Inspection Reports for Firwood Gardens
819 NE 122nd Ave, Portland, OR 97230, OR, 97230
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Inspection Report
Capacity: 85
Deficiencies: 30
Oct 13, 2025
Visit Reason
State-compiled facility profile showing 8 inspections from 2022-2025 with deficiency history and enforcement actions
Findings
Across multiple inspections from 2022 to 2025, the facility exhibited repeated deficiencies including failures in infection prevention and control, food sanitation, staffing and training, fire and life safety, resident care planning, and maintenance of building systems. Several deficiencies were not corrected at follow-up visits, indicating ongoing compliance challenges.
Complaint Details
Complaint investigations conducted on 8/11/2022 and 4/24/2025 substantiated failures in staffing, service plan implementation, and compliance with licensing rules. Specific findings included inadequate staffing, failure to update Acuity Based Staffing Tool, and failure to implement resident service plans.
Deficiencies (30)
| Description |
|---|
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to ensure kitchen cleanliness and proper food handling practices |
| Z0142 - Administration Compliance: Failed to comply with licensing rules for Residential Care and Assisted Living Facilities |
| C0295 - Infection Prevention & Control: Failed to establish and maintain infection prevention and control protocols |
| C0370 - Staffing Requirements and Training – Pre-service: Failed to ensure newly hired staff completed required pre-service dementia training |
| C0420 - Fire and Life Safety: Safety: Failed to conduct fire drills according to Oregon Fire Code and provide required fire safety instruction |
| C0455 - Inspections and Investigation: Insp Interval: Failed to ensure re-licensure survey plan of correction was implemented and satisfied the Department |
| C0510 - General Building Exterior: Failed to maintain exterior pathways in good repair, prevent rodent entry, and store garbage in covered containers |
| C0545 - Plumbing Systems: Failed to maintain hot water temperatures within required range in residents’ rooms and common areas |
| Z0155 - Staff Training Requirements: Failed to ensure newly hired staff completed required pre-service dementia training before providing care |
| C0260 - Service Plan: General: Failed to ensure implementation of services according to resident service plans |
| C0360 - Staffing Requirements and Training: Staffing: Failed to maintain adequate staffing and update Acuity Based Staffing Tool (ABST) |
| C0362 - Acuity Based Staffing Tool - Abst Time: Failed to update and maintain ABST reflecting resident care needs |
| C0363 - Acuity Based Staffing Tool - Updates & Plan: Failed to update and maintain ABST reflecting resident care needs |
| C0010 - Licensing Complaint Investigation: Deficiencies identified during complaint investigation related to compliance with state and local laws |
| C0231 - Reporting & Investigating Abuse-Other Action: Failed to thoroughly investigate and report unwitnessed falls and incidents |
| C0270 - Change of Condition and Monitoring: Failed to identify, document, and monitor changes of condition for residents |
| C0303 - Systems: Treatment Orders: Failed to ensure physician orders were documented and carried out as prescribed |
| C0305 - Systems: Resident Right to Refuse: Failed to notify physician when residents refused medication or treatment |
| C0310 - Systems: Medication Administration: Failed to ensure accurate MAR documentation and medication administration |
| C0315 - Systems: Treatment Administration: Failed to ensure accurate treatment administration records |
| C0325 - Systems: Self-Administration of Meds: Failed to evaluate resident's ability to self-administer medications quarterly |
| C0372 - Training Within 30 Days: Direct Care Staff: Failed to ensure newly hired direct care staff demonstrated competency within 30 days |
| C0422 - Fire and Life Safety: Training For Residents: Failed to ensure fire and life safety training included all required components |
| C0513 - Doors, Walls, Elevators, Odors: Failed to maintain interior and exterior materials and surfaces in good repair and clean |
| C0555 - Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable: Failed to ensure functioning exit door alarms and call systems |
| Z0162 - Compliance With Rules Health Care: Failed to provide health care services in accordance with licensing rules |
| Z0163 - Nutrition and Hydration: Failed to ensure individualized nutrition and hydration plans in resident service plans |
| Z0164 - Activities: Failed to ensure individualized activity plans based on resident evaluations |
| Z0176 - Resident Rooms: Failed to ensure residents were not locked out of their rooms |
| C0000 - Comment: Various comments related to inspections and compliance status |
Report Facts
Inspections on page: 8
Total deficiencies: 44
Total surveys: 8
Licensing violations: 10
Notices: 2
Licensed beds: 85
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tatiana Misa | Administrator | Named in multiple findings and interviews acknowledging deficiencies |
| Staff 1 | Administrator / Executive Director / Regional Director | Named in multiple findings and interviews acknowledging deficiencies |
| Staff 2 | Assistant Administrator / Dietary Manager / RN | Named in findings related to infection control and kitchen sanitation |
| Staff 3 | Director of Health Services / RCC | Named in findings related to staffing and medication administration |
| Staff 4 | Maintenance Director | Named in findings related to fire safety and plumbing |
| Staff 6 | Specific Needs Director of Health Services | Named in infection prevention and control findings |
| Staff 9 | Caregiver | Named in complaint investigation findings related to resident care |
| Staff 10 | Resident Care Coordinator | Named in staffing and ABST findings |
| Staff 12 | Caregiver | Named in training deficiencies |
| Staff 13 | Medication Technician | Named in training deficiencies |
| Staff 20 | Caregiver | Named in training deficiencies |
| Staff 21 | Caregiver | Named in training deficiencies |
| Staff 23 | Medication Technician | Named in training deficiencies |
| Staff 25 | Caregiver | Named in infection prevention and control findings |
| Staff 26 | Caregiver | Named in infection prevention and control findings |
| Staff 27 | Operations Support for Specific Needs Contract | Named in infection prevention and control findings |
| Staff 14 | Caregiver | Named in infection prevention and control findings |
| Staff 16 | Caregiver | Named in infection prevention and control findings |
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