Inspection Reports for Maple Grove Memory Care
17309 NE Glisan St, Portland, OR 97230, OR, 97230
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Inspection Report
Kitchen
Census: 51
Capacity: 68
Deficiencies: 30
Mar 25, 2025
Visit Reason
State-compiled facility profile showing 10 inspections from 2022-2025 with deficiency history and enforcement actions
Findings
The facility has multiple deficiencies across inspections including failures in medication administration, staffing, infection control, resident care plans, fire and life safety, and food sanitation. Several immediate plans of correction were requested and some deficiencies remain uncorrected as of the latest inspections.
Complaint Details
Multiple complaint investigations documented including failures in reasonable precautions, medication administration, staffing, infection control, and resident care plans.
Deficiencies (30)
| Description |
|---|
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to ensure kitchen practices and protocols were in accordance with Food Sanitation Rules |
| Z0142 - Administration Compliance: Failed to follow licensing rules for Residential Care and Assisted Living Facilities |
| C0160 - Reasonable Precautions: Failed to exercise reasonable precautions against conditions threatening health, safety, or welfare of residents including fire code violations |
| C0010 - Licensing Complaint Investigation: Findings of complaint investigation documented |
| C0303 - Systems: Treatment Orders: Failed to carry out medication and treatment orders as prescribed for multiple residents |
| C0360 - Staffing Requirements and Training: Staffing: Failed to provide sufficient qualified awake direct care staff to meet scheduled and unscheduled needs |
| C0362 - Acuity Based Staffing Tool - Abst Time: Failed to fully implement and update acuity-based staffing tool (ABST) |
| C0363 - Acuity Based Staffing Tool - Updates & Plan: Failed to fully implement and update acuity-based staffing tool (ABST) |
| C0260 - Service Plan: General: Failed to provide service plans reflective of resident needs |
| C0270 - Change of Condition and Monitoring: Failed to determine and document action or intervention needed for change of condition |
| C0300 - Systems: Medications and Treatments: Failed to ensure safe medication and treatment system and adequate professional oversight |
| C0301 - Systems: Medication Administration: Failed to ensure medications were set-up or poured and documented by same person who administers |
| C0310 - Systems: Medication Administration: Failed to keep accurate Medication Administration Record |
| C0280 - Resident Health Services: Failed to ensure RN performed assessment documenting findings, resident status, and interventions for significant change of condition |
| C0295 - Infection Prevention & Control: Failed to establish and maintain infection prevention and control protocols |
| C0340 - Restraints and Supportive Devices: Failed to ensure supportive device was assessed and instructions included on service plan |
| C0372 - Training Within 30 Days: Direct Care Staff: Failed to ensure newly hired staff completed required training within 30 days |
| C0420 - Fire and Life Safety: Safety: Failed to conduct fire drills every other month and provide fire and life safety instruction on alternate months |
| C0422 - Fire and Life Safety: Training For Residents: Failed to ensure residents were instructed on fire and life safety procedures within 24 hours of admission and annually |
| C0455 - Inspections and Investigation: Insp Interval: Failed to ensure re-licensure survey plan of correction was implemented and satisfied the Department |
| C0513 - Doors, Walls, Elevators, Odors: Failed to ensure environment was kept clean and in good repair |
| C0510 - General Building Exterior: Failed to provide accessible outdoor recreation area |
| C0010 - Licensing Complaint Investigation: Complaint investigation findings documented |
| C0243 - Resident Services: Adls: Failed to provide assistance with bathing and washing hair |
| C0361 - Acuity-Based Staffing Tool: Failed to fully implement and update acuity-based staffing tool |
| C0290 - Res Hlth Srvc: On- and Off-Site Health Srvc: Failed to ensure information and interventions from outside providers were communicated and service plans adjusted |
| C0302 - Systems: Tracking Control Substances: Failed to have effective system for tracking controlled substances |
| C0252 - Resident Move-In and Eval: Res Evaluation: Failed to ensure move-in evaluations addressed all required elements and were updated within 30 days |
| C0370 - Staffing Requirements and Training – Pre-Serv: Failed to provide staff with orientation to resident including service plan |
| C0000 - Comment: Various comments and findings documented |
Report Facts
Total inspections: 10
Total deficiencies: 57
Licensing violations: 10
Notices: 10
Licensed beds: 68
Census: 51
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Executive Director | Named in multiple findings including kitchen sanitation, complaint investigations, staffing, and administrative oversight |
| Staff 2 | Regional Director of Operations / Health Services Director / Assistant ED | Named in multiple findings related to medication errors, staffing, and administrative compliance |
| Staff 3 | Director of Nursing | Named in medication error findings and staffing tool updates |
| Staff 4 | Business Office Manager | Named in staffing and administrative findings |
| Staff 5 | Med Tech | Named in medication error findings |
| Staff 6 | Health Services Director, RN | Named in multiple findings including infection control, medication administration, and resident care |
| Staff 7 | Vice President of Clinical Operations | Named in administrative and compliance findings |
| Staff 9 | Caregiver | Named in staffing and resident care findings |
| Staff 10 | Caregiver | Named in staffing and resident care findings |
| Staff 11 | Med Tech | Named in medication administration and training findings |
| Staff 12 | Caregiver | Named in staffing and resident care findings |
| Staff 13 | Business Office Manager | Named in medication administration findings |
| Staff 15 | Regional Director of Nursing | Named in medication administration and infection control findings |
| Staff 18 | Administrator | Named in complaint investigation and infection control findings |
| Staff 20 | Vice President of Clinical Operations | Named in complaint investigation and infection control findings |
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