Deficiencies (last 4 years)
Deficiencies (over 4 years)
12.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
91% worse than Oregon average
Oregon average: 6.7 deficiencies/yearDeficiencies per year
36
27
18
9
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Sep 5, 2025
Visit Reason
The inspection was conducted based on complaints regarding medication administration, fall prevention, and accident hazards in the nursing home.
Complaint Details
The investigation was triggered by complaints related to missed medication administration, failure to implement fall prevention measures, and unsecured medications posing accident hazards.
Findings
The facility failed to administer prescribed medications to Resident 3, did not implement fall prevention interventions such as bed rails for Resident 9, and allowed unsecured medications in Resident 49's room, placing residents at risk for adverse medical consequences and injury.
Deficiencies (2)
F 0684: The facility failed to follow physician orders for Resident 3 by missing multiple doses of calcium citrate plus and calcium citrate with vitamin D. Resident 9's prescribed bilateral bed rails were not in place to assist with mobility.
F 0689: The facility failed to ensure Resident 49's environment was free from accident hazards by leaving unsecured medications visible and accessible in the resident's room.
Report Facts
Missed medication doses: 18
Observation dates: 3
Observation hours: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff 4 | LPN Care Manager | Confirmed missed medication doses for Resident 3 and acknowledged Resident 9's bed rails were not in place. |
| Staff 2 | DNS | Reviewed medication administration records and expected staff to notify pharmacy and physician about missed doses; acknowledged bed rails were not implemented for Resident 9. |
| Staff 12 | CMA | Confirmed medications were not administered due to unavailability and notified nurse about missed doses. |
| Staff 8 | CNA | Observed unsecured medications in Resident 49's room. |
| Staff 1 | Administrator | Verified that no unsecured medications should be at any resident's bedside. |
Inspection Report
Routine
Capacity: 51
Deficiencies: 5
Date: Sep 5, 2025
Visit Reason
Deficiencies related to medication administration failures and bed rail use were identified. Resident 3 missed multiple prescribed doses of calcium citrate supplements and Resident 9's bed rails were not implemented as ordered. Medication storage and supervision issues were also noted. All deficiencies were corrected by 9/22/2025.
Findings
Deficiencies related to medication administration failures and bed rail use were identified. Resident 3 missed multiple prescribed doses of calcium citrate supplements and Resident 9's bed rails were not implemented as ordered. Medication storage and supervision issues were also noted. All deficiencies were corrected by 9/22/2025.
Deficiencies (5)
F0000 - INITIAL COMMENTS
F0684 - Quality of Care
F0689 - Free of Accident Hazards/Supervision/Devices
M0000 - Initial Comments
M9999 - STATE OF OREGON ADMINISTRATIVE RULES
Inspection Report
Complaint Investigation
Capacity: 51
Deficiencies: 2
Date: May 29, 2025
Visit Reason
Complaint investigation found two deficiencies related to initial comments that were not corrected at the time of visit.
Findings
Complaint investigation found two deficiencies related to initial comments that were not corrected at the time of visit.
Deficiencies (2)
F0000 - INITIAL COMMENTS
M0000 - Initial Comments
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jun 13, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding failure to provide residents with written notice of the facility's bed hold policy during hospital transfers and failure to follow physician orders for resident care.
Complaint Details
The investigation found substantiated deficiencies related to failure to provide written bed hold policy notice and failure to follow physician orders for resident care.
Findings
The facility failed to provide a written bed hold policy to Resident 30 upon hospital transfer and failed to follow physician orders for daily weighing of Resident 81 with edema, placing residents at risk for lack of knowledge and adverse health effects.
Deficiencies (2)
F 0625: The facility failed to provide Resident 30 with a written notice of the bed hold policy at the time of hospital transfer on 3/23/24.
F 0684: The facility failed to follow physician orders for daily weighing of Resident 81 with edema, missing multiple weight measurements between 5/22/24 and 6/9/24.
Report Facts
Missed weight measurements: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DNS (Staff 2) | Confirmed bed hold policy was not provided to Resident 30. | |
| LPN-Resident Care Manager (Staff 3) | Acknowledged missed physician order for daily weights for Resident 81. |
Inspection Report
Complaint Investigation
Capacity: 51
Deficiencies: 5
Date: Jun 13, 2024
Visit Reason
Deficiencies included failure to provide written notice of bed hold policy, failure to follow physician orders for resident weights, and quality of care issues. Some deficiencies were corrected on first revisit but not corrected on second revisit.
Findings
Deficiencies included failure to provide written notice of bed hold policy, failure to follow physician orders for resident weights, and quality of care issues. Some deficiencies were corrected on first revisit but not corrected on second revisit.
Deficiencies (5)
F0000 - INITIAL COMMENTS
F0625 - Notice of Bed Hold Policy Before/Upon Trnsfr
F0684 - Quality of Care
M0000 - Initial Comments
M9999 - STATE OF OREGON ADMINISTRATIVE RULES
Inspection Report
Capacity: 51
Deficiencies: 1
Date: Jan 30, 2024
Visit Reason
One deficiency related to failure to report complete COVID-19 information to the National Healthcare Safety Network was identified and not corrected at time of visit.
Findings
One deficiency related to failure to report complete COVID-19 information to the National Healthcare Safety Network was identified and not corrected at time of visit.
Deficiencies (1)
F0884 - Reporting - National Health Safety Network
Inspection Report
Capacity: 51
Deficiencies: 1
Date: Sep 18, 2023
Visit Reason
One deficiency for failure to report complete COVID-19 information to NHSN was identified and not corrected at time of visit.
Findings
One deficiency for failure to report complete COVID-19 information to NHSN was identified and not corrected at time of visit.
Deficiencies (1)
F0884 - Reporting - National Health Safety Network
Inspection Report
Capacity: 51
Deficiencies: 1
Date: Sep 5, 2023
Visit Reason
One deficiency for failure to report complete COVID-19 information to NHSN was identified and not corrected at time of visit.
Findings
One deficiency for failure to report complete COVID-19 information to NHSN was identified and not corrected at time of visit.
Deficiencies (1)
F0884 - Reporting - National Health Safety Network
Inspection Report
Capacity: 51
Deficiencies: 1
Date: Jul 17, 2023
Visit Reason
One deficiency for failure to report complete COVID-19 information to NHSN was identified and not corrected at time of visit.
Findings
One deficiency for failure to report complete COVID-19 information to NHSN was identified and not corrected at time of visit.
Deficiencies (1)
F0884 - Reporting - National Health Safety Network
Inspection Report
Annual Inspection
Deficiencies: 13
Date: Mar 13, 2023
Visit Reason
Annual inspection survey conducted to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found to have multiple deficiencies including failure to ensure resident privacy, inaccurate resident assessments, incomplete care plans, inadequate activity programs, delayed injury reassessment after falls, medication administration errors, improper pressure ulcer care, lack of restorative activities, inadequate supervision during meals, insufficient incontinent care, lack of psychosocial interventions, improper Foley catheter care, and failure to provide influenza immunizations.
Deficiencies (13)
F 0583: The facility failed to ensure a resident's door was closed during care for 1 of 1 resident reviewed, risking privacy.
F 0585: The facility failed to follow-up on a report of a missing item for 1 of 1 resident reviewed, risking loss of personal property.
F 0641: The facility failed to ensure accurate assessments for 2 of 8 residents reviewed, risking inaccurate care.
F 0657: The facility failed to revise care plans to reflect current resident needs for 2 of 3 residents reviewed, risking unmet needs.
F 0679: The facility failed to provide a meaningful activity program for 1 of 4 residents reviewed, risking social isolation.
F 0684: The facility failed to reassess a resident after a fall and failed to administer medications as ordered for 2 residents, risking delayed care and adverse effects.
F 0686: The facility failed to follow care planned interventions for positioning for 1 of 3 residents reviewed, risking skin breakdown.
F 0688: The facility failed to provide restorative activities for 1 resident reviewed, risking decreased range of motion.
F 0689: The facility failed to supervise a resident during fluid intake for 1 of 2 residents reviewed, risking aspiration.
F 0690: The facility failed to provide appropriate incontinent care for 1 of 3 residents reviewed, risking hygiene and infection.
F 0742: The facility failed to evaluate and provide additional psychosocial interventions for 1 resident reviewed, risking increased depression.
F 0880: The facility failed to maintain a resident's Foley catheter drainage bag off the floor, risking urinary tract infections.
F 0883: The facility failed to provide influenza immunization for 1 of 5 residents reviewed despite consent, risking illness.
Report Facts
Residents reviewed: 8
Residents reviewed: 3
Residents reviewed: 4
Residents reviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Administrator | Acknowledged privacy door should be closed during care |
| Staff 2 | Director of Nursing Services (DNS) | Confirmed inaccurate assessments and medication errors |
| Staff 4 | Certified Nursing Assistant (CNA) | Reported lost item procedures and resident sleep/activity observations |
| Staff 7 | Licensed Practical Nurse Resident Care Manager (LPN RCM) | Acknowledged supervision failure during resident fluid intake |
| Staff 8 | Resident Care Manager (RNCM) | Acknowledged care plan and activity program deficiencies |
| Staff 9 | Activities Assistant | Observed resident activity participation and preferences |
| Staff 10 | Certified Nursing Assistant (CNA) | Reported incontinent care practices and resident supervision |
| Staff 11 | Agency CNA | Reported incontinent care schedule and repositioning |
| Staff 14 | Registered Nurse (RN) | Reported resident communication limitations and care expectations |
| Staff 15 | Registered Nurse (RN) | Identified pressure injury and care needs |
| Staff 16 | Certified Nursing Assistant (CNA) | Observed Foley catheter drainage bag placement |
| Staff 17 | Registered Nurse (RN) | Described fall assessment and neurological checks |
| Staff 18 | Registered Nurse (RN) | Assessed resident pain and notified physician after fall |
| Staff 20 | Restorative Aide (RA) | Described restorative activity program and documentation |
| Witness 1 | Family Member | Reported missing cellular phone |
| Witness 2 | Family Member | Reported resident found slumped in wheelchair in pain |
| Witness 3 | Physician | Confirmed notification after resident fall |
Inspection Report
Routine
Capacity: 51
Deficiencies: 16
Date: Mar 13, 2023
Visit Reason
Thirteen deficiencies identified including issues with resident privacy, grievances, assessment accuracy, care plan revisions, activities, quality of care, pressure ulcer prevention, range of motion, accident hazards, bowel/bladder care, mental health treatment, and infection control. Some deficiencies were corrected on first revisit but many remained uncorrected on second revisit.
Findings
Thirteen deficiencies identified including issues with resident privacy, grievances, assessment accuracy, care plan revisions, activities, quality of care, pressure ulcer prevention, range of motion, accident hazards, bowel/bladder care, mental health treatment, and infection control. Some deficiencies were corrected on first revisit but many remained uncorrected on second revisit.
Deficiencies (16)
F0000 - INITIAL COMMENTS
F0583 - Personal Privacy/Confidentiality of Records
F0585 - Grievances
F0641 - Accuracy of Assessments
F0657 - Care Plan Timing and Revision
F0679 - Activities Meet Interest/Needs Each Resident
F0684 - Quality of Care
F0686 - Treatment/Svcs to Prevent/Heal Pressure Ulcer
F0688 - Increase/Prevent Decrease in ROM/Mobility
F0689 - Free of Accident Hazards/Supervision/Devices
F0690 - Bowel/Bladder Incontinence, Catheter, UTI
F0742 - Treatment/Srvcs Mental/Psychoscial Concerns
F0880 - Infection Prevention & Control
F0883 - Influenza and Pneumococcal Immunizations
M0000 - Initial Comments
M9999 - STATE OF OREGON ADMINISTRATIVE RULES
Inspection Report
Capacity: 51
Deficiencies: 1
Date: Mar 6, 2023
Visit Reason
One deficiency for failure to report complete COVID-19 information to NHSN was identified and not corrected at time of visit.
Findings
One deficiency for failure to report complete COVID-19 information to NHSN was identified and not corrected at time of visit.
Deficiencies (1)
F0884 - Reporting - National Health Safety Network
Inspection Report
Capacity: 51
Deficiencies: 1
Date: Oct 17, 2022
Visit Reason
One deficiency for failure to report complete COVID-19 information to NHSN was identified and not corrected at time of visit.
Findings
One deficiency for failure to report complete COVID-19 information to NHSN was identified and not corrected at time of visit.
Deficiencies (1)
F0884 - Reporting - National Health Safety Network
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