Inspection Reports for Brookdale Troutdale
1201 SW Cherry Park Road,Troutdale, OR, OR
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Inspection Report
Complaint Investigation
Capacity: 61
Deficiencies: 39
Apr 30, 2025
Visit Reason
State-compiled facility profile showing 7 inspections from 2021 to 2025 with deficiency history and licensing violations.
Findings
Multiple inspections identified numerous deficiencies across various areas including staffing, infection control, resident care, service plans, medication administration, and facility safety. Several deficiencies were repeat citations with some corrected over time, while others remained uncorrected as of the latest inspections.
Complaint Details
Complaint investigations conducted on 3/12/2025 identified deficiencies related to staffing and licensing compliance that were not corrected as of the visit date.
Deficiencies (39)
| Description |
|---|
| C0360 - Staffing Requirements and Training: Staffing: Failure to consistently have qualified awake direct care staff sufficient in number to meet 24-hour scheduled and unscheduled needs of residents. |
| C0010 - Licensing Complaint Investigation: Findings related to compliance with Oregon Administrative Rules during complaint investigations. |
| C0155 - Facility Administration: Records: Failed to ensure complete and accurate records were maintained and not falsified for a sampled resident. |
| C0231 - Reporting & Investigating Abuse-Other Action: Failed to ensure investigations into physical injuries of unknown cause were documented and reported to appropriate authorities. |
| C0243 - Resident Services: Adls: Failed to provide services to assist residents in activities of daily living as required. |
| C0260 - Service Plan: General: Failed to ensure service plans were reflective of residents' current status, provided clear instructions, and were implemented. |
| C0270 - Change of Condition and Monitoring: Failed to ensure short term changes of condition were evaluated, interventions determined and communicated, and conditions monitored until resolution. |
| C0280 - Resident Health Services: Failed to ensure RN assessments were completed for significant changes of condition for sampled residents. |
| C0295 - Infection Prevention & Control: Failed to establish and maintain infection prevention and control protocols related to incontinence care and meal service. |
| C0330 - Systems: Psychotropic Medication: Failed to ensure MAR had resident-specific parameters and non-pharmacological interventions were attempted prior to PRN psychotropic medication administration. |
| C0361 - Acuity-Based Staffing Tool: Failed to implement an acuity-based staffing tool meeting regulatory requirements. |
| C0365 - Staffing Rqmt and Training: Training Rqmts: Failed to maintain documentation of staff competency and training completion. |
| C0420 - Fire and Life Safety: Safety: Failed to conduct unannounced fire drills every other month, maintain complete records, and provide life safety instruction to staff. |
| 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: Failed to ensure locked storage for poisons, chemicals, and toxic materials. |
| C0513 - Doors, Walls, Elevators, Odors: Failed to keep interior surfaces and equipment clean and in good repair. |
| H1511 - Individual Rights Settings Right to Freedom: Technical assistance provided regarding right to freedom from restraints. |
| H1515 - Physical Setting: Individual Accessible: Technical assistance provided regarding physical accessibility of residential settings. |
| H1518 - Individual Door Locks: Key Access: Technical assistance provided regarding key access to individual units. |
| H1521 - Individual Visitors: Any Time: Technical assistance provided regarding residents' rights to visitors at any time. |
| H1580 - Limitations: Threats to Health and Safety: Technical assistance provided regarding individually-based limitations due to health and safety threats. |
| Z0142 - Administration Compliance: Failed to follow licensing rules for Residential Care and Assisted Living Facilities; repeat citations noted. |
| Z0155 - Staff Training Requirements: Failed to ensure newly hired staff completed required pre-service orientation and demonstrated competency; annual training incomplete for some staff. |
| Z0162 - Compliance With Rules Health Care: Failed to provide health care services in accordance with licensing rules; repeat citations noted. |
| Z0163 - Nutrition and Hydration: Failed to develop individualized nutritional plans and daily meal programs based on resident preferences and needs. |
| Z0164 - Activities: Failed to develop individualized activity plans for sampled residents. |
| Z0165 - Behavior: Failed to evaluate and include behavioral symptoms impacting residents in service plans. |
| Z0168 - Outside Area: Failed to ensure residents had access to an enclosed, secured outdoor area. |
| Z0177 - Exit Doors: Failed to ensure emergency exit doors were not locked with keyed locks and outdoor fencing allowed egress. |
| C0160 - Reasonable Precautions: Failed to exercise reasonable precautions against conditions threatening resident health, safety, or welfare related to COVID-19 PPE use. |
| C0231 - Reporting & Investigating Abuse-Other Action: Failed to promptly investigate and report injuries of unknown cause and suspected abuse incidents. |
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to ensure kitchen was clean and in good repair per Food Sanitation Rules. |
| C0260 - Service Plan: General: Failed to ensure service plans were complete, reflective, and provided clear caregiving instructions. |
| C0270 - Change of Condition and Monitoring: Failed to evaluate, document, and monitor short term changes and falls for sampled residents. |
| C0280 - Resident Health Services: Failed to conduct RN assessments for significant changes of condition for sampled residents. |
| C0310 - Systems: Medication Administration: Failed to ensure MARs were accurate and provided clear instructions and parameters for PRN medications. |
| C0330 - Systems: Psychotropic Medication: Failed to ensure PRN psychoactive medications were used only after non-pharmacological interventions were attempted and documented. |
| C0420 - Fire and Life Safety: Safety: Failed to meet requirements for fire and life safety preparedness, instruction, and documentation. |
Report Facts
Inspections on page: 7
Total deficiencies: 42
Licensing violations: 10
Notices: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Executive Director | Named in multiple findings including staffing, record keeping, infection control, and plan of correction acknowledgments. |
| Staff 2 | RN, Health and Wellness Director | Named in multiple findings related to resident assessments, infection control, and plan of correction acknowledgments. |
| Staff 4 | District Director of Operations | Named in findings related to training, infection control, and plan of correction acknowledgments. |
| Staff 5 | District Director of Operations | Named in findings related to abuse investigations, infection control, and plan of correction acknowledgments. |
| Staff 28 | Regional RN | Named in findings related to record keeping, infection control, and plan of correction acknowledgments. |
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