; the surveyor later temped the taco meat at 82.4°F and the carrots at 93.2°F. A test tray showed soup at 127°F, carrots at 137.2°F, coffee at 112.2°F, juice at 58.4°F, and milk at 55.4°F. The registered dietician and kitchen manager both stated staff should follow recipes and temp food and drinks before service, and the kitchen manager stated staff should record temperatures on the appropriate log.
Infection Prevention and Control Program Not Maintained
Penalty
Summary
The facility did not establish and maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection. Surveyors found that residents with wounds and/or drains did not consistently have enhanced barrier precautions (EBP) identified in their records or communicated at the room entrance, and staff were observed handling soiled linens in a manner that contacted clothing and bare skin. R3 had diagnoses including cellulitis of both lower limbs and type 2 diabetes, intact cognition, and open wounds on both feet and right toes requiring twice-daily dressing changes. R3 had an order for EBP related to chronic wounds, but the room entrance initially did not have an EBP sign or a receptacle for PPE disposal, and R3's care plan did not indicate EBP. Although an EBP sign was later observed near the door, a receptacle near the door was still not present. R8 had diagnoses including type 2 diabetes and fractures, intact cognition, and open wounds on the buttocks with wound care orders, but there was no EBP order, no EBP sign at the room entrance, and no EBP notation in the care plan. R34 had morbid obesity, obstructive sleep apnea, a surgical wound with a drain, and intact cognition, but there was no EBP order, no EBP sign at the room entrance, and the care plan was not resident-specific for the wound and drain or reflective of EBP. In addition, a housekeeper was observed carrying soiled linens against clothing, bare forearms, and hands while transporting them to a drop-off room.
Failure to Update Catheter Care Plan and Monitor Urinary Output
Penalty
Summary
Appropriate care was not provided to prevent UTIs for one resident with a urinary catheter device. The resident was admitted with diagnoses including resistance to multiple antibiotics, urinary retention, and presence of urogenital implants, and had intact cognition with a BIMS score of 15. The resident reported having a catheter with a plastic open-and-close attachment that was operated independently, going to the bathroom about every 2 hours to open the valve and urinate, and doing all catheter care without staff assistance. The resident’s record showed orders for a Foley catheter, enhanced barrier precautions, and monitoring of Foley output every shift, but the care plan did not include the resident’s catheter, Flip Flo valve, catheter care, output monitoring, or enhanced barrier precautions. Staff documentation continued to reflect Foley catheter output monitoring, including recorded outputs on each shift, even though the resident stated the resident had a Flip Flo valve installed during a urology appointment and was no longer using a traditional Foley catheter in the same way. The resident also stated staff did not empty the catheter, clean or change the bag, measure output, or ask about the valve or nighttime drainage. During interviews, multiple staff members were unaware the resident had a Flip Flo device and were unfamiliar with how the resident was managing urinary drainage. The RN stated the resident had a regular catheter and did not know how to access the care plan, while the DON and ADON were also not aware the resident had switched to a Flip Flo device. The resident stated the catheter bag was drained in the morning and hung in the closet with amber urine remaining in the bottom, and the resident reported the bag had never been cleaned. Staff acknowledged that the catheter device, catheter care, and enhanced barrier precautions should have been reflected in the care plan, and that staff were documenting output even though they were not providing the catheter care being charted.
Failure to Provide Ordered Respiratory Care
Penalty
Summary
The facility did not provide necessary respiratory care and services for two residents who had respiratory-related needs. One resident, R16, had diagnoses including chronic respiratory failure with hypoxia, COPD, and obstructive sleep apnea, and was on continuous oxygen after a recent hospitalization for acute hypoxemic respiratory failure. R16 had an order to change oxygen tubing every week and if soiled, and to store the tubing in a plastic bag when not in use. On observation, R16 was using a portable oxygen tank with a nasal cannula and tubing dated 5/6/26, while the room concentrator was off and had a nasal cannula and tubing dated 4/22/26 lying on the bed. R16 stated the portable oxygen tubing had been changed that morning and that the room concentrator was used when in bed. The RN confirmed the portable tank tubing had been changed that morning and verified the tubing attached to the room concentrator should be changed at least weekly. The DON also verified oxygen tubing should be changed at least weekly. A second resident, R34, had diagnoses including heart failure with ejection fraction, morbid obesity, and obstructive sleep apnea, and had intact cognition. R34 told the surveyor that a CPAP machine was present but unplugged on the bedside table, with parts in a plastic bag, and that staff would not put it on despite the resident wanting to use it. R34 stated the machine had been used at home every time the resident slept, but staff said they did not have the specifications for when to use it. The record showed no CPAP order, and the care plan and Kardex did not indicate CPAP use. The DON stated the facility had a standing order for CPAP machines and that a physician order and care plan should identify CPAP use, but there were no documented refusals in the progress notes and staff had not assisted the resident with setup or operational settings.
Improper Return of Undeliverable Acetaminophen to Stock Bottle
Penalty
Summary
The facility did not provide pharmaceutical services to ensure the accurate administration of medication for 1 resident, R6, who had an order for acetaminophen. R6 was admitted with diagnoses including a compression fracture of the T5/T6 vertebra and had a BIMS score of 14 out of 15 on the 4/29/26 MDS, indicating intact cognition. On 5/5/26 at 11:37 AM, the surveyor observed Nurse Tech C obtain two 325 mg acetaminophen tablets from a stock bottle and place them in a medication cup for R6, but R6 was unavailable when the medication was attempted to be administered. After the attempt, Nurse Tech C returned to the medication cart and poured the acetaminophen tablets back into the stock bottle. During interview, Nurse Tech C stated she had been told that if a stock medication does not enter a resident's room, it can be returned to the original container. RN D stated the facility's policy indicates undeliverable medications should be wasted so they are not returned to the wrong bottle, and the DON also stated undeliverable medications should be wasted.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency (SA) in a timely manner for one resident. On December 13, 2024, a resident complained of arm pain during care and indicated that a staff member was bruising them. Staff discovered two round bruises on the back of the resident's right arm and a reddened area on the right elbow. Despite these findings, the facility did not report the potential allegation of abuse and injuries of unknown origin to the SA until December 15, 2024, which was not within the required timeframe. The resident involved had a history of chronic obstructive pulmonary disease (COPD), ulcer of the esophagus with bleeding, and a history of falling. The resident's Minimum Data Set (MDS) assessment indicated moderate cognitive impairment. The Nursing Home Administrator (NHA) initially documented the incident as a grievance and conducted an investigation, concluding that no abuse occurred. However, the NHA later decided to notify the SA after further discussion with the Director of Nursing (DON). The facility did not provide education on abuse or reporting following the incident.
Failure to Investigate Alleged Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate a potential allegation of abuse and injuries of unknown origin for a resident who complained of arm pain and was found with bruises. On the specified date, the resident reported arm pain during care, and staff discovered two round bruises on the back of the resident's right arm and a reddened area on the right elbow. The resident initially indicated that a staff member was responsible for the bruising but later mentioned possibly bumping the arm on a wheelchair tray. Despite these conflicting accounts, the facility did not conduct a comprehensive investigation into the potential abuse or the injuries of unknown origin. The facility's policy required immediate investigation of injuries of unknown origin to rule out abuse and mandated the removal of the alleged perpetrator from resident care during the investigation. However, the Nursing Home Administrator did not believe the injuries were the result of abuse and did not remove the staff member involved from resident care. Additionally, the facility did not provide staff education on the abuse policy and procedure, as noted by the surveyor. The resident had a history of chronic obstructive pulmonary disease, esophageal ulcer with bleeding, and a history of falling, with a moderate cognitive impairment as indicated by a BIMS score of 12 out of 15.
Delayed Notification of Change in Resident Condition
Penalty
Summary
The facility failed to ensure timely notification of a physician and resident representative regarding a change in condition for a resident. On November 10, 2024, staff observed a suspected burn on the resident's skin after using a hot pack. However, the resident's Nurse Practitioner was not notified until the following day, and the resident's Power of Attorney for Healthcare was not informed until four days later. This delay in communication was contrary to the facility's First Aid Treatment policy, which mandates immediate notification of any resident injury or illness to the attending physician and family. The resident involved had a history of acute and sub-acute endocarditis, end-stage renal disease, dependence on dialysis, and discitis. Despite having a Brief Interview for Mental Status score indicating no cognitive impairment, the resident's activated Power of Attorney for Healthcare was responsible for healthcare decisions. The incident was initially reported by a Licensed Practical Nurse to the Director of Nursing, who then informed the Nursing Home Administrator. However, there was a breakdown in communication among staff, as assumptions were made about who would notify the necessary parties, leading to the delay. The facility lacked documentation of staff education on the notification process, contributing to the deficiency.
Failure to Maintain Safe Environment Leads to Resident Injury
Penalty
Summary
The facility failed to ensure a resident's environment was free from accident hazards, resulting in a resident developing skin redness with blisters similar to a second-degree burn. The incident involved a resident with a history of endocarditis, end-stage renal disease, and discitis, who had a BIMS score indicating no cognitive impairment. The resident experienced back pain and requested a hot pack, which was applied by an LPN after using a topical analgesic cream. The LPN did not follow the facility's policy to check the skin every five minutes during the application of the hot pack. The LPN heated the hot pack in a microwave for less than two minutes and applied it to the resident's right hip. The resident initially indicated the hot pack was too hot, leading the LPN to reposition it. The LPN did not check the resident's skin after removing the hot pack and left it within the resident's reach. Later, CNAs discovered the reddened area and notified the LPNs, who assessed but did not measure the area. The LPNs did not offer a cold pack or notify the resident's Nurse Practitioner, assuming the follow-up would be completed by another LPN. The facility's policies were not adhered to, as the topical medication was not documented in the resident's TAR, and there was no staff education on using Muscle Rub with hot packs. The Muscle Rub used contained menthol and methyl salicylate, with instructions not to use it with a heating pad. The facility's failure to follow proper procedures and documentation led to the resident's injury, highlighting a deficiency in maintaining a safe environment free from accident hazards.
Failure to Report Allegation of Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident, identified as R4, to the State Agency (SA) as required by their policy and federal and state law. On September 20, 2024, R4 alleged that a Certified Nursing Assistant (CNA-C) was rough during care, and staff observed red marks on R4's arms. Despite these observations, the facility did not report the allegation to the SA. The facility's policy mandates that any allegations of abuse, neglect, or mistreatment be reported immediately, or within 2 hours if the allegation involves abuse or results in serious bodily injury, and within 24 hours if it does not. However, this protocol was not followed in R4's case. R4, who was admitted to the facility with diagnoses including cerebral infarction, type 2 diabetes, hypertensive chronic kidney disease, and a history of falling, had a moderate cognitive impairment as indicated by a BIMS score of 10 out of 15. The grievance filed on September 20, 2024, detailed that R4 expressed concerns about CNA-C's care to another CNA, who then reported it to an LPN. The LPN assessed R4's arms and noted red areas, but the incident was not reported to the SA. In contrast, a similar allegation involving another resident (R2) against the same CNA was reported to the SA on September 27, 2024. The Nursing Home Administrator confirmed the oversight but could not explain why R4's allegation was not reported while R2's was.
Failure to Investigate Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident, identified as R4, who reported that a Certified Nursing Assistant (CNA-C) was rough during care. On the date of the incident, R4 was observed to have red marks on their arms, which were reported by another CNA (CNA-D) to a Licensed Practical Nurse (LPN-E). LPN-E assessed R4's arms and noted flat and irregular red areas, but there was no documentation of a follow-up skin assessment or notification to R4's physician. The facility's grievance did not indicate how R4 and other residents were protected following the allegation, nor did it document interviews with other residents or corrective actions taken. The Director of Nursing (DON-B) confirmed the absence of documentation for nursing skin assessments, and the Nursing Home Administrator (NHA-A) admitted that other residents were not interviewed because they felt confident that abuse did not occur. NHA-A also confirmed that CNA-C was not removed from resident care areas following the allegation. Despite R4's moderate cognitive impairment and activated Power of Attorney for Healthcare, the facility did not adhere to its policy of promptly and thoroughly investigating abuse allegations, which includes removing the alleged perpetrator and protecting the resident.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 27 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Stevens Point
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Stevens Point Health Services | 1 mi | ★★★★★ | 0 | 0 |
| Edenbrook Of Wisconsin Rapids | 13.2 mi | ★★★★★ | 5 | 0 |
| Wisconsin Rapids Health Services | 14.8 mi | ★★★★★ | 15 | 0 |
| Edgewater Haven Nursing Home | 17.6 mi | ★★★★★ | 0 | 0 |
| Wi Veterans Home Moses Hall | 24.6 mi | ★★★★★ | 7 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.