Timberline Post Acute

In the surveyor’s words

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

• No harm, potential for more than minimal, isolatedF604Feb 13, 2026

  Based on interview and record review it was determined the facility failed to assess and correctly utilize a restraint for 1 of 1 sampled resident (#71) reviewed for elopement. This placed residents at risk for lack of freedom from physical restraints. Resident 71 was admitted to the facility in 1/2025 with diagnoses including respiratory failure and personality disorder.The 1/10/25 admission MDS revealed Resident 71 had a BIMS score of 12 (moderately cognitively intact) and poor safety awareness. […]

• No harm, potential for more than minimal, isolatedF636Feb 13, 2026

  Based on observation, interview, and record review it was determined the facility failed to implement a care plan after a comprehensive assessment for 1 of 1 sampled resident (#7) reviewed for communication. This place residents at risk for ineffective communication. Findings include: Resident 7 was admitted to the facility in 12/2025 with a diagnosis including cerebral palsy (neurological disorder affecting movement and muscle coordination).The 12/12/25 admission MDS and Communication CAA revealed Resident 7 had a BIMS score of 15 (cognitively intact), received speech therapy in the last seven days, and staff were to provide simple, short instructions to improve the resident's understanding of words. […]

• No harm, potential for more than minimal, isolatedF656Feb 13, 2026

  Based on observation, interview and record review it was determined the facility failed to develop a comprehensive care plan for 2 of 4 sampled residents (#s 3 and 6) reviewed for pain and incontinence. This placed residents at risk for unmet needs. Findings include:1. Resident 3 was admitted to the facility in 1/2026 with diagnoses including stroke. The 1/22/26 admission MDS indicated Resident 3 had a BIMS score of 14 (cognitively intact), her/his upper and lower extremities were impaired on one side, and she/he was assessed with the ability to eat independently. […]

• No harm, potential for more than minimal, isolatedF881Feb 13, 2026

  Based on observation, interview and record review it was determined the facility failed to ensure proper use of antibiotics for 1 of 1 sampled resident (#6) reviewed for UTIs. This placed residents at risk for drug resistant organisms. Findings include: Resident 6 admitted to the facility in 5/2025 with diagnoses including diabetes and muscle weakness. A 1/20/26 Physician Order instructed staff to administer ciprofloxacin 500 mg (antibiotic). No additional information was provided. On 1/22/26, laboratory results were obtained indicating Resident 6 did not have a urinary tract infection (UTI). A 1/25/26 progress note indicated clarification was requested for ciprofloxacin 500 mg twice daily. No follow up was documented. […]

• No harm, potential for more than minimal, isolatedF686Dec 9, 2025

  Based on interviews and record review it was determined the facility failed to identify, treat, and care plan for a pressure injury for 1 of 3 sampled residents (#1) reviewed for pressure injuries. This placed residents at risk for worsening pressure injuries. Findings include:Resident 1 was admitted to the facility on [DATE] with diagnoses including a right ankle fracture.CMS defines a Stage I Pressure Injury as an injury to intact skin that is characterized by non-blanchable redness (redness that does not fade when pressed on).CMS defines an Unstageable Pressure Injury as a pressure wound that cannot be staged due to slough/eschar (dead or dying tissue) covering the wound bed.The 9/11/25 admission Evaluation indicated on admission to the facility; Resident 1 had a soft mass on the middle… […]