Inspection Reports for Bayberry Commons
2211 Laura St, Springfield, OR 97477, United States, OR, 97477
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Inspection Report
Change Of Owner
Capacity: 14
Deficiencies: 35
Nov 12, 2025
Visit Reason
State-compiled facility profile showing 5 inspections from 2023-2025 with deficiency history and enforcement actions
Findings
Across multiple inspections from 2022 to 2025, the facility exhibited numerous deficiencies including failure to report and investigate abuse, inadequate infection prevention and control, insufficient resident monitoring and service planning, kitchen sanitation issues, staffing shortages, and failure to maintain a safe environment. Several deficiencies were repeated or not corrected at follow-up visits.
Complaint Details
The complaint investigations conducted on 11/2/2023 and 1/10/2023 documented findings related to licensing complaints and environmental issues, confirming multiple deficiencies and non-compliance with regulations.
Severity Breakdown
Not Corrected: 35
Deficiencies (35)
| Description | Severity |
|---|---|
| C0231 - Reporting & Investigating Abuse-Other Action: Failed to ensure injuries of unknown cause were reported and investigated properly | Not Corrected |
| C0270 - Change of Condition and Monitoring: Failed to document weekly progress to resolution for short-term changes of condition | Not Corrected |
| C0295 - Infection Prevention & Control: Failed to maintain infection prevention protocols related to glove use during incontinence care | Not Corrected |
| H1517 - Individual Privacy: Own Unit: Failed to ensure residents had privacy in their own units due to propped open doors | Not Corrected |
| H1580 - Limitations: Threats To Health And Safety: Failed to complete Individually Based Limitations when restricting resident rights | Not Corrected |
| Z0164 - Activities: Failed to evaluate residents for activities and develop individualized activity plans | Not Corrected |
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to maintain kitchen in good repair and sanitary manner; multiple repeat citations | Not Corrected |
| C0455 - Inspections and Investigation: Insp Interval: Failed to ensure kitchen survey plan of correction was implemented and satisfied the Department | Not Corrected |
| Z0142 - Administration Compliance: Failed to comply with licensing rules for the facility | Not Corrected |
| C0010 - Licensing Complaint Investigation: Findings documented for complaint investigation | Not Corrected |
| C0513 - Doors, Walls, Elevators, Odors: Findings documented for complaint investigation | Not Corrected |
| C0361 - Acuity-Based Staffing Tool: Failed to comply with staffing requirements | Not Corrected |
| C0000 - Comment: Findings of re-licensure survey documented | Not Corrected |
| C0150 - Facility Administration: Operation: Failed to provide effective oversight to ensure quality of care | Not Corrected |
| C0160 - Reasonable Precautions: Failed to ensure infection control and resident safety related to elopement risk | Not Corrected |
| C0231 - Reporting & Investigating Abuse-Other Action: Failed to promptly investigate and report injuries and altercations | Not Corrected |
| C0260 - Service Plan: General: Failed to ensure service plans reflected resident needs and were followed | Not Corrected |
| C0262 - Service Plan: Service Planning Team: Failed to develop service plans with required team participation | Not Corrected |
| C0280 - Resident Health Services: Failed to complete RN assessment for significant weight loss | Not Corrected |
| C0295 - Infection Prevention & Control: Failed to comply with masking requirements | Not Corrected |
| C0302 - Systems: Tracking Control Substances: Failed to accurately track controlled substances | Not Corrected |
| C0310 - Systems: Medication Administration: Failed to maintain accurate MARs for medications | Not Corrected |
| C0330 - Systems: Psychotropic Medication: Failed to ensure PRN medications had resident-specific parameters and non-drug interventions | Not Corrected |
| C0360 - Staffing Requirements and Training: Staffing: Failed to have sufficient caregivers to meet resident needs | Not Corrected |
| C0372 - Training Within 30 Days: Direct Care Staff: Failed to complete required training within 30 days of hire for some staff | Not Corrected |
| C0420 - Fire and Life Safety: Safety: Failed to document fire and life safety training and drills as required | Not Corrected |
| C0455 - Inspections and Investigation: Insp Interval: Failed to ensure re-licensure survey plan of correction was implemented | Not Corrected |
| C0510 - General Building Exterior: Failed to maintain courtyard surfaces, fencing, and secure chemicals | Not Corrected |
| C0513 - Doors, Walls, Elevators, Odors: Failed to maintain environment in clean and good repair | Not Corrected |
| C0555 - Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable: Failed to equip exit doors with operational alarms | Not Corrected |
| Z0140 - Administration Responsibilities: Failed to provide effective administrative oversight | Not Corrected |
| Z0142 - Administration Compliance: Failed to follow licensing rules; repeat citation | Not Corrected |
| Z0155 - Staff Training Requirements: Failed to ensure new hires completed required pre-service training and competency | Not Corrected |
| Z0162 - Compliance With Rules Health Care: Failed to provide health care services in accordance with licensing rules | Not Corrected |
| Z0168 - Outside Area: Failed to provide access to secured outdoor space without staff assistance | Not Corrected |
Report Facts
Inspections on page: 5
Total deficiencies: 35
Total surveys: 5
Total notices: 3
Licensed beds: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Executive Director / Interim Administrator | Named in multiple findings related to infection control, abuse reporting, kitchen sanitation, and administrative oversight |
| Staff 2 | MC Wellness Manager / MCC Program Manager | Named in multiple findings related to infection control, abuse reporting, resident privacy, and administrative oversight |
| Staff 13 | Regional RN / Memory Care Program Director | Named in infection control and administrative oversight findings |
| Staff 7 | Maintenance Director | Named in findings related to unsecured windows, fire and life safety, and chemical storage |
| Staff 10 | Caregiver | Named in training deficiencies |
| Staff 20 | Caregiver | Named in training deficiencies |
| Staff 3 | Business Office Manager | Named in training deficiencies |
| Staff 9 | Caregiver | Named in infection control and training deficiencies |
| Staff 17 | Caregiver | Named in staffing and infection control findings |
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