Inspection Report
Capacity: 118
Deficiencies: 12
Oct 30, 2025
Visit Reason
State-compiled facility profile showing 4 inspections from 2023-2025 with deficiency history and enforcement violations.
Findings
Across multiple inspections from 2023 to 2025, the facility exhibited deficiencies primarily related to kitchen sanitation, infection prevention and control, service plan accuracy, nursing delegation, fire and life safety, building maintenance, and plumbing systems. Some deficiencies were repeated and several plans of correction were implemented or planned.
Deficiencies (12)
| Description |
|---|
| C0240 - Resident Services Meals, Food Sanitation Rule: Facility failed to maintain kitchen sanitation and ensure food was prepared and served according to Food Sanitation Rules, including multiple areas with food spills, dirt, grease, and needed repairs. |
| C0295 - Infection Prevention & Control: Facility failed to have a designated Infection Control Specialist who completed required specialized training. |
| C0240 - Resident Services Meals, Food Sanitation Rule: Facility failed to ensure kitchen practices and protocols met Food Sanitation Rules; issues included food debris buildup, equipment needing repair, and improper food storage. |
| C0000 - Comment: Findings documented for re-licensure survey and revisits indicating compliance status. |
| C0260 - Service Plan: General: Facility failed to ensure service plans were reflective and provided clear direction for residents' care needs, including repeat citations. |
| C0282 - Rn Delegation and Teaching: Facility failed to ensure proper delegation and supervision of nursing tasks by unlicensed staff, including documentation deficiencies. |
| C0295 - Infection Prevention & Control: Facility failed to maintain infection prevention protocols during meal service, including improper glove use and hand hygiene. |
| C0420 - Fire and Life Safety: Safety: Facility failed to conduct and document fire drills and staff training according to Oregon Fire Code requirements, including repeat citations. |
| C0455 - Inspections and Investigation: Insp Interval: Facility failed to ensure re-licensure survey plan of correction was implemented and satisfied the Department. |
| C0610 - General Building Exterior: Facility failed to maintain exterior surfaces in good repair, including multiple drop-offs on pathways creating tripping hazards. |
| C0613 - General Building: Doors-Walls, Cleanable: Facility failed to keep environment clean and in good repair, including scuffed doors, stained carpet, and pervasive urine odor. |
| C0645 - Plumbing Systems: Facility failed to maintain water temperatures in residents' units within required range of 110-120 degrees Fahrenheit, including repeat citations. |
Report Facts
Inspections on page: 4
Total deficiencies: 12
Total surveys: 4
Total licensing violations: 18
Total abuse violations: 0
Total notices: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Steve Matthews | Executive Director | Named in multiple findings and plans of correction |
| Robert Kutschke | Dining Service Director | Named in kitchen sanitation deficiency findings and plans of correction |
| Staff 1 | Executive Director | Referenced in multiple inspection findings and acknowledgments |
| Staff 2 | Dining Service Director | Referenced in kitchen inspection findings and acknowledgments |
| Staff 3 | Resident Services Director, RN | Referenced in service plan and infection control findings |
| Staff 4 | Cook / Maintenance Director | Referenced in kitchen inspection findings |
| Staff 5 | Plant Operations Director | Referenced in fire and life safety findings and plans of correction |
| Staff 6 | Med Tech | Referenced in nursing delegation deficiency |
| Staff 8 | Med Tech | Referenced in nursing delegation deficiency |
| Staff 10 | Med Tech | Referenced in nursing delegation deficiency |
| Staff 11 | Plant Ops Associate | Referenced in plumbing systems inspection |
| Staff 19 | Plant Operations Director | Referenced in fire and life safety and plumbing systems inspections |
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