Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 The Oaks At Timberline during CMS and state inspections, most recent first.
Incomplete Care Plan for Diabetes and Insulin Use: A resident with DM was cognitively intact and receiving insulin, with an order for diabetic nail care and a later order for insulin glargine at bedtime. However, the comprehensive care plan did not include a diabetes or insulin focus/goal, and the Kardex also did not identify the resident as diabetic or note the nail care order. Staff stated they relied on the Kardex for care needs, and the DON said the Kardex was triggered from the care plan and that a diabetes care plan should have been present.
Medication administration was not done according to professional standards for one alert and oriented resident. A cup with several pills was left on the bedside table while the nurse left to get water, and the resident swallowed the medication without the nurse present. The record did not show approval for the resident to keep meds in the room or self-administer them, and the DON and an LPN stated staff were supposed to observe medication administration and not leave meds in a resident’s room.
Failure to use EBP during wound care for a resident with a Stage 3 pressure ulcer. The resident had an open wound to the mid back, but no EBP order, care plan, or sign was in place. During wound care, an LPN and the resident care manager entered the room without gowns, and the IP later stated the resident should have been on EBP. The DON said residents with open pressure wounds were expected to be on EBP.
The facility failed to label and date food items in the kitchen walk-in refrigerator, leading to the presence of expired, undated, and unlabeled opened items. The Dietary Supervisor acknowledged the oversight and discarded the items, while the Administrator confirmed the expectation for proper labeling and dating according to facility policy.
A resident with a history of depression and anxiety called for help after losing balance in bed, but an LPN did not assist, citing medication distribution duties. The resident felt unsafe and uncomfortable with the LPN's care, which exacerbated her anxiety and PTSD. The incident was reported, but the facility's investigation was unsubstantiated.
A facility failed to accurately complete the MDS assessment for a resident with diabetes mellitus. The MDS incorrectly indicated no insulin injections were given, while the EMAR showed multiple administrations of Insulin Lispro and Insulin Glargine. The Interim DON acknowledged the error and the need for modification.
The facility failed to timely implement Level II PASARR recommendations for two residents, one with serious mental health conditions and another with depression and anxiety. Recommendations for Resident 55 were delayed by 57 days, and for Resident 38 by seven months, despite receiving evaluations earlier. Staff acknowledged the delays, indicating a lapse in the process for updating care plans.
A facility failed to ensure a PASARR assessment accurately reflected a resident's mental health diagnoses, leading to an incomplete referral for a Level II PASARR. The resident, admitted with Adjustment Disorder and Bipolar Disorder, had no Level II PASARR despite a serious mental illness diagnosis. Staff acknowledged the oversight, citing an inaccurate Level I PASARR from the hospital and lack of documentation for a Level II referral.
A resident with Type 2 Diabetes Mellitus had a physician order to hold Insulin Lispro if their CBG was below 100 mg/dL. Despite this, insulin was administered on two occasions when the resident's CBG was below the threshold. A Resident Care Manager and LPN confirmed the error, acknowledging the insulin was given contrary to the physician's order.
A facility failed to provide adequate ADLs care for a resident, specifically in nail care. The resident, who required assistance with bathing and personal hygiene, was observed with long fingernails despite care plan instructions to keep them short. Staff confirmed that nail care was part of the shower routine, but it was not performed, placing the resident at risk of not receiving necessary care.
The facility failed to implement bowel management interventions for two residents, resulting in extended periods without bowel movements, contrary to the facility's protocol. Additionally, another resident did not receive scheduled dental care, with no documentation or rescheduling of missed appointments. Staff interviews confirmed these deficiencies, highlighting a lack of adherence to established care protocols.
The facility did not ensure that nursing assistants were screened through the nurse aide registry before providing care. Staff C, hired as a nursing assistant, lacked documentation from the registry. Staff B, responsible for human resources, misunderstood the registry requirements, thinking they applied only to NARs and not NACs. This oversight was being addressed at the time of the interview.
Incomplete Care Plan for Diabetes and Insulin Use
Penalty
Summary
The facility failed to develop a comprehensive care plan for Resident 34, who was admitted with multiple diagnoses including Diabetes Mellitus. The Medicare 5-Day MDS dated 12/28/2025 showed the resident was cognitively intact, had Diabetes Mellitus, and was receiving insulin injections. Physician orders dated 11/20/2025 documented that an LN was to perform diabetic nail care, and a later order dated 12/30/2025 showed Insulin Glargine daily at bedtime. The resident’s comprehensive care plan, initiated 11/20/2025, did not include a focus area or goal for diabetes and/or insulin use. The resident’s Kardex dated 03/03/2026 also did not identify the resident as diabetic or indicate that LNs were to perform diabetic nail care. During interview, the resident stated he had diabetes and was on insulin. Staff reported that care needs such as nail care or diabetes information were obtained from the Kardex, and the DON stated the Kardex information was triggered from the care plan and that a diabetes care plan should have been present.
Medication Left Unsupervised in Resident Room
Penalty
Summary
Medication administration was not performed according to professional standards of practice for one sampled resident. During an observation and interview, a small clear cup containing several pills was seen sitting on the resident’s bedside table while the nurse had left the room to get water. The resident stated that the nurse had left the medications there and then swallowed them without the nurse present. The resident’s quarterly MDS dated 02/07/2026 indicated the resident was alert and oriented. Record review did not show that the resident was approved to keep medications in the room or to take medications without nursing supervision. The facility’s policy on self-administration of medications required that the ability of an alert resident to self-administer be determined and that appropriate notation be placed in the care plan. During interviews, an LPN stated nursing was supposed to stay and observe a resident taking medication, and the DON stated staff were not to leave medication in a resident’s room and were supposed to monitor the resident taking the medication; the DON also stated a resident needed to be assessed, have an order, and be care planned before self-administering medications.
Failure to Use Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Provide and implement an infection prevention and control program was not maintained when the facility failed to implement Enhanced Barrier Precautions during wound care for a resident with a Stage 3 pressure ulcer to the mid back over a bony prominence. The resident was moderately cognitively impaired and at risk for pressure ulcers. Physician orders directed daily wound cleansing and dressing changes with collagen powder or sheet, calcium alginate, and bordered foam, and the skin care plan documented impaired skin integrity related to the Stage 3 pressure ulcer. Record review showed no physician order or care plan for Enhanced Barrier Precautions. During observation, the wound nurse/LPN and the resident care manager/LPN entered the resident’s room and performed wound care without donning a gown, and no EBP sign was posted outside the room. In interview, the wound nurse stated the resident did not have an EBP sign and that signs were posted when a gown was needed for wound care. The infection preventionist stated residents with excessive wound care or saturated dressings were placed on EBP and said she thought contained wounds did not need EBP, then acknowledged that pressure-related wounds needed to be on EBP and that this resident should have been on EBP. The DON stated it was her expectation that residents with open pressure wounds were on EBP.
Improper Food Labeling and Dating in Kitchen Refrigerator
Penalty
Summary
The facility failed to ensure proper labeling and dating of food items in the kitchen walk-in refrigerator, which was observed to contain expired, undated, and unlabeled opened items. Specifically, a jar of Maraschino cherries, a jar of peeled garlic, and a jar of Worcestershire sauce were labeled with use-by dates, while a jar of raspberry vinaigrette dressing and a bag of shredded cheddar cheese were not labeled or dated. Staff F, the Dietary Supervisor, acknowledged the oversight and discarded the items, stating that they should not have been there. The facility's policy requires opened items to be used within three days and unopened items to adhere to use-by dates. Staff A, the Administrator, confirmed the expectation for food items to be dated and labeled according to facility practice.
Resident's Call for Help Unanswered by LPN
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, as evidenced by an incident involving a resident who called out for help and was not immediately assisted by a licensed nurse. The resident, who was moderately cognitively impaired and had a history of depression and anxiety, experienced increased anxiety when others were angry or aggressive. On the day of the incident, the resident lost balance while trying to sit up on the side of the bed and called out for help, fearing a fall. A licensed nurse, identified as Staff G, was distributing medication and did not assist the resident, instead telling the resident that she could not help at that moment. The resident expressed feeling unsafe and uncomfortable with Staff G's care, stating that the incident made her feel like it was acceptable to stop dialysis and die. The resident's care plan indicated that staff should speak calmly to her, especially given her increased anxiety around anger or aggression. Despite the resident's distress, Staff G did not immediately respond to the call for help, and it was a Certified Nursing Assistant (CNA) who eventually assisted the resident. The resident's recount of the incident, as well as statements from other staff members, indicated that Staff G had yelled that she was busy and could not help, which was perceived as neglectful and disrespectful by the resident. The incident was reported to the facility's administration, and an investigation was conducted. However, the investigation was deemed unsubstantiated by the administrator. The resident's past medical and psychosocial history, including a history of abuse and panic attacks, was noted to have been triggered by the event. The facility's Social Services Director documented that the resident's PTSD and anxiety were exacerbated by seeing Staff G after the incident, further impacting the resident's trust and sense of safety within the facility.
Inaccurate MDS Assessment for Insulin Administration
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected a resident's health status and care needs. Specifically, for one resident with a diagnosis of diabetes mellitus, the Admission MDS inaccurately indicated that the resident did not receive insulin injections in the last seven days. However, a review of the resident's November 2024 Electronic Medication Administration Record (EMAR) showed that the resident received Insulin Lispro and Insulin Glargine on multiple occasions during that period. This discrepancy was acknowledged by the Interim Director of Nursing Services, who confirmed that the MDS was not coded correctly and needed modification.
Delayed Implementation of PASARR Recommendations for Two Residents
Penalty
Summary
The facility failed to implement the recommendations from the Level II Preadmission Screen and Resident Review (PASARR) for two residents, which placed them at risk of not receiving necessary mental health services. Resident 55, who was admitted with serious mental health conditions including Major Depressive Disorder and PTSD, had a Level II PASARR evaluation that recommended specific interventions for his care plan. However, these recommendations were not incorporated into his care plan until 57 days after admission, despite the facility receiving the PASARR evaluation 31 days after his admission. Similarly, Resident 38, who was admitted with Depression and Anxiety Disorder, had a Level II PASARR evaluation that included recommendations for her care plan. These recommendations were not added to her care plan until seven months after the evaluation was completed. The delay in incorporating these recommendations into the care plans of both residents indicates a failure in the facility's process for timely updating care plans based on PASARR evaluations. Interviews with facility staff revealed that there was an acknowledgment of the delay in implementing the PASARR recommendations. Staff C, a Regional Patient Advocacy Resource, confirmed that the recommendations for Resident 55 should have been incorporated sooner, and Staff A, the Administrator, agreed that the recommendations should have been implemented before the actual date. For Resident 38, Staff C indicated that the facility's process involved monthly follow-ups, but the responsibility for updating the care plan with PASARR recommendations lay with Social Services, which was not done in a timely manner.
Failure to Complete Accurate PASARR Assessment
Penalty
Summary
The facility failed to ensure that a Pre-Admission Screening and Resident Review (PASARR) assessment accurately reflected a resident's mental health diagnoses and that Level II PASARR evaluations were referred and completed in a timely manner. Resident 15, who was admitted with diagnoses including Adjustment Disorder and Bipolar Disorder, was found to have an incomplete PASARR process. The Admission Minimum Data Set assessment indicated moderate cognitive impairment, and the Level I PASARR did not identify the need for a Level II PASARR despite the presence of a serious mental illness diagnosis. The Electronic Health Record for Resident 15 documented a diagnosis of Bipolar Disorder and a physician's order for an antipsychotic medication, yet there was no evidence of a Level II PASARR or a referral for one. Staff C, responsible for social work and patient advocacy, acknowledged the oversight, noting that the facility received an inaccurate Level I PASARR from the hospital and failed to document a Level II referral. The facility administrator confirmed the expectation for accurate completion and referral of PASARR assessments.
Failure to Hold Insulin as Ordered for Diabetic Resident
Penalty
Summary
The facility failed to provide care and services according to professional standards of practice when insulin was not held as per physician orders for a resident reviewed for care provided meeting professional standards. The resident, who was admitted with a diagnosis of Type 2 Diabetes Mellitus, had a physician order dated 12/05/2024 for Insulin Lispro to be injected subcutaneously with meals, with instructions to hold the insulin if the Capillary Blood Glucose (CBG) level was less than 100 mg/dL. However, on 01/07/2025 and 01/14/2025, the resident's CBG levels were recorded as 91 mg/dL and 90 mg/dL, respectively, yet the insulin was administered contrary to the physician's order. Staff D, a Resident Care Manager and Licensed Practical Nurse, confirmed that the expectation was to hold the medication if the CBG was less than 100 mg/dL, acknowledging that the insulin was administered on the dates mentioned despite the CBG levels being below the threshold. This placed the resident at risk for medical complications and a diminished quality of life.
Failure to Provide Adequate Nail Care for a Resident
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADLs) care for a dependent resident, specifically in the area of nail care. Resident 25, who was alert and oriented, required substantial assistance with bathing and supervision with personal hygiene. The care plan for Resident 25 included instructions to keep fingernails short to avoid scratching and excessive moisture. Despite this, observations on two separate occasions revealed that Resident 25's fingernails were approximately 1/3 of an inch long, indicating that nail care was not performed as required. Staff members confirmed that nail care was supposed to be part of the resident's shower routine, as noted in the resident's Kardex. This oversight placed the resident at risk of not receiving necessary care and services.
Failure to Implement Bowel Management and Dental Care
Penalty
Summary
The facility failed to implement bowel management interventions for two residents, both of whom were moderately cognitively impaired. Resident 15 did not have a bowel movement for over 117 hours, and Resident 45 experienced similar delays in bowel movements, with intervals exceeding 89, 96, and 98 hours. Despite the facility's bowel protocol requiring intervention after three days without a bowel movement, the Medication Administration Records and Progress Notes for both residents did not show that the protocol was initiated. Staff interviews confirmed that the bowel management protocol should have been started but was not documented or executed as per policy. Additionally, the facility failed to ensure dental care was completed for another resident, who was also moderately cognitively impaired. This resident was referred for an emergency dental appointment for teeth extraction, with subsequent denture fitting planned. However, there was no documentation indicating that the resident attended the scheduled appointments, and staff were unable to provide reasons or documentation for the missed appointments or why they were not rescheduled. The resident expressed a desire to have the dental procedures completed, but the facility did not follow through with the necessary arrangements.
Failure to Screen Nursing Assistants Through Registry
Penalty
Summary
The facility failed to ensure that nursing assistants were properly screened through the nurse aide registry as required by OBRA before providing care to residents. This deficiency was identified for one of the two staff members reviewed for qualifications, specifically Staff C, who was hired on February 26, 2024. Upon review, it was found that Staff C's employee record lacked documentation from the nurse aide registry. During an interview on August 12, 2024, Staff B, the Human Resource and Payroll Representative, admitted to a misunderstanding regarding the registry requirements, believing it applied only to nursing assistants registered (NARs) and not to nursing assistants certified (NACs). Staff B was in the process of reviewing all NACs through the registry at the time of the interview.
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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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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bridge Crest Post Acute | 1 mi | ★★★★★ | 29 | 0 |
| Vancouver Specialty And Rehab Care | 4 mi | ★★★★★ | 29 | 0 |
| Hudson Bay Health And Rehabilitation | 4.1 mi | ★★★★★ | 14 | 0 |
| Marquis Piedmont Post Acute Rehab | 4.7 mi | ★★★★★ | 13 | 0 |
| Salmon Creek Post Acute & Rehabilitation | 5.5 mi | ★★★★★ | 27 | 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 July 2026) and official state health department websites.