Deficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Renewal
Capacity: 60
Deficiencies: 7
Apr 25, 2024
Visit Reason
State-compiled facility profile showing 2 inspections from 2023-01 to 2024-04 with deficiency history and licensing violations.
Findings
Across two inspections, the facility was found to be in substantial compliance during the most recent 2024 inspection with no deficiencies, while the 2023 re-licensure survey identified multiple deficiencies related to staffing training, annual inservice, and fire and life safety documentation, many of which were corrected by the follow-up visit.
Deficiencies (7)
| Description |
|---|
| C0000 - Comment: The findings of the kitchen inspection, conducted 04/25/24, are documented in this report. The facility was found to be in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000. |
| C0000 - Comment: The findings of the re-licensure survey conducted 01/03/23 through 01/05/23 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations. The findings of the revisit to the re-licensure survey of 01/05/23, conducted on 05/10/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs Division 54 for Residential Care and Assisted Living Facilities. |
| C0370 - Staffing Requirements and Training – Pre-Serv: Based on interview and record review, it was determined the facility failed to ensure pre-service dementia care training had been completed, with certification, prior to staff providing direct care to residents, for 4 of 4 newly hired staff (#s 6, 10, 11 and 12). |
| C0372 - Training Within 30 Days: Direct Care Staff: Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired direct care staff (#s 6, 11 and 12) demonstrated competency of skills in all assigned job duties within 30 days of hire. |
| C0374 - Annual and Biennial Inservice For All Staff: Based on interview and record review, it was determined the facility failed to ensure documented evidence of the required 12 hours of annual in-service training, including six hours of dementia care training, was completed for 3 of 3 long term staff (#s 5, 7 and 8) whose training records were reviewed. |
| C0420 - Fire and Life Safety: Safety: Based on interview and record review, it was determined the facility failed to ensure all required elements were documented for fire drills in accordance with Oregon Fire Code (OFC) and fire and life safety instruction was provided on alternate months. |
| C0422 - Fire and Life Safety: Training For Residents: Based on interview and record review, it was determined the facility failed to instruct new residents on fire and life safety within 24 hours of admission and provide Fire and Life Safety instruction to residents annually. |
Report Facts
Inspections on page: 2
Total deficiencies: 5
Total licensing violations: 14
Total surveys: 2
Licensed beds: 60
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Executive Director | Named in multiple findings related to training and fire safety deficiencies |
| Staff 6 | Caregiver | Named in deficiencies related to pre-service training and competency |
| Staff 10 | Cook | Named in deficiency related to pre-service training |
| Staff 11 | Caregiver | Named in deficiencies related to pre-service training and competency |
| Staff 12 | Caregiver | Named in deficiencies related to pre-service training and competency |
| Staff 5 | Caregiver | Named in annual inservice training deficiency |
| Staff 7 | Medication Technician | Named in annual inservice training deficiency |
| Staff 8 | Caregiver | Named in annual inservice training deficiency |
| Staff 2 | Named in fire and life safety training for residents deficiency |
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