Inspection Reports for Brookdale Forest Grove
3110 19th Avenue,Forest Grove, OR, OR
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Inspection Report
Kitchen
Capacity: 110
Deficiencies: 21
Aug 27, 2025
Visit Reason
State-compiled facility profile showing 10 inspections from 2023-2025 with deficiency history and enforcement actions.
Findings
Across multiple inspections from 2023 to 2025, the facility exhibited numerous deficiencies including failures in kitchen sanitation, resident services, infection control, staffing, service planning, and fire and life safety. Several deficiencies remained uncorrected over multiple visits, with some improvements noted in later corrections.
Complaint Details
Multiple complaint investigations conducted on 2023-01-17, 2023-03-07, and other dates identified numerous deficiencies related to licensing, resident rights, staffing, and service plans. Many deficiencies were not corrected at follow-up visits.
Deficiencies (21)
| Description |
|---|
| C0240 - Resident Services Meals, Food Sanitation Rule: Facility failed to ensure kitchen practices and protocols were in accordance with Food Sanitation Rules, including multiple areas needing cleaning and improper food storage. |
| C0010 - Licensing Complaint Investigation: Multiple complaint investigations identified deficiencies in compliance with state laws and regulations. |
| C0154 - Facility Administration: Policy & Procedure: Failed to implement effective methods of responding to and resolving resident complaints. |
| C0155 - Facility Administration: Records: Deficiencies noted in facility administration records. |
| C0260 - Service Plan: General: Service plans were not reflective of residents' current needs and lacked clear instructions. |
| C0300 - Systems: Medications and Treatments: Deficiencies in medication and treatment systems. |
| C0301 - Systems: Medication Administration: Deficiencies in medication administration systems. |
| C0303 - Systems: Treatment Orders: Deficiencies in treatment orders. |
| C0360 - Staffing Requirements and Training: Staffing: Failed to ensure adequate staffing and training. |
| C0361 - Acuity-Based Staffing Tool: Failed to implement an acuity-based staffing tool meeting regulation requirements. |
| C0370 - Staffing Requirements and Training – Pre-Serv: Newly hired staff lacked required pre-service orientation and dementia training. |
| C0372 - Training Within 30 Days: Direct Care Staff: Failed to ensure newly hired staff completed required training and demonstrated competency within 30 days. |
| C0420 - Fire and Life Safety: Safety: Failed to conduct fire drills every other month and provide staff instruction on alternate months. |
| C0422 - Fire and Life Safety: Training For Residents: Failed to ensure residents were instructed on fire and life safety procedures within 24 hours of admission and annually. |
| C0455 - Inspections and Investigation: Insp Interval: Failed to ensure re-licensure survey plan of correction was implemented and satisfied the Department. |
| C0510 - General Building Exterior: Exterior pathways and accesses were not maintained in good repair, creating hazards. |
| C0513 - Doors, Walls, Elevators, Odors: Interior and exterior materials and surfaces were not kept clean and in good repair. |
| C0545 - Plumbing Systems: Failed to ensure hot water temperatures in residents' apartments were maintained within 110-120 degrees Fahrenheit. |
| C0243 - Resident Services: Adls: Deficiencies in assistance with activities of daily living. |
| C0304 - Systems: Medication and Treatment Review: Deficiencies in medication and treatment review systems. |
| C0511 - General Building Interior: Deficiencies in building interior maintenance. |
Report Facts
Inspections on page: 10
Total deficiencies: 51
Total surveys: 10
Licensing violations: 10
Notices: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | District Director of Operations | Named in multiple findings related to administrative oversight, complaint investigations, and acknowledgment of deficiencies |
| Staff 2 | District Director of Clinical | Named in multiple findings related to clinical oversight and acknowledgment of deficiencies |
| Staff 4 | RN Oversite | Named in findings related to resident care and assessments |
| Staff 5 | Health and Wellness Coordinator | Named in findings related to monitoring and resident safety |
| Staff 8 | Maintenance Supervisor | Named in findings related to facility maintenance and fire safety |
| Staff 19 | Cook | Named in kitchen sanitation findings |
| Staff 33 | Executive Director II | Named in findings related to staffing and administrative oversight |
| Staff 34 | Health and Wellness Director III | Named in findings related to resident safety and abuse reporting |
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