Inspection Report
Kitchen
Census: 54
Capacity: 59
Deficiencies: 32
Oct 23, 2025
Visit Reason
State-compiled facility profile showing 7 inspections from 2021 to 2025 with deficiency history and enforcement actions
Findings
Across multiple inspections from 2021 to 2025, Emerald Gardens was found to have numerous deficiencies including failures in infection prevention and control, staffing sufficiency, medication administration, service plan accuracy, food sanitation, and staff training. Many deficiencies were repeated or not corrected at follow-up visits.
Complaint Details
Complaint investigation conducted on 2023-02-02 identified deficiencies related to compliance with state and local laws, including failure to implement effective methods of responding to and resolving resident complaints.
Deficiencies (32)
| Description |
|---|
| C0240 - Resident Services Meals, Food Sanitation Rule: Facility failed to maintain kitchen sanitation and food preparation in accordance with Food Sanitation Rules |
| Z0142 - Administration Compliance: Facility failed to follow licensing rules for Residential Care and Assisted Living Facilities |
| C0360 - Staffing Requirements and Training: Staffing: Facility failed to ensure sufficient direct care staff to meet residents' scheduled and unscheduled needs and fire safety standards |
| C0361 - Acuity-Based Staffing Tool: Facility failed to accurately capture care time and care elements in ABST for sampled residents |
| C0363 - Acuity Based Staffing Tool - Updates & Staffing Plan: Facility failed to update and review ABST evaluations timely and failed to staff per posted staffing plan |
| H1510 - Individual Rights Settings: Privacy, Dignity: Facility failed to ensure residents' privacy and dignity during personal ADL care |
| C0295 - Infection Prevention & Control: Facility failed to maintain infection prevention protocols for sampled and unsampled residents |
| C0330 - Systems: Psychotropic Medication: Facility failed to document non-pharmacological interventions prior to PRN psychotropic medication administration |
| C0000 - Comment: Kitchen inspections documented with findings and compliance status |
| C0010 - Licensing Complaint Investigation: Findings from complaint investigation related to compliance with state and local laws |
| C0154 - Facility Administration: Policy & Procedure: Failed to implement effective methods of responding to and resolving resident complaints |
| C0160 - Reasonable Precautions: Failed to exercise reasonable precautions and infection control for sampled resident |
| C0231 - Reporting & Investigating Abuse-Other Action: Failed to report injuries of unknown cause and conduct immediate investigations |
| C0242 - Resident Services: Activities: Failed to provide activity program based on individual and group interests |
| C0260 - Service Plan: General: Service plans not reflective of resident needs and not followed |
| C0262 - Service Plan: Service Planning Team: Service plans not developed by required service planning team |
| C0270 - Change of Condition and Monitoring: Failed to evaluate, monitor, and implement interventions for changes of condition |
| C0280 - Resident Health Services: Failed to ensure outside service providers' recommendations were followed and documented |
| C0300 - Systems: Medications and Treatments: Failed to ensure safe medication administration system and professional oversight |
| C0303 - Systems: Treatment Orders: Failed to ensure physician's orders were followed for sampled residents |
| C0310 - Systems: Medication Administration: Failed to maintain accurate medication administration records |
| C0315 - Systems: Treatment Administration: Failed to maintain accurate treatment administration records |
| C0325 - Systems: Self-Administration of Meds: Failed to ensure physician orders and evaluations for self-administered medications |
| C0340 - Restraints and Supportive Devices: Failed to ensure assessment prior to use of supportive device with restraining qualities |
| C0372 - Training Within 30 Days: Direct Care Staff: Failed to ensure newly hired direct care staff completed required training within 30 days |
| C0420 - Fire and Life Safety: Safety: Failed to conduct and document fire drills and life safety instruction per Oregon Fire Code |
| C0422 - Fire and Life Safety: Training For Residents: Failed to provide required fire and life safety training to residents |
| C0455 - Inspections and Investigation: Insp Interval: Failed to ensure relicensure survey plan of correction was implemented and satisfied |
| Z0155 - Staff Training Requirements: Failed to ensure required pre-service orientation, dementia training, competency demonstration, and annual in-service training completed |
| Z0162 - Compliance With Rules Health Care: Failed to provide health care services in accordance with licensing rules |
| Z0163 - Nutrition and Hydration: Failed to develop and follow individualized nutrition and hydration plans for residents |
| Z0164 - Activities: Failed to evaluate and develop individualized activity plans for residents |
Report Facts
Inspections on page: 7
Total deficiencies: 43
Licensing violations: 10
Notices: 2
Licensed beds: 59
Facility census: 54
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| TERESA SMITH | Administrator | Named as facility administrator in facility information |
| Staff 1 | Executive Director | Named in multiple findings and interviews related to deficiencies |
| Staff 2 | Wellness Director | Named in multiple findings and interviews related to deficiencies |
| Staff 3 | Cook or Wellness Nurse/RN | Named in kitchen and medication findings |
| Staff 6 | Operations Specialist | Named in multiple findings and interviews related to deficiencies |
| Staff 9 | Business Office Director | Named in staff training findings |
| Staff 14 | Dining Service Director or MA | Named in kitchen sanitation and staff training findings |
| Staff 15 | Cook or CG | Named in kitchen sanitation and staff training findings |
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