Deficiencies per Year
24
18
12
6
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 22
Aug 25, 2025
Visit Reason
State-compiled facility profile showing 9 inspections from 2021 to 2025 with deficiency history and enforcement actions.
Findings
Across multiple inspections from 2021 to 2025, the facility exhibited deficiencies including inadequate staffing levels, failure to update and maintain acuity-based staffing tools, incomplete resident evaluations, insufficient monitoring of changes of condition, environmental maintenance issues, and failure to ensure proper implementation of resident service plans and medication administration.
Complaint Details
Multiple complaint investigations documented, including failures in staffing, resident evaluations, service plans, and environmental conditions.
Severity Breakdown
Not Corrected: 22
Corrected: 1
Deficiencies (22)
| Description | Severity |
|---|---|
| C0360 - Staffing Requirements and Training: Staffing: Facility failed to have sufficient qualified awake direct care staff to meet 24-hour scheduled and unscheduled resident needs, including night shift understaffing placing residents at high risk. | Not Corrected |
| C0252 - Resident Move-in & Evaluation: Res Evaluation: Facility failed to update initial resident evaluations timely and ensure quarterly evaluations reflected resident needs for multiple residents. | Not Corrected |
| C0270 - Change of Condition and Monitoring: Facility failed to ensure resident-specific instructions/interventions were developed, communicated, and weekly progress documented until resolution for changes of condition. | Not Corrected |
| C0362 - Acuity Based Staffing Tool - ABST Time: Facility failed to accurately capture care time and care elements in ABST for all sampled residents. | Not Corrected |
| C0363 - Acuity Based Staffing Tool - Updates & Staffing Plan: Facility failed to update resident ABST entries at least quarterly. | Not Corrected |
| C0613 - General Building: Doors-Walls, Cleanable: Facility failed to maintain environment clean and in good repair with multiple areas needing cleaning and repair. | Not Corrected |
| H1521 - Individual Visitors: Any Time: Facility restricted resident rights to visitors without completing required individually based limitations (IBLs). | Not Corrected |
| H1580 - Limitations: Threats To Health And Safety: Facility failed to ensure IBLs were completed when restricting resident rights. | Not Corrected |
| C0242 - Resident Services: Activities: Facility failed to provide a daily program of social and recreational activities during staff absence. | Not Corrected |
| C0361 - Acuity-Based Staffing Tool: Facility failed to update ABST; many resident profiles not updated quarterly. | Not Corrected |
| C0610 - General Building Exterior: Facility failed to take measures to prevent entry of rodents, flies, mosquitoes, and other insects. | Not Corrected |
| C0010 - Licensing Complaint Investigation: Findings documented for complaint investigations. | Not Corrected |
| C0260 - Service Plan: General: Facility failed to ensure implementation of services and service plans reflective of resident needs. | Not Corrected |
| C0240 - Resident Services Meals, Food Sanitation Rule: Facility failed to maintain kitchen in good repair and sanitary manner with multiple food safety violations. | Corrected |
| C0000 - Comment: Kitchen inspection findings documented; facility in substantial compliance on revisit. | Not Corrected |
| C0330 - Systems: Psychotropic Medication: Facility failed to ensure PRN psychotropic medications had resident-specific symptoms and non-drug interventions documented. | Not Corrected |
| C0340 - Restraints and Supportive Devices: Facility failed to ensure assessments and documentation for supportive devices with restraining qualities. | Not Corrected |
| C0370 - Staffing Requirements and Training – Pre-Serv: Facility failed to ensure newly hired staff completed required pre-service orientation and dementia training prior to job duties. | Not Corrected |
| C0372 - Training Within 30 Days: Direct Care Staff: Facility failed to verify newly hired staff demonstrated competency within 30 days of hire. | Not Corrected |
| C0374 - Annual and Biennial Inservice For All Staff: Facility failed to ensure long-term staff completed required annual in-service training. | Not Corrected |
| C0420 - Fire and Life Safety: Safety: Facility failed to ensure fire drill records included all required elements per Oregon Fire Code. | Not Corrected |
| C0303 - Systems: Treatment Orders: Facility failed to ensure signed physician orders documented and medication orders carried out as prescribed. | Not Corrected |
Report Facts
Inspections on page: 9
Total deficiencies: 33
Total surveys: 9
Abuse violations: 0
Licensing violations: 10
Notices: 5
Facility census: 43
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Harding | Administrator | Named in multiple findings and acknowledgements across inspections |
| Staff 1 | Executive Director | Named in multiple findings and acknowledgements across inspections |
| Staff 4 | Resident Care Coordinator (RCC) | Named in findings related to resident evaluations and staffing |
| Staff 2 | Registered Nurse (RN) | Named in findings related to resident evaluations and monitoring |
| Staff 25 | Regional Nurse Consultant | Named in findings related to resident evaluations and monitoring |
| Staff 3 | Vice President of Operations | Named in findings related to resident evaluations and visitor restrictions |
| Staff 5 | Resident Care Coordinator (RCC) | Named in staffing and evaluation findings |
| Staff 6 | Business Office Manager | Named in findings related to resident evaluations and monitoring |
| Staff 9 | Medication Technician (MT) | Named in resident smoking evaluation findings |
| Staff 13 | Caregiver (CG) | Named in resident smoking evaluation findings |
| Staff 22 | Housekeeping | Named in findings related to evacuation device and staffing |
| Staff 12 | Caregiver (CG) | Named in findings related to evacuation device and staffing |
| Staff 15 | Caregiver (CG) | Named in findings related to evacuation device and staffing |
| Staff 20 | Caregiver (CG) | Named in findings related to evacuation device and staffing |
| Staff 10 | Medication Technician (MT) | Named in findings related to staffing |
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