Deficiencies per Year
32
24
16
8
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Re-Inspection
Capacity: 69
Deficiencies: 31
Nov 21, 2025
Visit Reason
State-compiled facility profile showing 10 inspections from 2022 to 2025 with deficiency history and enforcement actions.
Findings
Across multiple inspections from 2022 to 2025, the facility exhibited numerous deficiencies including failures in care planning, staffing shortages, medication administration errors, infection control lapses, resident rights communication, grievance handling, and discharge planning. Some deficiencies were corrected while others remained uncorrected at the time of inspections.
Complaint Details
Multiple inspections included complaint investigations related to licensure complaints and state licensure issues, including failure to notify family on resident discharge, medication errors, and resident rights violations.
Deficiencies (31)
| Description |
|---|
| F0000 - INITIAL COMMENTS |
| F0657 - Care Plan Timing and Revision: Failed to ensure care plans were timely revised to reflect resident needs and hospice care. |
| M0000 - Initial Comments |
| M0183 - Nursing Services: Minimum CNA Staffing: Insufficient CNA staffing on multiple dates. |
| M9999 - STATE OF OREGON ADMINISTRATIVE RULES |
| F0550 - Resident Rights/Exercise of Rights: Failed to ensure residents were notified of rights orally and in writing on an ongoing basis. |
| F0565 - Resident/Family Group and Response: Failed to respond effectively to resident council concerns. |
| F0572 - Notice of Rights and Rules: Failed to ensure residents were notified of rights and rights were posted. |
| F0585 - Grievances: Failed to ensure a system was in place to receive and resolve grievances. |
| F0600 - Free from Abuse and Neglect: Neglected to ensure resident needs were accommodated related to mechanical lift slings and briefs. |
| F0727 - RN 8 Hrs/7 days/Wk, Full Time DON: Failed to ensure RN coverage for at least eight consecutive hours on multiple days. |
| F0758 - Free from Unnec Psychotropic Meds/PRN Use: Failed to ensure residents were free of unnecessary psychotropic medications. |
| F0759 - Free of Medication Error Rts 5 Prcnt or More: Medication pass error rate exceeded 5%. |
| F0761 - Label/Store Drugs and Biologicals: Failed to ensure medications were secured and accessible only to authorized persons. |
| F0812 - Food Procurement,Store/Prepare/Serve-Sanitary: Failed to ensure food labeling, staff hair restraints, and kitchen sanitation. |
| F0880 - Infection Prevention & Control: Failed to disinfect shared glucometer and maintain sanitary grab bars. |
| F0636 - Comprehensive Assessments & Timing: Failed to comprehensively assess residents for dialysis and medications. |
| F0690 - Bowel/Bladder Incontinence, Catheter, UTI: Failed to ensure catheter drainage bag positioned properly. |
| F0804 - Nutritive Value/Appear, Palatable/Prefer Temp: Failed to ensure food served at appetizing temperature. |
| F0730 - Nurse Aide Peform Review-12 hr/yr In-Service: Failed to complete annual performance reviews for CNAs. |
| F0580 - Notify of Changes (Injury/Decline/Room, etc.): Failed to notify family when resident left AMA. |
| F0660 - Discharge Planning Process: Failed to ensure adequate preparation for resident discharge. |
| F0756 - Drug Regimen Review, Report Irregular, Act On: Pharmacy failed to identify potential duplicate medication. |
| F0757 - Drug Regimen is Free from Unnecessary Drugs: Failed to ensure resident was not administered duplicate medication. |
| F0602 - Free from Misappropriation/Exploitation: Failed to ensure residents were free from misappropriation of narcotic medications. |
| F0658 - Services Provided Meet Professional Standards: Failed to ensure staff adhered to professional standards regarding narcotic medication. |
| F0684 - Quality of Care: Failed to follow physician orders for incentive spirometer and bowel care. |
| F0688 - Increase/Prevent Decrease in ROM/Mobility: Failed to ensure residents received restorative aid therapy as ordered. |
| F0689 - Free of Accident Hazards/Supervision/Devices: Failed to provide supervision for swallowing safety resulting in immediate jeopardy. |
| F0692 - Nutrition/Hydration Status Maintenance: Failed to address change of condition for weight loss and dehydration. |
| F0000 - INITIAL COMMENTS |
Report Facts
Inspections on page: 10
Total deficiencies: 32
Licensing violations: 20
Abuse violations: 0
Notices: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Administrator | Named in multiple findings related to care plan revisions, medication errors, grievance process, and discharge planning |
| Staff 2 | DNS | Named in multiple findings related to care plan revisions, medication errors, grievance process, infection control, staffing, and discharge planning |
| Staff 3 | SLP | Named in findings related to swallowing supervision and care planning |
| Staff 4 | CNA | Named in findings related to swallowing supervision and infection control |
| Staff 5 | RNCM | Named in findings related to medication errors, infection control, and care planning |
| Staff 6 | LPN | Named in medication administration and discharge planning findings |
| Staff 7 | CNA/Regional RN | Named in restorative aid and infection control findings |
| Staff 8 | DNS/LPN | Named in medication review and discharge planning findings |
| Staff 9 | LPN | Named in infection control and medication administration findings |
| Staff 10 | LPN | Named in medication administration and food service findings |
| Staff 11 | LPN | Named in medication administration and discharge planning findings |
| Staff 13 | LPN/SS | Named in grievance and discharge planning findings |
| Staff 14 | Staffing Coordinator | Named in staffing findings |
| Staff 15 | Human Resources/Medical Director | Named in staffing and discharge planning findings |
| Staff 16 | CNA | Named in staffing and grievance findings |
| Staff 17 | CNA/Director of Rehabilitation Services | Named in resident rights and restorative aid findings |
| Staff 18 | CNA | Named in staffing findings |
| Staff 19 | CNA/LPN | Named in staffing and narcotic misappropriation findings |
| Staff 20 | Physical Therapist/LPN | Named in discharge planning and narcotic misappropriation findings |
| Staff 21 | CMA | Named in medication administration findings |
| Staff 23 | Pharmacist | Named in medication administration findings |
| Staff 24 | Dietary Manager | Named in food service and sanitation findings |
| Staff 25 | Dietary Aide | Named in food service and sanitation findings |
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