Inspection Reports for Brookdale Mt. Hood
25200 SE Stark St, Gresham, OR 97030, OR, 97030
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Inspection Report
Kitchen
Census: 70
Capacity: 88
Deficiencies: 37
Aug 20, 2025
Visit Reason
State-compiled facility profile showing 6 inspections from 2021 to 2025 with deficiency history and enforcement actions
Findings
Across multiple inspections from 2021 to 2025, the facility exhibited repeated deficiencies related to kitchen sanitation, staffing, resident care plans, medication administration, and fire and life safety. Several plans of correction were implemented but some deficiencies remained uncorrected at revisit inspections.
Complaint Details
The complaint investigation conducted on 07/28/2023 documented findings related to medication self-administration and acuity-based staffing tool deficiencies.
Deficiencies (37)
| Description |
|---|
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to maintain kitchen in good repair and sanitary manner with multiple food spills, debris, and equipment issues |
| C0370 - Staffing Requirements and Training – Pre-service: Failed to ensure staff preparing food had active food handler's certificates |
| C0455 - Inspections and Investigation: Insp Interval: Failed to ensure kitchen survey plan of correction was implemented and satisfied the Department |
| C0000 - Comment: Various comments related to inspections and compliance |
| C0150 - Facility Administration: Operation: Failed to provide adequate administrative oversight posing risk to resident safety |
| C0152 - Facility Administration: Required Postings: Failed to ensure most recent re-licensure survey was available to residents and visitors |
| C0160 - Reasonable Precautions: Failed to exercise reasonable precautions against conditions threatening resident health and safety |
| C0200 - Resident Rights and Protection - General: Failed to provide homelike environment with pervasive odors and unclean carpets |
| C0231 - Reporting & Investigating Abuse-Other Action: Failed to promptly investigate and report injury of unknown cause |
| C0252 - Resident Move-In and Eval: Res Evaluation: Failed to complete comprehensive resident evaluations and update service plans |
| C0260 - Service Plan: General: Failed to ensure service plans were clear, reflective of resident needs, and readily available |
| C0262 - Service Plan: Service Planning Team: Failed to ensure service plans were developed by required team including resident and staff |
| C0270 - Change of Condition and Monitoring: Failed to evaluate, communicate, and monitor changes of condition for residents |
| C0280 - Resident Health Services: Failed to complete timely RN assessments for significant changes of condition |
| C0290 - Res Hlth Srvc: On- and Off-Site Health Srvc: Failed to coordinate and communicate new interventions from outside providers |
| C0303 - Systems: Treatment Orders: Failed to carry out medication and treatment orders as prescribed |
| C0305 - Systems: Resident Right to Refuse: Failed to notify physician when resident refused consent to orders |
| C0310 - Systems: Medication Administration: Failed to ensure MARs were accurate and included resident-specific parameters |
| C0330 - Systems: Psychotropic Medication: Failed to document non-pharmacological interventions prior to psychotropic medication administration |
| C0361 - Acuity-Based Staffing Tool: Failed to implement an acuity-based staffing tool meeting regulation requirements |
| C0420 - Fire and Life Safety: Safety: Failed to ensure unannounced fire drills included all required components |
| C0422 - Fire and Life Safety: Training For Residents: Failed to ensure residents received annual fire and life safety training |
| C0510 - General Building Exterior: Failed to maintain exterior grounds orderly and free of litter and refuse |
| C0513 - Doors, Walls, Elevators, Odors: Failed to maintain interior surfaces clean, in good repair, and free of unpleasant odors |
| C0010 - Licensing Complaint Investigation: Licensing complaint investigation findings documented |
| C0325 - Systems: Self-Administration of Meds: Failed to ensure staff visually observed resident self-administering medication |
| C0361 - Acuity-Based Staffing Tool: Failed to implement an acuity-based staffing tool meeting regulation requirements |
| C0231 - Reporting & Investigating Abuse-Other Action: Failed to investigate resident incidents timely and report to SPD |
| C0252 - Resident Move-In and Eval: Res Evaluation: Failed to complete comprehensive resident evaluations and quarterly updates |
| C0260 - Service Plan: General: Failed to ensure service plans were reflective and provided clear direction |
| C0270 - Change of Condition and Monitoring: Failed to evaluate, communicate, and monitor changes of condition |
| C0280 - Resident Health Services: Failed to complete RN assessments for significant changes of condition |
| C0290 - Res Hlth Srvc: On- and Off-Site Health Srvc: Failed to coordinate care and implement outside provider recommendations |
| C0305 - Systems: Resident Right to Refuse: Failed to notify physician of resident medication refusals |
| C0360 - Staffing Requirements and Training: Staffing: Failed to maintain sufficient staffing to meet resident needs |
| C0455 - Inspections and Investigation: Insp Interval: Failed to ensure re-licensure survey plan of correction was implemented |
| C0513 - Doors, Walls, Elevators, Odors: Failed to maintain environment clean and in good repair |
Report Facts
Inspections on page: 6
Total deficiencies: 38
Total surveys: 6
Abuse violations: 0
Licensing violations: 10
Notices: 3
Licensed beds: 88
Resident census: 70
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Executive Director | Named in multiple findings related to kitchen sanitation, staffing, and resident care |
| Staff 2 | Health and Wellness Director | Named in findings related to resident care, medication administration, and abuse reporting |
| Staff 4 | Cook/Dishwasher | Named in food handler certificate deficiency |
| Staff 6 | Resident Care Coordinator | Named in findings related to resident care plans and monitoring |
| Staff 9 | Medication Technician | Named in medication administration and wound care findings |
| Staff 28 | Regional RN | Named in resident nutritional and wound care assessments |
| Staff 12 | Area Nurse Manager | Named in abuse reporting and training findings |
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