Deficiencies per Year
28
21
14
7
0
Unclassified
Inspection Report
Capacity: 70
Deficiencies: 26
Nov 24, 2025
Visit Reason
State-compiled facility profile showing 5 inspections from 2021 to 2025 with deficiency history and enforcement notices
Findings
Across multiple inspections from 2021 to 2025, the facility exhibited numerous deficiencies including failures in food sanitation, administration compliance, resident care plans, change of condition monitoring, medication administration, staffing, fire and life safety, and training. Some deficiencies were corrected over time, but several repeat citations and unresolved issues remain.
Deficiencies (26)
| Description |
|---|
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to maintain kitchen and kitchenettes in good repair and sanitary manner with multiple areas needing cleaning and repair |
| Z0142 - Administration Compliance: Failed to follow licensing rules for Residential Care and Assisted Living Facilities |
| C0000 - Comment: Various comments related to survey findings and compliance |
| C0231 - Reporting & Investigating Abuse-Other Action: Failed to report resident physical altercations and injuries of unknown cause to local SPD office |
| C0260 - Service Plan: General: Service plans not reflective of residents' current status or lacking clear directions to staff |
| C0270 - Change of Condition and Monitoring: Failed to evaluate, communicate, and monitor short term changes of condition for residents |
| C0280 - Resident Health Services: Failed to ensure RN assessments for significant changes of condition were timely and documented |
| C0310 - Systems: Medication Administration: MARs inaccurate and lacking medication specific instructions and parameters for PRN medications |
| C0315 - Systems: Treatment Administration: Failed to keep accurate treatment records for treatments administered |
| C0360 - Staffing Requirements and Training: Staffing: Failed to schedule minimum two direct care staff when two-person assist was required |
| C0361 - Acuity-Based Staffing Tool: Failed to address all evaluated care needs in the acuity-based staffing tool |
| C0372 - Training Within 30 Days: Direct Care Staff: Newly hired staff failed to complete required First Aid and abdominal thrust training within 30 days |
| C0420 - Fire and Life Safety: Safety: Failed to provide and document fire and life safety instruction on alternate months and conduct unannounced fire drills per Oregon Fire Code |
| C0422 - Fire and Life Safety: Training For Residents: Failed to re-instruct residents annually on fire and life safety procedures and keep written records |
| C0455 - Inspections and Investigation: Insp Interval: Failed to ensure re-licensure survey plan of correction was implemented and satisfied the Department |
| C0513 - Doors, Walls, Elevators, Odors: Failed to keep environment in good repair with multiple areas needing repair |
| Z0155 - Staff Training Requirements: Failed to ensure required annual in-service training hours and infectious disease training were completed by staff |
| Z0162 - Compliance With Rules Health Care: Failed to provide health care services in accordance with licensing rules |
| Z0163 - Nutrition and Hydration: Failed to develop individualized nutrition and hydration plans for residents |
| Z0164 - Activities: Failed to evaluate and develop individualized activity plans for residents |
| C0160 - Reasonable Precautions: Failed to exercise reasonable precautions to protect resident safety from hazardous chemicals |
| C0252 - Resident Move-In and Eval: Res Evaluation: Failed to ensure resident move-in evaluations contained all required elements and were updated timely |
| C0290 - Res Hlth Srvc: On- and Off-Site Health Srvc: Failed to coordinate care with outside providers for wound management |
| C0355 - Administrator: Administrator Requirements: Administrator failed to have 20 hours of documented continuing education credits each year |
| Z0165 - Behavior: Failed to coordinate outside consultation for behavioral symptoms impacting resident or others |
| C0545 - Plumbing Systems: Failed to maintain hot water temperatures within 110 to 120 degrees Fahrenheit in resident units and common areas |
Report Facts
Inspections on page: 5
Total deficiencies: 37
Total surveys: 5
Licensing violations: 10
Abuse violations: 0
Notices: 1
Total licensed beds: 70
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Mccoy | Administrator | Named as facility administrator in facility information |
| Staff 1 | Executive Director | Named in multiple findings and interviews related to deficiencies |
| Staff 2 | Operations Specialist | Named in multiple findings and interviews related to deficiencies |
| Staff 3 | RN | Named in findings related to resident health services and assessments |
| Staff 5 | Wellness RN | Named in findings related to resident health services and assessments |
| Staff 6 | Wellness Director | Named in findings related to resident care and training |
| Staff 7 | Wellness Director | Named in findings related to abuse reporting and resident care |
| Staff 8 | Wellness Director | Named in findings related to service plans and medication administration |
| Staff 10 | Housekeeping | Named in findings related to staff training requirements |
| Staff 14 | MT | Named in findings related to staff training requirements |
| Staff 17 | CG | Named in findings related to training within 30 days |
| Staff 18 | MT | Named in findings related to training within 30 days |
| Staff 19 | CG | Named in findings related to training within 30 days |
| Staff 20 | CG | Named in findings related to training within 30 days |
| Staff 21 | CG | Named in findings related to resident care |
| Staff 22 | MT | Named in findings related to training within 30 days |
| Staff 23 | CG | Named in findings related to resident care |
| Staff 26 | Wellness RN | Named in findings related to resident health services and assessments |
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