Cycle 1
Health 2024-09-27 · Fire 2024-09-27
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Albany, OR
Timberline Post Acute
5-star overall rating with 4-star inspections with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1023 6th Ave Sw, Albany, OR
(541) 926-8664
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
67
Certified beds
Average residents
59
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
1983-06-03
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
264 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.43
Registered nurse staffing · state 0.68 · national 0.68
LPN hours / resident day
0.92
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
3.51
Nurse aide staffing · state 3.37 · national 2.35
Total nurse hours
4.86
All reported nurse hours · state 4.95 · national 3.89
Licensed hours
1.35
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
4.26
Weekend nurse staffing · state 4.39 · national 3.43
Weekend RN hours
0.23
Weekend registered nurse coverage · state 0.44 · national 0.47
Physical therapist
0.14
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.44
CMS adjusted RN staffing hours
Adjusted total hours
4.97
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
43%
Annual RN turnover · state 53% · national 45%
Total nurse turnover
42%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,172
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
51.26
Composite VBP score used to determine payment impact.
Payment multiplier
1.0056
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.10
Baseline 15.61% · Performance 18.14% · Measure score 7.10 · Achievement 7.10 · Improvement 0
Healthcare-associated infections
3.69
Baseline 5.17% · Performance 6.73% · Measure score 3.69 · Achievement 3.69 · Improvement 0
Total nurse turnover
4.22
Baseline 41.94% · Performance 46.43% · Measure score 4.22 · Achievement 4.22 · Improvement 0
Adjusted total nurse staffing
5.49
Baseline 4.20 hours · Performance 4.64 hours · Measure score 5.49 · Achievement 5.49 · Improvement 2.29
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.27% |
10.72%
1.5 pts better
|
No Different than the National Rate · Eligible stays 234 · Observed rate 6.84% · Lower 95% interval 6.59% |
| Discharge to community | 64.79% |
50.57%
14.2 pts better
|
Better than the National Rate · Eligible stays 228 · Observed rate 62.72% · Lower 95% interval 58.48% |
| Medicare spending per beneficiary | 0.76 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 154 · Denominator 154 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 154 |
| Discharge self-care score | 31.36% |
53.69%
22.3 pts worse
|
Numerator 37 · Denominator 118 |
| Discharge mobility score | 27.12% |
50.94%
23.8 pts worse
|
Numerator 32 · Denominator 118 |
| Pressure ulcers or injuries, new or worsened | 1.3% |
2.29%
1 pts better
|
Numerator 2 · Denominator 154 · Adjusted rate 1.69% |
| Healthcare-associated infections requiring hospitalization | 6.73% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 123 · Observed rate 5.69% · Lower 95% interval 4.13% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 113 |
| Staff flu vaccination coverage | 30.83% |
42%
11.2 pts worse
|
Numerator 37 · Denominator 120 |
| Discharge function score | 44.92% |
56.45%
11.5 pts worse
|
Numerator 53 · Denominator 118 |
| Transfer of health information to provider | 99.24% |
95.95%
3.3 pts better
|
Numerator 130 · Denominator 131 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 38.75% |
25.2%
13.6 pts better
|
Numerator 31 · Denominator 80 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
95.5%
4.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.2%
4.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.2% |
2.4%
1.2 pts better
|
3.3%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 4.4% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.9% |
4.7%
2.8 pts better
|
11.4%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.5% · Q3 4.9% · Q4 0.0% · 4Q avg 1.9% |
| Percentage of long-stay residents who lose too much weight | 0.7% |
5.0%
4.3 pts better
|
5.4%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.7% · Q4 0.0% · 4Q avg 0.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.5% |
12.5%
2 pts better
|
19.6%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 20.0% · Q3 10.8% · Q4 7.3% · 4Q avg 10.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.6% |
14.7%
7.1 pts better
|
16.7%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 3.8% · Q3 9.7% · Q4 8.1% · 4Q avg 7.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 15.6% |
24.1%
8.5 pts better
|
16.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 15.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.3% |
15.8%
4.5 pts worse
|
14.9%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 23.5% · Q3 27.8% · Q4 15.0% · 4Q avg 20.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.2% |
1.7%
0.5 pts better
|
1.0%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.2% · Q4 2.5% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.6% |
2.0%
1.4 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.3% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.7% |
22.2%
5.5 pts better
|
19.8%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.1% · Q2 19.3% · Q3 15.9% · Q4 18.2% · 4Q avg 16.7% |
| Percentage of long-stay residents with pressure ulcers | 0.7% |
6.5%
5.8 pts better
|
5.1%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.5% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
85.4%
14.6 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.3% |
15.1%
3.2 pts worse
|
12.0%
6.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.3% · Observed 17.8% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.7%
1 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.2% |
81.2%
9 pts better
|
79.7%
10.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 14.3% |
21.6%
7.3 pts better
|
23.9%
9.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 14.3% · Observed 12.7% · Expected 21.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-02 · Fire 2023-06-02
9 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2019-05-31 · Fire 2019-05-31
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-09-27
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-10-28
D · Potential for more than minimal harm
2023-06-02
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2023-06-30
D · Potential for more than minimal harm
2023-06-02
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-06-30
D · Potential for more than minimal harm
2023-06-02
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-06-30
D · Potential for more than minimal harm
2019-05-31
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2019-06-20
D · Potential for more than minimal harm
2019-05-31
K932 · Smoke Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2019-06-20
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-09
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2026-01-05
D · Potential for more than minimal harm
2025-12-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-01-05
D · Potential for more than minimal harm
2024-09-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-28
D · Potential for more than minimal harm
2024-09-27
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-10-28
D · Potential for more than minimal harm
2024-09-27
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-10-28
D · Potential for more than minimal harm
2024-09-27
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-10-28
D · Potential for more than minimal harm
2024-09-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-28
D · Potential for more than minimal harm
2023-06-02
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2023-07-17
D · Potential for more than minimal harm
2023-06-02
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2022-10-14
D · Potential for more than minimal harm
2023-06-02
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2022-07-26
D · Potential for more than minimal harm
2023-06-02
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2023-07-17
D · Potential for more than minimal harm
2023-06-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-10-14
D · Potential for more than minimal harm
2023-06-02
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2023-07-17
D · Potential for more than minimal harm
2023-06-02
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-07-17
D · Potential for more than minimal harm
2023-06-02
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2023-07-17
D · Potential for more than minimal harm
2023-06-02
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2023-07-17
D · Potential for more than minimal harm
2019-05-31
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2019-06-19
Penalties and ownership
What sits behind the stars
Ownership
Providence Group Nh, LLC
5% Or Greater Direct Ownership Interest · Organization
Apt, Frederick
Operational/Managerial Control · Individual
Haddock, Anne
Operational/Managerial Control · Individual
Hancock, Mark
5% Or Greater Indirect Ownership Interest · Individual
Jergensen, Joshua
Operational/Managerial Control · Individual
Maier, Franki
Operational/Managerial Control · Individual
Mitchell, John
Operational/Managerial Control · Individual
Murray, Jason
5% Or Greater Indirect Ownership Interest · Individual
Pacs Group, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Pacs Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
Truist Bank
5% Or Greater Security Interest · Organization
Wang, Xin
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Regency Albany
Albany, OR
2-star overall rating with 2-star inspections with abuse icon flag with $30,911 in total fines with 19 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Mennonite Home
Albany, OR
3-star overall rating with 3-star inspections with $17,934 in total fines with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Corvallis Manor
Corvallis, OR
0-star overall rating with 0-star inspections with Special Focus status with $345,051 in total fines with 30 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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