Deficiencies per Year
24
18
12
6
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Complaint Investigation
Capacity: 80
Deficiencies: 22
Apr 28, 2025
Visit Reason
State-compiled facility profile showing 5 inspections from 2023-01 to 2025-04 with detailed deficiency history and enforcement actions.
Findings
Across multiple inspections, the facility exhibited numerous deficiencies including failures in kitchen sanitation, resident health services, medication administration, staff training, and documentation. Several deficiencies were repeat citations, and some posed risks of serious harm to residents. Plans of correction were requested and partially implemented.
Complaint Details
Complaint investigation conducted on 2025-02-27 identified deficiencies related to compliance with Oregon Administrative Rules 411 Division 54 and 57. The facility was found not corrected at the time of visit.
Deficiencies (22)
| Description |
|---|
| C0010 - Licensing Complaint Investigation: Findings from complaint investigation conducted 02/27/25 identifying deficiencies in compliance with Oregon Administrative Rules 411 Division 54 and 57. |
| C0240 - Resident Services Meals, Food Sanitation Rule: Facility failed to maintain kitchen cleanliness, proper food handling, and hygienic practices in accordance with OAR 333-150-0000 Food Sanitation Rules. |
| C0455 - Inspections and Investigation: Insp Interval: Facility failed to ensure relicensure survey plan of correction was implemented and satisfied the Department. |
| C0231 - Reporting & Investigating Abuse-Other Action: Facility failed to report and investigate injuries of unknown cause as suspected abuse for sampled residents. |
| C0252 - Resident Move-In and Eval: Res Evaluation: Facility failed to ensure move-in evaluations addressed all required elements and were updated as needed. |
| C0260 - Service Plan: General: Facility failed to ensure resident service plans were reflective of current care needs, updated timely, and provided clear direction to staff. |
| C0270 - Change of Condition and Monitoring: Facility failed to evaluate, document, communicate, and monitor changes of condition for sampled residents. |
| C0280 - Resident Health Services: Facility failed to ensure RN assessments were completed for significant changes of condition for sampled residents. |
| C0282 - Rn Delegation and Teaching: Facility failed to ensure delegation and supervision of nursing tasks were completed according to OSBN Division 47 rules. |
| C0290 - Res Hlth Srvc: On- and Off-Site Health Srvc: Facility failed to ensure outside service providers left written documentation and coordinated care with facility staff. |
| C0303 - Systems: Treatment Orders: Facility failed to ensure medication and treatment orders were carried out as prescribed and had signed physician orders. |
| C0305 - Systems: Resident Right to Refuse: Facility failed to notify physician or practitioner when residents refused medication or treatment orders. |
| C0310 - Systems: Medication Administration: Facility failed to ensure MARs included reasons for use, medication specific instructions, and resident-specific parameters for PRN meds. |
| C0325 - Systems: Self-Administration of Meds: Facility failed to ensure residents self-administering meds had physician orders and quarterly evaluations. |
| C0361 - Acuity-Based Staffing Tool: Facility failed to implement an acuity-based staffing tool meeting regulatory requirements. |
| C0370 - Staffing Requirements and Training – Pre-Serv: Facility failed to ensure newly hired staff completed required pre-service orientation and dementia training. |
| C0372 - Training Within 30 Days: Direct Care Staff: Facility failed to ensure newly hired direct care staff demonstrated competency within 30 days of hire. |
| C0374 - Annual and Biennial Inservice For All Staff: Facility failed to ensure veteran direct care staff completed required annual in-service training including dementia care. |
| C0420 - Fire and Life Safety: Safety: Facility failed to conduct and document fire drills and life safety instruction as required by Oregon Fire Code. |
| C0422 - Fire and Life Safety: Training For Residents: Facility failed to ensure residents received annual fire and life safety instruction. |
| C0455 - Inspections and Investigation: Insp Interval: Facility failed to ensure re-licensure and change of management plans of correction were implemented and satisfied the Department. |
| C0630 - House Keeping and Sanitation: Facility failed to ensure washing machines met minimum rinse temperature or used chemical disinfectant for soiled linens. |
Report Facts
Inspections on page: 5
Total deficiencies: 21
Total licensing violations: 20
Notices: 2
Licensed beds: 80
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Executive Director | Named in multiple findings and discussions regarding deficiencies and plans of correction |
| Staff 2 | Associate Executive Director | Named in multiple findings and discussions regarding deficiencies and plans of correction |
| Staff 3 | Wellness Nurse LPN | Named in findings related to resident care and medication administration |
| Staff 8 | Dietary Manager | Named in kitchen sanitation deficiency discussions |
| Staff 9 | Director of Health Services / RN | Named in findings related to RN assessments and delegation |
| Staff 16 | Health Services Technician | Named in staff training and resident care findings |
| Staff 19 | Medication Technician | Named in medication administration and refusal findings |
| Staff 24 | Caregiver | Named in housekeeping and sanitation findings |
| Staff 37 | Associate Executive Director | Named in service plan and staff training findings |
| Staff 38 | Registered Nurse | Named in RN assessment findings |
| Staff 39 | Memory Care Community Director | Named in service plan and staff training findings |
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