Deficiencies per Year
80
60
40
20
0
Unclassified
Inspection Report
Capacity: 92
Deficiencies: 41
Nov 21, 2025
Visit Reason
State-compiled facility profile showing 10 inspections from 2022-2025 with detailed deficiency history and enforcement actions.
Findings
Across multiple inspections from 2022 to 2025, the facility exhibited numerous deficiencies including failures in infection prevention, abuse prevention and investigation, staffing shortages, medication management, care planning, and environmental safety. Several deficiencies were repeated or not corrected, placing residents at risk for harm, unmet needs, and reduced quality of life.
Complaint Details
Multiple complaint investigations were conducted across inspections, including allegations of physical and verbal abuse, inadequate staffing, failure to report incidents timely, and failure to investigate injuries and abuse thoroughly.
Deficiencies (41)
| Description |
|---|
| F0000 - INITIAL COMMENTS |
| F0880 - Infection Prevention & Control: Failed to ensure proper infection control practices including PPE use and sterile procedures. |
| F0600 - Free from Abuse and Neglect: Failed to protect residents from physical and verbal abuse by staff. |
| M0000 - Initial Comments |
| M9999 - STATE OF OREGON ADMINISTRATIVE RULES: Refer to multiple cited deficiencies including F577, F582, F602, F607, F609, F610, F656, F684, F688, F690, F727, F761, F812, F838, F847, F865, F867, F883, F921. |
| F0842 - Resident Records - Identifiable Information: Failed to ensure accurate and complete resident records. |
| F0602 - Free from Misappropriation/Exploitation: Failed to ensure residents were free from medication misappropriation. |
| F0607 - Develop/Implement Abuse/Neglect Policies: Failed to implement thorough abuse investigation policies and coordination with QAPI. |
| F0609 - Reporting of Alleged Violations: Failed to report abuse allegations within mandated timeframes. |
| F0610 - Investigate/Prevent/Correct Alleged Violation: Failed to thoroughly investigate alleged abuse and injuries of unknown cause. |
| F0656 - Develop/Implement Comprehensive Care Plan: Failed to develop timely and comprehensive care plans addressing dental and other needs. |
| F0684 - Quality of Care: Failed to provide care and treatment as ordered for multiple residents including skin and medication monitoring. |
| F0688 - Increase/Prevent Decrease in ROM/Mobility: Failed to provide appropriate restorative services to prevent decline in range of motion. |
| F0690 - Bowel/Bladder Incontinence, Catheter, UTI: Failed to provide adequate incontinence care. |
| F0727 - RN 8 Hrs/7 days/Wk, Full Time DON: Failed to ensure RN coverage for eight consecutive hours daily. |
| F0761 - Label/Store Drugs and Biologicals: Failed to remove expired medications and secure medication carts. |
| F0791 - Routine/Emergency Dental Srvcs in NFs: Failed to ensure prompt dental services were obtained. |
| F0812 - Food Procurement,Store/Prepare/Serve-Sanitary: Failed to ensure sanitary food storage and handling. |
| F0838 - Facility Assessment: Failed to conduct a comprehensive facility-wide assessment. |
| F0847 - Entering into Binding Arbitration Agreements: Failed to ensure residents understood arbitration agreements. |
| F0865 - QAPI Prgm/Plan, Disclosure/Good Faith Attmpt: Failed to implement effective QAPI program addressing deficiencies. |
| F0867 - QAPI/QAA Improvement Activities: Failed to identify and correct quality deficiencies systematically. |
| F0883 - Influenza and Pneumococcal Immunizations: Failed to offer vaccines and obtain consents timely. |
| F0887 - COVID-19 Immunization: Failed to provide COVID-19 vaccine information and obtain consents. |
| F0921 - Safe/Functional/Sanitary/Comfortable Environ: Failed to maintain functional and comfortable environment including shower room heater. |
| M0182 - Nursing Services:Minimum Licensed Nurse Staff: Failed to maintain minimum RN coverage for charge nurse duties. |
| M0183 - Nursing Services: Minimum CNA Staffing: Failed to maintain minimum CNA staffing ratios. |
| F0552 - Right to be Informed/Make Treatment Decisions: Failed to provide risk and benefit information for psychotropic medications. |
| F0610 - Investigate/Prevent/Correct Alleged Violation: Failed to thoroughly investigate injuries and abuse allegations. |
| F0554 - Resident Self-Admin Meds-Clinically Approp: Failed to assess residents for safe self-administration of medications. |
| F0561 - Self-Determination: Failed to honor resident requests for medical appointments. |
| F0578 - Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir: Failed to obtain copies of advance directives. |
| F0584 - Safe/Clean/Comfortable/Homelike Environment: Failed to maintain clean and comfortable environment including bathroom floors. |
| F0609 - Reporting of Alleged Violations: Failed to report abuse incidents timely. |
| F0689 - Free of Accident Hazards/Supervision/Devices: Failed to provide adequate supervision to prevent elopement and falls. |
| F0697 - Pain Management: Failed to manage pain adequately and maintain medication availability. |
| F0725 - Sufficient Nursing Staff: Failed to provide sufficient nursing staff to meet resident needs. |
| F0801 - Qualified Dietary Staff: Failed to ensure qualified dietitian consultation. |
| F0810 - Assistive Devices - Eating Equipment/Utensils: Failed to provide appropriate adaptive eating equipment. |
| F0840 - Resident Allergies, Preferences, Substitutes: Failed to accommodate resident meal preferences. |
| F0908 - Essential Equipment, Safe Operating Condition: Failed to maintain resident care equipment in safe operating condition. |
Report Facts
Inspections on page: 10
Total deficiencies: 77
Total surveys: 10
Licensing violations: 20
Notices: 3
Days without RN coverage: 44
Days without minimum CNA staffing: 27
Days without RN coverage for 8 consecutive hours: 17
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Administrator / Executive Director | Named in multiple findings related to facility oversight, abuse investigations, staffing, and compliance monitoring. |
| Staff 2 | Director of Nursing (DNS) | Named in multiple findings related to nursing coverage, abuse investigations, infection control, and compliance. |
| Staff 3 | Regional Director of Clinical Operations | Named in findings related to abuse investigations, QAPI program, and compliance monitoring. |
| Staff 5 | Social Services Director | Named in abuse investigation findings and education related to abuse and neglect. |
| Staff 9 | LPN (Former CNA in abuse case) | Named in abuse allegation involving Resident 2. |
| Staff 19 | LPN | Named in infection control deficiency related to catheter irrigation. |
| Staff 25 | Business Office Manager | Named in findings related to arbitration agreement education. |
| Staff 33 | CNA | Named as alleged perpetrator in abuse investigations. |
| Staff 41 | CNA | Named as alleged perpetrator in abuse investigations. |
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