Inspection Reports for Azalea Gardens Senior Living
755 Elk Drive. Brookings, OR 97415, OR, 97415
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Inspection Report
Census: 36
Capacity: 40
Deficiencies: 13
Jun 17, 2025
Visit Reason
State-compiled facility profile showing 6 inspections from 2023-2025 with deficiency history and enforcement actions.
Findings
Across multiple inspections, the facility exhibited repeated deficiencies related to kitchen sanitation, resident services including medication administration, staffing, and compliance with licensing rules. Several deficiencies were noted as not corrected over multiple revisit dates, though some were eventually corrected. The facility was found in substantial compliance in some revisits but had ongoing issues in others.
Complaint Details
Multiple complaint investigations documented including medication errors, acuity-based staffing tool implementation failures, and abuse reporting compliance issues.
Deficiencies (13)
| Description |
|---|
| C0000 - Comment: Findings documented for kitchen inspections and re-licensure surveys including substantial compliance noted in revisits. |
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to maintain a clean and sanitary kitchen in accordance with Food Sanitation Rules OAR 333-150-000; repeated observations of debris, broken equipment, black discoloration, and unsanitary conditions. |
| C0455 - Inspections and Investigation: Insp Interval: Failed to ensure re-licensure survey plan of correction was implemented and satisfied the Department; repeat citation. |
| Z0142 - Administration Compliance: Failed to follow licensing rules for Residential Care and Assisted Living Facilities; repeat citation referencing C240. |
| C0303 - Systems: Treatment Orders: Failed to carry out medication and treatment orders as prescribed for sampled residents; medication errors and omissions documented. |
| C0361 - Acuity-Based Staffing Tool: Failed to fully implement an Acuity Based Staffing Tool; staffing levels did not align with tool recommendations and resident needs. |
| C0305 - Systems: Resident Right to Refuse: Failed to notify physician or practitioner of medication refusals for sampled residents. |
| Z0155 - Staff Training Requirements: Failed to ensure newly hired staff completed required pre-service and competency training. |
| Z0162 - Compliance With Rules Health Care: Failed to provide health care services in accordance with licensing rules; referenced multiple citations. |
| Z0164 - Activities: Failed to fully evaluate residents for activities and develop individualized activity plans. |
| C0010 - Licensing Complaint Investigation: Findings documented from on-site investigation for licensing compliance. |
| C0231 - Reporting & Investigating Abuse-Other Action: Findings documented from on-site investigation for abuse reporting compliance. |
| C0300 - Systems: Medications and Treatments: Findings documented from desk review for medication and treatment compliance. |
Report Facts
Inspections on page: 6
Total deficiencies: 18
Licensing violations: 10
Abuse violations: 0
Notices: 3
Licensed beds: 40
Current census: 36
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Administrator | Named in multiple findings including medication errors, staffing tool issues, and plan of correction acknowledgements |
| Staff 2 | Resident Care Coordinator (RCC) | Named in medication error finding and interviews |
| Staff 3 | Resident Care Manager / Resident Care Coordinator | Named in findings related to service plans, medication administration, and refusal notifications |
| Staff 4 | Business Office Manager | Named in staff training findings |
| Staff 5 | Business Office Manager | Named in kitchen sanitation findings |
| Staff 7 | Caregiver | Named in staff training deficiencies |
| Staff 8 | Caregiver | Named in staff training deficiencies |
| Staff 9 | Medication Technician | Named in staff training deficiencies |
| Staff 10 | Caregiver | Named in service plan findings |
| Staff 16 | Licensed Practical Nurse (LPN) | Named in multiple findings including service plans, medication administration, and refusal notifications |
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