Inspection Report Summary
The most recent inspection on July 22, 2025, found deficiencies related to kitchen sanitation, maintenance, and food preparation for puree texture meals, as well as noncompliance with licensing rules for the memory care community. Earlier inspections showed a pattern of issues including medication administration, resident care plans, staffing shortages, and multiple sanitation and maintenance problems, particularly in kitchen areas. Prior reports also noted deficiencies in facility administration, staff training, and safety precautions, with no enforcement actions or fines listed in the available reports. Complaint investigations were unsubstantiated or not noted, and no license suspensions or fines were reported. The inspection history indicates ongoing challenges with food service and staffing, with no clear improvement trend over time.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
11.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
76% worse than Oregon average
Oregon average: 6.7 deficiencies/yearDeficiencies per year
36
27
18
9
0
Inspection Report
Routine
Capacity: 122
Deficiencies: 2
Date: Jul 22, 2025
Visit Reason
Facility failed to maintain kitchen in good repair and sanitary manner; puree texture meals not nutritious or visually appropriate; multiple sanitation and maintenance issues observed; staff lacked knowledge on food safety and meal preparation.
Findings
Facility failed to maintain kitchen in good repair and sanitary manner; puree texture meals not nutritious or visually appropriate; multiple sanitation and maintenance issues observed; staff lacked knowledge on food safety and meal preparation.
Deficiencies (2)
OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule — Multiple sanitation and maintenance issues in kitchen areas
OAR 411-057-0140(2) Administration Compliance — Failure to comply with licensing rules for memory care community
Inspection Report
Complaint Investigation
Capacity: 122
Deficiencies: 1
Date: Mar 28, 2025
Visit Reason
Facility failed to ensure safe medication and treatment systems, proper resident care plans, adequate staffing, and compliance with licensing rules; multiple resident care and safety issues identified.
Findings
Facility failed to ensure safe medication and treatment systems, proper resident care plans, adequate staffing, and compliance with licensing rules; multiple resident care and safety issues identified.
Deficiencies (1)
OAR 411-054-0030 - Systems: Medications and Treatments and related regulations — Multiple deficiencies in medication administration, treatment documentation, resident care plans, and staffing
Inspection Report
Capacity: 122
Deficiencies: 33
Date: Mar 4, 2024
Visit Reason
Change of ownership survey revealed multiple deficiencies in facility administration, resident care, medication systems, staffing, and safety; many deficiencies not corrected at revisits.
Findings
Change of ownership survey revealed multiple deficiencies in facility administration, resident care, medication systems, staffing, and safety; many deficiencies not corrected at revisits.
Deficiencies (33)
OAR 411-054-0030 - Comment and related regulations — Multiple administrative and care deficiencies noted during change of ownership survey
OAR 411-054-0150 - Facility Administration: Operation and related regulations — Deficiencies in oversight and quality assurance
OAR 411-054-0160 - Reasonable Precautions and related regulations — Failure to protect residents from harm and choking risks
OAR 411-054-0200 - Resident Rights and Protection - General and related regulations — Failure to ensure dignity and respect for residents
OAR 411-054-0231 - Reporting & Investigating Abuse-Other Action and related regulations — Failure to promptly investigate and report incidents
OAR 411-054-0242 - Resident Services: Activities and related regulations — Failure to provide adequate social and recreational activities
OAR 411-054-0252 - Resident Move-In and Eval: Res Evaluation and related regulations — Failure to complete comprehensive resident evaluations
OAR 411-054-0260 - Service Plan: General and related regulations — Failure to maintain accurate and reflective service plans
OAR 411-054-0270 - Change of Condition and Monitoring and related regulations — Failure to monitor and document changes of condition
OAR 411-054-0280 - Resident Health Services and related regulations — Failure to complete timely RN assessments for significant changes
OAR 411-054-0282 - RN Delegation and Teaching and related regulations — Failure to properly delegate and document nursing tasks
OAR 411-054-0290 - Resident Health Services: On- and Off-Site Health Services and related regulations — Failure to coordinate and communicate outside provider services
OAR 411-054-0295 - Infection Prevention & Control and related regulations — Failure to have designated infection control specialist and protocols
OAR 411-054-0300 - Systems: Medications and Treatments and related regulations — Failure to ensure safe medication and treatment systems
OAR 411-054-0303 - Systems: Treatment Orders and related regulations — Failure to follow physician orders for medications and treatments
OAR 411-054-0304 - Systems: Medication and Treatment Review and related regulations — Failure to ensure medication reviews by pharmacist or RN
OAR 411-054-0310 - Systems: Medication Administration and related regulations — Failure to maintain accurate medication administration records
OAR 411-054-0315 - Systems: Treatment Administration and related regulations — Failure to document treatments administered
OAR 411-054-0330 - Systems: Psychotropic Medication and related regulations — Failure to provide resident-specific parameters and document non-drug interventions
OAR 411-054-0360 - Staffing Requirements and Training: Staffing and related regulations — Failure to provide sufficient qualified staff
OAR 411-054-0361 - Acuity-Based Staffing Tool and related regulations — Failure to update and staff according to acuity-based staffing tool
OAR 411-054-0372 - Training Within 30 Days: Direct Care Staff and related regulations — Failure to ensure timely training for new staff
OAR 411-054-0420 - Fire and Life Safety: Safety and related regulations — Failure to conduct and document fire drills and training
OAR 411-054-0422 - Fire and Life Safety: Training For Residents and related regulations — Failure to instruct residents on fire safety
OAR 411-054-0455 - Inspections and Investigation: Inspection Interval and related regulations — Failure to implement plan of correction
OAR 411-054-0510 - General Building Exterior and related regulations — Failure to maintain exterior grounds and pathways in good repair
OAR 411-054-0513 - Doors, Walls, Elevators, Odors and related regulations — Failure to maintain interior materials and surfaces in good repair
OAR 411-054-0555 - Call System, Exit Door Alarm, Phones, TV, or Cable and related regulations — Failure to maintain effective call and alarm systems
OAR 411-054-0570 - Administration Compliance and related regulations — Failure to comply with licensing rules (repeat citation)
OAR 411-054-0575 - Staff Training Requirements and related regulations — Failure to complete required training and competency evaluations
OAR 411-054-0580 - Compliance With Rules Health Care and related regulations — Failure to follow health care rules (repeat citation)
OAR 411-054-0585 - Nutrition and Hydration and related regulations — Failure to develop individualized nutrition and hydration plans
OAR 411-054-0590 - Activities and related regulations — Failure to provide meaningful and individualized activities
Inspection Report
Complaint Investigation
Capacity: 122
Deficiencies: 4
Date: Dec 13, 2023
Visit Reason
Facility failed to post current staffing plan, failed to have service plans readily available, and failed to provide sufficient qualified awake direct care staff; multiple deficiencies acknowledged by staff.
Findings
Facility failed to post current staffing plan, failed to have service plans readily available, and failed to provide sufficient qualified awake direct care staff; multiple deficiencies acknowledged by staff.
Deficiencies (4)
OAR 411-054-0152 - Facility Administration: Required Postings — Staffing plan not posted or outdated
OAR 411-054-0260 - Service Plan: General — Service plans not readily available to staff
OAR 411-054-0360 - Staffing Requirements and Training: Staffing — Insufficient qualified awake direct care staff
OAR 411-054-0361 - Acuity-Based Staffing Tool — Failed to adopt and implement acuity-based staffing tool
Inspection Report
Capacity: 122
Deficiencies: 1
Date: May 9, 2023
Visit Reason
Kitchen inspection revealed repeated sanitation and maintenance deficiencies including food contamination risks, equipment damage, and staff hygiene issues; some corrections made at revisits.
Findings
Kitchen inspection revealed repeated sanitation and maintenance deficiencies including food contamination risks, equipment damage, and staff hygiene issues; some corrections made at revisits.
Deficiencies (1)
OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule — Repeated sanitation and maintenance deficiencies in kitchen areas
Inspection Report
Complaint Investigation
Capacity: 122
Deficiencies: 3
Date: Apr 19, 2023
Visit Reason
Facility failed to update service plans quarterly and failed to provide sufficient qualified awake direct care staff; staffing levels below required standards.
Findings
Facility failed to update service plans quarterly and failed to provide sufficient qualified awake direct care staff; staffing levels below required standards.
Deficiencies (3)
OAR 411-054-0260 - Service Plan: General — Service plans not updated quarterly
OAR 411-054-0360 - Staffing Requirements and Training: Staffing — Insufficient qualified awake direct care staff
OAR 411-054-0361 - Acuity-Based Staffing Tool — Failed to fully implement and update acuity-based staffing tool
Inspection Report
Capacity: 122
Deficiencies: 3
Date: Nov 15, 2022
Visit Reason
Kitchen inspection found facility kitchens unclean and not following appropriate storage methods; staff lacked food handler certification; administration compliance issues noted.
Findings
Kitchen inspection found facility kitchens unclean and not following appropriate storage methods; staff lacked food handler certification; administration compliance issues noted.
Deficiencies (3)
OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule — Kitchen sanitation and storage deficiencies
OAR 411-054-0370 - Staffing Requirements and Training: Pre-Service — Staff lacked food handler certification
OAR 411-054-0570 - Administration Compliance — Failed to follow licensing rules
Loading inspection reports...
