Deficiencies per Year
36
27
18
9
0
Unclassified
Inspection Report
Capacity: 78
Deficiencies: 36
Nov 24, 2025
Visit Reason
State-compiled facility profile showing 10 inspections from 2022-2025 with deficiency history and enforcement actions
Findings
Across multiple inspections from 2022 to 2025, the facility exhibited numerous deficiencies including failures in quality of care, staffing shortages, medication administration, resident rights, wound care, and training. Several immediate jeopardy situations were identified, notably related to staffing and resident care, with ongoing corrective plans in place.
Complaint Details
Multiple inspections included complaint investigations related to resident care, staffing, and rights issues as detailed in the inspection findings.
Deficiencies (36)
| Description |
|---|
| F0000 - INITIAL COMMENTS |
| F0684 - Quality of Care: Failures in timely medication administration and bowel care leading to resident harm |
| M0000 - Initial Comments |
| M9999 - STATE OF OREGON ADMINISTRATIVE RULES |
| F0552 - Right to be Informed/Make Treatment Decisions: Failure to obtain consent for psychotropic medications |
| F0623 - Notice Requirements Before Transfer/Discharge: Failure to provide transfer notices and notify Ombudsman |
| F0625 - Notice of Bed Hold Policy Before/Upon Trnsfr: Failure to provide written bed hold policy notice |
| F0641 - Accuracy of Assessments: Failure to complete accurate mental health diagnoses in MDS |
| F0655 - Baseline Care Plan: Failure to implement baseline care plan for resident with pressure injury |
| F0657 - Care Plan Timing and Revision: Failure to revise care plans accurately for resident needs |
| F0658 - Services Provided Meet Professional Standards: Nurse Practitioner exceeded scope of practice |
| F0686 - Treatment/Svcs to Prevent/Heal Pressure Ulcer: Failure to initiate treatment for pressure injuries |
| F0695 - Respiratory/Tracheostomy Care and Suctioning: Failure to maintain oxygen equipment |
| F0758 - Free from Unnec Psychotropic Meds/PRN Use: Failure to identify clinical indications for antipsychotic use |
| F0812 - Food Procurement,Store/Prepare/Serve-Sanitary: Failure to wear hair restraints and properly store food |
| F0947 - Required In-Service Training for Nurse Aides: Failure to provide 12 hours annual training for CNA staff |
| M0143 - Employees: Criminal Record Checks: Failure to complete background check for newly hired staff |
| M0182 - Nursing Services:Minimum Licensed Nurse Staff: Failure to ensure RN charge nurse coverage for 8 consecutive hours |
| M0185 - Bariatric Criteria and Services: Failure to maintain minimum bariatric CNA staffing ratios |
| V0160 - Staffing: Failure to ensure RN coverage for 16 hours daily and sufficient CNA staffing on ventilator unit |
| F0550 - Resident Rights/Exercise of Rights: Failure to protect resident rights to make personal care decisions |
| F0578 - Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir: Failure to provide written info on advance directives |
| F0582 - Medicaid/Medicare Coverage/Liability Notice: Failure to provide Notice of Medicare Non-coverage |
| F0677 - ADL Care Provided for Dependent Residents: Failure to provide ADL care for dependent residents |
| F0679 - Activities Meet Interest/Needs Each Resident: Failure to provide ongoing activities program meeting resident needs |
| F0689 - Free of Accident Hazards/Supervision/Devices: Failure to provide eating assistance and monitor aspiration |
| F0690 - Bowel/Bladder Incontinence, Catheter, UTI: Failure to provide timely incontinence and catheter care |
| F0698 - Dialysis: Failure to assess residents after dialysis |
| F0725 - Sufficient Nursing Staff: Failure to ensure sufficient nursing staff and timely call light response |
| F0730 - Nurse Aide Peform Review-12 hr/yr In-Service: Failure to complete CNA annual performance reviews |
| F0757 - Drug Regimen is Free from Unnecessary Drugs: Failure to ensure residents free from unnecessary bowel medications |
| F0761 - Label/Store Drugs and Biologicals: Failure to store medications and supplies in locked compartments |
| F0825 - Provide/Obtain Specialized Rehab Services: Failure to provide specialized OT services as ordered |
| F0842 - Resident Records - Identifiable Information: Failure to accurately document medical records |
| F0865 - QAPI Prgm/Plan, Disclosure/Good Faith Attmpt: Failure to address staffing concerns in QAPI |
| V0170 - Staff Training: Failure to ensure administrator completed required continuing education for ventilator care |
Report Facts
Inspections on page: 10
Total deficiencies: 48
Total surveys: 10
Licensing violations: 20
Notices: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Administrator | Named in multiple findings related to medication errors, staffing, and training |
| Staff 2 | Director of Nursing Services (DNS) | Named in multiple findings related to medication errors, staffing, and training |
| Staff 3 | Resident Care Manager (RCM) | Named in medication administration and bowel care findings |
| Staff 4 | Nurse Practitioner | Named in findings related to diagnosis and care |
| Staff 5 | RN Care Manager | Named in medication administration and dialysis findings |
| Staff 6 | Certified Occupational Therapist (COTA) | Named in rehabilitation service findings |
| Staff 7 | LPN-Care Manager | Named in psychotropic medication consent and food safety findings |
| Staff 8 | Rehab Director | Named in rehabilitation service findings |
| Staff 9 | Certified Occupational Therapist | Named in rehabilitation service findings |
| Staff 14 | LPN | Named in oxygen equipment maintenance and medication administration findings |
| Staff 16 | LPN and Staffing Coordinator | Named in staffing and bowel care findings |
| Staff 19 | CNA | Named in incontinence care and training findings |
| Staff 20 | CNA | Named in incontinence care and training findings |
| Staff 21 | CNA | Named in training findings |
| Staff 22 | CNA | Named in training findings |
| Staff 23 | CNA | Named in training findings |
| Staff 24 | CNA | Named in staffing and call light response findings |
| Staff 25 | CNA | Named in resident rights findings |
| Staff 26 | Social Service Director | Named in transfer notice and bed hold policy findings |
| Staff 27 | RT Manager | Named in staff training findings |
| Staff 28 | Logistics Specialist for Ventilator Unit | Named in staff training findings |
| Staff 29 | Regional RN | Named in advance directive findings |
| Staff 30 | Medical Records Director and Regional HR Manager | Named in background check and wound care findings |
| Staff 31 | CNA | Named in foot care and aspiration findings |
| Staff 32 | RN and Social Services | Named in aspiration and foot care findings |
| Staff 33 | Cook | Named in food safety findings |
| Staff 34 | Former Nurse Practitioner | Named in diagnosis and medication findings |
| Staff 35 | CMA | Named in medication administration findings |
| Staff 36 | Social Services Director | Named in advance directive findings |
| Staff 37 | Occupational Therapist | Named in rehabilitation service findings |
| Staff 38 | Director of Operations | Named in staffing findings |
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