Inspection Report
Kitchen
Capacity: 122
Deficiencies: 46
Oct 17, 2025
Visit Reason
State-compiled facility profile showing 7 inspections from 2022-2025 with deficiency history and enforcement notices
Findings
Across multiple inspections from 2022 to 2025, the facility exhibited numerous deficiencies including failure to maintain kitchen sanitation and repair, inadequate resident care plans, insufficient staffing, incomplete medication administration and treatment records, lack of proper infection control, and failure to investigate and report incidents. Several deficiencies were repeated over multiple visits with partial or no correction noted.
Complaint Details
Complaint investigations conducted on 12/13/2023, 4/19/2023, and other dates documented multiple deficiencies including failure to update service plans, insufficient staffing, and licensing complaints.
Deficiencies (46)
| Description |
|---|
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to maintain kitchen in good repair and sanitary manner; multiple areas with food spills, dirt, grease, damaged equipment, and improper food storage |
| Z0142 - Administration Compliance: Failed to follow licensing rules for Residential Care and Assisted Living Facilities |
| C0300 - Systems: Medications and Treatments: Failed to ensure safe medication and treatment system and adequate professional oversight |
| C0150 - Facility Administration: Operation: Failed to provide effective oversight to ensure quality and care of services rendered |
| C0160 - Reasonable Precautions: Failed to exercise reasonable precautions against conditions threatening health and safety of residents, including improper diet textures causing choking risk and unsafe storage of razors |
| C0200 - Resident Rights and Protection - General: Failed to ensure residents treated with dignity and respect and had homelike environment; e.g., lack of meal assistance and shower access |
| C0231 - Reporting & Investigating Abuse-Other Action: Failed to promptly investigate and report incidents of abuse and neglect to local SPD office |
| C0242 - Resident Services: Activities: Failed to provide daily program of social and recreational activities based on resident needs |
| C0252 - Resident Move-In and Eval: Res Evaluation: Failed to ensure move-in evaluations contained all required elements and were updated quarterly or with condition changes |
| C0260 - Service Plan: General: Failed to ensure service plans were reflective of residents' needs, provided clear direction, and were implemented |
| C0270 - Change of Condition and Monitoring: Failed to evaluate, document, and monitor short-term and significant changes of condition for residents |
| C0280 - Resident Health Services: Failed to ensure RN assessments were completed timely documenting findings, resident status, and interventions for significant changes |
| C0282 - Rn Delegation and Teaching: Failed to ensure delegation and supervision of nursing tasks were completed and documented per Oregon State Board of Nursing rules |
| C0290 - Res Hlth Srvc: On- and Off-Site Health Srvc: Failed to ensure outside provider information and interventions were communicated and service plans adjusted |
| C0295 - Infection Prevention & Control: Failed to have a trained Infection Control Specialist and protocols to prevent communicable diseases |
| C0303 - Systems: Treatment Orders: Failed to follow physician orders and administer medications as ordered; missing signed orders |
| C0304 - Systems: Medication and Treatment Review: Failed to ensure pharmacist or RN reviewed medications and treatments at least every 90 days |
| C0310 - Systems: Medication Administration: Failed to maintain accurate medication administration records with reasons for use and parameters |
| C0315 - Systems: Treatment Administration: Failed to document treatments administered on treatment administration records |
| C0330 - Systems: Psychotropic Medication: Failed to ensure PRN psychotropic medications had resident-specific parameters and documented non-drug interventions |
| C0360 - Staffing Requirements and Training: Staffing: Failed to have sufficient number of caregivers to meet scheduled and unscheduled resident needs |
| C0361 - Acuity-Based Staffing Tool: Failed to update and staff according to acuity-based staffing tool requirements |
| C0372 - Training Within 30 Days: Direct Care Staff: Failed to ensure newly hired staff completed required First Aid and abdominal thrust training within 30 days |
| C0420 - Fire and Life Safety: Safety: Failed to conduct fire drills every other month on alternating shifts with required documentation and provide fire safety training |
| C0422 - Fire and Life Safety: Training For Residents: Failed to instruct residents on fire safety on admission and annually with documentation |
| C0455 - Inspections and Investigation: Insp Interval: Failed to ensure plan of correction was implemented and satisfied the Department |
| C0510 - General Building Exterior: Failed to maintain facility grounds free of refuse and exterior pathways in good repair |
| C0513 - Doors, Walls, Elevators, Odors: Failed to keep interior materials and surfaces clean and in good repair |
| C0555 - Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable: Failed to provide reliable emergency call system and exit door alarms |
| Z0155 - Staff Training Requirements: Failed to ensure newly hired staff completed required orientation, dementia training, and competency evaluations timely |
| Z0162 - Compliance With Rules Health Care: Failed to follow health care rules for Residential Care and Assisted Living Facilities |
| Z0163 - Nutrition and Hydration: Failed to develop individualized nutrition and hydration plans for residents |
| Z0164 - Activities: Failed to provide meaningful individualized activities and develop individualized activity plans |
| C0010 - Licensing Complaint Investigation: Findings documented for complaint investigation |
| C0152 - Facility Administration: Required Postings: Failed to have current staffing plan posted |
| C0260 - Service Plan: General: Failed to have service plans readily available to staff |
| C0360 - Staffing Requirements and Training: Staffing: Failed to provide qualified awake direct care staff sufficient in number |
| C0361 - Acuity-Based Staffing Tool: Failed to adopt and implement acuity-based staffing tool |
| C0010 - Licensing Complaint Investigation: Findings documented for complaint investigation |
| C0260 - Service Plan: General: Failed to update service plans quarterly |
| C0360 - Staffing Requirements and Training: Staffing: Failed to provide sufficient qualified awake direct care staff |
| C0361 - Acuity-Based Staffing Tool: Failed to fully implement and update acuity-based staffing tool |
| C0000 - Comment: Findings documented for kitchen inspection |
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to maintain kitchen in good repair and sanitary manner; repeated deficiencies over multiple visits |
| C0370 - Staffing Requirements and Training – Pre-Serv: Failed to ensure food handler's certificate for food preparer |
| C0455 - Inspections and Investigation: Insp Interval: Failed to ensure re-licensure survey plan of correction was implemented and satisfied the Department |
Report Facts
Inspections on page: 7
Total deficiencies: 48
Total surveys: 7
Licensing violations: 10
Notices: 3
Licensed beds: 122
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Executive Director | Named in multiple findings including kitchen sanitation, medication oversight, infection control, and staffing deficiencies |
| Staff 2 | Health Services Director / LPN | Named in multiple findings related to medication administration, resident care plans, infection control, and staffing |
| Staff 3 | RN | Named in findings related to medication administration, delegation, and resident assessments |
| Staff 18 | Business Office Manager | Named in findings related to staff training and staffing issues |
| Staff 27 | Resident Care Coordinator | Named in findings related to resident care plans and incident reporting |
| Staff 28 | Resident Care Coordinator | Named in treatment administration documentation findings |
| Staff 37 | Activities Assistant | Named in findings related to failure to provide adequate activities |
| Staff 43 | Regional RN | Named in delegation and teaching findings |
| Staff 45 | Maintenance Director | Named in findings related to exterior pathway maintenance |
| Staff 48 | Medication Technician | Named in delegation and medication administration findings |
| Staff 49 | Medication Technician | Named in delegation and medication administration findings |
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