Inspection Report
Renewal
Capacity: 153
Deficiencies: 16
Dec 14, 2023
Visit Reason
State-compiled facility profile showing 2 inspections from 2023 with deficiency history and enforcement/licensing violations.
Findings
Across two inspections in 2023, the facility exhibited multiple deficiencies including failure to monitor and document changes in resident conditions, incomplete staff training, medication administration errors, fire and life safety documentation issues, and inadequate infection prevention practices. Some deficiencies were corrected between visits, while others remained uncorrected at the latest visit.
Deficiencies (16)
| Description |
|---|
| C0000 - Comment: General comments and findings related to re-licensure and kitchen inspections. |
| C0270 - Change of Condition and Monitoring: Failed to ensure short-term changes of condition were evaluated, communicated, and monitored through resolution for sampled residents. |
| C0280 - Resident Health Services: Failed to ensure RN assessments were completed following significant changes of condition for a sampled resident. |
| C0290 - Res Hlth Srvc: On- and Off-Site Health Srvc: Failed to ensure outside providers left written clinical information necessary for supplemental care. |
| C0303 - Systems: Treatment Orders: Failed to carry out physician orders as prescribed, resulting in administration of contraindicated medications. |
| C0340 - Restraints and Supportive Devices: Failed to ensure supportive device with restraining qualities was assessed by RN, PT or OT prior to use and addressed all required elements. |
| C0374 - Annual and Biennial Inservice For All Staff: Failed to ensure required annual in-service training including dementia care was completed for sampled staff. |
| C0420 - Fire and Life Safety: Safety: Failed to ensure fire drills were conducted and documented per Oregon Fire Code and fire/life safety instruction was provided on alternate months. Repeat citation. |
| C0455 - Inspections and Investigation: Insp Interval: Failed to ensure re-licensure survey plan of correction was implemented and satisfied the Department. |
| C0522 - Common Use Areas: Social: Failed to ensure stoves in memory care common areas had keyed, remote switch or other safety device to ensure staff control. |
| C0640 - Heating and Ventilation: Failed to ensure heating elements did not exceed 120 degrees Fahrenheit where subject to incidental contact. |
| Z0142 - Administration Compliance: Failed to follow licensing rules for Residential Care and Assisted Living Facilities; repeat citation. |
| Z0155 - Staff Training Requirements: Failed to ensure sampled long term direct care staff completed required annual in-service training including dementia care. |
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to ensure kitchen was clean and in good repair per Food Sanitation Rules. |
| C0295 - Infection Prevention & Control: Failed to ensure staff wore medical grade face masks as required by OAR 333-019-1011. |
| Z0162 - Compliance With Rules Health Care: Failed to provide health care services in accordance with licensing rules; referred to C295. |
Report Facts
Inspections on page: 2
Total deficiencies: 16
Total surveys: 2
Licensing violations: 19
Abuse violations: 0
Notices: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Executive Director | Named in multiple findings including infection prevention and staff training |
| Staff 2 | Business Office Coordinator | Named in findings related to change of condition monitoring and medication errors |
| Staff 4 | Maintenance Director | Named in fire and life safety and stove safety findings |
| Staff 5 | Memory Care Director | Named in staff training and stove safety findings |
| Staff 6 | Assisted Living Facility - Resident Care Coordinator | Named in multiple findings including medication errors, change of condition, and outside provider communication |
| Staff 7 | Assisted Living Facility - RN | Named in medication error, restraint assessment, and change of condition findings |
| Staff 8 | LPN | Named in resident health services findings |
| Staff 11 | Medication Technician | Named in staff training deficiency |
| Staff 12 | Caregiver | Named in staff training deficiency |
| Staff 14 | Medication Technician | Named in staff training deficiency |
| Staff 15 | Caregiver | Named in staff training deficiency |
| Staff 19 | Maintenance Director | Named in fire and life safety repeat citation |
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