Inspection Report
Re-Inspection
Capacity: 51
Deficiencies: 21
Nov 18, 2025
Visit Reason
State-compiled facility profile showing 10 inspections from 2022-2025 with deficiency history and enforcement/licensing violations.
Findings
Across multiple inspections, the facility exhibited deficiencies related to medication administration, bed hold policy notification, infection control reporting, quality of care including failure to follow physician orders, accident hazards, care plan accuracy, and resident supervision. Several deficiencies were corrected while others remained uncorrected at the time of visits.
Complaint Details
Complaint investigations included failures in bed hold policy notification, quality of care including medication administration and resident supervision, and infection control reporting.
Severity Breakdown
Not Corrected: 9
Deficiencies (21)
| Description | Severity |
|---|---|
| F0000 - INITIAL COMMENTS | — |
| F0684 - Quality of Care: Failed to administer prescribed medications and implement fall prevention interventions including bed rails for residents. | — |
| F0689 - Free of Accident Hazards/Supervision/Devices: Medications left unsecured in resident room accessible to others. | — |
| M0000 - Initial Comments | — |
| M9999 - STATE OF OREGON ADMINISTRATIVE RULES | — |
| F0625 - Notice of Bed Hold Policy Before/Upon Trnsfr: Failed to provide written notice of bed hold policy to resident upon hospital transfer. | Not Corrected |
| F0684 - Quality of Care: Failed to follow physician orders for daily weights for resident with edema. | Not Corrected |
| F0884 - Reporting - National Health Safety Network: Failed to report complete COVID-19 information to CDC NHSN during required periods. | Not Corrected |
| F0583 - Personal Privacy/Confidentiality of Records: Failed to ensure resident door was closed during care. | — |
| F0585 - Grievances: Failed to follow-up timely on report of missing resident property. | — |
| F0641 - Accuracy of Assessments: Failed to ensure assessments accurately reflected residents' status. | — |
| F0657 - Care Plan Timing and Revision: Failed to revise care plans to reflect current resident needs. | — |
| F0679 - Activities Meet Interest/Needs Each Resident: Failed to ensure meaningful activity program for resident. | — |
| F0684 - Quality of Care: Failed to reassess resident after fall and administer medications as ordered. | — |
| F0686 - Treatment/Svcs to Prevent/Heal Pressure Ulcer: Failed to follow care planned interventions for positioning. | — |
| F0688 - Increase/Prevent Decrease in ROM/Mobility: Failed to provide restorative activities for resident. | — |
| F0689 - Free of Accident Hazards/Supervision/Devices: Failed to supervise resident during fluid intake. | — |
| F0690 - Bowel/Bladder Incontinence, Catheter, UTI: Failed to provide necessary incontinent care for resident. | — |
| F0742 - Treatment/Srvcs Mental/Psychoscial Concerns: Failed to evaluate resident for additional interventions for behavioral and emotional status. | — |
| F0880 - Infection Prevention & Control: Failed to maintain Foley catheter to prevent infections. | — |
| F0883 - Influenza and Pneumococcal Immunizations: Failed to provide influenza immunization to resident. | — |
Report Facts
Inspections on page: 10
Total deficiencies: 23
Licensing violations: 7
Abuse violations: 0
Notices: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Susan Platte | Administrator | Named in medication storage and supervision findings and other inspection findings |
| Staff 2 | Director of Nursing (DNS) | Named in multiple findings related to medication administration, care plan audits, and quality of care |
| Staff 4 | LPN Care Manager | Named in findings related to medication administration and bed rail implementation |
| Staff 12 | Certified Medication Aide (CMA) | Named in medication administration findings |
| Staff 1 | Administrator | Named in medication storage and supervision findings |
| Staff 3 | LPN-Resident Care Manager | Named in quality of care findings |
| Staff 8 | RN Care Manager (RNCM) | Named in multiple findings including resident supervision and psychosocial concerns |
| Staff 5 | Social Services | Named in grievance and psychosocial findings |
| Staff 7 | LPN Resident Care Manager | Named in supervision findings |
| Staff 10 | CNA | Named in incontinent care and positioning findings |
| Staff 11 | Agency CNA | Named in positioning and incontinent care findings |
| Staff 14 | RN | Named in incontinent care findings |
| Staff 15 | RN | Named in pressure ulcer findings |
| Staff 16 | CNA | Named in infection prevention findings |
| Staff 17 | RN | Named in fall assessment findings |
| Staff 18 | RN | Named in fall assessment findings |
| Staff 19 | LPN | Named in fall assessment findings |
| Staff 20 | Restorative Aide (RA) | Named in restorative activities findings |
| Staff 9 | Activities Assistant | Named in activity program findings |
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