Inspection Report
Complaint Investigation
Census: 43
Capacity: 66
Deficiencies: 27
Dec 1, 2025
Visit Reason
State-compiled facility profile showing 10 inspections from 2022-2025 with deficiency history and enforcement actions
Findings
Across multiple inspections from 2022 to 2025, the facility demonstrated repeated deficiencies including failure to maintain sanitary kitchen conditions, inadequate staffing levels, ineffective call system, incomplete resident evaluations and service plans, failure to investigate and report abuse incidents timely, and failure to conduct proper fire drills and safety measures.
Complaint Details
Multiple complaint investigations conducted on 10/10/2024, 10/7/2022, 12/27/2022, 10/13/2023, 11/28/2023, and 3/11/2024 revealed failures in medication administration, abuse reporting, change of condition monitoring, staffing, and other licensing compliance issues.
Deficiencies (27)
| Description |
|---|
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to maintain kitchen in good repair and sanitary manner, including food contamination risks and improper food storage |
| Z0142 - Administration Compliance: Failed to comply with licensing rules for Residential Care and Assisted Living Facilities |
| C0150 - Facility Administration: Operation: Failed to provide effective oversight for facility operation and quality of services |
| C0154 - Facility Administration: Policy & Procedure: Failed to implement effective methods of responding to and resolving resident complaints |
| C0231 - Reporting & Investigating Abuse-Other Action: Failed to investigate and report abuse or suspected abuse incidents timely to local SPD office |
| C0242 - Resident Services: Activities: Failed to provide daily program of social and recreational activities based on resident needs |
| C0252 - Resident Move-in & Evaluation: Res Evaluation: Failed to ensure resident evaluations were updated quarterly and reflective of current status |
| C0260 - Service Plan: General: Failed to ensure service plans were updated quarterly, reflective of resident needs, and implemented |
| C0270 - Change of Condition and Monitoring: Failed to determine, document, communicate, and monitor actions for resident changes of condition |
| C0330 - Systems: Psychotropic Medication: Failed to document non-pharmacological interventions prior to PRN psychotropic medication administration |
| C0360 - Staffing Requirements and Training: Staffing: Failed to have sufficient qualified awake direct care staff to meet resident needs and fire safety standards |
| C0362 - Acuity Based Staffing Tool - ABST Time: Failed to accurately capture care minutes on ABST for multiple residents |
| C0363 - Acuity Based Staffing Tool - Updates & Staffing Plan: Failed to update ABST before move-in and at least quarterly |
| C0420 - Fire and Life Safety: Safety: Failed to conduct fire drills per Oregon Fire Code and provide fire/life safety instruction on alternate months |
| C0540 - Heating and Ventilation: Failed to maintain minimum temperature of 70 degrees Fahrenheit in resident areas during daytime |
| C0555 - Call Sys, Exit Dr Alarm, Phones, TV, or Cable: Failed to provide operational call system connecting residents to staff and exit door alarms |
| H1517 - Individual Privacy: Own Unit: Failed to ensure privacy due to no locks on shared bathroom doors |
| Z0162 - Compliance with Rules Health Care: Failed to provide health care services in accordance with licensing rules |
| Z0163 - Nutrition and Hydration: Failed to provide individualized daily meal program based on resident preferences and needs |
| Z0164 - Activities: Failed to develop individualized activity plans based on resident evaluations |
| Z0165 - Behavior: Failed to include behavioral symptoms and interventions on service plans for residents with documented behaviors |
| Z0176 - Resident Rooms: Failed to individually identify resident rooms to assist recognition |
| C0010 - Licensing Complaint Investigation: Various failures to comply with state and local laws and regulations during complaint investigations |
| C0300 - Systems: Medications and Treatments: Failed to carry out medication and treatment orders as prescribed |
| C0303 - Systems: Treatment Orders: Failed to carry out medication and treatment orders as prescribed |
| C0361 - Acuity-Based Staffing Tool: Failed to fully implement and update acuity-based staffing tool |
| C0158 - Disclosure & Notification to Potential Res: Failed to immediately notify Department of severe interruption of physical plant services |
Report Facts
Inspections on page: 10
Total deficiencies: 47
Total surveys: 10
Licensing violations: 10
Notices: 9
Facility licensed beds: 66
Facility census: 43
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Anita Rodney | Administrator | Named as facility administrator in facility information |
| Staff 1 | Executive Director (ED) | Named in multiple findings and interviews related to deficiencies and acknowledgements |
| Staff 2 | Regional Director of Operations | Named in multiple findings and interviews related to deficiencies and acknowledgements |
| Staff 10 | Medication Technician (MT) | Named in call system deficiency findings |
| Staff 11 | Caregiver (CG) | Named in call system deficiency findings |
| Staff 19 | Caregiver (CG) | Named in call system deficiency findings |
| Staff 4 | Medication Technician (MT) | Named in kitchen and service plan deficiency findings |
| Staff 16 | Administrator | Named in medication error and abuse reporting deficiency findings |
| Staff 13 | Caregiver | Named in training deficiency findings |
| Staff 14 | Caregiver | Named in training deficiency findings |
| Staff 15 | Caregiver | Named in training deficiency findings |
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