Inspection Report
Capacity: 88
Deficiencies: 49
Jul 2, 2025
Visit Reason
State-compiled facility profile showing multiple inspections from 2022 to 2025 with detailed deficiency history and enforcement actions.
Findings
Across multiple inspections from 2022 to 2025, the facility exhibited numerous deficiencies including failures in resident rights, staffing shortages, medication administration errors, infection control lapses, environmental issues, and inadequate follow-up on grievances and notifications. Several deficiencies were corrected while others remained uncorrected at the time of the latest inspections.
Complaint Details
Multiple inspections included complaint investigations related to resident rights, staffing, medication errors, abuse, and environmental concerns. Specific complaints involved failure to notify representatives of hospital transfers, failure to respond to grievances, and substantiated financial misappropriation by staff.
Deficiencies (49)
| Description |
|---|
| F0000 - INITIAL COMMENTS |
| F0552 - Right to be Informed/Make Treatment Decisions: Failed to ensure residents were fully informed and able to participate in health care decisions, including failure to use translator services for a Spanish-speaking resident. |
| F0585 - Grievances: Failed to provide written grievance resolution or communication regarding a resident's grievance, placing residents at risk for unaddressed concerns. |
| F0628 - Discharge Process: Failed to provide written bed hold notification at time of hospital transfer for a resident. |
| F0659 - Qualified Persons: Allowed unqualified medical assistant to administer medications, risking medication errors. |
| F0695 - Respiratory/Tracheostomy Care and Suctioning: Failed to provide respiratory care under physician orders, including lack of oxygen orders for a resident. |
| F0697 - Pain Management: Failed to provide appropriate pain management and timely provider notification for breakthrough pain. |
| F0755 - Pharmacy Srvcs/Procedures/Pharmacist/Records: Failed to maintain accurate narcotic drug records and verification signatures. |
| F0921 - Safe/Functional/Sanitary/Comfortable Environ: Failed to ensure sufficient supplies such as bariatric sheets and towels, causing uncomfortable environment. |
| M0000 - Initial Comments |
| M9999 - STATE OF OREGON ADMINISTRATIVE RULES: Refer to multiple F-tags for residents' rights, notice requirements, care plans, nursing services, pharmaceutical services, and physical environment. |
| F0550 - Resident Rights/Exercise of Rights: Failed to ensure residents' rights to dignified existence and self-determination, including long call light response times and disrespectful staff behavior. |
| F0558 - Reasonable Accommodations Needs/Preferences: Failed to accommodate residents with correct fit of incontinence briefs and appropriate supplies, risking skin breakdown and discomfort. |
| F0580 - Notify of Changes (Injury/Decline/Room, etc.): Failed to notify physician of significant change in condition for a resident. |
| F0725 - Sufficient Nursing Staff: Failed to provide sufficient nursing staff to meet residents' needs, resulting in long call light wait times and unmet care needs. |
| F0806 - Resident Allergies, Preferences, Substitutes: Failed to ensure residents' food preferences were honored. |
| M0185 - Bariatric Criteria and Services: Failed to maintain state minimum bariatric CNA staffing requirements. |
| F0609 - Reporting of Alleged Violations: Failed to report abuse investigation results to State Survey Agency within required timeframe. |
| F0684 - Quality of Care: Failed to provide bowel medications as ordered, risking constipation. |
| F0686 - Treatment/Svcs to Prevent/Heal Pressure Ulcer: Failed to address wound healing recommendations timely. |
| F0689 - Free of Accident Hazards/Supervision/Devices: Failed to eliminate risk of elopement for a resident. |
| F0691 - Colostomy, Urostomy, or Ileostomy Care: Failed to follow physician orders and maintain ostomy supplies, risking skin breakdown. |
| F0880 - Infection Prevention & Control: Failed to ensure proper placement of urinary catheter bag and infection control practices. |
| F0759 - Free of Medication Error Rts 5 Prcnt or More: Failed to maintain medication error rate below 5%, with documented errors. |
| F0761 - Label/Store Drugs and Biologicals: Failed to ensure medication storage temperatures were logged and maintained. |
| F0812 - Food Procurement,Store/Prepare/Serve-Sanitary: Failed to store and handle food in a sanitary manner. |
| F0575 - Required Postings: Failed to have required Long Term Care Ombudsman poster posted. |
| M0320 - Dietary Services: Diets and Menus: Failed to ensure minimum food supply for dietary services. |
| F0802 - Sufficient Dietary Support Personnel: Failed to ensure enough dietary personnel assigned each shift. |
| F0803 - Menus Meet Resident Nds/Prep in Adv/Followed: Failed to follow posted menus for meals served. |
| F0805 - Food in Form to Meet Individual Needs: Failed to serve residents correct food texture. |
| F0641 - Accuracy of Assessments: Failed to accurately code MDS assessments for residents. |
| F0685 - Treatment/Devices to Maintain Hearing/Vision: Failed to address vision needs timely. |
| F0688 - Increase/Prevent Decrease in ROM/Mobility: Failed to apply splint for resident with impaired range of motion. |
| F0692 - Nutrition/Hydration Status Maintenance: Failed to ensure sufficient fluid intake and follow nutritional supplement recommendations. |
| F0791 - Routine/Emergency Dental Srvcs in NFs: Failed to assist residents in obtaining timely dental services. |
| F0582 - Medicaid/Medicare Coverage/Liability Notice: Failed to provide required written notifications to residents regarding Medicare non-coverage. |
| F0584 - Safe/Clean/Comfortable/Homelike Environment: Failed to provide safe, clean, and homelike environment including addressing noise and missing personal property. |
| F0602 - Free from Misappropriation/Exploitation: Failed to ensure residents were free from financial misappropriation by staff. |
| F0657 - Care Plan Timing and Revision: Failed to revise resident care plan timely to reflect current dietary needs. |
| F0658 - Services Provided Meet Professional Standards: Failed to ensure services met professional standards including medication administration and abuse prevention. |
| F0684 - Quality of Care: Failed to administer medications as ordered for residents. |
| F0689 - Free of Accident Hazards/Supervision/Devices: Failed to maintain exterior safety railing, risking injury. |
| F0725 - Sufficient Nursing Staff: Failed to ensure sufficient staffing to meet resident care needs. |
| F0806 - Resident Allergies, Preferences, Substitutes: Failed to ensure residents' food preferences were honored. |
| F0842 - Resident Records - Identifiable Information: Failed to ensure medical records were complete and accurate. |
| F0880 - Infection Prevention & Control: Failed to ensure clean, safe drinking water and infection control practices. |
| M0183 - Nursing Services: Minimum CNA Staffing: Failed to maintain minimum CNA staffing requirements. |
| M0185 - Bariatric Criteria and Services: Failed to maintain state minimum bariatric CNA staffing requirements. |
Report Facts
Inspections on page: 10
Total deficiencies: 58
Licensing violations: 10
Notices: 2
Licensed beds: 88
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 2 | DNS | Named in multiple findings related to communication failures, staffing, and grievance handling |
| Staff 1 | Administrator | Named in multiple findings related to grievance follow-up, staffing, and facility management |
| Staff 22 | LPN | Named in medication administration and resident communication deficiencies |
| Staff 21 | CNA | Named in financial misappropriation findings |
| Staff 6 | CNA | Named in communication and resident care deficiencies |
| Staff 25 | Dietary Manager | Named in findings related to food service and menu issues |
| Staff 9 | LPN Resident Care Manager Assistant | Named in resident care and record documentation deficiencies |
| Staff 11 | LPN-Resident Care Manager | Named in resident care and staffing findings |
| Staff 3 | Regional Clinical Nurse | Named in medication administration and staffing findings |
| Staff 19 | RN | Named in medication administration and staffing findings |
| Staff 20 | Staffing Coordinator | Named in staffing and medication administration findings |
| Staff 24 | Social Service Director | Named in grievance and environmental findings |
| Staff 27 | Maintenance Director | Named in environmental and equipment maintenance findings |
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