Deficiencies (last 4 years)
Deficiencies (over 4 years)
21.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
221% worse than Oregon average
Oregon average: 6.7 deficiencies/yearDeficiencies per year
40
30
20
10
0
Inspection Report
Complaint Investigation
Capacity: 80
Deficiencies: 2
Date: Nov 25, 2025
Visit Reason
No deficiencies were identified during this survey.
Findings
No deficiencies were identified during this survey.
Deficiencies (2)
F0000 - INITIAL COMMENTS — No deficiencies identified in this survey.
M0000 - Initial Comments — No deficiencies identified in this survey.
Inspection Report
Complaint Investigation
Capacity: 80
Deficiencies: 10
Date: Nov 24, 2025
Visit Reason
Seven deficiencies were identified including failure to notify responsible parties of changes, insufficient nursing staff, inaccurate posted nurse staffing information, medication errors, inadequate administration oversight, and incomplete facility assessment. All deficiencies were corrected by the revisit.
Findings
Seven deficiencies were identified including failure to notify responsible parties of changes, insufficient nursing staff, inaccurate posted nurse staffing information, medication errors, inadequate administration oversight, and incomplete facility assessment. All deficiencies were corrected by the revisit.
Deficiencies (10)
F0000 - INITIAL COMMENTS — Initial comments noted deficiencies related to resident care and staffing.
F0580 - Notify of Changes (Injury/Decline/Room, etc.) — Facility failed to notify resident's emergency contact of change in condition and hospitalization.
F0725 - Sufficient Nursing Staff — Facility was short staffed resulting in delayed care and unmet resident needs.
F0732 - Posted Nurse Staffing Information — Direct Care Staff Daily Reports were incomplete and inaccurate.
F0760 - Residents are Free of Significant Med Errors — Medication administration errors occurred including late administration of seizure medications.
F0835 - Administration — Facility failed to ensure sufficient staffing and oversight resulting in delayed care and medication errors.
F0838 - Facility Assessment — Facility assessment was not comprehensive and did not accurately address staffing needs and resident acuity.
M0000 - Initial Comments — Initial comments noted deficiencies related to resident care and staffing.
M0183 - Nursing Services: Minimum CNA Staffing — Facility failed to maintain minimum CNA staffing ratios.
M9999 - STATE OF OREGON ADMINISTRATIVE RULES — Refer to multiple cited deficiencies.
Inspection Report
Complaint Investigation
Capacity: 80
Deficiencies: 2
Date: Nov 6, 2025
Visit Reason
No deficiencies were identified during this survey.
Findings
No deficiencies were identified during this survey.
Deficiencies (2)
F0000 - INITIAL COMMENTS — No deficiencies identified in this survey.
M0000 - Initial Comments — No deficiencies identified in this survey.
Inspection Report
Kitchen
Capacity: 50
Deficiencies: 1
Date: Aug 26, 2025
Visit Reason
The facility failed to ensure the kitchen was maintained in accordance with Oregon Food Sanitation Rules. Issues included buildup of dust, grease, food debris, worn spatulas, expired test strips, and lack of alcohol wipes for sanitizing thermometers.
Findings
The facility failed to ensure the kitchen was maintained in accordance with Oregon Food Sanitation Rules. Issues included buildup of dust, grease, food debris, worn spatulas, expired test strips, and lack of alcohol wipes for sanitizing thermometers.
Deficiencies (1)
OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule
Inspection Report
Complaint Investigation
Capacity: 80
Deficiencies: 16
Date: Apr 28, 2025
Visit Reason
Fifteen deficiencies were identified including failure to obtain informed consent for psychotropic medications, failure to assess residents for self-administration of medications, failure to provide bowel care, vision treatment, dialysis care, sufficient nursing staff, nurse aide performance reviews, pharmacy services, medication error rates, laboratory services, infection prevention and control, criminal background checks, minimum CNA staffing, and nurse call system functionality. Some deficiencies were corrected on revisit while others remained uncorrected.
Findings
Fifteen deficiencies were identified including failure to obtain informed consent for psychotropic medications, failure to assess residents for self-administration of medications, failure to provide bowel care, vision treatment, dialysis care, sufficient nursing staff, nurse aide performance reviews, pharmacy services, medication error rates, laboratory services, infection prevention and control, criminal background checks, minimum CNA staffing, and nurse call system functionality. Some deficiencies were corrected on revisit while others remained uncorrected.
Deficiencies (16)
F0000 - INITIAL COMMENTS — Initial comments noted multiple deficiencies related to resident care and facility operations.
F0552 - Right to be Informed/Make Treatment Decisions — Facility failed to obtain informed consent prior to administration of psychotropic medication.
F0554 - Resident Self-Admin Meds-Clinically Approp — Facility failed to assess residents for safe self-administration of medications.
F0684 - Quality of Care — Facility failed to administer bowel care medication and follow physician orders.
F0685 - Treatment/Devices to Maintain Hearing/Vision — Facility failed to ensure residents received vision treatment and follow-up.
F0698 - Dialysis — Facility failed to ensure dialysis care and post-dialysis assessments were completed.
F0725 - Sufficient Nursing Staff — Facility failed to ensure sufficient staffing to meet resident care needs.
F0732 - Posted Nurse Staffing Information — Facility failed to maintain accurate Direct Care Staff Daily Reports.
F0755 - Pharmacy Srvcs/Procedures/Pharmacist/Records — Facility failed to provide timely pharmaceutical services.
F0759 - Free of Medication Error Rts 5 Prcnt or More — Facility failed to maintain medication error rate below 5%.
F0770 - Laboratory Services — Facility failed to obtain lab samples as ordered.
F0880 - Infection Prevention & Control — Facility failed to implement appropriate infection control for C. diff.
M0000 - Initial Comments — Initial comments noted multiple deficiencies related to resident care and facility operations.
M0143 - Employees: Criminal Record Checks — Facility failed to ensure background checks were completed every two years.
M0183 - Nursing Services: Minimum CNA Staffing — Facility failed to maintain minimum CNA staffing ratios.
M9999 - STATE OF OREGON ADMINISTRATIVE RULES — Refer to multiple cited deficiencies.
Inspection Report
Complaint Investigation
Capacity: 80
Deficiencies: 4
Date: Feb 20, 2025
Visit Reason
One deficiency was identified related to failure to notify resident's responsible party in writing prior to room change. The deficiency was not corrected on revisit.
Findings
One deficiency was identified related to failure to notify resident's responsible party in writing prior to room change. The deficiency was not corrected on revisit.
Deficiencies (4)
F0000 - INITIAL COMMENTS — Initial comments noted deficiencies related to resident rights and notification.
F0559 - Choose/Be Notified of Room/Roommate Change — Facility failed to notify resident's responsible party in writing prior to room change.
M0000 - Initial Comments — Initial comments noted deficiencies related to resident rights and notification.
M9999 - STATE OF OREGON ADMINISTRATIVE RULES — Refer to F559.
Inspection Report
Complaint Investigation
Capacity: 80
Deficiencies: 2
Date: Dec 12, 2024
Visit Reason
No deficiencies were identified during this survey.
Findings
No deficiencies were identified during this survey.
Deficiencies (2)
F0000 - INITIAL COMMENTS — No deficiencies identified in this survey.
M0000 - Initial Comments — No deficiencies identified in this survey.
Inspection Report
Complaint Investigation
Capacity: 80
Deficiencies: 6
Date: Oct 31, 2024
Visit Reason
Three deficiencies were identified including failure to protect residents from abuse and neglect, failure to provide professional standard services, and failure to assess and monitor pressure ulcers. Some deficiencies were corrected on revisit while others remained uncorrected.
Findings
Three deficiencies were identified including failure to protect residents from abuse and neglect, failure to provide professional standard services, and failure to assess and monitor pressure ulcers. Some deficiencies were corrected on revisit while others remained uncorrected.
Deficiencies (6)
F0000 - INITIAL COMMENTS — Initial comments noted deficiencies related to abuse, neglect, and care standards.
F0600 - Free from Abuse and Neglect — Facility failed to protect residents from neglect and timely response to call lights.
F0658 - Services Provided Meet Professional Standards — Facility failed to adhere to professional standards related to abuse and neglect.
F0686 - Treatment/Svcs to Prevent/Heal Pressure Ulcer — Facility failed to assess and monitor pressure ulcers consistently.
M0000 - Initial Comments — Initial comments noted deficiencies related to abuse, neglect, and care standards.
M9999 - STATE OF OREGON ADMINISTRATIVE RULES — Refer to multiple cited deficiencies.
Inspection Report
Complaint Investigation
Capacity: 80
Deficiencies: 4
Date: Feb 23, 2024
Visit Reason
One deficiency was identified related to failure to ensure resident environment was free from accident hazards resulting in a resident sustaining third degree burns. The deficiency was not corrected on revisit.
Findings
One deficiency was identified related to failure to ensure resident environment was free from accident hazards resulting in a resident sustaining third degree burns. The deficiency was not corrected on revisit.
Deficiencies (4)
F0000 - INITIAL COMMENTS — Initial comments noted deficiencies related to resident safety and accident hazards.
F0689 - Free of Accident Hazards/Supervision/Devices — Facility failed to prevent resident injury from electric baseboard heater hazard.
M0000 - Initial Comments — Initial comments noted deficiencies related to resident safety and accident hazards.
M9999 - STATE OF OREGON ADMINISTRATIVE RULES — Refer to F689.
Inspection Report
Complaint Investigation
Capacity: 80
Deficiencies: 26
Date: Feb 12, 2024
Visit Reason
Twenty-five deficiencies were identified including failure to complete baseline care plans timely, falsification of resident records, failure to complete discharge summaries, failure to provide ADL care, failure to assess and treat skin conditions, failure to provide catheter care, failure to provide oxygen therapy, failure to ensure dialysis care, failure to maintain sufficient nursing staff, failure to maintain posted nurse staffing information, failure to provide pharmacy services timely, failure to monitor medication error rates, failure to maintain laboratory services, failure to provide palatable food, failure to maintain accurate resident records, failure to complete admission skin assessments, failure to maintain minimum licensed nurse and CNA staffing, failure to maintain nurse call system, and failure to comply with multiple administrative rules. Some deficiencies were corrected on revisit while others remained uncorrected.
Findings
Twenty-five deficiencies were identified including failure to complete baseline care plans timely, falsification of resident records, failure to complete discharge summaries, failure to provide ADL care, failure to assess and treat skin conditions, failure to provide catheter care, failure to provide oxygen therapy, failure to ensure dialysis care, failure to maintain sufficient nursing staff, failure to maintain posted nurse staffing information, failure to provide pharmacy services timely, failure to monitor medication error rates, failure to maintain laboratory services, failure to provide palatable food, failure to maintain accurate resident records, failure to complete admission skin assessments, failure to maintain minimum licensed nurse and CNA staffing, failure to maintain nurse call system, and failure to comply with multiple administrative rules. Some deficiencies were corrected on revisit while others remained uncorrected.
Deficiencies (26)
F0000 - INITIAL COMMENTS — Initial comments noted multiple deficiencies related to resident care and facility operations.
F0655 - Baseline Care Plan — Facility failed to complete baseline care plans within 48 hours of admission.
F0658 - Services Provided Meet Professional Standards — Facility failed to ensure accurate documentation and professional standards of care.
F0661 - Discharge Summary — Facility failed to complete comprehensive discharge summaries.
F0677 - ADL Care Provided for Dependent Residents — Facility failed to provide ADL care to dependent residents.
F0684 - Quality of Care — Facility failed to assess and treat skin conditions and administer medications as ordered.
F0689 - Free of Accident Hazards/Supervision/Devices — Facility failed to follow care plan resulting in resident fall.
F0690 - Bowel/Bladder Incontinence, Catheter, UTI — Facility failed to provide adequate catheter care.
F0694 - Parenteral/IV Fluids — Facility failed to provide care for central venous port.
F0695 - Respiratory/Tracheostomy Care and Suctioning — Facility failed to follow oxygen administration orders and maintain equipment.
F0698 - Dialysis — Facility failed to ensure dialysis treatment and monitoring.
F0725 - Sufficient Nursing Staff — Facility failed to provide sufficient nursing staff to meet resident needs.
F0732 - Posted Nurse Staffing Information — Facility failed to maintain accurate staffing reports.
F0755 - Pharmacy Srvcs/Procedures/Pharmacist/Records — Facility failed to obtain medications timely.
F0756 - Drug Regimen Review, Report Irregular, Act On — Facility failed to respond to pharmacy recommendations timely.
F0757 - Drug Regimen is Free from Unnecessary Drugs — Facility failed to monitor blood glucose for diabetic resident.
F0758 - Free from Unnec Psychotropic Meds/PRN Use — Facility failed to obtain informed consent for psychotropic medications.
F0760 - Residents are Free of Significant Med Errors — Facility failed to follow physician orders for medication administration.
F0761 - Label/Store Drugs and Biologicals — Facility failed to maintain proper medication storage temperatures.
F0770 - Laboratory Services — Facility failed to complete laboratory testing as ordered.
F0804 - Nutritive Value/Appear, Palatable/Prefer Temp — Facility failed to provide palatable and appealing food.
F0842 - Resident Records - Identifiable Information — Facility failed to ensure accurate resident records.
F0727 - RN 8 Hrs/7 days/Wk, Full Time DON — Facility failed to ensure RN coverage for eight consecutive hours daily.
M0182 - Nursing Services:Minimum Licensed Nurse Staff — Facility failed to ensure RN served as charge nurse for eight consecutive hours.
M0183 - Nursing Services: Minimum CNA Staffing — Facility failed to maintain minimum CNA staffing ratios.
M9999 - STATE OF OREGON ADMINISTRATIVE RULES — Refer to multiple cited deficiencies.
Inspection Report
Complaint Investigation
Capacity: 80
Deficiencies: 5
Date: Sep 12, 2023
Visit Reason
Two deficiencies were identified including failure to thoroughly investigate resident-to-resident incidents and failure to ensure resident received care in accordance with professional standards. Some deficiencies were corrected on revisit while others remained uncorrected.
Findings
Two deficiencies were identified including failure to thoroughly investigate resident-to-resident incidents and failure to ensure resident received care in accordance with professional standards. Some deficiencies were corrected on revisit while others remained uncorrected.
Deficiencies (5)
F0000 - INITIAL COMMENTS — Initial comments noted deficiencies related to abuse investigations and resident care.
F0610 - Investigate/Prevent/Correct Alleged Violation — Facility failed to comprehensively investigate resident-to-resident verbal and aggressive incidents.
F0684 - Quality of Care — Facility failed to ensure resident received care in accordance with professional standards.
M0000 - Initial Comments — Initial comments noted deficiencies related to abuse investigations and resident care.
M9999 - STATE OF OREGON ADMINISTRATIVE RULES — Refer to F610 and F684.
Inspection Report
State Licensure, Other
Capacity: 50
Deficiencies: 2
Date: Aug 31, 2023
Visit Reason
Initial kitchen inspection found cleaning deficiencies; re-visit found substantial compliance.
Findings
Initial kitchen inspection found cleaning deficiencies; re-visit found substantial compliance.
Deficiencies (2)
C0000 - Comment
OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule
Inspection Report
Complaint Investigation
Capacity: 50
Deficiencies: 2
Date: Feb 15, 2023
Visit Reason
Complaint investigation identified failure to fully implement and update an Acuity Based Staffing Tool (ABST).
Findings
Complaint investigation identified failure to fully implement and update an Acuity Based Staffing Tool (ABST).
Deficiencies (2)
Licensing Complaint Investigation
Acuity-Based Staffing Tool
Inspection Report
Validation, Re-licensure
Capacity: 50
Deficiencies: 3
Date: Jan 17, 2023
Visit Reason
Deficiencies found related to building maintenance and call system alarms; re-visit found substantial compliance after corrections.
Findings
Deficiencies found related to building maintenance and call system alarms; re-visit found substantial compliance after corrections.
Deficiencies (3)
C0000 - Comment
General Building: Doors-Walls, Cleanable
Call System
Inspection Report
State Licensure, Other
Capacity: 50
Deficiencies: 1
Date: Sep 29, 2022
Visit Reason
Facility was in substantial compliance with food sanitation rules.
Findings
Facility was in substantial compliance with food sanitation rules.
Deficiencies (1)
C0000 - Comment
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