Inspection Report
Renewal
Census: 15
Capacity: 15
Deficiencies: 28
Oct 20, 2025
Visit Reason
State-compiled facility profile showing 5 inspections from 2022-2025 with deficiency history and enforcement actions
Findings
Across multiple inspections from 2022 to 2025, the facility demonstrated numerous deficiencies including failure to maintain accurate and reflective service plans, inadequate infection prevention and control, insufficient staffing during overnight shifts, failure to conduct timely RN assessments for significant changes of condition, and lack of proper documentation and monitoring of medication administration and resident activities.
Complaint Details
The complaint investigation conducted on 10/24/2023 documented findings related to compliance with OARs 411 Division 54 and 57 for Residential Care and Assisted Living Facilities and Memory Care Communities.
Deficiencies (28)
| Description |
|---|
| C0260 - Service Plan: General: Failed to ensure service plans were reflective of residents’ current status and care needs and provided clear direction to staff |
| C0280 - Resident Health Services: Failed to ensure timely RN assessment for significant change of condition and proper meal assistance |
| C0295 - Infection Prevention & Control: Failed to maintain infection prevention and control protocols including hand hygiene and glove use |
| C0330 - Systems: Psychotropic Medication: Failed to ensure resident-specific parameters and documentation of non-pharmacological interventions prior to PRN psychotropic medication administration |
| C0340 - Restraints and Supportive Devices: Failed to ensure thorough assessment of supportive devices with restraining qualities by RN, PT, or OT |
| C0360 - Staffing Requirements and Training: Staffing: Failed to have sufficient qualified awake direct care staff during overnight shifts |
| C0422 - Fire and Life Safety: Training for Residents: Failed to ensure residents were instructed in fire and life safety procedures at least annually |
| H1511 - Individual Rights Settings Right to Freedom: Failed to ensure all individuals had the right to freedom from restraints |
| Z0142 - Administration Compliance: Failed to comply with licensing rules for Residential Care and Assisted Living Facilities |
| Z0162 - Compliance with Rules Health Care: Failed to provide health care services in accordance with licensing rules |
| Z0164 - Activities: Failed to evaluate residents for activities and develop individualized activity plans |
| C0010 - Licensing Complaint Investigation: Findings documented for complaint investigation |
| C0301 - Systems: Medication Administration: Failed to ensure staff visually observed resident take medication |
| C0303 - Systems: Treatment Orders: Failed to carry out medication orders as prescribed |
| C0361 - Acuity-Based Staffing Tool: Failed to adopt and update acuity-based staffing tool appropriately |
| C0450 - Inspections and Investigations: Failed to provide records to Department upon request |
| C0160 - Reasonable Precautions: Failed to implement effective infection control methods |
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to ensure kitchen was clean and in good repair |
| C0242 - Resident Services: Activities: Failed to provide daily activity program based on individual and group needs |
| C0262 - Service Plan: Service Planning Team: Failed to ensure service plans were developed by required service planning team |
| C0270 - Change of Condition and Monitoring: Failed to monitor and evaluate falls and changes of condition until resolved |
| C0330 - Systems: Psychotropic Medication: Failed to ensure PRN psychotropic medications had resident-specific parameters and documentation |
| C0420 - Fire and Life Safety: Safety: Failed to provide and document fire and life safety instruction to staff every other month |
| C0455 - Inspections and Investigation: Insp Interval: Failed to ensure change of ownership survey plan of correction was implemented and satisfied Department |
| C0513 - Doors, Walls, Elevators, Odors: Failed to ensure environment was clean, in good repair, and free from odors |
| Z0173 - Secure Outdoor Recreation Area: Failed to ensure outdoor furniture was of sufficient weight and design to prevent injury or elopement |
| Z0176 - Resident Rooms: Failed to individually identify residents' rooms to assist recognition |
| C0000 - Comment: Facility was in substantial compliance with food sanitation rules during inspections with no deficiencies |
Report Facts
Inspections on page: 5
Total deficiencies: 30
Total surveys: 5
Licensing violations: 9
Abuse violations: 0
Notices: 1
Licensed beds: 15
Census: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Executive Director | Named in multiple findings including service plan, infection control, RN assessment, psychotropic medication, staffing, and fire safety |
| Staff 2 | Assistant Executive Director | Named in findings related to service plan and infection control |
| Staff 3 | Vice President of Operations / Assistant Executive Director | Named in findings related to service plan, infection control, medication administration, and fire safety |
| Staff 4 | Medication Technician / Caregiver | Named in infection prevention and control findings |
| Staff 5 | Medication Technician / Caregiver | Named in observation of feeding assistance |
| Staff 6 | Medication Technician / Caregiver | Named in infection prevention and control and medication administration findings |
| Staff 9 | Medication Technician / Caregiver | Named in infection prevention and control findings |
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