Deficiencies (last 3 years)
Deficiencies (over 3 years)
11.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
75% worse than Oregon average
Oregon average: 6.7 deficiencies/yearDeficiencies per year
28
21
14
7
0
Census
Latest occupancy rate
71% occupied
Based on a October 2025 inspection.
Census over time
Inspection Report
Census: 40
Capacity: 56
Deficiencies: 27
Oct 10, 2025
Visit Reason
Multiple deficiencies identified including ineffective quality improvement program, failure to report and investigate abuse, incomplete resident evaluations and service plans, inadequate monitoring of changes of condition, insufficient resident health services assessments, infection control lapses, medication administration issues, staffing shortages and training deficiencies, and failure to maintain privacy and dignity of residents.
Findings
Multiple deficiencies identified including ineffective quality improvement program, failure to report and investigate abuse, incomplete resident evaluations and service plans, inadequate monitoring of changes of condition, insufficient resident health services assessments, infection control lapses, medication administration issues, staffing shortages and training deficiencies, and failure to maintain privacy and dignity of residents.
Deficiencies (27)
| Description |
|---|
| OAR 411-054-0025 (9) Facility Administration: Quality Improvement (9) QUALITY IMPROVEMENT PROGRAM. The facility must develop and conduct an ongoing quality improvement program. |
| OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place. |
| OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. |
| OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate it. |
| OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short-term or significant. |
| OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services. |
| OAR 411-054-0045(2) Res Hlth Srvc: On- and Off-Site Health Srvc (2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in access to health services. |
| OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control programs. |
| OAR 411-054-0055 (1)(e) Systems: Tracking Control Substances (e) The facility must have a system approved by a pharmacist consultant or registered nurse. |
| OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept. |
| OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription. |
| OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff. |
| OAR 411-054-0037 (1a)(2-3) Acuity Based Staffing Tool - Elements (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING. Facilities must select and implement an acuity-based staffing tool. |
| OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements. |
| OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST. |
| OAR 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job duties. |
| OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. |
| OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures. |
| OAR411-004-0020(1)(c) Individual Rights Settings: Privacy, Dignity (1) Residential and non-residential HCB settings must have all of the following qualities. |
| OAR411-004-0020(2)(d) Individual Privacy: Own Unit (2) Provider owned, controlled, or operated residential settings must have all of the following qualities. |
| OAR 411-054-0034 (1)(c)(B)&(5)(a)(A-C) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. |
| OAR 411-057-0140(1) Administration Responsibilities (1) The licensee is responsible for the operation of the memory care community and the provision of services. |
| OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and applicable laws. |
| OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a comprehensive training program. |
| OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. |
| OAR 411-057-0160(2)(c)(A)(B) Nutrition and Hydration (c) A daily meal program for nutrition and hydration must be provided based upon the resident's needs. |
| OAR 411-057-0160(2d) Activities (d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. |
Inspection Report
Complaint Investigation
Census: 40
Capacity: 56
Deficiencies: 2
Jul 17, 2024
Visit Reason
Facility failed to implement a service plan reflecting resident needs and failed to fully implement and update an acuity-based staffing tool. Issues included lack of hospice notification and incomplete staffing plan updates.
Findings
Facility failed to implement a service plan reflecting resident needs and failed to fully implement and update an acuity-based staffing tool. Issues included lack of hospice notification and incomplete staffing plan updates.
Deficiencies (2)
| Description |
|---|
| OAR 411-054-0036 (1-4) Service Plan: General (ALL deficiencies merged) |
| OAR 411-054-0037 Acuity Based Staffing Tool - Documentation (ALL deficiencies merged) |
Inspection Report
Census: 40
Capacity: 56
Deficiencies: 2
Feb 26, 2024
Visit Reason
Kitchen inspection revealed multiple food sanitation violations including unclean equipment and improper sanitizer monitoring. Facility failed to follow infection control and licensing rules. Some issues were corrected by revisit.
Findings
Kitchen inspection revealed multiple food sanitation violations including unclean equipment and improper sanitizer monitoring. Facility failed to follow infection control and licensing rules. Some issues were corrected by revisit.
Deficiencies (2)
| Description |
|---|
| OAR 411-054-0030 Resident Services Meals, Food Sanitation Rule (ALL deficiencies merged) |
| OAR 411-057-0140 Administration Compliance (ALL deficiencies merged) |
Inspection Report
Census: 40
Capacity: 56
Deficiencies: 4
May 8, 2023
Visit Reason
Re-licensure survey found the facility in substantial compliance with some deficiencies in reasonable precautions, infection control, food sanitation, staff training, and individualized activity plans. Some deficiencies were corrected by revisit.
Findings
Re-licensure survey found the facility in substantial compliance with some deficiencies in reasonable precautions, infection control, food sanitation, staff training, and individualized activity plans. Some deficiencies were corrected by revisit.
Deficiencies (4)
| Description |
|---|
| OAR 411-054-0160 Reasonable Precautions and Infection Control (ALL deficiencies merged) |
| OAR 411-054-0030 Resident Services Meals, Food Sanitation Rule (ALL deficiencies merged) |
| OAR 411-057-0155 Staff Training Requirements (ALL deficiencies merged) |
| OAR 411-057-0160 Activities (ALL deficiencies merged) |
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