Deficiencies per Year
12
9
6
3
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Complaint Investigation
Census: 48
Capacity: 55
Deficiencies: 12
May 20, 2024
Visit Reason
State-compiled facility profile showing 3 inspections from 2022-2024 with deficiency history and enforcement/licensing violations.
Findings
Across all inspections, the facility exhibited multiple deficiencies including failure to implement an Acuity Based Staffing Tool, food sanitation and kitchen maintenance issues, incomplete service plans, infection prevention lapses, and medication administration errors. Some deficiencies were corrected over time while others remained uncorrected at the last visits.
Complaint Details
Complaint investigation conducted on 05/20/2024 identified deficiencies related to licensing compliance and acuity based staffing tool implementation.
Deficiencies (12)
| Description |
|---|
| C0010 - Licensing Complaint Investigation: Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes. |
| C0361 - Acuity-Based Staffing Tool: Failed to fully implement and update an Acuity Based Staffing Tool for 3 of 6 sampled residents. |
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to ensure proper food storage, preparation, sanitation, employee infection control, and kitchen maintenance in accordance with Food Sanitation Rules OAR 333-150-0000. |
| C0455 - Inspections and Investigation: Insp Interval: Failed to ensure re-licensure survey plan of correction was implemented and satisfied the Department. |
| Z0142 - Administration Compliance: Failed to follow licensing rules for Residential Care and Assisted Living Facilities. |
| C0000 - Comment: Findings of the kitchen inspection and re-visits documented; facility was in substantial compliance by last revisit. |
| C0154 - Facility Administration: Policy & Procedure: Failed to implement effective methods of responding to and resolving resident complaints. |
| C0260 - Service Plan: General: Failed to ensure resident service plans were reflective of care needs, followed, and provided clear direction for 3 of 4 sampled residents. |
| C0295 - Infection Prevention & Control: Failed to ensure consistent compliance with masking requirements as prescribed in OAR 333-019-1011. |
| C0310 - Systems: Medication Administration: Failed to ensure an accurate MAR was maintained including resident specific instructions for 1 of 3 sampled residents. |
| Z0162 - Compliance With Rules Health Care: Failed to provide health care services in accordance with licensing rules; referred to other citations. |
| Z0165 - Behavior: Failed to provide individualized service plan for behavioral symptoms impacting resident or others for 1 sampled resident. |
Report Facts
Inspections on page: 3
Total deficiencies: 10
Total surveys: 3
Licensed beds: 55
Current census: 48
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Executive Director | Named in findings related to Acuity Based Staffing Tool, food sanitation, complaint investigation, and other deficiencies |
| Staff 3 | Regional Director of Operations | Named in infection prevention and medication administration findings |
| Staff 4 | Cook | Named in food sanitation and infection control deficiencies |
| Staff 5 | Resident Care Coordinator | Named in infection prevention and behavioral service plan findings |
| Staff 19 | Resident Care Coordinator | Named in infection prevention and behavioral service plan findings |
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