Deficiencies per Year
80
60
40
20
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Complaint Investigation
Census: 46
Capacity: 53
Deficiencies: 47
Nov 19, 2025
Visit Reason
State-compiled facility profile showing 10 inspections from 2023-2025 with detailed deficiency history and enforcement findings.
Findings
Across multiple inspections, the facility exhibited numerous deficiencies including failure to follow physician orders, inadequate infection control practices, incomplete care plans, failure to protect residents from abuse, and lapses in staff training and competency. Several deficiencies were not corrected at follow-up visits, indicating ongoing compliance challenges.
Complaint Details
Multiple complaint investigations were conducted including failures in medication administration, abuse reporting and investigation, infection control, and resident rights violations.
Severity Breakdown
Immediate Jeopardy: 1
Deficiencies (47)
| Description | Severity |
|---|---|
| F0000 - INITIAL COMMENTS | — |
| F0684 - Quality of Care: Medication errors including excessive oxycodone dosing and wrong medication administration to residents. | — |
| M0000 - Initial Comments | — |
| M9999 - STATE OF OREGON ADMINISTRATIVE RULES | — |
| F0689 - Free of Accident Hazards/Supervision/Devices: Failed to ensure falls were evaluated and care plan interventions followed for sampled residents. | — |
| F0880 - Infection Prevention & Control: Failed to ensure staff followed contact precautions and proper glove and PPE use during wound care. | — |
| F0554 - Resident Self-Admin Meds-Clinically Approp: Failed to assess and evaluate resident's ability to safely self-administer medications. | — |
| F0559 - Choose/Be Notified of Room/Roommate Change: Failed to provide written notification to residents prior to room or roommate changes. | — |
| F0578 - Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir: Failed to provide information on formulating advanced directives to resident. | — |
| F0582 - Medicaid/Medicare Coverage/Liability Notice: Failed to provide required and complete liability notices timely to residents. | — |
| F0600 - Free from Abuse and Neglect: Failed to protect residents from verbal and physical abuse and failed to report allegations timely. | — |
| F0609 - Reporting of Alleged Violations: Failed to report allegations of abuse timely and failed to investigate abuse allegations properly. | — |
| F0638 - Qrtly Assessment at Least Every 3 Months: Failed to complete quarterly MDS assessments timely for sampled residents. | — |
| F0656 - Develop/Implement Comprehensive Care Plan: Failed to develop timely comprehensive care plans for sampled residents. | — |
| F0657 - Care Plan Timing and Revision: Failed to revise care plans to reflect resident-centered care and involve residents/representatives. | — |
| F0658 - Services Provided Meet Professional Standards: Failed to follow manufacturer instructions for insulin pen priming during administration. | — |
| F0684 - Quality of Care: Failed to follow orders for thickened liquids and bowel care resulting in risk for aspiration and constipation. | — |
| F0689 - Free of Accident Hazards/Supervision/Devices: Failed to conduct timely smoking evaluations and implement interventions after smoking incident. | — |
| F0698 - Dialysis: Failed to provide ongoing assessment and monitoring for complications after dialysis treatments. | — |
| F0726 - Competent Nursing Staff: Failed to ensure staff had mandatory training, competencies, and skills necessary to provide nursing services. | — |
| F0756 - Drug Regimen Review, Report Irregular, Act On: Failed to ensure physician response to pharmacy recommendations for antibiotic use. | — |
| F0757 - Drug Regimen is Free from Unnecessary Drugs: Failed to hold antihypertensive medications per physician parameters, risking adverse effects. | — |
| F0758 - Free from Unnec Psychotropic Meds/PRN Use: Failed to ensure PRN psychotropic medications had required 14-day stop dates. | — |
| F0867 - QAPI/QAA Improvement Activities: Failed to develop and implement effective QAPI program with measurable goals and follow-up. | — |
| F0868 - QAA Committee: Failed to maintain QAA committee with required participants for two quarters. | — |
| F0880 - Infection Prevention & Control: Failed to maintain effective infection prevention program including proper glucometer disinfection and hand hygiene. | Immediate Jeopardy |
| F0947 - Required In-Service Training for Nurse Aides: Failed to ensure CNA staff received required abuse, neglect, and dementia care in-service training. | — |
| F0561 - Self-Determination: Failed to promote self-determination and honor room preferences for sampled resident. | — |
| F0583 - Personal Privacy/Confidentiality of Records: Failed to ensure personal privacy during medical conversations. | — |
| F0584 - Safe/Clean/Comfortable/Homelike Environment: Failed to maintain carpet, flooring, and doors in good repair. | — |
| F0677 - ADL Care Provided for Dependent Residents: Failed to provide appropriate grooming and hygiene assistance. | — |
| F0690 - Bowel/Bladder Incontinence, Catheter, UTI: Failed to provide adequate support to maintain continence. | — |
| F0695 - Respiratory/Tracheostomy Care and Suctioning: Failed to follow physician orders for continuous oxygen use and humidification. | — |
| F0761 - Label/Store Drugs and Biologicals: Failed to ensure medication storage areas were free of expired medications. | — |
| F0868 - QAA Committee: Failed to have Medical Director attend QAA/QAPI meetings. | — |
| F0561 - Self-Determination: Failed to promote self determination for resident regarding room changes. | — |
| F0582 - Medicaid/Medicare Coverage/Liability Notice: Failed to inform residents in writing of financial coverage changes. | — |
| F0584 - Safe/Clean/Comfortable/Homelike Environment: Failed to maintain facility environment in good repair. | — |
| F0656 - Develop/Implement Comprehensive Care Plan: Failed to develop comprehensive person-centered care plan for resident. | — |
| F0677 - ADL Care Provided for Dependent Residents: Failed to provide appropriate ADL assistance for resident. | — |
| F0690 - Bowel/Bladder Incontinence, Catheter, UTI: Failed to support continence for resident. | — |
| F0695 - Respiratory/Tracheostomy Care and Suctioning: Failed to follow oxygen therapy orders for resident. | — |
| F0730 - Nurse Aide Perform Review-12 hr/yr In-Service: Failed to complete annual performance reviews for CNA staff. | — |
| F0761 - Label/Store Drugs and Biologicals: Failed to store drugs and biologicals in locked compartments. | — |
| F0842 - Resident Records - Identifiable Information: Failed to ensure physician visit notes were in clinical record. | — |
| F0947 - Required In-Service Training for Nurse Aides: Failed to ensure CNA staff received 12 hours annual in-service training. | — |
| M0183 - Nursing Services: Minimum CNA Staffing: Failed to maintain state minimum CNA staffing ratios. | — |
Report Facts
Inspections on page: 10
Total deficiencies: 44
Total surveys: 10
Licensed beds: 53
Facility census: 46
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 5 | LPN | Named in medication error finding related to excessive oxycodone dosing |
| Staff 2 | Director of Nursing (DON) | Acknowledged findings related to medication errors, abuse reporting, and infection control deficiencies |
| Staff 1 | Administrator | Acknowledged medication error and privacy deficiencies |
| Staff 22 | LPN (agency) | Named in medication error related to wrong medication administration |
| Staff 3 | RN consultant | Confirmed incomplete fall evaluations |
| Staff 4 | LPN | Observed improper glove use and PPE removal during wound care |
| Staff 19 | LPN | Observed not priming insulin pen before administration |
| Staff 2 | DNS | Acknowledged care plan and training deficiencies |
| Staff 8 | LPN | Observed resident anxiety related to room change |
| Staff 27 | Physician's Assistant | Observed discussing private health information in non-private area |
| Staff 1 | Administrator | Acknowledged failure of Medical Director to attend QAA/QAPI meetings |
| Staff 23 | Former Medical Director | Failed to attend QAA/QAPI meetings |
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