Timberline Post Acute

Inspectors wroteBased 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. A 6/16/25 revised Care Plan indicated Resident 71 had a Wander Guard (an alarm attached to a resident at risk for wandering) and was at risk for leaving the facility without notifying staff. Review of Resident 71's clinical record revealed no consent or evaluation for the use of her/his Wander Guard. A 6/17/25 Elopement Risk Evaluation indicated Resident 71 was a low risk for elopement. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observations, interviews, and record review, it was determined the facility failed to follow infection control practices when providing wound care to 1 of 3 sampled residents (#3) reviewed for pressure injuries. This placed residents at risk for infection.

Inspectors wroteBased on interview and record review it was determined the facility failed to follow physician orders for 1 of 5 residents (#1) reviewed for unnecessary medications. This placed residents at risk for adverse side effects of medications. Findings Include: Resident 1 was admitted to the facility in 8/2018 with diagnoses including diabetes. A review of Resident 1's Physician Orders revealed a 7/27/24 order for sumatriptan succinate (a medication used to treat migraines) 25 mg as needed for migraines daily, may repeat dose in two hours if the first dose was ineffective. A review of Resident 1's 9/1/24 through 9/25/24 MAR revealed on 9/20/24 Resident 1 was given sumatriptan succinate 25 mg at 2:46 PM with effective results and a second dose of sumatriptan succinate 25 mg was given on 9/20/24 at 11:04 PM with effective results. [...]

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to obtain oxygen orders for 1 of 2 sampled residents (#211) reviewed for respiratory care. This placed residents at risk for adverse side effects of oxygen use without orders.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure pharmacy recommendations were addressed by the physician for 1 of 5 sampled residents (#33) reviewed for unnecessary medications. This placed residents at risk for adverse side effects of medications.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to protect resident identifiable information for 3 of 3 sampled residents (#s 17, 22 and 32) reviewed for record management. This placed residents at risk for unauthorized use of their personal information.

Inspectors wroteBased on observation, interview and record review, it was determined the facility failed to ensure resident equipment was kept sanitary and proper hand hygiene was completed during a dressing change for 2 of 2 sampled residents (#s 6 and 19) and, ensure proper hand hygiene was completed during meals for 1 of 3 halls reviewed for dining, pressure ulcers and tube feeding. This placed residents at risk for unsanitary equipment and cross contamination.

Inspectors wroteBased on interview and record review it was determined the facility failed to involve a resident in care planning for 1 of 4 sampled residents (#53) reviewed for discharge. This placed residents at risk for lack of unidentified care needs.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a physician was notified of a change in skin condition for 1 of 1 sampled resident (#62) reviewed for non-pressure skin. This placed residents at risk for delayed care. On 10/14/22 the Past Noncompliance was corrected when the facility completed a root cause analysis of the incident and determined there was a failure to notify a physician of a new skin issue, obtain orders and monitor the resident. The Plan of Correction included: 1. Skin sweep of all residents in the facility, 2. Education to all Licensed Staff on the Skin at Risk Policy and Provider Notification, and 3. Monthly Quality Assurance Program Improvement audits and reviews until the facility was in compliance.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents were free from abuse for 2 of 8 sampled residents (#37 and 67) reviewed for abuse. This placed residents at risk for abuse.

Inspectors wroteBased on interview and record review it was determined the facility failed to complete a Significant Change MDS within the required timeframe for 2 of 5 sampled residents (#s 32 and 51) reviewed for hospice and ADLs. This placed residents at risk for unassessed needs.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a resident's newly identified skin issue was treated and monitored for 1 of 1 sampled resident (#62) reviewed for non-pressure skin conditions. This placed residents at risk for worsening skin issues. On 10/14/22 the Past Noncompliance was corrected when the facility completed a root cause analysis of the incident and determined there was a failure to notify a physician of a new skin issue, obtain orders and monitor the resident. The Plan of Correction included: 1. Skin sweep of all residents in the facility, 2. Education to all Licensed Staff on Skin at Risk Policy (including monitoring) and Provider Notification and 3. Monthly Quality Assurance Program Improvement audits and reviews until the facility was in compliance.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure residents were provided podiatry care and/or referrals for podiatry for 1 of 4 sampled residents (# 10) reviewed for ADLs. This placed residents at risk for lack of foot care.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a resident was supervised to prevent falls for 1 of 6 sampled residents (#22) reviewed for accidents. This placed residents at risk for injury.

Inspectors wroteBased on interview and record review it was determined the facility failed to make an appointment for denture refitting for 1 of 1 sampled resident (#10) reviewed for dental. This placed residents at risk for decreased food intake.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure the resident received food as ordered for 1 of 5 sampled residents (#6) reviewed for food. This placed residents at risk for lack of dining enjoyment.