Above average — CMS composite of the measures below.
The next survey window likely opens around January 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 Timberline Post Acute during CMS and state inspections, most recent first.
A resident with cerebral palsy had an admission MDS and Communication CAA showing a BIMS of 15, recent SLP services, and a need for staff to use simple, short instructions, rephrase information, and speak louder to improve understanding. A later SLP communication report added guidance to avoid speaking down to the resident and to repeat words to confirm understanding, but the revised care plan still had no communication focus or interventions. Staff later confirmed there were no care plan interventions for communication, and the DNS acknowledged the resident had no communication care plan despite the CAA findings.
The facility failed to develop comprehensive care plans for two residents. One resident with a stroke had right-sided weakness, could not complete a menu, and needed cut food and straws, but these needs were not reflected in the care plan. Another resident with a history of uterine cancer had no focused care plan area for that condition, despite records noting the cancer history, a cancer institute appointment, and the resident expressing fear about the diagnosis.
A resident admitted with diabetes and muscle weakness was ordered ciprofloxacin for a presumed UTI, but lab results later showed no UTI. A progress note documented that clarification was requested for ciprofloxacin 500 mg BID, but no follow-up was documented. The DNS later confirmed there was no clinical indication for the antibiotic.
Inappropriate Use of Wander Guard Without Evaluation or Consent: A resident with respiratory failure, personality disorder, and poor safety awareness was assigned a Wander Guard despite no documented consent or evaluation for its use. The resident was later found to have left the facility after removing the device, and staff acknowledged the alarm was being used to monitor the resident’s safety even though it was inappropriate and not supported by the record.
A resident admitted with a right ankle fracture and a non-blanchable red area on the back did not receive appropriate wound assessment, provider notification, or care planning. The LPN did not inform the wound care nurse or provider, and the wound was not monitored or added to the TAR. The DON confirmed that required follow-up and care planning were not completed, and later documentation showed the wound progressed to an unstageable pressure injury without investigation.
An LPN failed to follow proper infection control practices while providing wound care to a resident with diabetes. The LPN did not change gloves or perform hand hygiene between treating multiple wounds, and only performed hand hygiene after leaving the room. The facility's infection preventionist confirmed that this practice did not meet the expected standards for glove changes and hand hygiene between wound sites.
A resident with diabetes was prescribed sumatriptan succinate for migraines, with specific instructions for administration. On one occasion, the resident received a second dose of the medication outside the prescribed timeframe without obtaining new orders from the provider, as confirmed by an RNCM.
A resident admitted with acute respiratory failure was observed using oxygen via nasal cannula without any physician orders. Despite being observed on two occasions using oxygen at two liters per minute, a review of the resident's physician orders showed no evidence of oxygen orders. An RN case manager confirmed the resident was using oxygen without orders.
A facility failed to address pharmacy recommendations for a resident with COPD and sleep apnea, who continued to receive fluticasone nasal spray twice daily despite a recommendation to reduce it to once daily. The physician assistant had agreed to the change, but the oversight was confirmed by an RNCM, placing the resident at risk for adverse side effects.
The facility failed to protect resident-identifiable information during meal service. Meal tickets with residents' names and diet types were found in clear garbage bags on carts for dirty dishes, instead of being placed in a confidential shred bin. Staff confirmed the breach of protocol, risking unauthorized use of personal information.
The facility failed to maintain proper infection control and hygiene practices, affecting two residents and meal service. A resident's suctioning device was not consistently emptied or cleaned, with staff unclear on responsibilities. Another resident's dressing change was conducted without proper hand hygiene. Additionally, a CNA did not perform hand hygiene between meal tray deliveries, contrary to facility protocols.
Failure to Add Communication Interventions to Care Plan
Penalty
Summary
The facility failed to implement a communication care plan after completing a comprehensive assessment for a resident admitted with cerebral palsy. The admission MDS and Communication CAA documented that the resident had a BIMS score of 15, had received speech therapy in the last seven days, and required staff to provide simple, short instructions, rephrase information, and elevate their voices to improve understanding; the CAA also indicated that a care plan for effective communication was needed. A facility Communications Report completed later stated that the SLP instructed staff to avoid speaking down to the resident, take time to understand the resident, and repeat the resident’s spoken words to confirm understanding. However, the revised care plan contained no communication focus or interventions for staff to follow. During observation, the resident was noted to not speak distinctly and stated it was difficult for staff to understand them. A CNA stated there were no care plan interventions to help communicate with the resident and that understanding the resident required great effort, while the DNS acknowledged the resident had no communication care plan or interventions despite the CAA findings.
Failure to Develop Comprehensive Care Plans for Eating Needs and Cancer History
Penalty
Summary
The facility failed to develop a comprehensive care plan for 2 of 4 sampled residents reviewed for pain and incontinence. Resident 3 was admitted with a stroke diagnosis, had a BIMS score of 14, and was documented as having impaired upper and lower extremities on one side while still being assessed as able to eat independently on the admission MDS. Later skilled nursing notes documented right-sided weakness, inability to move fingers, and inability to lift the hand or arms. During an observation, the resident was unable to complete a menu and called staff back for assistance. The Dietary Manager stated she completed food preferences but was not aware the resident could not complete menus or likely needed cut food, and a CNA stated the resident required cut food and straws, which was not indicated in the care plan. The RNCM acknowledged the care plan needed communication and details related to eating after the stroke and was not resident-centered. Resident 6 was admitted with diagnoses including cancer and muscle weakness, and the admission MDS indicated urinary incontinence and no history of cancer. However, the history and physical later documented a history of uterine cancer, and the comprehensive care plan did not include a focused area addressing that history. A progress note documented an appointment with the cancer institute, and the resident stated she/he had a history of uterine cancer and expressed fears related to the condition. The RNCM acknowledged the resident had a history of uterine cancer and confirmed the care plan was not resident-centered.
Improper Antibiotic Use for a Resident Without a UTI
Penalty
Summary
The facility failed to ensure proper use of antibiotics for one resident reviewed for UTIs. The resident was admitted in 5/2025 with diagnoses including diabetes and muscle weakness. On 1/20/26, a physician order directed staff to administer ciprofloxacin 500 mg, but no additional information was provided with the order. Laboratory results obtained on 1/22/26 indicated the resident did not have a UTI. A progress note dated 1/25/26 documented that clarification was requested for ciprofloxacin 500 mg twice daily, but no follow-up was documented. On 2/10/26, the DNS reviewed the laboratory results and confirmed the resident did not have a UTI and that there was no clinical indication for the prescribed antibiotic.
Inappropriate Use of Wander Guard Without Evaluation or Consent
Penalty
Summary
The facility failed to assess and correctly use a Wander Guard for one resident reviewed for elopement. The resident was admitted with diagnoses including respiratory failure and personality disorder, had a BIMS score of 12 indicating moderate cognitive intactness, and was documented as having poor safety awareness. The care plan identified the resident as having a Wander Guard and being at risk for leaving the facility without notifying staff, but the clinical record contained no consent or evaluation for the device. An elopement risk evaluation later described the resident as low risk for elopement, noted that the resident was allowed to go outside and showed no exit-seeking behaviors, and stated the Wander Guard was placed to alert staff when the resident left the building because of fall risk. The resident later left the facility without informing staff after removing the Wander Guard. The elopement investigation stated the resident was under emotional stress and used the outdoors as a coping strategy. Staff later stated the Wander Guard was used to alert staff to monitor the resident for safety when leaving the building, and that once the resident understood the sign-out process, the resident no longer attempted to elope. Another staff member acknowledged the Wander Guard was inappropriate for the resident and confirmed there was no evaluation or consent for its use.
Failure to Identify and Care Plan for Pressure Injury on Admission
Penalty
Summary
The facility failed to identify, treat, and care plan for a pressure injury for one resident who was admitted with a right ankle fracture and a red, non-blanchable soft mass on the middle of the back. Upon admission, the area met the definition of a Stage I pressure injury, but there was no documentation of provider notification, treatment orders, or wound care planning. The nurse who completed the admission did not inform the wound care nurse or provider about the non-blanchable area, and no treatment orders were obtained. The resident's care plan only indicated a risk for pressure injuries, without addressing the existing wound. Subsequent documentation showed that the wound was not assessed by an RN after admission, was not monitored weekly, was not added to the treatment administration record (TAR), and the provider and RN were not notified. Later progress notes documented an abrasion and, eventually, an unstageable pressure injury at the same site, but there was no investigation into the progression or cause of the wound. Facility leadership confirmed that required assessments, monitoring, and care planning were not completed for the pressure injury.
Failure to Follow Infection Control Practices During Wound Care
Penalty
Summary
Staff 6, an LPN, was observed providing wound care to a resident admitted in December 2023 with diagnoses including diabetes. During the procedure, Staff 6 donned a gown, gloves, and face mask before entering the resident's room. She cleaned a wound on the resident's right thumb and, without changing gloves or performing hand hygiene, applied a clean dressing to the thumb, then proceeded to clean and dress a wound on the resident's left big toe. After removing her gloves, she did not perform hand hygiene before donning a new pair of gloves to apply cream to the resident's knee. Hand hygiene was only performed after leaving the resident's room. Staff 6 later acknowledged she did not change gloves between wounds and did not perform hand hygiene as required. The facility's infection preventionist confirmed that the expected practice is to perform hand hygiene before and after donning gloves and to change gloves between each wound to prevent cross-contamination.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to adhere to physician orders for a resident who was prescribed sumatriptan succinate for migraines. The resident, admitted in August 2018 with a diagnosis of diabetes, had a physician order dated July 27, 2024, for sumatriptan succinate 25 mg to be taken as needed for migraines, with the possibility of a repeat dose in two hours if the first dose was ineffective. On September 20, 2024, the resident was administered sumatriptan succinate 25 mg at 2:46 PM, which was effective. However, a second dose was given at 11:04 PM, which was not in accordance with the physician's orders. Staff 7, a Registered Nurse Case Manager (RNCM), confirmed that the second dose was administered without obtaining new orders from the provider, which was a deviation from the prescribed treatment plan.
Failure to Obtain Oxygen Orders for Resident
Penalty
Summary
The facility failed to obtain oxygen orders for a resident who was admitted with a diagnosis of acute respiratory failure. The resident was observed using oxygen via nasal cannula at two liters per minute on two separate occasions. A review of the resident's physician orders revealed no evidence of oxygen orders. A registered nurse case manager acknowledged that the resident was using oxygen but did not have the necessary orders.
Failure to Address Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were addressed by the physician for a resident reviewed for unnecessary medications. The resident, who was admitted with chronic obstructive pulmonary disease and sleep apnea, had a pharmacy recommendation in August 2024 to change the administration of fluticasone nasal spray from twice daily to once daily for congestion. Although the physician assistant agreed to this change and signed the recommendation, a review of the resident's medication administration records for August and September 2024 revealed that the resident continued to receive the medication twice daily. On September 27, 2024, a registered nurse case manager (RNCM) confirmed that the facility did not act upon the pharmacist's recommendation, acknowledging that the recommendation was overlooked. This oversight placed the resident at risk for adverse side effects of medications.
Failure to Protect Resident-Identifiable Information
Penalty
Summary
The facility failed to protect resident-identifiable information for three residents during meal service. On two separate occasions, meal tickets containing the names and diet types of residents were found in clear plastic garbage bags without lids, located on carts used for dirty dishes next to the dining room. These meal tickets were supposed to be placed in a confidential shred bin to ensure the privacy of resident information. Staff members, including CNAs and the DNS, confirmed the presence of resident-identifiable information in the garbage. The staff acknowledged that the meal tickets should have been disposed of in a confidential manner, as per the facility's protocol. This oversight placed residents at risk for unauthorized use of their personal information.
Infection Control and Hygiene Lapses in Resident Care
Penalty
Summary
The facility failed to maintain sanitary conditions and proper hand hygiene, as evidenced by the handling of resident equipment and procedures. Resident 19, who was admitted with muscular dystrophy and dysphagia, relied on a suctioning device to manage saliva and phlegm due to swallowing difficulties. Observations revealed that the suctioning device was consistently over half full, and there was confusion among staff regarding who was responsible for emptying and cleaning it. Staff members provided conflicting statements about their responsibilities, and there was no documentation in the resident's clinical record about the cleaning schedule or responsible personnel. In another instance, Resident 6, who was admitted with paraplegia, experienced improper hand hygiene during a dressing change. An LPN was observed changing the dressing around the resident's nephrostomy tube without changing gloves or performing hand hygiene between steps. The LPN admitted to not performing hand hygiene during dressing changes, contrary to the expected infection control practices outlined by the RNCM, who confirmed the lapse in protocol. Additionally, during meal service, a CNA was observed delivering meal trays to residents without performing hand hygiene between deliveries. The CNA acknowledged that hand hygiene was not consistently performed between tray deliveries, which was contrary to the facility's expectations as stated by the DNS. These lapses in infection control practices placed residents at risk for unsanitary conditions and potential cross-contamination.
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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 Albany
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Regency Albany | 0.8 mi | ★★★★★ | 14 | 0 |
| Mennonite Home | 3.4 mi | ★★★★★ | 8 | 0 |
| Corvallis Manor Nursing & Rehabilitation Center | 6.8 mi | — | 20 | 0 |
| Avamere Rehabilitation Of Lebanon | 11.6 mi | ★★★★★ | 28 | 0 |
| Lebanon Veterans Home | 11.7 mi | ★★★★★ | 17 | 0 |
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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.