Timberwood Nursing And Rehabilitation Center
Timberwood Nursing and Rehabilitation Center in Livingston, TX — inspection on January 14, 2026.
Found 6 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
0.2 mg, give 1 tablet by mouth every 12 hours for hypertension.
Give for SBP greater than 160On the
01/02/2026 at 8:00 a.m., the BP was 149/80 administered by MA [NAME] at 8:00 p.m., the BP was
01/04/2026 at 8:00 p.m., the BP was 148/80 administered by MA C;- 01/07/2026 at 8:00 p.m., the BP was 154/76 administered by MA C;- 01/08/2026 at 8:00 p.m., the BP was 148/76 administered by MA C;- 01/09/2026 at 8:00 p.m., the BP was 154/76 administered by MA C;- 01/03/2026 at 8:00 p.m., the BP was 133/77 administered by MA C;During observation and interview on 01/12/26 at 9:10 a.m. indicated Resident #75 was lying in hospital bed. Resident #75 was alert, and no signs of distress were noted. Resident #75 did not mention any concerns regarding her Clonidine when she was asked if she had any issues regarding her medications.
During an interview on 01/14/2026 at 2:15 p.m., MA M said on 1/02/2026 at 8:00 a.m. she administered Resident #75's Clonidine and should not have because her systolic blood pressure was not greater than 160. MA M said it was an oversight administering the B/P medications to Resident #75. MA M said she received in-services from the facility especially regarding medication administration, unnecessary medications, medication errors and that she received in-services at least monthly. MA M said a negative effect if a resident received a medication that was not accurate would be a medication error and the resident could have received a dose that was not needed.
During an interview on 01/14/2026 at 2:30 p.m., the DON said her expectations were for all medications to be administered per physician orders including according to parameters.
The DON said the Medication Aide or Nurse administering medications on the cart are responsible for following the physician orders written on the medication administration record.
The DON said an adverse effect Resident #75 could experience receiving a medication incorrectly could result in the resident's blood pressure becoming lower.
The DON said Resident #32 was given the wrong dosage of medication.
The DON said she expected her nurses to pass medications and do basic medication functions like following the 5 Rights of Medication Administration and notify the Physician for anything out of the ordinary.
The DON said the risk to residents would be not receiving the correct therapeutic dosages of medications.
During an interview on 01/14/2026 at 2:40 p.m., the Administrator said his expectations were for all nursing staff to follow physician orders when administering medication to include following parameters.
The administrator said an adverse effect a resident could have if not given the accurate dosage of medication was adverse side effects depending on the medication.
During an interview on 01/14/2026 at 2:44 p.m., MA C said she should have held Resident #75's Clonidine medications as prescribed by the physician's parameter.
She said if her initials were documented on the MAR, then the Clonidine was given and should not have been because the blood pressure was less than 160. MA C said it was ordered routine and to give it but that she should have read the order better. CM C said she had been educated and re-educated on administering medications with parameters at least yearly.
She said she needed to slow down more and focus on reading what the order says to do. MA C said Resident #75's blood pressure could have bottomed out.A facility policy titled Administering Medications revised dated August 2022 indicated the following. 2.
Medications must be administered in accordance with the written orders pf the attending physician.
455745 01/14/2026
Timberwood Nursing and Rehabilitation Center 4001 Hwy 59 North Livingston, TX 77351
Clonidine medications as prescribed by the physician's parameter.
She said if her initials were
read the order better. CM C said she had been educated and re-educated on administering medications
the order says to do. MA C said Resident #75's blood pressure could have bottomed out.
A facility policy titled Administering Medications revised dated August 2022 indicated the following. 2.
Medications must be administered in accordance with the written orders of the attending physician.
455745 01/14/2026
Timberwood Nursing and Rehabilitation Center 4001 Hwy 59 North Livingston, TX 77351
medication was adverse side effects depending on the medication.
The Administrator stated he
prescribed by the physician's parameter.
She said if her initials were documented on the MAR, then
C said it was ordered routine and to give it but that she should have read the order better. CM C said she had been educated and re-educated on administering medications with parameters at least yearly.
She said she needed to slow down more and focus on reading what the order says to do. MA C said Resident #75's blood pressure could have bottomed out.A facility policy titled Administering Medications revised dated August 2022 indicated the following. 2.
Medications must be administered in accordance with the written orders of the attending physician.
455745 01/14/2026
Timberwood Nursing and Rehabilitation Center 4001 Hwy 59 North Livingston, TX 77351
01/14/26 at 2:40 p.m., the Administrator said he expected the medication cart to be locked when not
it.
The Administrator said if the medication cart was not locked, other people or residents could take
The Administrator said if a resident took a medication not intended for them, it could possibly cause a health issue for that resident.A review of the facility's Policy revised 05/22, for Medication Administration- Oral included that; .9.
The medication card is to be kept in clear view and in reach of the person administering medications at all times it is to be locked when the medication nurse is away from the cart.A review of the facility's Policy revised 05/22, for Medication Access and Storage, E-kit access included that; .2.
Only licensed nurses, the Consultant Pharmacist and those lawfully authorized to administer medications (e.g., medication aids) are allowed access to medications.
Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access.
Findings included: During an observation on 01/12/26 at 09:24 a.m. of the kitchen indicated the following:-3 muffin pans with dark brown food debris baked on outside and stacked together;-11 baking sheets with dark brown and/or black debris buildup baked on outside and inside stacked together; -3 skillets with dark brown build up outside; and-1 skillet with the interior anti-stick coating flaking off.
During an interview on 01/12/26 at 09:26 a.m. the DM said DM said pans should be clean without debris buildup.
She said the debris buildup could cause food borne illness.
During an observation on 01/13/26 at 11:45 a.m. of the kitchen during the meal preparation indicated there were 3 large steam table pans with brown debris build up on top corner.
Record review of an Infection Control Policy/Procedure for Dietary Services revised 05/2007 indicated .8.
Dietary Housekeeping:.C.
Dirty equipment should never touch food. D.
All work surfaces, utensils, and equipment should be cleaned and sanitized after each use.
Record review of The Food and Drug Administration Code at http://www.fda.gov/food/guidanceregulation accessed on 01/13/26 indicated the following: .4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils.(B)The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
455745 01/14/2026
Timberwood Nursing and Rehabilitation Center 4001 Hwy 59 North Livingston, TX 77351
Findings included:During an observation and interview on 01/13/26 at 11:45 a.m. left front burner on the stove would not light.
The DM said the pilot light was out and she used a multipurpose lighter to light the burner.
The left oven also would not light and the DM said she would have to light it with a lighter.
The DM used a multipurpose lighter to light the oven. DM said the stove should light without using a lighter.
She said having to light the stove with a lighter which could cause an explosion possibly causing injuries to residents. On 01/14/26 at 10:28 a.m. surveyor requested a policy regarding the functioning of the stove.
Record review of the FDA Food Code 2022 accessed at https://www.fda.gov/food/retail-food-protection/fda-food-code 4-5 Maintenance and Operation4-501 Equipment4-501.11 Good Repair and Proper Adjustment.(A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. No policy regarding equipment maintenance and operation was provided prior to exit.
455745 01/14/2026
Timberwood Nursing and Rehabilitation Center 4001 Hwy 59 North Livingston, TX 77351