Inspection Reports for
Kelly Gardens Residential Care
813 NE KELLY AVE, GRESHAM, OR, 97030
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
5.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
15% better than Oregon average
Oregon average: 6.7 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Change Of Owner
Capacity: 61
Deficiencies: 4
Date: Apr 16, 2025
Visit Reason
Facility failed to ensure physician or practitioner was notified when residents refused medications or treatments. Staffing plan failed to meet Specific Needs Contract requirements. Grounds were not kept orderly and free of litter and refuse. Multiple deficiencies remain uncorrected as of last revisit.
Findings
Facility failed to ensure physician or practitioner was notified when residents refused medications or treatments. Staffing plan failed to meet Specific Needs Contract requirements. Grounds were not kept orderly and free of litter and refuse. Multiple deficiencies remain uncorrected as of last revisit.
Deficiencies (4)
OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order.
OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan
OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval
OAR 411-054-0200 (3) General Building Exterior
Inspection Report
Complaint Investigation
Capacity: 61
Deficiencies: 3
Date: Apr 8, 2025
Visit Reason
Facility failed to fully implement acuity-based staffing tool (ABST) and failed to provide sufficient awake direct care staff to meet residents' needs. Staffing plan did not meet Specific Needs Contract requirements. Deficiencies were not corrected at time of inspection.
Findings
Facility failed to fully implement acuity-based staffing tool (ABST) and failed to provide sufficient awake direct care staff to meet residents' needs. Staffing plan did not meet Specific Needs Contract requirements. Deficiencies were not corrected at time of inspection.
Deficiencies (3)
OAR 411-054-0360 Staffing Requirements and Training: Staffing
OAR 411-054-0362 Acuity Based Staffing Tool - Abst Time
OAR 411-054-0363 Acuity Based Staffing Tool - Updates & Plan
Inspection Report
Capacity: 61
Deficiencies: 1
Date: Dec 5, 2023
Visit Reason
Kitchen inspection found facility in substantial compliance with relevant OARs for Residential Care and Assisted Living Facilities and Oregon Health Service Food Sanitation Rules.
Findings
Kitchen inspection found facility in substantial compliance with relevant OARs for Residential Care and Assisted Living Facilities and Oregon Health Service Food Sanitation Rules.
Deficiencies (1)
C0000 - Comment
Inspection Report
Initial Licensure
Capacity: 61
Deficiencies: 9
Date: Jul 18, 2022
Visit Reason
Initial licensure survey identified multiple deficiencies including medication administration, psychotropic medication documentation, acuity-based staffing tool implementation, staff training, and building exterior maintenance. Some deficiencies were corrected in subsequent revisits, others remained uncorrected.
Findings
Initial licensure survey identified multiple deficiencies including medication administration, psychotropic medication documentation, acuity-based staffing tool implementation, staff training, and building exterior maintenance. Some deficiencies were corrected in subsequent revisits, others remained uncorrected.
Deficiencies (9)
OAR 411-054-0310 Systems: Medication Administration
OAR 411-054-0330 Systems: Psychotropic Medication
OAR 411-054-0361 Acuity-Based Staffing Tool
OAR 411-054-0372 Training Within 30 Days: Direct Care Staff
OAR 411-054-0455 Inspections and Investigation: Insp Interval
OAR 411-054-0555 Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable
Z0142 Administration Compliance
Z0155 Staff Training Requirements
Z0162 Compliance With Rules Health Care
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