Inspection Reports for Brookdale Ontario
1372 Southwest 8th Avenue,Ontario, OR, OR
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Inspection Report
Capacity: 82
Deficiencies: 21
Jan 16, 2025
Visit Reason
State-compiled facility profile showing 4 inspections from 2021 to 2025 with deficiency history and enforcement actions.
Findings
Across all inspections, the facility demonstrated multiple deficiencies related to resident care evaluations, service plans, medication administration, staffing tools, training, fire and life safety, and kitchen sanitation. Some deficiencies were corrected in follow-up visits, while others remained uncorrected as of the latest inspection.
Deficiencies (21)
| Description |
|---|
| C0000 - Comment: General comments and findings documented in various inspections. |
| C0231 - Reporting & Investigating Abuse-Other Action: Failed to ensure injuries of unknown cause were reported as suspected abuse unless properly investigated. |
| C0252 - Resident Move-In and Eval: Res Evaluation: Failed to ensure move-in evaluations addressed all required elements for sampled residents. |
| C0260 - Service Plan: General: Service plans lacked clear caregiving instructions and were not reflective of residents' current care needs. |
| C0270 - Change of Condition and Monitoring: Failed to determine, document, and communicate actions or interventions needed for changes of condition for sampled residents. |
| C0310 - Systems: Medication Administration: MARs were inaccurate, lacked medication-specific instructions, and were not properly initialed by staff. |
| C0361 - Acuity-Based Staffing Tool: Failed to implement an acuity-based staffing tool that converts residents' care needs into staff hours. |
| C0370 - Staffing Requirements and Training – Pre-Serv: Failed to ensure staff completed required HCBS and infectious disease training. |
| C0374 - Annual and Biennial Inservice For All Staff: Failed to ensure staff completed annual infectious disease training. |
| C0420 - Fire and Life Safety: Safety: Failed to include and document all required elements in fire drills and provide fire and life safety instruction to staff. |
| C0422 - Fire and Life Safety: Training For Residents: Failed to provide fire safety instruction to residents at least annually. |
| C0455 - Inspections and Investigation: Insp Interval: Failed to ensure relicensure survey plan of correction was implemented and satisfied the Department. |
| C0510 - General Building Exterior: Exterior pathways had multiple drop-offs creating potential hazards. |
| C0513 - Doors, Walls, Elevators, Odors: Environment was not maintained in good repair; raised gardening beds in disrepair with exposed nails and detached boards. |
| C0555 - Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable: Exit doors were not equipped with an alarming device or acceptable system to alert staff when residents exited. |
| C0240 - Resident Services Meals, Food Sanitation Rule: Kitchen was not maintained in accordance with Food Sanitation Rules; multiple areas dirty or in disrepair. |
| C0200 - Resident Rights and Protection - General: Failed to provide a safe and homelike environment for a resident living with cats; unsanitary conditions observed. |
| C0302 - Systems: Tracking Control Substances: Failed to accurately track controlled substances administered by the facility. |
| C0303 - Systems: Treatment Orders: Failed to carry out medication or treatment orders as prescribed for sampled residents. |
| C0305 - Systems: Resident Right to Refuse: Failed to notify physician or practitioner when residents refused medications. |
| C0325 - Systems: Self-Administration of Meds: Failed to evaluate resident's ability to safely self-administer medications. |
Report Facts
Inspections on page: 4
Total deficiencies: 30
Total licensing violations: 20
Total abuse violations: 0
Total notices: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Business Office Coordinator | Named in multiple findings related to reporting, evaluations, and training acknowledgments |
| Staff 3 | Health and Wellness Coordinator | Named in multiple findings related to reporting, evaluations, and training acknowledgments |
| Staff 7 | Designee | Named in multiple findings related to reporting, evaluations, and training acknowledgments |
| Staff 4 | Maintenance Manager | Named in findings related to building exterior, fire safety, and door alarms |
| Staff 2 | RN | Named in medication administration and refusal findings |
| Staff 17 | Executive Director | Named in staffing tool implementation findings |
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