Deficiencies per Year
28
21
14
7
0
Unclassified
Inspection Report
Capacity: 104
Deficiencies: 26
Nov 7, 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 exhibited numerous deficiencies including failure to provide timely specialized rehabilitative services, inadequate investigation of neglect allegations, medication errors, failure to initiate CPR timely, and issues with resident care plans and safety measures. Several deficiencies were corrected while others remained uncorrected at the time of visits.
Complaint Details
Multiple inspections included complaint investigations related to neglect, medication errors, failure to initiate CPR timely, and other resident care concerns.
Deficiencies (26)
| Description |
|---|
| F0000 - INITIAL COMMENTS |
| M0000 - Initial Comments |
| F0688 - Increase/Prevent Decrease in ROM/Mobility: Failure to timely obtain and implement Ankle Foot Orthosis (AFO) for Resident 63. |
| F0699 - Trauma Informed Care: Failure to develop trauma informed care plan for Resident 8 with PTSD. |
| F0761 - Label/Store Drugs and Biologicals: Medications in storage were not labeled and/or dated appropriately. |
| F0825 - Provide/Obtain Specialized Rehab Services: Delay in implementing aural rehabilitation services for Resident 63. |
| M9999 - STATE OF OREGON ADMINISTRATIVE RULES |
| F0625 - Notice of Bed Hold Policy Before/Upon Trnsfr: Failure to provide written notice of bed-hold policy to residents 11 and 47 upon hospital transfer. |
| F0656 - Develop/Implement Comprehensive Care Plan: Failure to develop comprehensive care plan for pressure ulcer for Resident 60. |
| F0684 - Quality of Care: Failure to monitor and treat skin conditions for Resident 17. |
| F0689 - Free of Accident Hazards/Supervision/Devices: Failure to maintain safe water temperatures in 11 resident rooms. |
| F0692 - Nutrition/Hydration Status Maintenance: Failure to provide prescribed therapeutic diet for Resident 221. |
| F0695 - Respiratory/Tracheostomy Care and Suctioning: Failure to follow oxygen administration orders for Resident 269. |
| F0732 - Posted Nurse Staffing Information: Failure to accurately complete Direct Care Staff Daily Report for 3 days. |
| F0812 - Food Procurement,Store/Prepare/Serve-Sanitary: Failure to ensure resident refrigerators were free of expired and/or unlabeled foods. |
| F0842 - Resident Records - Identifiable Information: Failure to ensure accurate medication indication for Resident 4. |
| F0658 - Services Provided Meet Professional Standards: Failure to ensure Staff 4 adhered to professional standards regarding emergency action and documentation for Resident 10. |
| F0678 - Cardio-Pulmonary Resuscitation (CPR): Failure to provide timely CPR for Resident 10, resulting in immediate jeopardy. |
| F0697 - Pain Management: Failure to manage pain medication administration times for Resident 376. |
| F0759 - Free of Medication Error Rts 5 Prcnt or More: Medication error rate of 39% due to improper administration via G-tube for Resident 37. |
| F0842 - Resident Records - Identifiable Information: Failure to ensure labs were available and records accurate for Residents 2 and 39. |
| M0141 - Employees Reference Checks and Verifications: Failure to document completion of reference checks for 5 newly hired staff. |
| F0610 - Investigate/Prevent/Correct Alleged Violation: Failure to thoroughly investigate neglect allegation for Resident 16. |
| F0684 - Quality of Care: Failure to administer medications as ordered for Resident 11. |
| F0689 - Free of Accident Hazards/Supervision/Devices: Failure to prevent Resident 16 from aspirating on food, resulting in death. |
| M0160 - RN Care Manager: Training: Failure to ensure RN Care Manager (Staff 4) had required training within nine months of hire. |
Report Facts
Inspections on page: 10
Total deficiencies: 24
Licensing violations: 19
Abuse violations: 0
Notices: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 4 | LPN | Named in medication error and CPR delay findings; suspended pending investigation |
| Staff 2 | Director of Nursing Services (DNS) | Referenced in multiple findings and inspections related to oversight and acknowledgments |
| Staff 1 | Administrator | Referenced in multiple findings and inspections related to oversight and acknowledgments |
| Staff 5 | LPN | Referenced in aural rehabilitation deficiency |
| Staff 12 | HR/Staffing | Acknowledged staffing report deficiencies |
| Staff 9 | LPN Resident Care Coordinator | Referenced in oxygen administration and restorative care findings |
Loading inspection reports...
