Inspection Reports for Clackamas Heights Senior Living
14550 Southeast Vista Lane, Milwaukie, OR 97267, OR, 97267
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Inspection Report
Complaint Investigation
Census: 12
Capacity: 40
Deficiencies: 27
May 19, 2025
Visit Reason
State-compiled facility profile showing 7 inspections from 2021-2025 with deficiency history and compliance findings.
Findings
Across multiple inspections from 2021 to 2025, the facility exhibited numerous deficiencies including failures in infection control, staff training, food sanitation, fire and life safety, housekeeping, medication administration, and resident care planning. Several deficiencies remained uncorrected as of the latest inspections.
Complaint Details
The report includes complaint investigations conducted on 08/31/2022, 03/24/2023, and 05/19/2025 documenting multiple deficiencies related to facility compliance with state regulations.
Deficiencies (27)
| Description |
|---|
| C0010 - Licensing Complaint Investigation: Findings of on-site investigations documenting compliance issues with OARs 411 Division 54 for Residential Care and Assisted Living Facilities. |
| C0240 - Resident Services Meals, Food Sanitation Rule: Failure to ensure kitchen practices and protocols were in accordance with Food Sanitation Rules OARs 333-150-0000, including unclean kitchen areas and improperly maintained food storage. |
| C0372 - Training Within 30 Days of Hire – Direct Care Staff: Facility failed to ensure caregiving staff demonstrated competency in required areas within 30 days of hire. |
| C0374 - Annual and Biennial Inservice for All Staff: Facility failed to ensure required annual in-service training was completed by direct care and non-direct care staff. |
| C0420 - Fire and Life Safety: Safety: Facility failed to conduct fire drills according to Oregon Fire Code and provide fire and life safety instruction to staff on alternate months. |
| C0422 - Fire and Life Safety: Training for Residents: Facility failed to instruct residents within 24 hours of admission and annually in fire and life safety procedures. |
| C0530 - Housekeeping and Laundry: Facility failed to have capacity for locked storage of chemicals and equipment in on-site laundry facilities used by staff. |
| C0545 - Plumbing Systems: Facility failed to maintain hot water temperatures in residents' units and community bathrooms within 110-120 degrees Fahrenheit. |
| C0555 - Call Sys, Exit Dr Alarm, Phones, TV, or Cable: Facility failed to provide exit door alarms or acceptable systems to alert staff when residents exited the building. |
| C0000 - Comment: Findings of kitchen inspection and re-inspection documenting compliance status with OARs 411-054-0030 and Food Sanitation Rules. |
| C0151 - Facility Administration: Criminal History: Facility failed to submit background check for criminal fitness determination for a staff member. |
| C0243 - Resident Services: ADLs: Facility failed to provide household services essential for resident health and comfort based on needs and preferences. |
| C0252 - Resident Move-In and Eval: Res Evaluation: Facility failed to contact emergency contact and document notification of resident's passing. |
| C0295 - Infection Prevention & Control: Facility failed to maintain infection prevention and control protocols to provide a safe, sanitary environment. |
| C0360 - Staffing Requirements and Training: Staffing: Facility failed to have sufficient staff to meet scheduled and unscheduled resident needs. |
| C0361 - Acuity-Based Staffing Tool: Facility failed to fully implement an Acuity-Based Staffing Tool (ABST) as required. |
| C0513 - Doors, Walls, Elevators, Odors: Facility failed to keep interior materials and surfaces clean and free of unpleasant odors. |
| C0231 - Reporting & Investigating Abuse-Other Action: Facility failed to investigate injuries of unknown cause to rule out abuse or neglect. |
| C0260 - Service Plan: General: Facility failed to ensure service plans were reflective, provided clear direction, and updated quarterly for sampled residents. |
| C0262 - Service Plan: Service Planning Team: Facility failed to ensure service plans were developed by a Service Planning Team including required participants. |
| C0270 - Change of Condition and Monitoring: Facility failed to evaluate, determine interventions, and monitor short-term changes of condition for sampled residents. |
| C0303 - Systems: Treatment Orders: Facility failed to ensure physician orders were carried out as prescribed for sampled residents. |
| C0310 - Systems: Medication Administration: Facility failed to ensure MARs were accurate and provided resident-specific parameters and staff instructions. |
| C0330 - Systems: Psychotropic Medication: Facility failed to ensure PRN psychoactive medications were given only for specific symptoms and after non-drug interventions. |
| C0370 - Staffing Requirements and Training – Pre-Serv: Facility failed to ensure newly-hired direct care staff completed required pre-service orientation topics prior to job start. |
| C0510 - General Building Exterior: Facility failed to maintain exterior pathways in good repair and store garbage in covered containers. |
| C0515 - Resident Units: Facility failed to ensure operable resident windows above second floor had fall prevention design features. |
Report Facts
Inspections on page: 7
Total deficiencies: 35
Total surveys: 7
Licensing violations: 10
Abuse violations: 0
Notices: 0
Licensed beds: 40
Facility census: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Executive Director | Named in multiple findings including infection control, fire safety, training, and staffing deficiencies |
| Staff 3 | Owner / Lead Cook / LPN | Named in findings related to kitchen sanitation, infection control, medication administration, and service plan issues |
| Staff 4 | Owner / Maintenance | Named in findings related to plumbing, fire safety, and environmental maintenance |
| Staff 15 | Nurse | Named in training and fire safety findings |
| Staff 2 | Administrator / Owner / RCC / Maintenance | Named in kitchen sanitation and maintenance related findings |
| Staff 5 | Universal Worker / Medication Technician | Named in exit door alarm deficiency |
| Staff 7 | Medication Aide | Named in training and medication administration deficiencies |
| Staff 11 | Medication Aide | Named in medication administration deficiency |
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