Deficiencies per Year
16
12
8
4
0
Unclassified
Inspection Report
Capacity: 23
Deficiencies: 3
Aug 4, 2025
Visit Reason
Facility failed to maintain kitchen in good repair and sanitary manner per Food Sanitation Rules; multiple areas with food spills, dirt, and repair needs; staff observed with improper hair restraints and food handling practices; plan of correction includes cleaning trainings and repairs.
Findings
Facility failed to maintain kitchen in good repair and sanitary manner per Food Sanitation Rules; multiple areas with food spills, dirt, and repair needs; staff observed with improper hair restraints and food handling practices; plan of correction includes cleaning trainings and repairs.
Deficiencies (3)
| Description |
|---|
| OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule — Kitchen sanitation and maintenance deficiencies |
| OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval — Failed to ensure kitchen survey plan of correction was implemented |
| OAR 411-057-0140(2) Administration Compliance — Failed to follow licensing rules for Residential Care and Assisted Living Facilities |
Inspection Report
Capacity: 23
Deficiencies: 12
Apr 10, 2025
Visit Reason
Multiple deficiencies including service plan inaccuracies, failure to monitor changes of condition, infection prevention lapses, psychotropic medication issues, administrator qualifications, acuity based staffing tool inaccuracies, environmental maintenance, and administration compliance; many deficiencies not corrected at revisits.
Findings
Multiple deficiencies including service plan inaccuracies, failure to monitor changes of condition, infection prevention lapses, psychotropic medication issues, administrator qualifications, acuity based staffing tool inaccuracies, environmental maintenance, and administration compliance; many deficiencies not corrected at revisits.
Deficiencies (12)
| Description |
|---|
| OAR 411-054-0036 (1-4) Service Plan: General — Service plans not reflective of resident needs and lacking clear direction |
| OAR 411-054-0040 (1-2) Change of Condition and Monitoring — Failed to document progress monitoring and provide clear directions for short term changes |
| OAR 411-054-0050(1-5) Infection Prevention & Control — Failed to maintain infection prevention protocols during incontinent episode and meal service |
| OAR 411-054-0055 (6) Systems: Psychotropic Medication — PRN medications lacked resident-specific parameters and documentation of non-pharmacological interventions |
| OAR 411-054-0065 (1-3) Administrator Qualification and Requirements — Failed to employ full-time administrator on site at least 40 hours/week |
| OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time — Failed to accurately capture care time and care elements for residents |
| OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan — Failed to complete/update ABST evaluations prior to move-in and quarterly |
| OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors — Facility environment not maintained clean and in good repair |
| OAR 411-054-0200 (8) Heating and Ventilation — Wall heaters exceeded 120 degrees Fahrenheit posing risk |
| OAR 411-057-0140(2) Administration Compliance — Failed to follow licensing rules for Residential Care and Assisted Living Facilities |
| OAR 411-057-0160(2b) Compliance with Rules Health Care — Failed to provide health care services in accordance with licensing rules |
| OAR 411-057-0160(2)(c)(A)(B) Nutrition and Hydration — Failed to develop individualized nutrition and hydration plans for residents |
Inspection Report
Capacity: 23
Deficiencies: 4
Aug 6, 2024
Visit Reason
Kitchen inspection found issues with maintaining kitchen in good repair and sanitary manner; deficiencies corrected by revisit on 10/10/24.
Findings
Kitchen inspection found issues with maintaining kitchen in good repair and sanitary manner; deficiencies corrected by revisit on 10/10/24.
Deficiencies (4)
| Description |
|---|
| OAR 411-054-0030 Resident Services Meals, Food Sanitation Rule — Kitchen sanitation and maintenance deficiencies |
| OAR 411-054-0030 Resident Services Meals, Food Sanitation Rule — Kitchen sanitation and maintenance deficiencies |
| OAR 411-054-0050 Infection Prevention & Control — Lack of policy for exclusion of sick food service workers |
| OAR 411-057-0140 Administration Compliance — Failed to follow licensing rules |
Inspection Report
Capacity: 23
Deficiencies: 4
Jul 6, 2023
Visit Reason
Kitchen inspection identified sanitation issues and missing food handler cards for staff; deficiencies corrected by revisit on 10/16/23.
Findings
Kitchen inspection identified sanitation issues and missing food handler cards for staff; deficiencies corrected by revisit on 10/16/23.
Deficiencies (4)
| Description |
|---|
| OAR 411-054-0030 Resident Services Meals, Food Sanitation Rule — Kitchen sanitation and maintenance deficiencies |
| OAR 411-054-0030 Resident Services Meals, Food Sanitation Rule — Kitchen sanitation and maintenance deficiencies |
| OAR 411-054-0370 Staffing Requirements and Training – Pre-Serv — Food handlers certificates missing for some kitchen staff |
| OAR 411-057-0140 Administration Compliance — Failed to follow licensing rules |
Inspection Report
Complaint Investigation
Capacity: 23
Deficiencies: 2
Jan 13, 2023
Visit Reason
Complaint investigation found failure to exercise reasonable precautions against conditions threatening resident health and safety; issues with toileting assistance.
Findings
Complaint investigation found failure to exercise reasonable precautions against conditions threatening resident health and safety; issues with toileting assistance.
Deficiencies (2)
| Description |
|---|
| OAR 411-054-0010 Licensing Complaint Investigation — Failure to exercise reasonable precautions for resident safety |
| OAR 411-054-0160 Reasonable Precautions — Failure to exercise reasonable precautions for resident safety |
Inspection Report
Capacity: 23
Deficiencies: 15
Nov 15, 2021
Visit Reason
Re-licensure survey identified multiple deficiencies including abuse reporting, service plans, controlled substances tracking, treatment orders, restraints, staff training, fire safety, building maintenance, and administration compliance; many corrected by revisit in early 2022.
Findings
Re-licensure survey identified multiple deficiencies including abuse reporting, service plans, controlled substances tracking, treatment orders, restraints, staff training, fire safety, building maintenance, and administration compliance; many corrected by revisit in early 2022.
Deficiencies (15)
| Description |
|---|
| OAR 411-054-0231 Reporting & Investigating Abuse-Other Action — Failure to promptly investigate and report resident incidents |
| OAR 411-054-0240 Resident Services Meals, Food Sanitation Rule — Kitchen sanitation and maintenance deficiencies |
| OAR 411-054-0260 Service Plan: General — Service plans not reflective of resident needs and lacking clear direction |
| OAR 411-054-0302 Systems: Tracking Controlled Substances — Failed to accurately track controlled substances administered |
| OAR 411-054-0303 Systems: Treatment Orders — Failed to ensure physician orders were available and carried out as prescribed |
| OAR 411-054-0340 Restraints and Supportive Devices — Failed to complete thorough assessments for supportive devices |
| OAR 411-054-0372 Training Within 30 Days: Direct Care Staff — Failed to complete required training within 30 days of hire |
| OAR 411-054-0420 Fire and Life Safety: Safety — Fire and life safety documentation incomplete |
| OAR 411-054-0422 Fire and Life Safety: Training For Residents — Failed to ensure fire safety requirements met |
| OAR 411-054-0510 General Building Exterior — Courtyard surfaces not maintained in good repair |
| OAR 411-054-0513 Doors, Walls, Elevators, Odors — Facility environment not maintained clean and in good repair |
| OAR 411-054-1518 Individual Door Locks: Key Access — Residents lacked keys to their units per evaluated need |
| OAR 411-057-0142 Administration Compliance — Failed to follow licensing rules |
| OAR 411-057-0155 Staff Training Requirements — Failed to complete required pre-service and annual training |
| OAR 411-057-0162 Compliance With Rules Health Care — Failed to provide health care services in accordance with licensing rules |
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