Deficiencies per Year
28
21
14
7
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Re-Inspection
Capacity: 18
Deficiencies: 25
Oct 30, 2025
Visit Reason
State-compiled facility profile showing 5 inspections from 2022 to 2025 with deficiency history and enforcement actions
Findings
Across multiple inspections from 2022 to 2025, the facility exhibited numerous deficiencies including failure to investigate and report abuse, inadequate resident services and activities, insufficient infection control, incomplete staff training, fire and life safety noncompliance, environmental maintenance issues, and deficiencies in kitchen sanitation and food safety. Many findings were repeated or not corrected at follow-up visits.
Severity Breakdown
Not Corrected: 27
Deficiencies (25)
| Description | Severity |
|---|---|
| C0231 - Reporting & Investigating Abuse-Other Action: Failed to ensure incidents and injuries of unknown cause were promptly investigated and reported to local SPD | Not Corrected |
| C0242 - Resident Services: Activities: Failed to provide a daily program of social and recreational activities based on resident needs | Not Corrected |
| C0270 - Change of Condition and Monitoring: Failed to ensure resident-specific instructions and weekly progress documentation for short term changes of condition | Not Corrected |
| C0295 - Infection Prevention & Control: Failed to ensure proper infection control practices during meal service | Not Corrected |
| C0372 - Training Within 30 Days of Hire – Direct Care Staff: Failed to ensure newly hired staff demonstrated competency in required areas within 30 days | Not Corrected |
| C0420 - Fire and Life Safety: Safety: Failed to conduct fire drills according to Oregon Fire Code on alternate months with required documentation | Not Corrected |
| C0422 - Fire and Life Safety: Training for Residents: Failed to ensure residents received fire and life safety training within 24 hours of admission and annually | Not Corrected |
| C0513 - Doors, Walls, Elevators, Odors: Failed to maintain environment clean and in good repair including carpet stains, damaged furniture, and missing flooring | Not Corrected |
| C0555 - Call Sys, Exit Dr Alarm, Phones, TV, or Cable: Failed to provide manually operated emergency call system in resident-used toilet facilities | Not Corrected |
| H1517 - Individual Privacy: Own Unit: Failed to ensure privacy due to no locks on shared bathroom doors | Not Corrected |
| H1518 - Individual Door Locks: Key Access: Failed to provide residents keys to their individual units | Not Corrected |
| Z0142 - Administration Compliance: Failed to comply with licensing rules for Residential Care and Assisted Living Facilities | Not Corrected |
| Z0155 - Staff Training Requirements: Failed to ensure staff completed required orientation, pre-service, dementia, and annual in-service training | Not Corrected |
| Z0162 - Compliance with Rules Health Care: Failed to provide health care services in accordance with licensing rules | Not Corrected |
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to maintain kitchen in good repair and sanitary manner, and ensure food safety | Not Corrected |
| C0000 - Comment: Documented findings of kitchen inspections and re-visits | Not Corrected |
| C0252 - Resident Move-In and Eval: Res Evaluation: Failed to ensure move-in evaluations addressed all required elements | Not Corrected |
| C0260 - Service Plan: General: Failed to ensure service plans were reflective of residents' current care needs and provided clear direction | Not Corrected |
| C0280 - Resident Health Services: Failed to ensure RN assessment for significant changes of condition | Not Corrected |
| C0310 - Systems: Medication Administration: Failed to ensure MARs included medication-specific parameters for PRN medications | Not Corrected |
| C0330 - Systems: Psychotropic Medication: Failed to ensure resident-specific parameters and non-drug interventions for PRN psychotropic medications | Not Corrected |
| C0361 - Acuity-Based Staffing Tool: Failed to complete and update acuity-based staffing tool for all residents | Not Corrected |
| Z0163 - Nutrition and Hydration: Failed to develop and follow individualized nutrition and hydration plans | Not Corrected |
| Z0164 - Activities: Failed to provide meaningful individualized activity plans for residents | Not Corrected |
| Z0165 - Behavior: Failed to provide individualized service plan for behavioral symptoms | Not Corrected |
Report Facts
Inspections on page: 5
Total deficiencies: 36
Total surveys: 5
Licensing violations: 10
Abuse violations: 0
Notices: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Executive Director (ED) | Named in multiple findings including abuse reporting, infection control, staff training, fire safety, and administration compliance |
| Staff 2 | Memory Care Director (AHSD) | Named in findings related to abuse reporting, infection control, activities, and staff training |
| Staff 3 | Licensed Practical Nurse (LPN) | Named in findings related to abuse reporting, infection control, and staff training |
| Staff 9 | Caregiver (CG) | Named in staff training deficiencies |
| Staff 13 | Caregiver (CG) | Named in staff training deficiencies |
| Staff 16 | Caregiver (CG) | Named in staff training deficiencies |
| Staff 10 | Caregiver (CG) | Named in infection control and call system findings |
| Staff 12 | Caregiver (CG) | Named in infection control and activities findings |
| Staff 5 | Caregiver (CG) | Named in call system deficiency |
| Staff 6 | Memory Care Director | Named in privacy and fire safety findings |
| Staff 3 | Regional RN | Named in multiple findings related to assessments and acuity staffing |
| Staff 15 | Caregiver (CG) | Named in staff training and service plan deficiencies |
| Staff 7 | Medication Technician (MT) | Named in staff training deficiencies |
| Staff 2 | Dining Services Director | Named in kitchen sanitation and food safety findings |
| Staff 3 | Maintenance Director | Named in kitchen sanitation and fire safety findings |
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