Timberwood Nursing And Rehabilitation Center
Inspection Findings
F-Tag F0627
F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
with discharge instructions. The DON said ADON A called the physician to inform him of the incident but did not receive an order for discharge from the physician nor nurse practitioner before discharge. The DON said
she was not up to date on the facilities immediate discharge policy and procedure. She said the Administrator and her were out of town for work resulting in an inappropriate discharge for Resident #1. The DON said she was responsible for responsible for ensuring staff follow facility policy/procedures. She said
the ombudsman should have been notified of Resident #1 discharge, the facility should have had a physician order for discharge, and they should have documented the basis for Resident #1's discharge in his medical records prior to discharge. She said if the discharge policy is not followed it could cause residents to have improper discharges. During an interview with the Administrator on 11/18/2025 at 12:40 p.m. he said the DON and him jointly made the decision together to discharge Resident #1 immediately due to the incident. He said the DON told ADON A to call Resident #1's Family Member B and tell her to pick -up Resident up immediately for discharge. He said no staff member notified the ombudsman of the discharge or called the wife after the incident to follow- up with discharge instructions. The Administrator said the facility did not properly discharge Resident #1 nor did they follow their policy for resident discharges. He said the facility did not have a physician's order for discharge. He verbally acknowledged the facility should have had a physician's order before discharge and they should have documented the basis for Resident #1's discharge in his medical records prior to discharge. The Administrator said if the discharge policy is not followed it leads to residents not being properly discharged . During an interview with ADON A on 11/18/2025 at 1:00 p.m. she called Resident #1's Family Member B and told her she need to pick up her husband immediately. The ADON A said she did not call the ombudsman to notify her of Resident #1 discharge. She said she did not have a written physician's order for Resident #1 discharge, nor had she completed a discharge summary in his medical records. The ADON A said the facility did not follow facility policy and procedure on resident discharges. The ADON A said she was not aware of the facility policy/procedures for an appropriate discharge and never had an incident were a male resident had his hand up a female resident's shirt before. She said if the staff fails to follow the facilities discharge policy it will place residents at risk for improper discharges. During an interview with the social worker on 11/18/2025 at 3:10 p.m. she said she was made aware of the incident the next day (02/19/2025) by the DON. She said she did not contact Resident #1's Family Member B to discuss the basis of his discharge, nor did she provide medical resources to the wife post discharge. The social worker said she did not document anything in Resident #1's medical records regarding his discharge. Record review of facility policy Criteria for Transfer and Discharge original date: 11/2016 and revision/ review date:12/2023, indicated: Policy: It is the policy of this facility that each resident will remain in the facility, and not be transferred or discharged unless the discharge or transfer is appropriate as per the existing criteria. When
the facility transfers or discharges a resident, the Facility shall ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving healthcare institution or provider.3. When the Facility transfers or discharges a resident, who meets the criteria specified above (A-F), the resident's medical records shall include documentation of the basis for
the transfer.5. The facility shall document if the transfer or discharge is necessary because the safety of individuals in the Facility is endangered due to the clinical or behavioral status of the resident OR because
the health of individuals in the Facility would overwise be endangered.
Event ID:
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If continuation sheet
Timberwood Nursing and Rehabilitation Center in Livingston, TX inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Livingston, TX, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Timberwood Nursing and Rehabilitation Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.