Deficiencies per Year
24
18
12
6
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Complaint Investigation
Capacity: 72
Deficiencies: 24
Apr 29, 2025
Visit Reason
State-compiled facility profile showing 10 inspections from 2023-2025 with deficiency history and enforcement violations.
Findings
Across multiple inspections from 2023 to 2025, the facility exhibited numerous deficiencies including failures in quality of care, medication administration, infection control reporting, pressure ulcer treatment, trauma-informed care, and medication storage. Several deficiencies remained uncorrected at follow-up visits, indicating ongoing compliance challenges.
Complaint Details
Multiple inspections were complaint investigations related to licensure complaints and state licensure issues, including failure to investigate abuse allegations and medication misappropriation.
Deficiencies (24)
| Description |
|---|
| F0000 - INITIAL COMMENTS |
| F0684 - Quality of Care: Failed to follow physician orders for therapy, incontinence care, and call light accessibility for residents. |
| M0000 - Initial Comments |
| M9999 - STATE OF OREGON ADMINISTRATIVE RULES: Refer to F684 |
| F0552 - Right to be Informed/Make Treatment Decisions: Failed to obtain consent prior to vaccine administration. |
| F0578 - Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir: Failed to obtain advance directives for a resident. |
| F0610 - Investigate/Prevent/Correct Alleged Violation: Failed to thoroughly investigate abuse allegations. |
| F0685 - Treatment/Devices to Maintain Hearing/Vision: Failed to address orders for corrective lenses. |
| F0686 - Treatment/Svcs to Prevent/Heal Pressure Ulcer: Failed to assess and monitor pressure ulcers and provide appropriate wound care. |
| F0689 - Free of Accident Hazards/Supervision/Devices: Failed to monitor residents at risk for elopement and follow safety care plans. |
| F0699 - Trauma Informed Care: Failed to provide trauma-informed care and include trauma triggers in care plans. |
| F0756 - Drug Regimen Review, Report Irregular, Act On: Failed to address pharmacy recommendations for medications. |
| F0770 - Laboratory Services: Failed to process physician laboratory orders timely. |
| F0791 - Routine/Emergency Dental Srvcs in NFs: Failed to make dental appointment for resident. |
| F0884 - Reporting - National Health Safety Network: Failed to report complete COVID-19 information to CDC's NHSN during required periods. |
| F0677 - ADL Care Provided for Dependent Residents: Failed to provide incontinence care for dependent residents. |
| F0658 - Services Provided Meet Professional Standards: Failed to adhere to medication administration standards causing significant medication errors. |
| F0684 - Quality of Care: Failed to ensure medications were available per physician orders for multiple residents. |
| F0686 - Treatment/Svcs to Prevent/Heal Pressure Ulcer: Failed to ensure weekly skin and wound assessments and appropriate wound care. |
| F0755 - Pharmacy Srvcs/Procedures/Pharmacist/Records: Failed to ensure safe and secure handling of controlled medications and adherence to best practices. |
| F0760 - Residents are Free of Significant Med Errors: Failed to administer medication for prevention of blood clots resulting in significant medication error. |
| F0761 - Label/Store Drugs and Biologicals: Failed to ensure controlled drugs were accurately identified, counted, and stored securely. |
| F0812 - Food Procurement,Store/Prepare/Serve-Sanitary: Failed to store milk-based nutritional supplements correctly. |
| F0842 - Resident Records - Identifiable Information: Failed to ensure medical records were complete and accurately documented; evidence of copied and pasted notes. |
Report Facts
Inspections on page: 10
Total Surveys: 10
Total Deficiencies: 27
Licensing Violations: 20
Abuse Violations: 0
Notices: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Paige Ryan | Administrator | Named in multiple findings related to facility administration and oversight |
| Staff 1 | Administrator | Named in findings related to quality of care and investigations |
| Staff 2 | Director of Nursing Services (DNS) | Named in multiple findings related to investigations, medication errors, and oversight |
| Staff 3 | RN Consultant Manager (RNCM) | Named in medication error and wound care findings |
| Staff 8 | LPN Resident Care Manager | Named in medication and care findings |
| Staff 9 | LPN | Named in medication errors and documentation deficiencies |
| Staff 15 | CMA | Named in medication errors and quality of care findings |
| Staff 16 | CNA | Named in incontinence care deficiency and termination |
| Staff 19 | LPN | Named in medication errors |
| Staff 6 | Nurse Practitioner (NP) | Interviewed regarding medication and wound care deficiencies |
| Staff 10 | CNA | Named in pressure ulcer care findings |
| Staff 11 | CNA | Named in pressure ulcer care and trauma-informed care findings |
| Staff 14 | CNA | Named in pressure ulcer care findings |
| Staff 7 | CNA | Named in abuse investigation and accident hazard findings |
| Staff 4 | PCA | Named in incontinence care findings |
| Staff 5 | LPN | Named in accident hazard findings |
| Staff 3 | Social Service Director | Named in advance directive and dental appointment findings |
| Staff 8 | CNA | Named in incontinence care findings |
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