Deficiencies per Year
80
60
40
20
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Complaint Investigation
Census: 29
Capacity: 142
Deficiencies: 41
May 22, 2025
Visit Reason
State-compiled facility profile showing 6 inspections from 2021 to 2025 with deficiency history and enforcement actions
Findings
Across multiple inspections, the facility was found to have numerous deficiencies including failure to ensure resident rights, inadequate reporting and investigation of abuse, incomplete resident evaluations and service plans, insufficient monitoring of changes of condition, failure to conduct timely RN assessments, poor infection prevention practices, fire and life safety violations, environmental maintenance issues, and staff training deficiencies.
Complaint Details
Survey W4DU dated 2025-02-26 is a complaint investigation with 1 citation (C0010) and 0 deficiencies.
Severity Breakdown
Not Corrected: 44
Deficiencies (41)
| Description | Severity |
|---|---|
| C0010 - Licensing Complaint Investigation: Licensing complaint investigation with 1 citation | — |
| C0200 - Resident Rights and Protection - General: Failed to ensure a homelike environment during meal service by using disposable cups instead of reusable cups | Not Corrected |
| C0231 - Reporting & Investigating Abuse-Other Action: Failed to report injuries of unknown cause to local SPD office as suspected abuse in multiple cases | Not Corrected |
| C0252 - Resident Move-in & Evaluation: Res Evaluation: Failed to ensure move-in evaluations addressed all required elements for sampled residents | Not Corrected |
| C0260 - Service Plan: General: Failed to ensure service plans were completed following quarterly evaluations, reflective of residents' needs, provided clear direction to staff, and were implemented | Not Corrected |
| C0270 - Change of Condition and Monitoring: Failed to monitor changes of condition at least weekly until resolved for sampled residents | Not Corrected |
| C0280 - Resident Health Services: Failed to ensure RN completed timely assessments for significant changes of condition | Not Corrected |
| C0290 - Res Hlth Srvc: On- and Off-Site Health Srvc: Failed to coordinate care with outside providers to ensure continuity of care | Not Corrected |
| C0295 - Infection Prevention & Control: Failed to maintain infection prevention and control protocols during ADL care and meal service | Not Corrected |
| C0303 - Systems: Treatment Orders: Failed to ensure physician orders were carried out as prescribed for nutritional supplements | Not Corrected |
| C0420 - Fire and Life Safety: Safety: Failed to conduct unannounced fire drills according to Oregon Fire Code and provide fire and life safety instruction on alternating months | Not Corrected |
| 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 garbage was stored in covered refuse containers and grounds kept orderly and free of litter | Not Corrected |
| C0513 - Doors, Walls, Elevators, Odors: Failed to maintain environment in clean and good repair including damaged handrails, furniture, walls, and stained chairs | Not Corrected |
| C0530 - Housekeeping and Laundry: Failed to ensure laundry facilities had separate area with closed containers for soiled linens and clothing and proper one-way flow | Not Corrected |
| C0540 - Heating and Ventilation: Failed to ensure temperature of areas surrounding fireplaces did not exceed 120 degrees Fahrenheit | Not Corrected |
| C0545 - Plumbing Systems: Failed to maintain hot water temperature in residents' units within 110 - 120 degrees Fahrenheit | Not Corrected |
| H1517 - Individual Privacy: Own Unit: Failed to provide privacy in units with shared bathrooms lacking locks | Not Corrected |
| Z0142 - Administration Compliance: Failed to comply with licensing rules for Residential Care and Assisted Living Facilities | Not Corrected |
| Z0155 - Staff Training Requirements: Failed to ensure newly hired and long-term staff completed required training and demonstrated competency | Not Corrected |
| Z0162 - Compliance with Rules Health Care: Failed to provide health care services in accordance with licensing rules | Not Corrected |
| Z0164 - Activities: Failed to ensure activity evaluations addressed required components and individualized activity plans were developed | Not Corrected |
| C0000 - Comment: Kitchen inspections documented findings and substantial compliance noted on revisit | — |
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to ensure kitchen practices and protocols complied with Food Sanitation Rules | Not Corrected |
| Z0142 - Administration Compliance: Failed to follow licensing rules, referencing C240 | Not Corrected |
| C0000 - Comment: Kitchen inspections documented findings and substantial compliance noted on revisit | — |
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to ensure food prepared in accordance with Food Sanitation Rules | Not Corrected |
| Z0142 - Administration Compliance: Failed to follow licensing rules, referencing C240 | Not Corrected |
| C0000 - Comment: Kitchen inspection findings documented with substantial compliance on revisit | — |
| C0252 - Resident Move-In and Eval: Res Evaluation: Failed to ensure move-in evaluations addressed all required elements | Not Corrected |
| C0270 - Change of Condition and Monitoring: Failed to monitor skin conditions until resolution for sampled residents | Not Corrected |
| C0370 - Staffing Requirements and Training – Pre-Serv: Failed to ensure pre-service orientation and dementia care training completed prior to providing care | Not Corrected |
| C0372 - Training Within 30 Days: Direct Care Staff: Failed to ensure newly hired staff demonstrated competency and completed required training within 30 days | Not Corrected |
| C0374 - Annual and Biennial Inservice For All Staff: Failed to ensure long term staff completed required annual in-service training | Not Corrected |
| C0420 - Fire and Life Safety: Safety: Failed to provide fire and life safety instruction to staff on alternate months of fire drills | Not Corrected |
| C0422 - Fire and Life Safety: Training For Residents: Failed to provide fire and life safety training for residents at least annually | Not Corrected |
| C0455 - Inspections and Investigation: Insp Interval: Failed to ensure relicensure survey plan of correction was implemented and satisfied the Division | Not Corrected |
| C0515 - Resident Units: Failed to ensure operable windows had fall prevention mechanisms | Not Corrected |
| C0540 - Heating and Ventilation: Failed to ensure wall heaters did not exceed 120 degrees Fahrenheit | Not Corrected |
| C0555 - Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable: Failed to provide exit door alarms or systems to alert staff when residents exited | Not Corrected |
| Z0142 - Administration Compliance: Failed to follow licensing rules referencing multiple citations including C370, C372, C374, C420, C422, C515, C540 and C555 | Not Corrected |
Report Facts
Inspections on page: 6
Total deficiencies: 39
Total surveys: 6
Total licensing violations: 15
Total abuse violations: 0
Total notices: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Executive Director | Named in multiple findings including infection prevention, fire and life safety, and coordination of care |
| Staff 2 | Memory Care Administrator | Named in multiple findings and interviews acknowledging deficiencies |
| Staff 3 | Health Services Director | Named in findings related to RN assessments, reporting, and staff training |
| Staff 4 | Food Services Director | Named in findings related to meal service and reusable cups |
| Staff 5 | Resident Care Manager | Named in findings related to abuse reporting and infection prevention |
| Staff 9 | MCC Caregiver | Named in findings related to infection prevention and nutritional supplement administration |
| Staff 11 | MCC Caregiver | Named in findings related to hot water temperature and infection prevention |
| Staff 13 | MCC Caregiver | Named in staff training deficiencies |
| Staff 14 | MCC Medication Technician | Named in staff training deficiencies |
| Staff 21 | MCC Medication Aide | Named in staff training deficiencies and nutritional supplement administration |
| Staff 27 | Director of Maintenance | Named in fire and life safety and environmental maintenance findings |
| Staff 28 | Maintenance Staff | Named in grounds maintenance findings |
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