Inspection Report Summary
The most recent inspection on November 19, 2025, identified deficiencies related to monitoring changes of condition, controlled substances tracking, staff training, and compliance with administration and health care rules. Earlier inspections showed recurring issues with resident care monitoring, staff training, medication administration, and food sanitation, with some deficiencies corrected after revisits. Complaint investigations found deficiencies in abuse reporting, service plans, staffing tools, and individualized care programs, but no enforcement actions or fines were listed in the available reports. Most complaints were unsubstantiated, and no license suspensions or fines were noted. The facility’s inspection history shows ongoing challenges in several areas without a clear pattern of overall improvement or worsening.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
7.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
9% worse than Oregon average
Oregon average: 6.7 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Re-licensure
Capacity: 28
Deficiencies: 5
Date: Nov 19, 2025
Visit Reason
Facility failed to determine, communicate, and monitor actions or interventions for changes of condition for sampled residents. Controlled substances tracking system was inadequate. Staff training within 30 days of hire was incomplete. Facility failed to comply with licensing rules for administration and health care services.
Findings
Facility failed to determine, communicate, and monitor actions or interventions for changes of condition for sampled residents. Controlled substances tracking system was inadequate. Staff training within 30 days of hire was incomplete. Facility failed to comply with licensing rules for administration and health care services.
Deficiencies (5)
OAR 411-054-0040 — Change of Condition and Monitoring
OAR 411-054-0055 — Systems: Tracking Control Substances
OAR 411-054-0070 — Training Within 30 Days of Hire – Direct Care Staff
OAR 411-057-0140 — Administration Compliance
OAR 411-057-0160 — Compliance with Rules Health Care
Inspection Report
State Licensure
Capacity: 28
Deficiencies: 3
Date: May 16, 2024
Visit Reason
Kitchen inspection revealed multiple sanitation deficiencies initially not corrected by revisit. Facility failed to follow licensing rules for Residential Care and Assisted Living Facilities.
Findings
Kitchen inspection revealed multiple sanitation deficiencies initially not corrected by revisit. Facility failed to follow licensing rules for Residential Care and Assisted Living Facilities.
Deficiencies (3)
OAR 411-054-0030 — Resident Services Meals, Food Sanitation Rule
OAR 411-054-0030 — Resident Services Meals, Food Sanitation Rule
OAR 411-057-0140 — Administration Compliance
Inspection Report
Complaint Investigation
Capacity: 28
Deficiencies: 7
Date: May 15, 2024
Visit Reason
Facility failed to immediately notify authorities of abuse incidents, lacked complete service plans, failed medication administration systems, did not fully implement acuity-based staffing tool, and failed to provide individualized nutrition, hydration, and activities programs.
Findings
Facility failed to immediately notify authorities of abuse incidents, lacked complete service plans, failed medication administration systems, did not fully implement acuity-based staffing tool, and failed to provide individualized nutrition, hydration, and activities programs.
Deficiencies (7)
OAR 411-054-0010 — Licensing Complaint Investigation
OAR 411-054-0231 — Reporting & Investigating Abuse-Other Action
OAR 411-054-0260 — Service Plan: General
OAR 411-054-0310 — Systems: Medication Administration
OAR 411-054-0361 — Acuity-Based Staffing Tool
OAR 411-054-0163 — Nutrition and Hydration
OAR 411-054-0164 — Activities
Inspection Report
State Licensure
Capacity: 28
Deficiencies: 1
Date: Jul 7, 2023
Visit Reason
Kitchen inspection found facility in substantial compliance with food sanitation rules.
Findings
Kitchen inspection found facility in substantial compliance with food sanitation rules.
Deficiencies (1)
OAR 411-054-0000 — Comment
Inspection Report
Validation
Capacity: 28
Deficiencies: 13
Date: Aug 8, 2022
Visit Reason
Facility failed to monitor changes of condition, provide resident-specific instructions, maintain documentation of outside service providers, notify physicians of medication refusals, ensure staff training compliance, conduct fire drills, maintain building repairs, and implement acuity-based staffing tool. Many deficiencies were corrected by revisit in December 2022.
Findings
Facility failed to monitor changes of condition, provide resident-specific instructions, maintain documentation of outside service providers, notify physicians of medication refusals, ensure staff training compliance, conduct fire drills, maintain building repairs, and implement acuity-based staffing tool. Many deficiencies were corrected by revisit in December 2022.
Deficiencies (13)
OAR 411-054-0000 — Comment
OAR 411-054-0270 — Change of Condition and Monitoring
OAR 411-054-0280 — Resident Health Services
OAR 411-054-0290 — On- and Off-Site Health Services
OAR 411-054-0305 — Resident Right to Refuse
OAR 411-054-0330 — Psychotropic Medication
OAR 411-054-0361 — Acuity-Based Staffing Tool
OAR 411-054-0372 — Training Within 30 Days: Direct Care Staff
OAR 411-054-0420 — Fire and Life Safety: Safety
OAR 411-054-0513 — Doors, Walls, Elevators, Odors
OAR 411-057-0140 — Administration Compliance
OAR 411-057-0155 — Staff Training Requirements
OAR 411-057-0162 — Compliance With Rules Health Care
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