Inspection Report
Kitchen
Census: 22
Capacity: 27
Deficiencies: 29
Dec 1, 2025
Visit Reason
State-compiled facility profile showing 8 inspections from 2021 to 2025 with deficiency history and enforcement actions
Findings
Across multiple inspections from 2021 to 2025, the facility exhibited numerous deficiencies including failure to maintain kitchen sanitation, inadequate staffing levels, incomplete resident evaluations and service plans, insufficient infection control practices, and failure to implement plans of correction. Some deficiencies were repeated across inspections with partial or no correction noted.
Complaint Details
The complaint investigation conducted on 05/23/2025 identified deficiencies related to compliance with Oregon Administrative Rules 411 Division 54 and 57, including staffing and investigations.
Deficiencies (29)
| Description |
|---|
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to maintain kitchen cleanliness and food sanitation in accordance with OAR 333-150-0000, including accumulation of food debris, poor infection control, and equipment in disrepair |
| C0370 - Staffing Requirements and Training – Pre-service: Failed to ensure staff preparing food had active food handler's certificates |
| C0450 - Inspections and Investigations: Failed to cooperate with inspections and ensure plan of correction was implemented |
| C0455 - Inspections and Investigation: Insp Interval: Failed to ensure re-licensure survey plan of correction was implemented and satisfied the Department |
| Z0142 - Administration Compliance: Failed to comply with licensing rules for Residential Care and Assisted Living Facilities |
| Z0155 - Staff Training Requirements: Failed to ensure staff completed required pre-service orientation, dementia training, and infectious disease training |
| C0010 - Licensing Complaint Investigation: Findings from complaint investigations documented |
| C0360 - Staffing Requirements and Training: Staffing: Insufficient number of caregiving staff to meet resident needs and fire safety standards |
| C0362 - Acuity Based Staffing Tool - Abst Time: Failed to maintain and update acuity based staffing tool |
| C0363 - Acuity Based Staffing Tool - Updates & Plan: Failed to update acuity based staffing tool and develop staffing plan accordingly |
| C0231 - Reporting & Investigating Abuse-Other Action: Failed to report physical injuries of unknown cause as suspected abuse |
| C0242 - Resident Services: Activities: Failed to provide daily program of social and recreational activities based on resident needs |
| C0243 - Resident Services: Adls: Failed to provide assistance with activities of daily living for a sampled resident |
| C0252 - Resident Move-In and Eval: Res Evaluation: Failed to complete resident evaluations before move-in and document updates after significant changes |
| C0260 - Service Plan: General: Failed to ensure service plans were reflective of resident needs and provided clear direction to staff |
| C0270 - Change of Condition and Monitoring: Failed to determine, communicate, and document actions for changes of condition and monitor until resolution |
| C0280 - Resident Health Services: Failed to ensure timely RN assessments and participation in service planning for significant changes of condition |
| C0295 - Infection Prevention & Control: Failed to maintain effective infection prevention and control protocols |
| C0330 - Systems: Psychotropic Medication: Failed to document non-pharmacological interventions prior to PRN psychotropic medication administration |
| C0340 - Restraints and Supportive Devices: Failed to assess and instruct on use of supportive devices with restraining qualities |
| C0361 - Acuity-Based Staffing Tool: Failed to ensure all residents were entered and tool updated quarterly or after significant changes |
| C0422 - Fire and Life Safety: Training For Residents: Failed to instruct residents on fire and life safety procedures within 24 hours of admission and annually |
| C0513 - Doors, Walls, Elevators, Odors: Failed to maintain interior materials and surfaces in good repair and free from unpleasant odors |
| H1518 - Individual Door Locks: Key Access: Failed to ensure only appropriate staff and individuals had keys to units |
| C0160 - Reasonable Precautions: Failed to implement effective infection control methods including glove use and catheter bag storage |
| C0305 - Systems: Resident Right to Refuse: Failed to notify physician when resident refused consent to orders |
| C0310 - Systems: Medication Administration: Failed to ensure MARs included resident-specific parameters for PRN medications |
| C0372 - Training Within 30 Days: Direct Care Staff: Failed to document competency and required training within 30 days of hire |
| C0420 - Fire and Life Safety: Safety: Failed to conduct fire drills and provide fire safety instruction per Oregon Fire Code |
Report Facts
Inspections on page: 8
Total deficiencies: 56
Total licensing violations: 20
Total notices: 1
Licensed beds: 27
Facility census: 22
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Executive Director | Named in multiple findings related to food handler certification, plan of correction discussions, and inspection interviews |
| Staff 2 | Health and Wellness Director | Named in multiple findings related to infection control, resident evaluations, and plan of correction discussions |
| Staff 3 | Memory Care Director | Named in multiple findings related to infection control, resident care, staffing, and plan of correction discussions |
| Staff 5 | Cook | Named in food handler certificate deficiency |
| Staff 23 | Regional RN | Named in findings related to resident assessments and service planning |
| Staff 8 | Co-director of Health Services and Quality Assurance | Named in findings related to resident evaluations and training |
| Staff 14 | Dining Services Manager | Named in kitchen sanitation and food service deficiencies |
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