Deficiencies per Year
80
60
40
20
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Capacity: 35
Deficiencies: 59
Nov 12, 2025
Visit Reason
State-compiled facility profile showing 6 inspections from 2021 to 2025 with detailed deficiency history and enforcement actions.
Findings
Across multiple inspections from 2021 to 2025, the facility exhibited numerous deficiencies including failures in facility administration, resident care, medication administration, staff training, fire and life safety, and environmental maintenance. Several repeat citations and unresolved deficiencies were noted, indicating ongoing compliance challenges.
Complaint Details
The 2024 inspection included a complaint investigation related to licensing and licensure complaints with findings of multiple deficiencies including failure to maintain records, provide adequate meals, implement service plans, infection control, medication oversight, staffing, and training.
Deficiencies (59)
| Description |
|---|
| C0150 - Facility Administration: Operation: Failed to provide effective oversight to ensure quality of care and services rendered in the facility. |
| C0152 - Facility Administration: Required Postings: Failed to ensure required postings were in a routinely accessible and conspicuous location to residents and visitors. |
| C0156 - Facility Administration: Quality Improvement: Failed to develop and conduct ongoing quality improvement programs evaluating services, staff performance, resident outcomes, and satisfaction. |
| C0160 - Reasonable Precautions: Failed to exercise reasonable precautions against conditions threatening health, safety, or welfare of residents, including tripping hazards from metal eye hooks. |
| C0231 - Reporting & Investigating Abuse-Other Action: Failed to immediately notify local SPD office of incidents of suspected abuse for sampled residents. |
| C0252 - Resident Move-in & Evaluation: Res Evaluation: Failed to ensure resident move-in evaluations addressed all required elements for sampled resident. |
| C0260 - Service Plan: General: Failed to ensure service plans were implemented for sampled resident. |
| C0282 - RN Delegation and Teaching: Failed to ensure delegation and supervision of nursing care tasks were completed per OSBN Division 47 rules. |
| C0303 - Systems: Treatment Orders: Failed to ensure written, signed physician or legally recognized practitioner orders were carried out as prescribed. |
| C0310 - Systems: Medication Administration: Failed to ensure accurate Medication Administration Records (MARs) including documentation of insulin doses. |
| C0372 - Training Within 30 Days of Hire – Direct Care Staff: Failed to ensure direct care staff had documented evidence of First Aid and abdominal thrust training within 30 days of hire. |
| C0420 - Fire and Life Safety: Safety: Failed to conduct fire drills per Oregon Fire Code and maintain written fire drill records documenting required components. |
| C0422 - Fire and Life Safety: Training for Residents: Failed to instruct residents on fire and life safety procedures within 24 hours of admission and annually with written records. |
| C0435 - Emergency and Disaster Planning: Failed to conduct emergency preparedness drills at least twice a year. |
| 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 ensure exterior grounds were orderly and free of litter or refuse. |
| C0513 - Doors, Walls, Elevators, Odors: Failed to ensure environment was kept clean and in good repair with multiple observed damages and unclean areas. |
| H1517 - Individual Privacy: Own Unit: Failed to ensure residents had privacy in own unit due to lack of locks on shared bathroom doors. |
| H1518 - Individual Door Locks: Key Access: Failed to provide keys to residents for their units. |
| L0152 - Facility Administration: Required Postings: Failed to ensure LGBTQIA2S+ Nondiscrimination Notice was posted in accessible and conspicuous locations. |
| Z0142 - Administration Compliance: Failed to comply with licensing rules for Residential Care and Assisted Living Facilities. |
| Z0155 - Staff Training Requirements: Failed to ensure newly hired direct care staff completed required pre-service orientation and dementia training topics and demonstrated competency within 30 days of hire. |
| 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 were developed and followed for sampled residents. |
| Z0168 - Outside Area: Failed to provide access to secured outdoor space and walkways allowing residents to enter and return without staff assistance. |
| Z0173 - Secure Outdoor Recreation Area: Failed to have a written policy detailing when doors to outdoor recreation area may be locked during nighttime or severe weather. |
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to maintain kitchen in good repair and sanitary manner per Food Sanitation Rules. |
| C0155 - Facility Administration: Records: Failed to ensure resident records were kept for minimum required time and maintained during ownership transfer. |
| C0240 - Resident Services Meals, Food Sanitation Rule (2024 inspection): Failed to provide three daily nutritious meals and maintain kitchen cleanliness and food safety. |
| C0260 - Service Plan: General (2024 inspection): Failed to ensure implementation of service plans for sampled residents. |
| C0295 - Infection Prevention & Control: Failed to designate an Infection Control Specialist and maintain infection control protocols. |
| C0300 - Systems: Medications and Treatments: Failed to ensure adequate professional oversight of medication and treatment administration system. |
| C0303 - Systems: Treatment Orders (2024 inspection): Failed to carry out medication orders as prescribed for multiple residents. |
| C0360 - Staffing Requirements and Training: Staffing: Failed to provide qualified awake direct care staff sufficient to meet resident needs. |
| C0361 - Acuity-Based Staffing Tool: Failed to fully implement an Acuity Based Staffing Tool (ABST). |
| C0374 - Annual and Biennial Inservice For All Staff: Failed to verify direct care staff demonstrated satisfactory performance in assigned duties. |
| C0240 - Resident Services Meals, Food Sanitation Rule (2021 inspection): Failed to ensure kitchen cleanliness and repair. |
| C0155 - Facility Administration: Records (2021 inspection): Failed to maintain complete and accurate resident records and prohibit falsification. |
| C0160 - Reasonable Precautions (2021 inspection): Failed to exercise reasonable precautions against conditions threatening resident health and safety. |
| C0231 - Reporting & Investigating Abuse-Other Action (2021 inspection): Failed to promptly investigate injuries of unknown cause and document investigations. |
| C0260 - Service Plan: General (2021 inspection): Failed to ensure service plans were reflective, updated, and followed for sampled residents. |
| C0262 - Service Plan: Service Planning Team: Failed to ensure service plans were developed by a service planning team including resident and legal representative. |
| C0270 - Change of Condition and Monitoring: Failed to evaluate, develop interventions, and monitor residents with significant changes of condition. |
| C0300 - Systems: Medications and Treatments (2021 inspection): Failed to ensure safe medication and treatment system and adequate oversight. |
| C0303 - Systems: Treatment Orders (2021 inspection): Failed to ensure medication and treatment orders were carried out as prescribed. |
| C0310 - Systems: Medication Administration (2021 inspection): Failed to ensure MARs were accurate and included reasons for use and resident-specific parameters. |
| C0372 - Training Within 30 Days: Direct Care Staff (2021 inspection): Failed to ensure newly hired staff demonstrated competency in First Aid and abdominal thrust within 30 days of hire. |
| C0420 - Fire and Life Safety: Safety (2021 inspection): Failed to conduct and document fire drills and provide fire and life safety training per Oregon Fire Code. |
| C0422 - Fire and Life Safety: Training For Residents (2021 inspection): Failed to ensure residents received fire and life safety training with documentation. |
| C0513 - Doors, Walls, Elevators, Odors (2021 inspection): Failed to maintain environment clean and in good repair with multiple observed damages. |
| C0555 - Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable: Failed to equip exit door with alarm and provide call system connecting resident units to staff pagers. |
| Z0140 - Administration Responsibilities: Failed to provide effective administrative oversight of the Memory Care Community. |
| Z0142 - Administration Compliance (2021 inspection): Failed to comply with licensing rules referencing multiple citations. |
| Z0155 - Staff Training Requirements (2021 inspection): Failed to ensure newly hired staff completed required training and competency demonstration. |
| Z0160 - Resident Services: Failed to ensure residents had diagnosis of dementia requiring secured environment and support for progressive symptoms. |
| Z0162 - Compliance With Rules Health Care (2021 inspection): Failed to provide health care services in accordance with licensing rules referencing multiple citations. |
| Z0163 - Nutrition and Hydration (2021 inspection): Failed to develop and follow individualized nutrition and hydration plans for residents. |
| Z0164 - Activities: Failed to provide meaningful activities and individualized activity plans for residents. |
| Z0168 - Outside Area (2021 inspection): Failed to ensure residents had access to enclosed, secured outdoor area. |
Report Facts
Inspections on page: 6
Total deficiencies: 65
Total surveys: 6
Abuse violations: 0
Licensing violations: 10
Notices: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Executive Director (ED) | Named in multiple findings including facility oversight, fire safety, and administrative compliance |
| Staff 2 | Memory Care Community Administrator (MCC Administrator) | Named in multiple findings including oversight, reporting abuse, fire safety, and plan of correction responsibilities |
| Staff 3 | RN of Delegation and Wellness | Named in delegation and medication administration findings |
| Staff 5 | Business Office Manager (BOM) | Named in staff training and competency findings |
| Staff 13 | Med Tech (MT) | Named in medication administration and staff training findings |
| Staff 16 | Med Tech (MT) | Named in medication administration and MAR documentation findings |
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