Inspection Report
Kitchen
Capacity: 117
Deficiencies: 19
Oct 13, 2025
Visit Reason
State-compiled facility profile showing 5 inspections from 2022-2025 with deficiency history and licensing violations.
Findings
Across multiple inspections, the facility exhibited repeated deficiencies related to kitchen sanitation, administration compliance, staffing tools, resident care plans, infection control, medication management, staff training, and fire and life safety. Several deficiencies were not corrected at revisit, indicating ongoing compliance challenges.
Complaint Details
Inspection SW48 on 2024-08-05 was a complaint investigation related to licensure complaint involving failure to implement Acuity Based Staffing Tool.
Deficiencies (19)
| Description |
|---|
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to maintain kitchen in good repair and sanitary manner, including food spills, equipment repair needs, improper food storage, and improper food textures served. |
| Z0142 - Administration Compliance: Failed to follow licensing rules for Residential Care and Assisted Living Facilities, referencing related deficiencies. |
| C0361 - Acuity-Based Staffing Tool: Failed to fully implement and update an Acuity Based Staffing Tool as required. |
| C0000 - Comment: Documented findings of kitchen inspection and revisit showing substantial compliance at revisit. |
| C0160 - Reasonable Precautions: Failed to exercise reasonable precautions against conditions threatening resident health and safety, including improper glove use and infection control. |
| C0252 - Resident Move-In and Eval: Res Evaluation: Failed to ensure move-in evaluations addressed all required elements prior to admission. |
| C0260 - Service Plan: General: Failed to ensure service plans were reflective of residents' needs and provided clear direction to staff. |
| C0270 - Change of Condition and Monitoring: Failed to ensure residents with short-term changes were evaluated, interventions developed and monitored. |
| C0280 - Resident Health Services: Failed to ensure RN assessments were completed timely for significant changes of condition related to weight loss. |
| C0295 - Infection Prevention & Control: Failed to ensure designated Infection Control Specialist completed required training. |
| C0302 - Systems: Tracking Control Substances: Failed to ensure controlled substances were logged and administered accurately. |
| C0330 - Systems: Psychotropic Medication: Failed to ensure reasons for PRN psychotropic medication use were documented and non-pharmacological interventions attempted. |
| C0372 - Training Within 30 Days: Direct Care Staff: Failed to ensure newly hired direct care staff demonstrated competency within 30 days of hire. |
| C0420 - Fire and Life Safety: Safety: Failed to conduct fire drills according to Oregon Fire Code with required documentation. |
| C0422 - Fire and Life Safety: Training For Residents: Failed to ensure residents were re-instructed on fire and life safety procedures annually. |
| C0555 - Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable: Failed to ensure exit doors were equipped with operational alarms to alert staff when residents exited. |
| Z0155 - Staff Training Requirements: Failed to ensure newly hired direct care staff completed required pre-service orientation and dementia training within timelines. |
| Z0162 - Compliance With Rules Health Care: Failed to provide health care services in accordance with licensing rules, referencing multiple citations. |
| Z0176 - Resident Rooms: Failed to ensure residents were not locked out of their rooms and visitors could access residents when requested. |
Report Facts
Inspections on page: 5
Total deficiencies: 22
Licensing violations: 9
Licensed beds: 117
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Administrator | Named in multiple findings including Acuity Based Staffing Tool, Infection Prevention, and Resident Care deficiencies |
| Staff 2 | Director of Nursing | Named in multiple findings including Acuity Based Staffing Tool, Resident Care, and Infection Prevention |
| Staff 3 | Compliance Specialist | Named in multiple findings including Acuity Based Staffing Tool and Resident Care |
| Staff 5 | Memory Care Coordinator | Named in multiple findings including Resident Care and Staff Training |
| Staff 9 | Facility Compliance Specialist | Named in Acuity Based Staffing Tool finding |
| Staff 10 | Executive Director | Named in Acuity Based Staffing Tool finding |
| Staff 27 | Environmental Services Director | Named in Infection Prevention & Control deficiency |
| Staff 28 | Staffing Development Coordinator | Named in Staff Training deficiencies |
Loading inspection reports...
