Inspection Report
Complaint Investigation
Capacity: 119
Deficiencies: 31
Sep 11, 2025
Visit Reason
State-compiled facility profile showing 10 inspections from 2023-2025 with detailed deficiency history and enforcement actions.
Findings
Across multiple inspections from 2023 to 2025, the facility exhibited numerous deficiencies including failure to provide adequate care, insufficient staffing, improper infection control, failure to follow physician orders, and inadequate resident rights protections. Several deficiencies were corrected while others remained uncorrected at the time of reporting.
Complaint Details
Multiple inspections included complaint investigations related to resident care, staffing, infection control, and medication errors.
Deficiencies (31)
| Description |
|---|
| F0000 - INITIAL COMMENTS |
| M0000 - Initial Comments |
| F0689 - Free of Accident Hazards/Supervision/Devices: Failed to ensure resident care equipment was monitored, resulting in resident injury from broken shower chair. |
| F0690 - Bowel/Bladder Incontinence, Catheter, UTI: Failed to provide adequate incontinent and catheter care for sampled residents. |
| M9999 - STATE OF OREGON ADMINISTRATIVE RULES: Refer to F689 and F690. |
| F0550 - Resident Rights/Exercise of Rights: Failed to ensure residents were treated with dignity during medication administration. |
| F0553 - Right to Participate in Planning Care: Failed to include resident's representative in care planning process. |
| F0580 - Notify of Changes (Injury/Decline/Room, etc.): Failed to notify physician regarding refusals and changes in condition for sampled residents. |
| F0623 - Notice Requirements Before Transfer/Discharge: Failed to notify required parties of resident hospitalizations. |
| F0625 - Notice of Bed Hold Policy Before/Upon Trnsfr: Failed to provide written notice of bed hold policy at time of hospital transfer. |
| F0657 - Care Plan Timing and Revision: Failed to complete comprehensive care plans timely and revise care plans for sampled residents. |
| F0658 - Services Provided Meet Professional Standards: Failed to ensure professional standards for medication administration and infection control. |
| F0679 - Activities Meet Interest/Needs Each Resident: Failed to provide meaningful activities to dependent residents. |
| F0686 - Treatment/Svcs to Prevent/Heal Pressure Ulcer: Failed to properly assess pressure ulcers for sampled residents. |
| F0689 - Free of Accident Hazards/Supervision/Devices: Failed to supervise resident while eating, risking aspiration or choking. |
| F0695 - Respiratory/Tracheostomy Care and Suctioning: Failed to assess and monitor respiratory status and maintain respiratory equipment. |
| F0725 - Sufficient Nursing Staff: Failed to provide sufficient staffing for sampled residents. |
| F0760 - Residents are Free of Significant Med Errors: Failed to ensure residents were free from significant medication errors. |
| F0847 - Entering into Binding Arbitration Agreements: Failed to ensure residents understood arbitration agreements. |
| F0880 - Infection Prevention & Control: Failed to ensure proper sanitization and infection control standards for multiple residents. |
| F0881 - Antibiotic Stewardship Program: Failed to ensure antibiotic was indicated for use for sampled resident. |
| F0552 - Right to be Informed/Make Treatment Decisions: Failed to ensure cognitively impaired resident's representative was provided risk and benefits of psychotropic medication. |
| F0554 - Resident Self-Admin Meds-Clinically Approp: Failed to comprehensively assess resident's ability to self-administer medications. |
| F0641 - Accuracy of Assessments: Failed to accurately assess resident's gradual dose reduction status and dental status. |
| F0684 - Quality of Care: Failed to follow physician orders and care plans for medications and ADLs. |
| F0755 - Pharmacy Srvcs/Procedures/Pharmacist/Records: Failed to reorder pain medications timely. |
| F0758 - Free from Unnec Psychotropic Meds/PRN Use: Failed to monitor residents for psychotropic medication side effects. |
| F0842 - Resident Records - Identifiable Information: Failed to ensure resident records were complete for sampled resident. |
| F0745 - Provision of Medically Related Social Service: Failed to obtain specialized physician appointments for sampled resident. |
| M0182 - Nursing Services:Minimum Licensed Nurse Staff: Failed to ensure RN coverage for at least eight consecutive hours per day on certain days. |
| F0884 - Reporting - National Health Safety Network: Failed to report complete COVID-19 information to CDC NHSN during required period. |
Report Facts
Inspections on page: 10
Total deficiencies: 36
Total surveys: 10
Licensing violations: 20
Abuse violations: 0
Notices: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 28 | RN | Named in medication error and infection control findings related to medication crushing and glucometer sanitization |
| Staff 1 | Administrator | Named in multiple findings including staffing, care plan, and resident rights |
| Staff 2 | DNS | Named in multiple findings including staffing, infection control, and medication monitoring |
| Staff 6 | LPN | Named in resident dignity and incontinent care findings |
| Staff 5 | LPN-Resident Care Manager | Named in resident dignity and care plan findings |
| Staff 3 | LPN-Resident Care Manager | Named in medication and respiratory care findings |
| Staff 4 | LPN | Named in activities and medication monitoring findings |
| Staff 10 | LPN | Named in respiratory care and incontinent care findings |
| Staff 21 | CMA | Named in staffing and fall investigation findings |
| Staff 22 | CNA | Named in staffing and infection control findings |
| Staff 17 | Infection Preventionist | Named in antibiotic stewardship and infection control findings |
| Staff 20 | Social Services Director | Named in resident dignity findings |
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