Deficiencies (last 4 years)
Deficiencies (over 4 years)
13.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
101% worse than Oregon average
Oregon average: 6.7 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Capacity: 104
Deficiencies: 2
Nov 7, 2025
Visit Reason
No deficiencies found during this Complaint, Re-Licensure survey.
Findings
No deficiencies found during this Complaint, Re-Licensure survey.
Deficiencies (2)
| Description |
|---|
| F0000 - INITIAL COMMENTS |
| M0000 - Initial Comments |
Inspection Report
Complaint Investigation
Capacity: 104
Deficiencies: 2
Oct 15, 2025
Visit Reason
No deficiencies found during this Complaint, Re-Licensure survey.
Findings
No deficiencies found during this Complaint, Re-Licensure survey.
Deficiencies (2)
| Description |
|---|
| F0000 - INITIAL COMMENTS |
| M0000 - Initial Comments |
Inspection Report
Complaint Investigation
Capacity: 104
Deficiencies: 7
Aug 8, 2025
Visit Reason
Multiple deficiencies including failure to timely obtain an ankle-foot orthosis (AFO), failure to provide trauma informed care, improper labeling and storage of drugs and biologicals, failure to provide specialized rehab services timely, and other issues impacting resident care and safety.
Findings
Multiple deficiencies including failure to timely obtain an ankle-foot orthosis (AFO), failure to provide trauma informed care, improper labeling and storage of drugs and biologicals, failure to provide specialized rehab services timely, and other issues impacting resident care and safety.
Deficiencies (7)
| Description |
|---|
| F0000 - INITIAL COMMENTS |
| F0688 - Increase/Prevent Decrease in ROM/Mobility |
| F0699 - Trauma Informed Care |
| F0761 - Label/Store Drugs and Biologicals |
| F0825 - Provide/Obtain Specialized Rehab Services |
| M0000 - Initial Comments |
| M9999 - STATE OF OREGON ADMINISTRATIVE RULES |
Inspection Report
Complaint Investigation
Capacity: 104
Deficiencies: 2
Feb 19, 2025
Visit Reason
No deficiencies found during this Complaint, Licensure Complaint, State Licensure survey.
Findings
No deficiencies found during this Complaint, Licensure Complaint, State Licensure survey.
Deficiencies (2)
| Description |
|---|
| F0000 - INITIAL COMMENTS |
| M0000 - Initial Comments |
Inspection Report
Complaint Investigation
Capacity: 104
Deficiencies: 2
Jul 9, 2024
Visit Reason
No deficiencies found during this Complaint, Licensure Complaint, State Licensure survey.
Findings
No deficiencies found during this Complaint, Licensure Complaint, State Licensure survey.
Deficiencies (2)
| Description |
|---|
| F0000 - INITIAL COMMENTS |
| M0000 - Initial Comments |
Inspection Report
Complaint Investigation
Capacity: 104
Deficiencies: 2
Jun 13, 2024
Visit Reason
No deficiencies found during this Complaint, Licensure Complaint, State Licensure survey.
Findings
No deficiencies found during this Complaint, Licensure Complaint, State Licensure survey.
Deficiencies (2)
| Description |
|---|
| F0000 - INITIAL COMMENTS |
| M0000 - Initial Comments |
Inspection Report
Complaint Investigation
Capacity: 104
Deficiencies: 13
Mar 25, 2024
Visit Reason
Multiple deficiencies including failure to provide written bed-hold notices, failure to develop comprehensive care plans, failure to monitor and treat skin conditions, failure to ensure safe water temperatures, failure to maintain nutrition/hydration status, failure to follow respiratory care orders, failure to post accurate nurse staffing information, failure to ensure food safety, and failure to maintain accurate resident records.
Findings
Multiple deficiencies including failure to provide written bed-hold notices, failure to develop comprehensive care plans, failure to monitor and treat skin conditions, failure to ensure safe water temperatures, failure to maintain nutrition/hydration status, failure to follow respiratory care orders, failure to post accurate nurse staffing information, failure to ensure food safety, and failure to maintain accurate resident records.
Deficiencies (13)
| Description |
|---|
| F0000 - INITIAL COMMENTS |
| F0625 - Notice of Bed Hold Policy Before/Upon Trnsfr |
| F0656 - Develop/Implement Comprehensive Care Plan |
| F0684 - Quality of Care |
| F0689 - Free of Accident Hazards/Supervision/Devices |
| F0692 - Nutrition/Hydration Status Maintenance |
| F0695 - Respiratory/Tracheostomy Care and Suctioning |
| F0732 - Posted Nurse Staffing Information |
| F0812 - Food Procurement,Store/Prepare/Serve-Sanitary |
| F0842 - Resident Records - Identifiable Information |
| M0000 - Initial Comments |
| M0182 - Nursing Services:Minimum Licensed Nurse Staff |
| M9999 - STATE OF OREGON ADMINISTRATIVE RULES |
Inspection Report
Complaint Investigation
Capacity: 104
Deficiencies: 5
Jun 26, 2023
Visit Reason
Deficiencies related to failure to initiate CPR timely resulting in resident death, failure to meet professional standards in emergency action and documentation, and failure to complete required investigations and documentation for nursing services.
Findings
Deficiencies related to failure to initiate CPR timely resulting in resident death, failure to meet professional standards in emergency action and documentation, and failure to complete required investigations and documentation for nursing services.
Deficiencies (5)
| Description |
|---|
| F0000 - INITIAL COMMENTS |
| F0658 - Services Provided Meet Professional Standards |
| F0678 - Cardio-Pulmonary Resuscitation (CPR) |
| M0000 - Initial Comments |
| M9999 - STATE OF OREGON ADMINISTRATIVE RULES |
Inspection Report
Complaint Investigation
Capacity: 104
Deficiencies: 7
Jan 13, 2023
Visit Reason
Deficiencies including failure to manage resident pain adequately, medication error rates exceeding 5%, failure to complete employee reference checks, and failure to maintain accurate resident records.
Findings
Deficiencies including failure to manage resident pain adequately, medication error rates exceeding 5%, failure to complete employee reference checks, and failure to maintain accurate resident records.
Deficiencies (7)
| Description |
|---|
| F0000 - INITIAL COMMENTS |
| F0697 - Pain Management |
| F0759 - Free of Medication Error Rts 5 Prcnt or More |
| F0842 - Resident Records - Identifiable Information |
| M0000 - Initial Comments |
| M0141 - Employees Reference Checks and Verifications |
| M9999 - STATE OF OREGON ADMINISTRATIVE RULES |
Inspection Report
Complaint Investigation
Capacity: 104
Deficiencies: 12
Aug 17, 2022
Visit Reason
Deficiencies including failure to thoroughly investigate neglect allegations, failure to administer medications as ordered, failure to prevent aspiration resulting in resident death, failure to ensure RN Care Manager training, and failure to maintain accurate nursing services and abuse prevention.
Findings
Deficiencies including failure to thoroughly investigate neglect allegations, failure to administer medications as ordered, failure to prevent aspiration resulting in resident death, failure to ensure RN Care Manager training, and failure to maintain accurate nursing services and abuse prevention.
Deficiencies (12)
| Description |
|---|
| F0000 - INITIAL COMMENTS |
| F0610 - Investigate/Prevent/Correct Alleged Violation |
| F0684 - Quality of Care |
| F0689 - Free of Accident Hazards/Supervision/Devices |
| F0692 - Nutrition/Hydration Status Maintenance |
| F0695 - Respiratory/Tracheostomy Care and Suctioning |
| F0732 - Posted Nurse Staffing Information |
| F0812 - Food Procurement,Store/Prepare/Serve-Sanitary |
| F0842 - Resident Records - Identifiable Information |
| M0000 - Initial Comments |
| M0160 - RN Care Manager: Training |
| M9999 - STATE OF OREGON ADMINISTRATIVE RULES |
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