The Oaks at Timberline

In the surveyor’s words

From the most serious findings on record at The Oaks at Timberline, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Jan 27, 2025

  Based on observation and interview, the facility failed to ensure food items were labeled and had when opened dates in 1 of 1 kitchen walk-in refrigerators reviewed for food storage in a sanitary manner. This failure placed residents at risk for cross-contamination, food borne illness, and a diminished quality of life. Findings included . On [DATE] at 10:21 AM, the kitchen walk-in refrigerator was observed with the following expired, undated, and unlabeled opened items: 1. Jar of Maraschino Cherries- labeled with use by date of [DATE] 2. Jar of Peeled Garlic- labeled with use by date of [DATE] 3. Jar of Worcestershire Sauce- labeled with use by date of [DATE] 4. Jar of Raspberry Vinaigrette Dressing- not labeled or dated 5. […]

• No harm, potential for more than minimal, widespreadF880Mar 27, 2023

  Based on observation, interview, and record review, the facility failed to implement an infection control program documenting the monitoring of controls for 1 of 1 water management program and failed to provide wound dressing changes without the risk of contaminating the site for 2 of 5 sampled residents (24 & 29) reviewed for infection prevention and control related to the water management program and wound care. This failure placed residents at risk for potential bacterial water and wound contamination. Findings included . <Water Management Program> On 03/23/2023 at 10:26 AM, Staff D, Director of Environmental Services, said he could not provide documentation of the results of the controls he monitored and tested for possible contamination of Legionella (waterborne bacteria) growth. […]

• No harm, potential for more than minimal, widespreadF623Oct 28, 2021

  Based on interview and record review, the facility failed to provide written notice of transfer to the resident and/or the resident's representative describing the reason for the transfer for six of six sampled residents (12, 40, 58, 25, 45 & 71) reviewed for hospitalization . This failure placed residents at risk of not being informed of their condition, unmet care needs and a diminished quality of life. Findings included . 1) Resident 12 was admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, widespreadF625Oct 28, 2021

  Based on interview and record review, the facility failed to provide the resident and/or the resident representative a written bed-hold notification upon transfer for six of six sampled residents (12, 25, 40, 45, 58 & 71) reviewed for hospitalization . This failure placed residents and their representatives at risk of not being informed of their right to hold the bed while the resident was at the hospital. Findings included . 1) Resident 25 was admitted to the facility on [DATE]. The Minimum Data Set (MDS), an assessment tool, dated 08/19/2021, showed the resident was alert, oriented and able to make her own decisions. The MDS history showed the resident was hospitalized on [DATE] and 07/22/2021. […]

• No harm, potential for more than minimal, patternF584Feb 7, 2024

  Based on interview, observation and record review, the facility failed to maintain a clean homelike environment by failing to ensure resident room windows were clean for 9 of 43 resident rooms (4, 5, 6, 19, 25, 28, 38, 41 & 44) reviewed for environment. This failure placed residents at risk for a diminished quality of life. Findings included . The Resident Council Minutes, dated 01/25/2024, documented, the windows need washing. On 02/04/2024 at 11:42 AM, Resident 2 said the window in her room was dirty. The window was observed to have brown discoloration and debris on the lower left side of the window. The rest of the window was cloudy. […]