Deficiencies per Year
12
9
6
3
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Capacity: 71
Deficiencies: 11
Oct 21, 2024
Visit Reason
State-compiled facility profile showing 10 inspections from 2023-09 to 2024-10 with deficiency history and enforcement violations.
Findings
Across multiple inspections, the facility exhibited deficiencies including failure to maintain a homelike environment, incomplete comprehensive assessments, medication administration errors, inadequate staffing ratios, and failure to report complete COVID-19 data to the National Healthcare Safety Network. Several deficiencies were corrected after initial visits, while others remained uncorrected as of the latest inspection.
Complaint Details
Complaint investigation dated 2024-07-18 found medication administration errors resulting in hospitalization of a resident due to duplicate anticoagulant dosing.
Deficiencies (11)
| Description |
|---|
| F0000 - INITIAL COMMENTS |
| F0584 - Safe/Clean/Comfortable/Homelike Environment: Failed to maintain a homelike environment with window cleanliness for 1 of 1 facility reviewed. |
| F0636 - Comprehensive Assessments & Timing: Failed to comprehensively assess 3 of 7 sampled residents for medications, behavior and mood. |
| F0684 - Quality of Care: Failed to follow physician orders for medication administration and implement bowel care timely for 1 of 5 sampled residents. |
| F0761 - Label/Store Drugs and Biologicals: Failed to ensure medications were labeled with administration instructions for 1 of 5 residents observed. |
| F0842 - Resident Records - Identifiable Information: Failed to ensure records were complete and accurate for 1 of 5 residents reviewed for medications. |
| M0000 - Initial Comments |
| M0183 - Nursing Services: Minimum CNA Staffing: Failed to meet CNA to NA staffing ratio on 13 of 40 days reviewed. |
| M9999 - STATE OF OREGON ADMINISTRATIVE RULES: Refer to multiple deficiencies including F584, F636, F684, F761, F842. |
| F0760 - Residents are Free of Significant Med Errors: Failed to properly administer anticoagulant medication to 1 of 2 sampled residents resulting in hospitalization. |
| F0884 - Reporting - National Health Safety Network: Failed to report complete COVID-19 information to CDC's NHSN during multiple seven-day periods as required by regulation. |
Report Facts
Inspections on page: 10
Total Surveys: 10
Total Deficiencies: 15
Licensing Violations: 10
Abuse Violations: 0
Notices: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Administrator | Named in medication error finding and comprehensive assessment findings |
| Staff 2 | DNS | Named in multiple findings including medication administration, staffing ratios, and quality of care |
| Staff 3 | Social Service Director | Named in comprehensive assessment findings |
| Staff 4 | LPN | Named in medication error and comprehensive assessment findings |
| Staff 6 | CMA | Named in medication labeling deficiency |
| Staff 7 | Consultant Pharmacist | Named in medication labeling deficiency |
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