Deficiencies (last 4 years)
Deficiencies (over 4 years)
11.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
69% worse than Oregon average
Oregon average: 6.7 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Kitchen
Capacity: 64
Deficiencies: 2
Jul 9, 2025
Visit Reason
Facility failed to ensure kitchen practices and protocols were in accordance with Food Sanitation Rules. Multiple areas in kitchens needed cleaning and repair. Deficiencies were not corrected on revisit.
Findings
Facility failed to ensure kitchen practices and protocols were in accordance with Food Sanitation Rules. Multiple areas in kitchens needed cleaning and repair. Deficiencies were not corrected on revisit.
Deficiencies (2)
| Description |
|---|
| OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule — Kitchen sanitation and food safety protocols not met |
| OAR 411-057-0140(2) Administration Compliance — Failed to follow licensing rules for Residential Care and Assisted Living Facilities |
Inspection Report
Change Of Owner
Capacity: 64
Deficiencies: 17
Dec 19, 2024
Visit Reason
Multiple deficiencies including failure to provide effective oversight, reasonable precautions, resident rights, abuse reporting, service plan implementation, change of condition monitoring, resident health services, infection control, restraints, staffing, fire and life safety, and building maintenance. Many deficiencies were not corrected on revisits.
Findings
Multiple deficiencies including failure to provide effective oversight, reasonable precautions, resident rights, abuse reporting, service plan implementation, change of condition monitoring, resident health services, infection control, restraints, staffing, fire and life safety, and building maintenance. Many deficiencies were not corrected on revisits.
Deficiencies (17)
| Description |
|---|
| OAR 411-054-0025 (1) Facility Administration: Operation — Failed to provide effective oversight and quality of care |
| OAR 411-054-0025 (4) Reasonable Precautions — Failed to exercise reasonable precautions to protect resident health and safety |
| OAR 411-054-0027 (1) Resident Rights and Protection - General — Failed to ensure dignity, respect, and safe environment |
| OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action — Failed to report and investigate abuse and injuries of unknown cause |
| OAR 411-054-0036 (1-4) Service Plan: General — Failed to ensure service plans were reflective, clear, and implemented |
| OAR 411-054-0040 (1-2) Change of Condition and Monitoring — Failed to determine, communicate, and monitor changes of condition |
| OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services — Failed to ensure timely RN assessments and documented interventions |
| OAR 411-054-0050(1-5) Infection Prevention & Control — Failed to follow infection control protocols during ADL care |
| OAR 411-054-0060 Restraints and Supportive Devices — Failed to assess devices with restraining qualities quarterly |
| OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time — Failed to accurately capture care time and care elements |
| OAR 411-054-0090 (1-2) Fire and Life Safety: Safety — Failed to provide fire and life safety instruction on alternate months |
| OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents — Failed to instruct residents on fire safety within 24 hours of admission |
| OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval — Failed to ensure plan of correction was implemented and satisfied Department |
| OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors — Failed to keep interior and exterior materials and surfaces clean and in good repair |
| OAR411-004-0020(1)(c) Individual Rights Settings: Privacy, Dignity — Failed to ensure resident privacy and dignity during ADL care |
| OAR411-004-0020(2)(e) Individual Door Locks: Key Access — Failed to ensure residents and appropriate staff had keys to units |
| OAR 411-057-0140(2) Administration Compliance — Failed to follow licensing rules for Residential Care and Assisted Living Facilities |
Inspection Report
State Licensure Other
Capacity: 64
Deficiencies: 2
May 2, 2024
Visit Reason
Kitchen inspection found issues with dishwashing machines not meeting temperature and sanitation requirements and hood vents with dust and grease buildup. Deficiencies corrected on revisit.
Findings
Kitchen inspection found issues with dishwashing machines not meeting temperature and sanitation requirements and hood vents with dust and grease buildup. Deficiencies corrected on revisit.
Deficiencies (2)
| Description |
|---|
| OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule — Kitchen sanitation and food safety protocols not met initially, corrected on revisit |
| OAR 411-057-0140(2) Administration Compliance — Failed to follow licensing rules initially, corrected on revisit |
Inspection Report
Complaint Investigation
Capacity: 64
Deficiencies: 7
Feb 7, 2024
Visit Reason
Facility failed to immediately notify local Department office of incidents of abuse or suspected abuse for multiple residents. Also failed to ensure service plans were implemented and included service planning team, failed to implement acuity based staffing tool, failed to provide required staff training, and failed to provide a working call system connecting resident units to care staff.
Findings
Facility failed to immediately notify local Department office of incidents of abuse or suspected abuse for multiple residents. Also failed to ensure service plans were implemented and included service planning team, failed to implement acuity based staffing tool, failed to provide required staff training, and failed to provide a working call system connecting resident units to care staff.
Deficiencies (7)
| Description |
|---|
| OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action — Failed to immediately notify local Department office of abuse incidents |
| OAR 411-054-0036 (1-4) Service Plan: General — Failed to ensure implementation and clear directions in service plans |
| OAR 411-054-0036 (2) Service Plan: Service Planning Team — Failed to include resident or legal representative in service planning team |
| OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time — Failed to implement acuity based staffing tool |
| OAR 411-054-0035 (5) Staffing Requirements and Training – Pre-Serv — Failed to ensure required dementia and other training for staff |
| OAR 411-054-0055 (6) Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable — Failed to provide call system connecting resident units to care staff |
| OAR 411-054-0075 (7) Staff Training Requirements — Failed to ensure required training for staff |
Inspection Report
State Licensure Other
Capacity: 64
Deficiencies: 1
May 30, 2023
Visit Reason
Kitchen inspection found the facility was in substantial compliance with food sanitation rules.
Findings
Kitchen inspection found the facility was in substantial compliance with food sanitation rules.
Deficiencies (1)
| Description |
|---|
| OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule — Kitchen found in substantial compliance |
Inspection Report
Complaint Investigation
Capacity: 64
Deficiencies: 2
Oct 18, 2022
Visit Reason
Complaint investigation found failure to provide designated awake caregivers in each building, and failure to staff according to acuity based staffing tool.
Findings
Complaint investigation found failure to provide designated awake caregivers in each building, and failure to staff according to acuity based staffing tool.
Deficiencies (2)
| Description |
|---|
| OAR 411-054-0036 (2) Staffing Requirements and Training: Staffing — Failed to provide designated awake caregivers in each building |
| OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time — Failed to staff according to acuity based staffing tool |
Inspection Report
Validation Re Licensure
Capacity: 64
Deficiencies: 14
Feb 28, 2022
Visit Reason
Re-licensure survey found multiple deficiencies including kitchen sanitation, service plan development and implementation, change of condition monitoring, medication administration, staff training, fire and life safety, building maintenance, and administration compliance. Some deficiencies were corrected on revisits, others remained.
Findings
Re-licensure survey found multiple deficiencies including kitchen sanitation, service plan development and implementation, change of condition monitoring, medication administration, staff training, fire and life safety, building maintenance, and administration compliance. Some deficiencies were corrected on revisits, others remained.
Deficiencies (14)
| Description |
|---|
| OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule — Kitchen sanitation and food safety protocols not met |
| OAR 411-054-0025 (2) Resident Move-In and Evaluation — Failed to ensure move-in evaluations addressed all required elements |
| OAR 411-054-0036 (1-4) Service Plan: General — Failed to ensure service plans were reflective and provided clear directions |
| OAR 411-054-0036 (2) Service Plan: Service Planning Team — Failed to ensure service plans were developed by a service planning team |
| OAR 411-054-0040 (1-2) Change of Condition and Monitoring — Failed to ensure short term changes of condition were identified and monitored |
| OAR 411-054-0303 (7) Systems: Treatment Orders — Failed to ensure medication orders were carried out as prescribed |
| OAR 411-054-0310 (8) Systems: Medication Administration — Failed to ensure MARs were accurate and provided clear instructions |
| OAR 411-054-0372 (9) Training Within 30 Days: Direct Care Staff — Failed to ensure new hires completed required training |
| OAR 411-054-0420 (10) Fire and Life Safety: Safety — Failed to provide fire and life safety instruction on alternate months |
| OAR 411-054-0455 (11) Inspections and Investigation: Insp Interval — Failed to ensure plan of correction was implemented and satisfied Department |
| OAR 411-054-0510 (12) General Building Exterior — Failed to maintain exterior pathways in good repair |
| OAR 411-057-0140(2) Administration Compliance — Failed to follow licensing rules for Residential Care and Assisted Living Facilities |
| OAR 411-057-0155 (14) Staff Training Requirements — Failed to ensure staff completed required annual in-service training |
| OAR 411-057-0162 (15) Compliance With Rules Health Care — Failed to provide health care services in accordance with licensing rules |
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