Deficiencies per Year
80
60
40
20
0
Unclassified
Inspection Report
Complaint Investigation
Capacity: 120
Deficiencies: 42
Dec 9, 2025
Visit Reason
State-compiled facility profile showing 10 inspections from 2023-2025 with detailed deficiency history and enforcement actions.
Findings
Across multiple inspections from 2023 to 2025, the facility exhibited numerous deficiencies including failure to provide adequate nursing staff, medication errors, inadequate infection control, failure to follow physician orders, and issues with resident dignity and care. Several deficiencies remained uncorrected at the time of the most recent inspections.
Complaint Details
Multiple inspections were complaint investigations related to licensure complaints and state licensure issues, including allegations of abuse, neglect, medication errors, staffing shortages, and failure to follow physician orders.
Deficiencies (42)
| Description |
|---|
| F0000 - INITIAL COMMENTS |
| F0552 - Right to be Informed/Make Treatment Decisions: Failed to obtain consents for psychotropic medications for multiple residents. |
| F0554 - Resident Self-Admin Meds-Clinically Approp: Failed to ensure safe system for resident self-administration of medication. |
| F0557 - Respect, Dignity/Right to have Prsnl Property: Resident was told to urinate in bed when staff unavailable causing degradation. |
| F0565 - Resident/Family Group and Response: Failed to provide response to Resident Council grievances. |
| F0578 - Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir: Failed to assist resident with formulating advance directive. |
| F0580 - Notify of Changes (Injury/Decline/Room, etc.): Failed to notify physician or resident representative of refusals and changes in condition. |
| F0584 - Safe/Clean/Comfortable/Homelike Environment: Failed to maintain residents' rooms clean, in good repair, and free of clutter. |
| F0585 - Grievances: Failed to provide written grievance resolution or communication for multiple residents. |
| F0600 - Free from Abuse and Neglect: Failed to protect resident from physical abuse by staff resulting in injury. |
| F0609 - Reporting of Alleged Violations: Failed to report timely to State Survey Agency for allegation of elopement. |
| F0610 - Investigate/Prevent/Correct Alleged Violation: Failed to thoroughly investigate injury for resident abuse incident. |
| F0623 - Notice Requirements Before Transfer/Discharge: Failed to notify Ombudsman of resident hospitalizations. |
| F0625 - Notice of Bed Hold Policy Before/Upon Trnsfr: Failed to provide bed hold policy to residents upon hospital transfer. |
| F0657 - Care Plan Timing and Revision: Failed to revise care plans to reflect current resident needs and preferences. |
| F0658 - Services Provided Meet Professional Standards: Staff falsified documentation related to medication administration. |
| F0677 - ADL Care Provided for Dependent Residents: Failed to provide adequate bathing and grooming for dependent residents. |
| F0679 - Activities Meet Interest/Needs Each Resident: Failed to provide meaningful activities for dependent residents. |
| F0680 - Qualifications of Activity Professional: Failed to provide qualified professional to direct activities program. |
| F0684 - Quality of Care: Failed to administer medication as prescribed and failed to answer call lights timely. |
| F0685 - Treatment/Devices to Maintain Hearing/Vision: Failed to follow through on hearing maintenance services. |
| F0686 - Treatment/Svcs to Prevent/Heal Pressure Ulcer: Failed to timely assess and treat pressure ulcer. |
| F0689 - Free of Accident Hazards/Supervision/Devices: Failed to ensure supervision and fall prevention leading to resident injury. |
| F0690 - Bowel/Bladder Incontinence, Catheter, UTI: Failed to provide adequate catheter and incontinent care. |
| F0695 - Respiratory/Tracheostomy Care and Suctioning: Failed to provide respiratory care per physician orders. |
| F0697 - Pain Management: Failed to provide pain medications as ordered. |
| F0698 - Dialysis: Failed to ensure proper dialysis care and monitoring post dialysis. |
| F0725 - Sufficient Nursing Staff: Failed to provide sufficient nursing staff to meet resident needs. |
| F0727 - RN 8 Hrs/7 days/Wk, Full Time DON: Failed to staff RN for 8 consecutive hours daily for multiple days. |
| F0732 - Posted Nurse Staffing Information: Failed to post accurate and complete staffing information. |
| F0745 - Provision of Medically Related Social Service: Failed to obtain specialized physician appointments. |
| F0755 - Pharmacy Srvcs/Procedures/Pharmacist/Records: Failed to obtain resident medication due to pharmacy issues. |
| F0758 - Free from Unnec Psychotropic Meds/PRN Use: Failed to monitor residents on psychotropic medications. |
| F0760 - Residents are Free of Significant Med Errors: Failed to prevent significant medication error. |
| F0812 - Food Procurement,Store/Prepare/Serve-Sanitary: Failed to serve food at appropriate temperatures and maintain sanitary conditions. |
| F0847 - Entering into Binding Arbitration Agreements: Failed to ensure residents understood arbitration agreements. |
| F0880 - Infection Prevention & Control: Failed to ensure proper PPE use and infection control practices. |
| M0000 - Initial Comments |
| M0182 - Nursing Services:Minimum Licensed Nurse Staff: Failed to ensure RN served as charge nurse for 8 consecutive hours. |
| M0183 - Nursing Services: Minimum CNA Staffing: Failed to maintain minimum CNA staffing requirements. |
| M9999 - STATE OF OREGON ADMINISTRATIVE RULES |
| F0919 - Resident Call System: Failed to ensure call light was accessible for resident. |
Report Facts
Inspections on page: 10
Total deficiencies: 50
Total surveys: 10
Licensing violations: 20
Abuse violations: 0
Notices: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 74 | CNA | Named in physical abuse finding involving Resident 82 |
| Staff 20 | CMA | Named in medication error involving Resident 41 |
| Staff 5 | Unit Manager-LPN | Named in multiple findings including wound care and abuse investigation |
| Staff 2 | DNS | Named in multiple findings including infection control and abuse investigation |
| Staff 1 | Administrator | Named in multiple findings and interviews |
| Staff 7 | Activities Director | Named in activities program qualification deficiency |
| Staff 59 | Admissions Coordinator | Named in arbitration agreement deficiency |
| Staff 14 | LPN Resident Care Manager | Named in psychotropic medication monitoring deficiency |
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