Inspection Report Summary
The most recent inspection on June 6, 2025, identified multiple deficiencies related to residents' rights, grievance resolution, discharge notifications, qualified personnel, respiratory and pain management, pharmacy records, and the environment, with several issues not corrected on revisit. Earlier inspections showed a pattern of similar deficiencies involving resident rights, staffing, safe environment, care quality, and regulatory compliance, with many issues recurring despite revisits. Inspectors frequently cited problems in resident rights communication, staffing sufficiency, infection control, and medication management. Complaint investigations were conducted but were unsubstantiated or did not result in additional deficiencies. The overall trend indicates persistent challenges with compliance, as deficiencies have continued over time without clear improvement.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
21.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
221% worse than Oregon average
Oregon average: 6.7 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Routine
Capacity: 88
Deficiencies: 11
Date: Jun 6, 2025
Visit Reason
Facility failed to ensure residents' rights to be informed and make treatment decisions, grievance resolution, discharge process notifications, qualified persons administering medications, respiratory care, pain management, pharmacy records, safe environment, and other regulatory requirements. Multiple deficiencies were not corrected on revisit.
Findings
Facility failed to ensure residents' rights to be informed and make treatment decisions, grievance resolution, discharge process notifications, qualified persons administering medications, respiratory care, pain management, pharmacy records, safe environment, and other regulatory requirements. Multiple deficiencies were not corrected on revisit.
Deficiencies (11)
F0000 - INITIAL COMMENTS
F0552 - Right to be Informed/Make Treatment Decisions
F0585 - Grievances
F0628 - Discharge Process
F0659 - Qualified Persons
F0695 - Respiratory/Tracheostomy Care and Suctioning
F0697 - Pain Management
F0755 - Pharmacy Srvcs/Procedures/Pharmacist/Records
F0921 - Safe/Functional/Sanitary/Comfortable Environ
M0000 - Initial Comments
M9999 - STATE OF OREGON ADMINISTRATIVE RULES
Inspection Report
Complaint Investigation
Capacity: 88
Deficiencies: 2
Date: Apr 2, 2025
Visit Reason
No deficiencies identified. Initial comments noted but not corrected.
Findings
No deficiencies identified. Initial comments noted but not corrected.
Deficiencies (2)
F0000 - INITIAL COMMENTS
M0000 - Initial Comments
Inspection Report
Complaint Investigation
Capacity: 88
Deficiencies: 9
Date: Jan 6, 2025
Visit Reason
Deficiencies related to resident rights, grievance handling, notification of changes, staffing, resident allergies/preferences, and other care standards. Multiple deficiencies corrected on first revisit but not on second.
Findings
Deficiencies related to resident rights, grievance handling, notification of changes, staffing, resident allergies/preferences, and other care standards. Multiple deficiencies corrected on first revisit but not on second.
Deficiencies (9)
F0000 - INITIAL COMMENTS
F0550 - Resident Rights/Exercise of Rights
F0558 - Reasonable Accommodations Needs/Preferences
F0580 - Notify of Changes (Injury/Decline/Room, etc.)
F0725 - Sufficient Nursing Staff
F0806 - Resident Allergies, Preferences, Substitutes
M0000 - Initial Comments
M0185 - Bariatric Criteria and Services
M9999 - STATE OF OREGON ADMINISTRATIVE RULES
Inspection Report
Complaint Investigation
Capacity: 88
Deficiencies: 2
Date: May 6, 2024
Visit Reason
No deficiencies identified. Initial comments noted but not corrected.
Findings
No deficiencies identified. Initial comments noted but not corrected.
Deficiencies (2)
F0000 - INITIAL COMMENTS
M0000 - Initial Comments
Inspection Report
Complaint Investigation
Capacity: 88
Deficiencies: 18
Date: Jan 26, 2024
Visit Reason
Multiple deficiencies including resident rights, grievance response, reporting of alleged violations, quality of care, accident hazards, ostomy care, respiratory care, staffing, medication error rates, medication storage, food procurement, infection control, and equipment safety. Many deficiencies corrected on first revisit but not on second.
Findings
Multiple deficiencies including resident rights, grievance response, reporting of alleged violations, quality of care, accident hazards, ostomy care, respiratory care, staffing, medication error rates, medication storage, food procurement, infection control, and equipment safety. Many deficiencies corrected on first revisit but not on second.
Deficiencies (18)
F0000 - INITIAL COMMENTS
F0550 - Resident Rights/Exercise of Rights
F0565 - Resident/Family Group and Response
F0609 - Reporting of Alleged Violations
F0684 - Quality of Care
F0686 - Treatment/Svcs to Prevent/Heal Pressure Ulcer
F0689 - Free of Accident Hazards/Supervision/Devices
F0691 - Colostomy, Urostomy, or Ileostomy Care
F0695 - Respiratory/Tracheostomy Care and Suctioning
F0725 - Sufficient Nursing Staff
F0759 - Free of Medication Error Rts 5 Prcnt or More
F0761 - Label/Store Drugs and Biologicals
F0812 - Food Procurement,Store/Prepare/Serve-Sanitary
F0880 - Infection Prevention & Control
M0000 - Initial Comments
M0183 - Nursing Services: Minimum CNA Staffing
M0185 - Bariatric Criteria and Services
M9999 - STATE OF OREGON ADMINISTRATIVE RULES
Inspection Report
Complaint Investigation
Capacity: 88
Deficiencies: 5
Date: Oct 6, 2023
Visit Reason
Deficiencies related to required postings and initial comments. Ombudsman poster was missing on first floor. Some deficiencies corrected on first revisit but not on second.
Findings
Deficiencies related to required postings and initial comments. Ombudsman poster was missing on first floor. Some deficiencies corrected on first revisit but not on second.
Deficiencies (5)
F0000 - INITIAL COMMENTS
F0575 - Required Postings
M0000 - Initial Comments
M0320 - Dietary Services: Diets and Menus
M9999 - STATE OF OREGON ADMINISTRATIVE RULES
Inspection Report
Complaint Investigation
Capacity: 88
Deficiencies: 17
Date: Sep 7, 2023
Visit Reason
Multiple deficiencies including notification of hospital transfers, safe environment, misappropriation of funds, care plan revisions, professional standards, medication administration, accident hazards, dietary staffing and food service, resident records, infection control, equipment safety, and CNA staffing. Many deficiencies corrected on first revisit but not on second.
Findings
Multiple deficiencies including notification of hospital transfers, safe environment, misappropriation of funds, care plan revisions, professional standards, medication administration, accident hazards, dietary staffing and food service, resident records, infection control, equipment safety, and CNA staffing. Many deficiencies corrected on first revisit but not on second.
Deficiencies (17)
F0000 - INITIAL COMMENTS
F0580 - Notify of Changes (Injury/Decline/Room, etc.)
F0584 - Safe/Clean/Comfortable/Homelike Environment
F0602 - Free from Misappropriation/Exploitation
F0657 - Care Plan Timing and Revision
F0658 - Services Provided Meet Professional Standards
F0684 - Quality of Care
F0688 - Increase/Prevent Decrease in ROM/Mobility
F0692 - Nutrition/Hydration Status Maintenance
F0725 - Sufficient Nursing Staff
F0740 - Behavioral Health Services
F0791 - Routine/Emergency Dental Srvcs in NFs
F0842 - Resident Records - Identifiable Information
F0880 - Infection Prevention & Control
M0000 - Initial Comments
M0183 - Nursing Services: Minimum CNA Staffing
M9999 - STATE OF OREGON ADMINISTRATIVE RULES
Inspection Report
Capacity: 88
Deficiencies: 3
Date: Jun 6, 2023
Visit Reason
No deficiencies identified. Initial comments noted but not corrected.
Findings
No deficiencies identified. Initial comments noted but not corrected.
Deficiencies (3)
E0000 - Initial Comments
F0000 - INITIAL COMMENTS
M0000 - Initial Comments
Inspection Report
Complaint Investigation
Capacity: 88
Deficiencies: 4
Date: Dec 29, 2022
Visit Reason
Deficiencies related to laboratory services, care plan accuracy, and administrative rules. Some deficiencies corrected on first revisit but not on second.
Findings
Deficiencies related to laboratory services, care plan accuracy, and administrative rules. Some deficiencies corrected on first revisit but not on second.
Deficiencies (4)
F0000 - INITIAL COMMENTS
F0770 - Laboratory Services
M0000 - Initial Comments
M9999 - STATE OF OREGON ADMINISTRATIVE RULES
Inspection Report
Complaint Investigation
Capacity: 88
Deficiencies: 15
Date: Nov 7, 2022
Visit Reason
Deficiencies related to reasonable accommodations, Medicaid/Medicare notices, safe environment, accuracy of assessments, vision care, ROM/mobility, nutrition/hydration, nursing staff sufficiency, behavioral health, dental services, resident records, and CNA staffing. Many deficiencies corrected on first revisit but not on second.
Findings
Deficiencies related to reasonable accommodations, Medicaid/Medicare notices, safe environment, accuracy of assessments, vision care, ROM/mobility, nutrition/hydration, nursing staff sufficiency, behavioral health, dental services, resident records, and CNA staffing. Many deficiencies corrected on first revisit but not on second.
Deficiencies (15)
F0000 - INITIAL COMMENTS
F0558 - Reasonable Accommodations Needs/Preferences
F0582 - Medicaid/Medicare Coverage/Liability Notice
F0584 - Safe/Clean/Comfortable/Homelike Environment
F0641 - Accuracy of Assessments
F0685 - Treatment/Devices to Maintain Hearing/Vision
F0688 - Increase/Prevent Decrease in ROM/Mobility
F0692 - Nutrition/Hydration Status Maintenance
F0725 - Sufficient Nursing Staff
F0740 - Behavioral Health Services
F0791 - Routine/Emergency Dental Srvcs in NFs
F0842 - Resident Records - Identifiable Information
M0000 - Initial Comments
M0183 - Nursing Services: Minimum CNA Staffing
M9999 - STATE OF OREGON ADMINISTRATIVE RULES
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