Inspection Reports for Chateau Gardens Memory Care
2669 S Cloverleaf Loop, Springfield, OR 97477, United States, OR, 97477
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Inspection Report
Re-Inspection
Capacity: 28
Deficiencies: 30
Aug 26, 2025
Visit Reason
State-compiled facility profile showing 10 inspections from 2022-2025 with deficiency history and enforcement notices
Findings
Across multiple inspections from 2022 to 2025, the facility exhibited numerous deficiencies including failure to promptly investigate and report abuse, incomplete resident evaluations and service plans, medication administration errors, inadequate staff training, fire and life safety violations, and environmental maintenance issues. Deficiencies were consistently noted as not corrected at follow-up visits.
Complaint Details
Multiple complaint investigations conducted in 2023 and 2024 documented findings of non-compliance with licensing rules including staffing, medication administration, service plans, and acuity based staffing tool implementation.
Deficiencies (30)
| Description |
|---|
| C0231 - Reporting & Investigating Abuse-Other Action: Failed to promptly investigate and report incidents of abuse to local SPD office for multiple residents |
| C0252 - Resident Move-in & Evaluation: Res Evaluation: Failed to ensure move-in evaluations addressed all required elements and were completed prior to admission |
| C0260 - Service Plan: General: Failed to ensure service plans reflected residents' needs, provided clear direction, and were consistently implemented |
| C0270 - Change of Condition and Monitoring: Failed to determine, document, communicate, and monitor interventions for residents with changes of condition |
| C0303 - Systems: Treatment Orders: Failed to carry out medication and treatment orders as prescribed by physician or legally recognized practitioner |
| C0305 - Systems: Resident Right to Refuse: Failed to notify physician when resident refused consent to medication or treatment orders |
| C0310 - Systems: Medication Administration: Failed to maintain accurate MARs including resident-specific parameters for PRN medications |
| C0330 - Systems: Psychotropic Medication: Failed to ensure PRN psychotropic medications had resident-specific parameters and non-drug interventions |
| C0340 - Restraints and Supportive Devices: Failed to ensure devices with restraining qualities were assessed and documented properly |
| C0372 - Training Within 30 Days of Hire – Direct Care Staff: Failed to ensure newly hired direct care staff demonstrated competency in first aid and abdominal thrust within 30 days |
| C0420 - Fire and Life Safety: Safety: Failed to conduct fire drills in accordance with Oregon Fire Code on alternate months and shifts with complete documentation |
| C0422 - Fire and Life Safety: Training for Residents: Failed to instruct residents in fire and life safety procedures within 24 hours of admission and annually |
| C0510 - General Building Exterior: Failed to maintain courtyard surfaces and pathways in good repair |
| C0513 - Doors, Walls, Elevators, Odors: Failed to maintain environment clean and in good repair with multiple areas needing cleaning or repair |
| H1518 - Individual Door Locks: Key Access: Failed to provide all residents with keys to their units |
| Z0142 - Administration Compliance: Failed to comply with licensing rules for Residential Care and Assisted Living Facilities |
| Z0155 - Staff Training Requirements: Failed to ensure newly hired staff completed all pre-service orientation and training requirements before job duties |
| Z0162 - Compliance with Rules Health Care: Failed to provide health care services in accordance with licensing rules |
| Z0163 - Nutrition and Hydration: Failed to develop individualized nutrition and hydration plans included in residents' care plans |
| Z0164 - Activities: Failed to develop individualized activity plans based on activity evaluations for residents |
| Z0173 - Secure Outdoor Recreation Area: Failed to ensure fencing was at least six feet high and furniture was weighted to prevent elopement |
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to maintain kitchen in good repair and sanitary manner per Food Sanitation Rules |
| C0535 - Kitchen and Food Storage: Failed to have a commercial dishwasher as required for facility capacity |
| C0360 - Staffing Requirements and Training: Staffing: Staffing deficiencies noted during complaint investigation |
| C0363 - Acuity Based Staffing Tool - Updates & Plan: Failed to update and implement acuity based staffing tool |
| C0155 - Facility Administration: Records: Failed to develop and implement policy prohibiting falsification of records |
| C0361 - Acuity-Based Staffing Tool: Failed to fully implement and update acuity based staffing tool |
| C0365 - Staffing Rqmt and Training: Training Rqmts: Failed to have training program to determine competency of direct care staff |
| C0282 - Rn Delegation and Teaching: Failed to ensure delegation and supervision of nursing tasks per OSBN rules |
| C0555 - Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable: Failed to ensure exit doors had operational alarms or acceptable alert systems |
Report Facts
Inspections on page: 10
Total deficiencies: 59
Licensing violations: 10
Notices: 3
Licensed beds: 28
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Britney King | Administrator | Named as Interim ED and involved in acknowledgment of findings and plans of correction |
| Staff 1 | Executive Director (ED) | Named in multiple findings and acknowledgments related to abuse reporting, medication administration, and staff training |
| Staff 2 | Resident Care Coordinator (RCC) | Named in multiple findings and acknowledgments related to abuse reporting, medication administration, and staff training |
| Staff 3 | Medication Technician / Resident Care Coordinator | Named in findings related to medication errors and training |
| Staff 4 | Maintenance Director | Named in findings related to fire and life safety and environmental maintenance |
| Staff 6 | Business Office Manager | Named in acknowledgment of staff training documentation deficiencies |
| Staff 7 | Medication Technician | Named in findings related to staff training and competency |
| Staff 9 | Medication Technician / Caregiver | Named in findings related to staff training and competency |
| Staff 10 | Caregiver | Named in findings related to staff training and competency |
| Staff 18 | Housekeeping | Named in findings related to staff training and competency |
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