Inspection Reports for RN Villa Senior Care
401 NE 139th Ave, Portland, OR 97230, OR, 97230
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Inspection Report
Re-Inspection
Deficiencies: 26
Jun 25, 2025
Visit Reason
State-compiled facility profile showing 6 inspections from 2021 to 2025 with deficiency history and enforcement actions
Findings
Across multiple inspections from 2021 to 2025, the facility demonstrated repeated deficiencies including failure to maintain accurate and complete resident records, inadequate service plans, insufficient nursing assessments and interventions for changes of condition, medication administration errors, staffing shortages, and failure to comply with fire and life safety requirements.
Complaint Details
Complaint investigations conducted on 2/7/2023 and 1/8/2024 identified multiple deficiencies including failure to provide nutritious meals, inadequate service plans, medication errors, staffing shortages, and infection prevention failures.
Deficiencies (26)
| Description |
|---|
| C0155 - Facility Administration: Records: Failed to ensure the preparation, completeness, and accuracy of documentation or records for sampled residents |
| C0260 - Service Plan: General: Failed to ensure service plans were reflective of residents’ needs, provided clear instructions to staff, and were implemented |
| C0270 - Change of Condition and Monitoring: Failed to update service plans for significant changes and monitor/document short-term changes of condition |
| C0280 - Resident Health Services: Failed to ensure timely RN assessments and interventions for residents with significant changes of condition |
| C0303 - Systems: Treatment Orders: Failed to carry out medication and treatment orders as prescribed |
| C0420 - Fire and Life Safety: Safety: Failed to conduct fire drills according to Oregon Fire Code and maintain required documentation |
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to provide three daily nutritious, palatable meals and maintain kitchen cleanliness |
| C0282 - RN Delegation and Teaching: Failed to ensure delegation and teaching was provided and documented by RN for insulin injections |
| C0300 - Systems: Medications and Treatments: Failed to ensure safe medication system with adequate professional oversight |
| C0301 - Systems: Medication Administration: Failed to visually observe resident take medication |
| C0310 - Systems: Medication Administration: Failed to maintain accurate MARs including administration instructions and parameters |
| C0360 - Staffing Requirements and Training: Staffing: Failed to have qualified awake direct care staff sufficient to meet residents’ needs |
| C0372 - Training Within 30 Days: Direct Care Staff: Failed to verify direct care staff demonstrated satisfactory performance in assigned duties |
| C0154 - Facility Administration: Policy & Procedure: Failed to implement effective methods of responding to and resolving resident complaints |
| C0156 - Facility Administration: Quality Improvement: Failed to develop and conduct ongoing quality improvement programs |
| C0160 - Reasonable Precautions: Failed to exercise reasonable precautions against conditions threatening resident health, safety, or welfare |
| C0252 - Resident Move-In and Eval: Res Evaluation: Failed to ensure move-in evaluations addressed all required elements |
| C0262 - Service Plan: Service Planning Team: Failed to include resident and others in service planning team |
| C0370 - Staffing Requirements and Training – Pre-Serv: Failed to ensure newly hired direct care staff completed required pre-service orientation |
| C0374 - Annual and Biennial Inservice For All Staff: Failed to ensure long-term staff completed required annual in-service training including dementia care |
| C0422 - Fire and Life Safety: Training For Residents: Failed to provide fire and life safety training to residents within 24 hours of move-in and annually |
| C0435 - Emergency and Disaster Planning: Failed to have emergency preparedness plan and conduct drills at least twice a year |
| C0455 - Inspections and Investigation: Insp Interval: Failed to ensure re-licensure survey plan of correction was implemented and satisfied the Department |
| C0510 - General Building Exterior: Failed to take measures to prevent entry of rodents, flies, mosquitoes and other insects |
| C0513 - Doors, Walls, Elevators, Odors: Failed to keep interior clean, in good repair, and free from unpleasant odors |
| C0555 - Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable: Failed to ensure exit doors were equipped with alarms or acceptable alert systems |
Report Facts
Inspections on page: 6
Total deficiencies: 48
Total surveys: 6
Licensing violations: 10
Notices: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Executive Director | Named in multiple findings and acknowledgments across inspections |
| Staff 2 | Regional Director of Operations | Named in multiple findings and acknowledgments across inspections |
| Staff 4 | Registered Nurse (RN) | Named in medication administration and delegation findings |
| Staff 6 | Caregiver (CG) | Named in treatment order and infection prevention findings |
| Staff 15 | Maintenance Supervisor | Named in fire and life safety findings |
| Staff 7 | Lead Enrichment | Named in fire and life safety findings |
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