Deficiencies (last 4 years)
Deficiencies (over 4 years)
9.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
39% worse than Oregon average
Oregon average: 6.7 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Routine
Deficiencies: 1
Jul 15, 2025
Visit Reason
The inspection was conducted to assess compliance with food safety and sanitary standards in the facility's kitchen.
Findings
The facility failed to properly store food and maintain sanitary conditions in the kitchen, including issues such as improper food labeling, storage of raw chicken above eggs, employees not wearing hairnets, and failure to wash hands, placing residents at risk for foodborne illness.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to properly store food and maintain sanitary conditions in the kitchen, including sticky surfaces, unsealed and undated food items, improper storage of raw chicken above eggs, and employees not wearing hairnets or washing hands. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Date of inspection: Jul 15, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 21 | Cook | Observed not washing hands before donning gloves and confirmed improper food storage and labeling practices |
| Staff 22 | Dietary Manager | Confirmed employees were not wearing hairnets and food safety policies were not followed |
| Staff 1 | Administrator | Stated expectation for staff to follow food safety guidelines and kitchen policies |
Inspection Report
Annual Inspection
Deficiencies: 9
May 12, 2025
Visit Reason
The inspection was conducted as part of a regulatory compliance survey to assess the facility's adherence to health and safety standards, including resident care, environment, medication management, and safety protocols.
Findings
The facility was found deficient in multiple areas including failure to maintain a homelike environment, inadequate personal property protection, untimely abuse investigation reporting, incomplete care plan updates, insufficient assistance with activities of daily living, inadequate foot care, unsafe smoking practices, improper medication storage and expired medications, serving cold food to residents on contact precautions, and non-functional call light systems in resident rooms.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 9
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to ensure a comfortable and homelike environment and reasonable care for protection of resident property from loss or theft for 3 of 8 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to timely report results of abuse investigations to the State Survey Agency for 2 of 4 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to revise, update and implement the care plan for 1 of 5 sampled residents reviewed for accidents, placing resident at risk for unmet nutritional needs. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide necessary services to maintain good grooming and personal hygiene for 1 of 4 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure dependent residents were provided assistance with toenail care for 2 of 4 sampled residents reviewed for foot care. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure supervision and safety interventions were in place to prevent smoking related accidents for 1 of 2 sampled residents reviewed for smoking safety. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to store all medications and biologicals under proper temperature controls and ensure expired medications were identified and disposed of for 1 medication storage room and 1 medication cart. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure food was served at an appetizing temperature for 1 of 2 sampled residents reviewed for food. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure the call light system was functional for 4 of 24 sampled residents reviewed for a functional call light system. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 3
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 4
Expired medications: 3
Temperature: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Administrator | Acknowledged issues with call light system, medication storage, and expectations for meal service and abuse investigation reporting |
| Staff 2 | Director of Nursing Services (DNS) | Responsible for medication refrigerator logs and auditing expired medications |
| Staff 4 | Maintenance Director | Reported call light system issues and cleaning responsibilities |
| Staff 5 | Resident Care Manager (RCM) | Unaware of resident holding smoking items in room |
| Staff 7 | RN Care Manager (RNCM) | Stated Resident 29 required supervision for all ADLs |
| Staff 9 | Activity Director | Responsible for replacing remote controls for televisions |
| Staff 10 | Registered Nurse (RN) | Acknowledged Resident 30 needed podiatry appointment for toenail care |
| Staff 13 | Certified Nursing Assistant (CNA) | Observed residents' television and hygiene issues, and smoking policy enforcement |
| Staff 14 | Certified Nursing Assistant (CNA) | Observed Resident 48's eating supervision needs and food reheating policy |
| Staff 19 | Certified Nursing Assistant (CNA) | Observed Resident 30's toenail care needs and television remote control issue |
| Staff 20 | Certified Nursing Assistant (CNA) | Acknowledged Resident 29's ADL independence and responsibility for toenail care |
| Staff 21 | Regional Nurse Consultant | Verified medication refrigerator temperature and acknowledged expired medications |
| Staff 22 | Central Supply | Verified medication refrigerator temperature |
| Staff 23 | Certified Medication Aide (CMA) | Acknowledged expired naloxone on medication cart |
| Staff 24 | Certified Nursing Assistant (CNA) | Reported broken bed and late abuse investigation submission |
| Staff 25 | Certified Nursing Assistant (CNA) | Reported Resident 29's ADL independence |
| Staff 27 | Certified Nursing Assistant (CNA) | Unaware of call light issues |
| Staff 28 | Certified Nursing Assistant (CNA) | Unaware of call light issues |
| Staff 29 | Certified Nursing Assistant (CNA) | Unaware of call light issues |
| Staff 31 | Certified Nursing Assistant (CNA) | Acknowledged responsibility for toenail care |
| Staff 32 | Certified Nursing Assistant (CNA) | Reported food reheating policy for residents on contact precautions |
| Staff 33 | Dietary Manager | Aware of complaints about cold food and unresolved resolution |
Inspection Report
Complaint Investigation
Deficiencies: 2
May 12, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report results of abuse investigations and failure to provide an ongoing person-centered activities program for residents.
Findings
The facility failed to report results of abuse investigations to the State Survey Agency within the required timeframe for 2 of 4 sampled residents, placing residents at risk for abuse. Additionally, the facility failed to provide an ongoing person-centered activities program for 1 sampled resident, resulting in a decline in psychosocial well-being and diminished quality of life.
Complaint Details
The complaint investigation found that the facility failed to report abuse investigation results within the required timeframe for residents #7 and #19. It also found failure to provide adequate activities for resident #33, including lack of participation in activities and one-to-one visits, and failure to accommodate resident preferences such as music, reading, gardening, and religious visits.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to timely report suspected abuse investigations results to proper authorities for 2 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide an ongoing person-centered activities program for 1 resident, including lack of individualized activities and one-to-one visits. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for abuse reporting: 4
Residents affected by abuse reporting deficiency: 2
Resident reviewed for activities deficiency: 1
Dates of activity task record review: From 2025-04-09 through 2025-05-08
Date abuse incident report: Sep 20, 2024
Date abuse report submitted: 2024-09-27 (one day late)
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 24 | Former Administrator | Mentioned in relation to late submission of abuse investigation |
| Staff 1 | Administrator | Acknowledged late submission of abuse investigation and expectation for timely reporting |
| Staff 18 | CNA | Provided observations about Resident 33's activity participation |
| Staff 19 | CNA | Provided observations about Resident 33's activity participation |
| Staff 13 | CNA | Provided observations about Resident 33's activity participation |
| Staff 9 | Activity Director | Discussed Resident 33's activity program and lack of individualized visits |
| Staff 2 | DNS | Expected individualized activity program including one-to-one visits for Resident 33 |
Inspection Report
Complaint Investigation
Deficiencies: 1
Feb 6, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to implement care plan interventions to prevent elopement for a high-risk resident.
Findings
The facility failed to implement care plan interventions to prevent elopement for Resident 1, who was identified as high risk and had multiple unwitnessed exits from the facility, resulting in potential harm. Staff acknowledged lack of awareness and failure to provide required supervision.
Complaint Details
The complaint investigation found that Resident 1, admitted in 2/2024 with significant cognitive impairment, had multiple unwitnessed exits from the facility, was found wandering outside, and staff failed to provide 30-minute checks or timely reporting of the elopement risk.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to implement care plan interventions to prevent elopement for Resident 1. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
BIMS score: 9
Deficiencies cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 5 | CNA | Unaware of Resident 1's elopement risk and failed to provide 30-minute checks. |
| Staff 2 | DNS | Confirmed facility failed to implement care plan interventions. |
| Staff 3 | Clinical Management Specialist | Acknowledged failure to implement care plan interventions. |
Inspection Report
Complaint Investigation
Deficiencies: 1
May 17, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding an alleged abuse incident involving Resident 1 and a staff member (Witness 1) on 05/10/2024.
Findings
The facility substantiated abuse against Resident 1 by Witness 1, who physically grabbed, dragged, and held the resident down on the bed while yelling and taunting. The incident was witnessed by multiple staff members who intervened and escorted Witness 1 out of the building. The resident reported no physical harm but felt emotional impact. The facility implemented a plan of correction including psychosocial monitoring and staff education.
Complaint Details
The complaint investigation found substantiated abuse based on resident and witness statements. The incident involved a physical confrontation where Witness 1 held Resident 1 down on the bed and verbally taunted the resident. The facility investigation confirmed the abuse occurred on 05/10/2024.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to protect residents from all types of abuse including physical and verbal abuse by staff. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled for abuse review: 5
Residents affected: 1
Date of incident: May 10, 2024
Date survey completed: May 17, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Witness 1 | Provider | Named in abuse incident involving Resident 1 |
| Staff 3 | RCM | Witnessed and stopped the altercation |
| Staff 4 | CNA | Witnessed the abuse incident |
| Staff 6 | CNA | Reported no change in resident's psychosocial mood or behavior after incident |
| Staff 1 | Administrator | Verified the incident occurred |
| Staff 2 | DNS | Verified the incident occurred |
Inspection Report
Deficiencies: 3
Apr 26, 2024
Visit Reason
The inspection was conducted to assess compliance with physician orders and the adequacy of medical condition assessments for residents, focusing on weight monitoring and medication administration.
Findings
The facility failed to ensure physician orders were followed and medical conditions were properly assessed for three sampled residents, resulting in risks of worsening health conditions and unmet needs. Specifically, PRN medication orders were not consistently administered, and significant weight changes were not adequately evaluated or addressed.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to follow physician orders for PRN Furosemide administration for Resident 5 despite documented weight gain. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to assess, evaluate, or provide justification for significant weight loss in Resident 1. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to assess or justify significant weight gain in Resident 2 with no documented evaluation. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Weight loss: 43.9
Weight gain: 14.8
Medication dosage: 40
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 2 | Director of Nursing Services (DNS) | Acknowledged expectations for following physician orders and weight monitoring procedures |
Inspection Report
Complaint Investigation
Deficiencies: 1
Apr 2, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure safety interventions to prevent elopement for a resident who left the facility without authorization or proper documentation.
Findings
The facility failed to implement adequate safety measures to prevent elopement for Resident 1, who left the facility on 3/24/24 without informing staff or signing out, stayed out for two days, and was readmitted after hospitalization. The care plan did not reflect interventions related to this behavior, and staff acknowledged gaps in documentation and failure to notify authorities timely.
Complaint Details
The investigation was complaint-related, focusing on Resident 1's unauthorized elopement on 3/24/24. Staff reported the resident left without telling anyone and was missing for two days. The facility did not document the elopement properly, failed to update the care plan with relevant interventions, and delayed police notification. The complaint was substantiated by these findings.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure safety interventions were in place to prevent elopement for Resident 1 who left the facility without authorization or documentation. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Date of resident admission: 202311
Date of elopement: Mar 24, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 9 | Licensed Practical Nurse (LPN) | Reported Resident 1 was out of the facility on 3/24/24 |
| Staff 3 | Certified Nursing Assistant (CNA) | Stated Resident 1 left the facility without telling anyone |
| Staff 6 | Registered Nurse (RN) | Provided wound care to Resident 1 on 3/24/24 and reported previous elopement incident |
| Staff 2 | Director of Nursing Services (DNS) | Instructed night shift nurse to hold off on calling police due to recent behavior change |
| Staff 10 | Assistant Administrator | Acknowledged Resident 1 left facility and expected care plan updates |
| Staff 1 | Administrator | Acknowledged gaps in documentation and failure to notify police timely |
Inspection Report
Annual Inspection
Deficiencies: 7
Dec 4, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with regulatory requirements related to resident care, safety, staffing, medication administration, infection control, and other operational standards.
Findings
The facility was found deficient in multiple areas including failure to accommodate resident needs related to lighting, failure to notify the State Long Term Care Ombudsman of hospitalizations, incomplete dental assessments, untimely response to call lights, medication administration errors exceeding 5%, improper arbitration venue, and inadequate infection prevention and control practices.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 6
Level of Harm - Potential for minimal harm: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to ensure resident needs and preferences related to lighting were accommodated for 2 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure the Office of the State Long Term Care Ombudsman was notified of resident hospitalization for 1 sampled resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to comprehensively assess a resident's dental status for 1 sampled resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure resident call lights were answered timely for 1 sampled resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure residents were free from a medication error rate of five percent or more for 2 sampled residents; medication error rate was eight percent. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure arbitration would be held in a location convenient to both the resident and the facility. | Level of Harm - Potential for minimal harm |
| Failed to adhere to transmission based precautions for 1 sampled resident and failed to process and transport laundry to prevent potential cross contamination. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication administration error rate: 8
Call light response times: 39
Call light response times: 25
Call light response times: 27
Call light response times: 65
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 6 | Maintenance Director | Named in deficiency related to lighting cord length and reporting. |
| Staff 11 | Social Services Director | Named in deficiency related to failure to notify Ombudsman of hospitalization. |
| Staff 1 | Administrator | Named in deficiencies related to Ombudsman notification, call light expectations, and infection control acknowledgment. |
| Staff 13 | RNCM | Named in deficiency related to incomplete dental assessment. |
| Staff 4 | Assistant Administrator | Named in deficiency related to call light response times and arbitration venue. |
| Staff 15 | LPN | Named in medication administration error related to insulin pen use. |
| Staff 14 | CMA | Named in medication administration error and infection control deficiencies. |
| Staff 8 | Regional Nurse Consultant | Named in infection control deficiency acknowledgment. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Oct 5, 2023
Visit Reason
The inspection was conducted due to concerns about delayed call light response times reported by residents and staff, specifically regarding the facility's call light system functionality and timeliness of staff response.
Findings
The facility failed to ensure a working call light system was available in each resident's bathroom and bathing area, resulting in delayed response times. Observations and interviews confirmed call light monitors were inaudible, call light indicators did not activate, and staff did not carry notification devices, causing residents to experience delays of 30 minutes to over an hour for assistance.
Complaint Details
The complaint investigation found substantiated issues with call light response times being frequently delayed, with documented delays ranging from over 20 minutes to over an hour. Staff confirmed the lack of call light notification devices and inaudible monitors contributed to the delays.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure a call light system was adequately equipped to relay resident calls to caregivers, resulting in delayed response times on 2 of 2 hallways reviewed. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Call light response times over 20 minutes: 12
Call light response times over 30 minutes: 13
Call light response times over 40 minutes: 2
Call light response times over 50 minutes: 4
Call light response times over 1 hour: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 14 | CNA | Confirmed call light response times were often delayed due to inability to see or hear call lights |
| Staff 7 | CNA | Stated call light response times were delayed because staff could not hear or see monitors when not nearby |
| Staff 9 | CNA | Confirmed call light notification devices were missing or broken and not replaced |
| Staff 1 | Administrator | Confirmed call light response times were not acceptable and expected response within five minutes |
Inspection Report
Complaint Investigation
Deficiencies: 11
Sep 13, 2022
Visit Reason
The inspection was conducted based on complaints and concerns regarding medication consent, residents' rights to advance directives, bathing assistance, range of motion therapy, RN staffing coverage, medication administration errors, medication security, food safety, therapy services, and staff training.
Findings
The facility was found deficient in multiple areas including failure to obtain informed consent for psychotropic medication, failure to discuss or document advance directives, inadequate bathing assistance for residents, failure to provide ordered therapy services, lack of RN coverage for eight consecutive hours on multiple days, medication administration errors exceeding 5%, unsecured medication carts, improper food storage temperatures and inadequate hand hygiene facilities in the kitchen, and insufficient staff training on abuse prevention and dementia care.
Complaint Details
The visit was complaint-related, triggered by multiple concerns including medication consent, advance directives, bathing care, therapy services, staffing, medication errors, medication security, food safety, and staff training. Substantiation status is not explicitly stated.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 11
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to obtain informed consent prior to administration of a psychotropic medication for 1 of 5 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop and implement policies and procedures regarding residents' rights to formulate advance directives for 4 of 4 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide bathing assistance for 3 of 4 sampled residents reviewed for ADL care. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure residents with limited range of motion received appropriate care and services to maintain their level of functioning for 1 of 2 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure RN coverage for eight consecutive hours per day for 9 of 68 days reviewed for staffing. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure a medication administration error rate of less than 5%, with two errors in 27 opportunities (7.41% error rate). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure medications and biologicals were secured and only accessible to authorized persons; medication carts were left unlocked and unattended. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to store food at appropriate temperature and failed to provide a designated hand hygiene sink with adequate water pressure and temperature in the kitchen. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement therapy orders in a timely manner for 1 of 1 sampled resident reviewed for therapy services. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure staff received annual training on abuse, neglect, exploitation of resident property and dementia management for 9 of 10 randomly selected staff. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to have a system in place to ensure CNA staff received 12 hours of in-service training annually for 4 of 5 randomly selected staff members. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication administration error rate: 7.41
RN coverage missing days: 9
Training hours: 8
Training hours: 10
Training hours: 4
Training hours: 3
Cook refrigerator temperature: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 12 | LPN Resident Care Manager | Interviewed regarding medication consent and therapy order for Resident 19. |
| Staff 31 | Regional Nurse Consultant | Interviewed regarding medication consent, RN coverage, medication errors, medication cart security, and staff training. |
| Staff 6 | Assistant Administrator | Interviewed regarding advance directives policies and procedures. |
| Staff 7 | Shower Aide | Interviewed regarding bathing assistance and shower logs. |
| Staff 11 | CNA | Interviewed regarding bathing documentation and resident refusals. |
| Staff 2 | RNCM | Confirmed bathing care was not provided as scheduled for Resident 36. |
| Staff 8 | LPN | Observed medication administration and medication cart security issues. |
| Staff 34 | CMA | Observed medication administration and medication cart security issues. |
| Staff 15 | LPN | Interviewed regarding medication administration timing. |
| Staff 1 | Administrator | Acknowledged RN coverage issues and staff training deficiencies. |
| Staff 32 | Rehab Director | Confirmed therapy orders for Resident 20 were not completed. |
| Staff 33 | LPN | Acknowledged medication cart security issues. |
| Staff 5 | Cook | Reported cook refrigerator temperature issues and inadequate hand washing sink. |
Loading inspection reports...
