Deficiencies (last 4 years)
Deficiencies (over 4 years)
10.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
57% worse than Oregon average
Oregon average: 6.7 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
65% occupied
Based on a September 2025 inspection.
Census over time
Inspection Report
Census: 43
Capacity: 66
Deficiencies: 2
Sep 22, 2025
Visit Reason
Facility failed to maintain kitchen in good repair and sanitary manner; multiple food safety and sanitation issues observed including pest presence, damaged flooring, improper food storage, and inadequate staff food handling practices.
Findings
Facility failed to maintain kitchen in good repair and sanitary manner; multiple food safety and sanitation issues observed including pest presence, damaged flooring, improper food storage, and inadequate staff food handling practices.
Deficiencies (2)
| Description |
|---|
| OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule — Kitchen sanitation and food safety violations observed including unclean surfaces, damaged flooring, pest contamination, and improper food handling. |
| OAR 411-057-0140(2) Administration Compliance — Failure to follow licensing rules for Residential Care and Assisted Living Facilities as related to kitchen deficiencies. |
Inspection Report
Census: 43
Capacity: 66
Deficiencies: 16
Jan 30, 2025
Visit Reason
Multiple deficiencies including failure in facility administration, reporting and investigating abuse, resident services activities, resident evaluations, service plans, change of condition monitoring, psychotropic medication systems, staffing requirements, acuity-based staffing tool implementation, fire and life safety, heating and ventilation, call system and exit door alarms, individual privacy, and resident room identification.
Findings
Multiple deficiencies including failure in facility administration, reporting and investigating abuse, resident services activities, resident evaluations, service plans, change of condition monitoring, psychotropic medication systems, staffing requirements, acuity-based staffing tool implementation, fire and life safety, heating and ventilation, call system and exit door alarms, individual privacy, and resident room identification.
Deficiencies (16)
| Description |
|---|
| OAR 411-054-0025 (1) Facility Administration: Operation — Failed to provide effective oversight for facility operation and quality of services. |
| OAR 411-054-0025 (7) Facility Administration: Policy & Procedure — Failed to implement effective methods of responding to and resolving resident complaints. |
| OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action — Failed to ensure incidents were investigated and reported to local SPD office timely. |
| OAR 411-054-0030 (1)(c-d) Resident Services: Activities — Failed to provide daily program of social and recreational activities based on resident needs. |
| OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation — Failed to ensure evaluations were updated quarterly and reflective of residents’ current status. |
| OAR 411-054-0036 (1-4) Service Plan: General — Failed to ensure service plans were updated quarterly, reflective of resident needs, and implemented. |
| OAR 411-054-0040 (1-2) Change of Condition and Monitoring — Failed to determine and document actions or interventions for changes of condition and monitor progress. |
| OAR 411-054-0055 (6) Systems: Psychotropic Medication — Failed to ensure non-pharmacological interventions were attempted and documented prior to PRN psychotropic medication administration. |
| OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing — Failed to have sufficient qualified awake direct care staff to meet resident needs and fire safety standards. |
| OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time — Failed to accurately capture care time and update ABST timely. |
| OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan — Failed to update ABST before resident move-in and at least quarterly. |
| OAR 411-054-0090 (1-2) Fire and Life Safety: Safety — Failed to conduct fire drills according to Oregon Fire Code and provide fire and life safety instruction on alternate months. |
| OAR 411-054-0200 (8) Heating and Ventilation — Failed to maintain resident areas at minimum temperature of 70 degrees Fahrenheit during the day. |
| OAR 411-054-0200 (11-13) Call Sys, Exit Dr Alarm, Phones, TV, or Cable — Failed to provide operational call system and exit door alarms to alert staff. |
| OAR411-004-0020(2)(d) Individual Privacy: Own Unit — Failed to ensure privacy and dignity related to no locks on shared bathroom doors. |
| OAR 411-057-0140(2) Administration Compliance — Failed to follow licensing rules for Residential Care and Assisted Living Facilities. |
Inspection Report
Complaint Investigation
Census: 43
Capacity: 66
Deficiencies: 3
Oct 10, 2024
Visit Reason
Facility failed to determine and document actions or interventions needed for short-term change of condition, and failed to carry out medication and treatment orders as prescribed for sampled residents.
Findings
Facility failed to determine and document actions or interventions needed for short-term change of condition, and failed to carry out medication and treatment orders as prescribed for sampled residents.
Deficiencies (3)
| Description |
|---|
| OAR 411-054-0270 Change of Condition and Monitoring — Failed to determine and document needed actions or interventions for short-term change of condition. |
| OAR 411-054-0300 Systems: Medications and Treatments — Failed to carry out medication and treatment orders as prescribed. |
| OAR 411-054-0303 Systems: Treatment Orders — Failed to carry out medication and treatment orders as prescribed. |
Inspection Report
Complaint Investigation
Census: 43
Capacity: 66
Deficiencies: 1
Oct 10, 2024
Visit Reason
Facility failed to carry out treatment orders as prescribed for sampled residents.
Findings
Facility failed to carry out treatment orders as prescribed for sampled residents.
Deficiencies (1)
| Description |
|---|
| OAR 411-054-0303 Systems: Treatment Orders — Failed to carry out medication and treatment orders as prescribed. |
Inspection Report
Complaint Investigation
Census: 43
Capacity: 66
Deficiencies: 3
Mar 11, 2024
Visit Reason
Facility failed to immediately notify Department of severe interruption of physical plant services, failed to carry out medication and treatment orders as prescribed, and failed to maintain fire detection and protection equipment.
Findings
Facility failed to immediately notify Department of severe interruption of physical plant services, failed to carry out medication and treatment orders as prescribed, and failed to maintain fire detection and protection equipment.
Deficiencies (3)
| Description |
|---|
| OAR 411-054-0158 Disclosure & Notification to Potential Res — Failed to immediately notify Department of severe interruption of physical plant services. |
| OAR 411-054-0303 Systems: Treatment Orders — Failed to carry out medication and treatment orders as prescribed. |
| OAR 411-054-0421 Fire and Life Safety: Safety — Failed to maintain fire detection and protection equipment. |
Inspection Report
Complaint Investigation
Census: 43
Capacity: 66
Deficiencies: 5
Nov 28, 2023
Visit Reason
Facility failed to notify Department of abuse incidents, failed to ensure service plans were updated quarterly and available, failed to carry out medication and treatment orders as prescribed, failed to provide sufficient staffing, and failed to verify direct care staff training.
Findings
Facility failed to notify Department of abuse incidents, failed to ensure service plans were updated quarterly and available, failed to carry out medication and treatment orders as prescribed, failed to provide sufficient staffing, and failed to verify direct care staff training.
Deficiencies (5)
| Description |
|---|
| OAR 411-054-0231 Reporting & Investigating Abuse-Other Action — Failed to notify Department of abuse incidents. |
| OAR 411-054-0260 Service Plan: General — Failed to ensure service plans were updated quarterly and readily available. |
| OAR 411-054-0303 Systems: Treatment Orders — Failed to carry out medication and treatment orders as prescribed. |
| OAR 411-054-0360 Staffing Requirements and Training: Staffing — Failed to provide sufficient qualified awake direct care staff to meet resident needs. |
| OAR 411-054-0372 Training Within 30 Days: Direct Care Staff — Failed to verify direct care staff had demonstrated satisfactory performance in assigned duties. |
Inspection Report
Complaint Investigation
Census: 43
Capacity: 66
Deficiencies: 5
Oct 13, 2023
Visit Reason
Facility failed to immediately notify local APD or AAA of abuse incidents, failed to provide three daily nutritious meals and snacks, failed to ensure service plans were updated quarterly, and failed to fully implement and update acuity-based staffing tool.
Findings
Facility failed to immediately notify local APD or AAA of abuse incidents, failed to provide three daily nutritious meals and snacks, failed to ensure service plans were updated quarterly, and failed to fully implement and update acuity-based staffing tool.
Deficiencies (5)
| Description |
|---|
| OAR 411-054-0010 Licensing Complaint Investigation — Findings documented from on-site investigation. |
| OAR 411-054-0231 Reporting & Investigating Abuse-Other Action — Failed to immediately notify local APD or AAA of abuse incidents. |
| OAR 411-054-0240 Resident Services Meals, Food Sanitation Rule — Failed to provide three daily nutritious meals and snacks; kitchen sanitation issues noted. |
| OAR 411-054-0260 Service Plan: General — Failed to ensure service plans were updated quarterly. |
| OAR 411-054-0361 Acuity-Based Staffing Tool — Failed to fully implement and update acuity-based staffing tool. |
Inspection Report
Complaint Investigation
Census: 43
Capacity: 66
Deficiencies: 5
Dec 27, 2022
Visit Reason
Facility failed to immediately notify local Department or AAA of abuse or suspected abuse, failed to ensure service plans were updated quarterly, failed to fully implement and update acuity-based staffing tool, and failed to provide requested documents timely.
Findings
Facility failed to immediately notify local Department or AAA of abuse or suspected abuse, failed to ensure service plans were updated quarterly, failed to fully implement and update acuity-based staffing tool, and failed to provide requested documents timely.
Deficiencies (5)
| Description |
|---|
| OAR 411-054-0010 Licensing Complaint Investigation — Findings documented from complaint investigation. |
| OAR 411-054-0231 Reporting & Investigating Abuse-Other Action — Failed to immediately notify local Department or AAA of abuse or suspected abuse. |
| OAR 411-054-0270 Change of Condition and Monitoring — Failed to ensure resident monitoring and reporting system implemented 24-hours a day. |
| OAR 411-054-0361 Acuity-Based Staffing Tool — Failed to fully implement and update acuity-based staffing tool. |
| OAR 411-054-0450 Inspections and Investigations — Failed to provide records to Department upon request. |
Inspection Report
Complaint Investigation
Census: 43
Capacity: 66
Deficiencies: 2
Oct 7, 2022
Visit Reason
Facility failed to fully implement and update acuity-based staffing tool and failed to provide a completed ABST.
Findings
Facility failed to fully implement and update acuity-based staffing tool and failed to provide a completed ABST.
Deficiencies (2)
| Description |
|---|
| OAR 411-054-0010 Licensing Complaint Investigation — Findings documented from complaint investigation. |
| OAR 411-054-0361 Acuity-Based Staffing Tool — Failed to fully implement and update acuity-based staffing tool; no completed ABST. |
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