Inspection Reports for HOLI Senior Living
188 NE 77th Ave, Hillsboro, OR 97124, USA, OR, 97124
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Inspection Report
Kitchen
Census: 50
Capacity: 90
Deficiencies: 46
May 27, 2025
Visit Reason
State-compiled facility profile showing 4 inspections from 2022-2025 with deficiency history and enforcement actions
Findings
Across four inspections from 2022 to 2025, the facility exhibited multiple deficiencies including failures in food sanitation, administration compliance, resident care plans, medication administration, staffing, fire and life safety, and environmental maintenance. Several deficiencies were repeated or not corrected timely, with plans of correction documented for each.
Complaint Details
Complaint investigation conducted on 01/24/2024 identified deficiencies including failure to investigate and report injury of unknown cause, failure to ensure bathing assistance, failure to follow physician orders, and other compliance issues.
Deficiencies (46)
| Description |
|---|
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to ensure kitchen practices and protocols were in accordance with Food Sanitation Rules including cleaning and labeling issues |
| Z0142 - Administration Compliance: Failed to follow licensing rules for Residential Care and Assisted Living Facilities |
| C0010 - Licensing Complaint Investigation: Deficiencies identified during complaint investigation |
| C0231 - Reporting & Investigating Abuse-Other Action: Failed to investigate and report injury of unknown cause for sampled resident |
| C0260 - Service Plan: General: Failed to ensure residents received regular bathing assistance and service plans were reflective and followed |
| C0303 - Systems: Treatment Orders: Failed to follow physician orders as prescribed for sampled residents |
| C0000 - Comment: Kitchen inspection findings and revisit documented |
| C0150 - Facility Administration: Operation: Failed to ensure adequate administrative oversight and supervision |
| C0154 - Facility Administration: Policy & Procedure: Failed to implement effective complaint resolution methods |
| C0156 - Facility Administration: Quality Improvement: Failed to develop and conduct ongoing quality improvement programs |
| C0160 - Reasonable Precautions: Failed to implement infection control and exercise reasonable precautions |
| C0231 - Reporting & Investigating Abuse-Other Action: Failed to ensure thorough investigations to rule out neglect |
| C0242 - Resident Services: Activities: Failed to provide social and recreational activity program based on resident needs |
| C0252 - Resident Move-In and Eval: Res Evaluation: Failed to ensure initial move-in evaluations included all required elements |
| C0260 - Service Plan: General: Failed to ensure service plans were reflective, clear, 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 representatives |
| C0270 - Change of Condition and Monitoring: Failed to evaluate, document, communicate, and monitor changes of condition for sampled residents |
| C0280 - Resident Health Services: Failed to ensure RN assessments and interventions for significant changes of condition |
| C0282 - Rn Delegation and Teaching: Failed to ensure teaching, delegation, and supervision of nursing tasks per OSBN rules |
| C0290 - Res Hlth Srvc: On- and Off-Site Health Srvc: Failed to coordinate on-site health services with outside providers and ensure documentation |
| C0300 - Systems: Medications and Treatments: Failed to ensure safe medication administration system and professional oversight |
| C0302 - Systems: Tracking Control Substances: Failed to accurately track controlled substances administered |
| C0303 - Systems: Treatment Orders: Failed to carry out medication orders as prescribed for sampled residents |
| C0310 - Systems: Medication Administration: Failed to ensure MARs were accurate and included clear parameters for medication administration |
| C0315 - Systems: Treatment Administration: Failed to keep accurate treatment records for treatments administered |
| C0325 - Systems: Self-Administration of Meds: Failed to evaluate residents' ability to self-administer medications and obtain physician orders |
| C0340 - Restraints and Supportive Devices: Failed to ensure assessments for assistive devices with restraining qualities |
| C0360 - Staffing Requirements and Training: Staffing: Failed to have sufficient caregivers to meet resident needs during night shift |
| C0361 - Acuity-Based Staffing Tool: Failed to implement an acuity-based staffing tool meeting regulations |
| C0370 - Staffing Requirements and Training – Pre-Serv: Failed to ensure pre-service orientation was completed and documented for sampled staff |
| C0372 - Training Within 30 Days: Direct Care Staff: Failed to ensure newly-hired direct care staff demonstrated competency within 30 days |
| C0420 - Fire and Life Safety: Safety: Failed to provide fire and life safety instruction on alternate months and document required fire drill components |
| C0422 - Fire and Life Safety: Training For Residents: Failed to ensure residents were instructed on fire and life safety procedures within 24 hours of admission |
| C0455 - Inspections and Investigation: Insp Interval: Failed to ensure relicensure survey plan of correction was implemented and satisfied the Department |
| C0510 - General Building Exterior: Failed to ensure courtyard pathways did not have drop-offs and grounds were free from refuse |
| C0513 - Doors, Walls, Elevators, Odors: Failed to keep interior environment clean and in good repair |
| C0530 - Housekeeping and Laundry: Failed to ensure washing machines had minimum rinse temperature or used chemical disinfectant |
| C0540 - Heating and Ventilation: Failed to ensure wall heater covers did not exceed 120 degrees Fahrenheit in areas subject to incidental contact |
| C0555 - Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable: Failed to ensure exit door alarms were functioning to alert staff |
| H1518 - Individual Door Locks: Key Access: Failed to ensure residents were provided keys to their units per evaluated needs |
| H1523 - Individual Freedom: Access to Food Any Time: Failed to ensure residents had freedom and support to access food at any time |
| 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 nutritional plans were developed and included in service plans |
| Z0164 - Activities: Failed to evaluate and develop individualized activity plans for sampled residents |
| Z0168 - Outside Area: Failed to provide access to secured outdoor space allowing residents to enter and return without staff assistance |
| Z0173 - Secure Outdoor Recreation Area: Failed to have written policy detailing when outdoor recreation area doors may be locked |
Report Facts
Inspections on page: 4
Total deficiencies: 47
Total surveys: 4
Licensing violations: 7
Notices: 1
Licensed beds: 90
Facility census: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Executive Director | Named in multiple findings related to administration, investigations, and acknowledgements |
| Staff 2 | Director of Wellness | Named in multiple findings related to nursing, infection control, and acknowledgements |
| Staff 3 | Resident Care Coordinator | Named in service planning and investigation findings |
| Staff 4 | Marketing and Sales Director | Named in complaint investigation acknowledgements |
| Staff 5 | Regional Director of Operations | Named in complaint investigation acknowledgements |
| Staff 7 | Medication Technician | Named in medication administration findings |
| Staff 10 | Medication Technician | Named in medication administration and delegation findings |
| Staff 15 | Director of Operations | Named in multiple findings and acknowledgements |
| Staff 18 | Maintenance Director | Named in environmental and fire safety findings |
| Staff 22 | Director of Wellness, RN | Named in nursing and medication findings |
| Staff 26 | Medication Technician | Named in training and competency findings |
| Staff 28 | Medication Technician | Named in training and competency findings |
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