Deficiencies per Year
32
24
16
8
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Capacity: 76
Deficiencies: 30
Dec 12, 2025
Visit Reason
State-compiled facility profile showing 10 inspections from 2023-07 to 2025-12 with deficiency history and enforcement notices
Findings
Across multiple inspections, the facility exhibited numerous deficiencies including failure to ensure sufficient nursing and CNA staffing, medication errors, inadequate discharge summaries, failure to follow physician orders, and issues with resident rights and safety. Several deficiencies were corrected while others remained uncorrected at the time of inspections.
Complaint Details
Multiple inspections included complaint investigations related to resident abuse, medication errors, staffing shortages, and failure to follow physician orders.
Deficiencies (30)
| Description |
|---|
| F0000 - INITIAL COMMENTS |
| F0609 - Reporting of Alleged Violations |
| F0636 - Comprehensive Assessments & Timing |
| F0725 - Sufficient Nursing Staff |
| M0000 - Initial Comments |
| M9999 - STATE OF OREGON ADMINISTRATIVE RULES |
| F0550 - Resident Rights/Exercise of Rights |
| F0552 - Right to be Informed/Make Treatment Decisions |
| F0580 - Notify of Changes (Injury/Decline/Room, etc.) |
| F0583 - Personal Privacy/Confidentiality of Records |
| F0585 - Grievances |
| F0625 - Notice of Bed Hold Policy Before/Upon Trnsfr |
| F0655 - Baseline Care Plan |
| F0660 - Discharge Planning Process |
| F0677 - ADL Care Provided for Dependent Residents |
| F0684 - Quality of Care |
| F0685 - Treatment/Devices to Maintain Hearing/Vision |
| F0686 - Treatment/Svcs to Prevent/Heal Pressure Ulcer |
| F0688 - Increase/Prevent Decrease in ROM/Mobility |
| F0689 - Free of Accident Hazards/Supervision/Devices |
| F0759 - Free of Medication Error Rts 5 Prcnt or More |
| F0761 - Label/Store Drugs and Biologicals |
| F0847 - Entering into Binding Arbitration Agreements |
| M0143 - Employees: Criminal Record Checks |
| M0183 - Nursing Services: Minimum CNA Staffing |
| F0884 - Reporting - National Health Safety Network |
| F0600 - Free from Abuse and Neglect |
| F0744 - Treatment/Service for Dementia |
| F0760 - Residents are Free of Significant Med Errors |
| F0690 - Bowel/Bladder Incontinence, Catheter, UTI |
Report Facts
Inspections on page: 10
Total deficiencies: 33
Licensing violations: 10
Notices: 1
Days with insufficient CNA staffing: 20
Medication error rate: 5.13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 2 | DNS | Named in multiple findings including medication errors, staffing, and discharge summary deficiencies |
| Staff 3 | RNCM | Named in medication error and discharge summary findings |
| Staff 5 | CMA/CNA | Named in medication administration and late medication findings |
| Staff 25 | HR | Named in outing supervision and criminal record check findings |
| Staff 26 | Staffing Coordinator | Named in outing supervision findings |
| Staff 4 | Social Services | Named in findings related to resident rights and discharge planning |
| Staff 12 | CNA | Witness to resident verbal abuse incident |
| Staff 24 | RCM-LPN | Named in multiple findings including abuse and medication errors |
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