Inspection Reports for Brookdale Oswego Springs Portland
11552 SW Lesser Rd, Portland, OR 97219, OR, 97219
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Inspection Report
Complaint Investigation
Census: 68
Capacity: 82
Deficiencies: 27
Mar 14, 2025
Visit Reason
State-compiled facility profile showing 4 inspections from 2022-2025 with deficiency history and enforcement actions
Findings
Across multiple inspections from 2022 to 2025, the facility exhibited numerous deficiencies including medication errors, inadequate staffing, failure to maintain sanitary kitchen conditions, incomplete resident evaluations, insufficient training, and failure to properly investigate incidents and abuse allegations. Some deficiencies were corrected over time, but several remained uncorrected at the latest visits.
Complaint Details
Complaint investigations conducted on 04/20/2023 and 02/06/2024 identified deficiencies related to medication errors and failure to implement an Acuity Based Staffing Tool (ABST).
Deficiencies (27)
| Description |
|---|
| C0303 - Systems: Treatment Orders: Failed to carry out medication orders as prescribed for a sampled resident |
| C0000 - Comment: Kitchen inspection found accumulation of food spills, dirt, and unsanitary conditions; multiple repairs needed; infection control issues; food storage violations; and use of disposable meal service for room trays |
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to maintain kitchen in good repair and sanitary manner per Food Sanitation Rules OAR 333-150-000 |
| C0000 - Comment: Multiple citations related to re-licensure survey including failure to comply with OARs 411 Division 54 and 004 |
| C0150 - Facility Administration: Operation: Failed to provide effective administrative oversight to ensure quality of care and services |
| C0154 - Facility Administration: Policy & Procedure: Failed to implement effective methods of responding to and resolving resident complaints |
| C0200 - Resident Rights and Protection - General: Failed to ensure residents treated with dignity and respect related to ADL needs and safe environment |
| C0231 - Reporting & Investigating Abuse-Other Action: Failed to promptly investigate and report injuries, falls, and resident altercations to local SPD office |
| C0252 - Resident Move-In and Eval: Res Evaluation: Failed to ensure resident evaluations were sufficient, accurate, and reflective of care needs |
| C0260 - Service Plan: General: Failed to ensure service plans were person centered, updated quarterly, reflective of needs, and followed for sampled residents |
| C0270 - Change of Condition and Monitoring: Failed to evaluate, develop instructions, and monitor changes of condition to resolution for sampled residents |
| C0280 - Resident Health Services: Failed to ensure timely RN assessments documenting findings, status, and interventions for sampled residents |
| C0303 - Systems: Treatment Orders: Failed to carry out medication and treatment orders as prescribed for sampled residents |
| C0310 - Systems: Medication Administration: Failed to ensure MARs were accurate, included resident-specific parameters, and were initialed by administering staff |
| C0325 - Systems: Self-Administration of Meds: Failed to ensure quarterly evaluations for residents self-administering medications |
| C0330 - Systems: Psychotropic Medication: Failed to document non-pharmacological interventions prior to administration of psychotropic meds |
| C0360 - Staffing Requirements and Training: Staffing: Failed to ensure sufficient direct care staff to meet resident needs and timely call light responses |
| C0361 - Acuity-Based Staffing Tool: Failed to update ABST to determine appropriate staffing levels addressing all required ADLs |
| C0370 - Staffing Requirements and Training – Pre-Serv: Failed to document required pre-service orientation and infectious disease training for new and long-term staff |
| C0372 - Training Within 30 Days: Direct Care Staff: Failed to verify and document competency of newly hired direct care staff within 30 days |
| C0374 - Annual and Biennial Inservice For All Staff: Failed to ensure required annual dementia in-service training for long-term direct care staff |
| C0420 - Fire and Life Safety: Safety: Failed to document all required components on fire drill records |
| C0422 - Fire and Life Safety: Training For Residents: Failed to ensure residents received fire and life safety instruction 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 |
| C0613 - General Building: Doors-Walls, Cleanable: Failed to keep interior and exterior materials and equipment clean and in good repair |
| C0622 - Common Use Areas: Social: Failed to ensure stove in activity room had safety device and mailboxes met USPS requirements |
| C0640 - Heating and Ventilation: Failed to ensure heating elements did not exceed 120 degrees F in areas subject to incidental contact |
Report Facts
Inspections on page: 4
Total Surveys: 4
Total Deficiencies: 26
Abuse Violations: 0
Licensing Violations: 20
Notices: 1
Licensed Beds: 82
Resident Census: 68
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Executive Director | Named in multiple findings related to medication errors, staffing, and administrative oversight |
| Staff 2 | Health & Wellness Director | Named in multiple findings related to medication errors, staffing, and administrative oversight |
| Staff 3 | District Director of Operations | Named in multiple findings related to medication errors, staffing, and administrative oversight |
| Staff 6 | Med Tech / Server / Maintenance Manager | Named in medication error and kitchen sanitation findings |
| Staff 7 | Resident Care Coordinator / Business Office Manager | Named in medication administration and training findings |
| Staff 10 | Caregiver | Named in resident care and dignity findings |
| Staff 11 | Caregiver | Named in resident care and dignity findings |
| Staff 13 | Medication Technician | Named in staffing and training findings |
| Staff 20 | District Director of Clinical Operations | Named in multiple findings related to staffing and training |
| Staff 23 | Executive Director | Named in medication and staffing tool findings |
| Staff 24 | Health and Wellness Director | Named in medication and staffing tool findings |
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