Inspection Reports for Rosewood Park Independent & Assisted Living Residence
OR, 97123
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Inspection Report
Kitchen
Capacity: 95
Deficiencies: 31
Oct 13, 2025
Visit Reason
State-compiled facility profile showing 7 inspections from 2022-2025 with deficiency history and enforcement notices
Findings
The facility has multiple deficiencies across inspections including failures in medication administration, treatment orders, kitchen sanitation, staffing tools, service plan accuracy, infection prevention, and fire safety. Several deficiencies are repeat citations with plans of correction in progress.
Complaint Details
Multiple complaint investigations noted failures in medication administration, treatment orders, acuity-based staffing tool implementation, and licensure complaints with unresolved deficiencies.
Deficiencies (31)
| Description |
|---|
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to ensure kitchen practices and protocols were in accordance with Food Sanitation Rules including cleanliness and food storage |
| C0303 - Systems: Treatment Orders: Failed to carry out medication and treatment orders as prescribed for multiple residents |
| C0310 - Systems: Medication Administration: Failed to maintain accurate Medication Administration Records (MARs) |
| C0361 - Acuity-Based Staffing Tool: Failed to fully implement and update an acuity-based staffing tool |
| C0010 - Licensing Complaint Investigation: Licensing complaint investigation deficiencies noted |
| C0155 - Facility Administration: Records: Failed to maintain required records |
| C0200 - Resident Rights and Protection - General: Failed to ensure residents received services promoting privacy, respect and dignity |
| C0231 - Reporting & Investigating Abuse-Other Action: Failed to investigate and report incidents of abuse or neglect |
| C0260 - Service Plan: General: Failed to ensure service plans were current, reflective, and followed |
| C0262 - Service Plan: Service Planning Team: Failed to ensure service plans were developed by a proper service planning team including resident and staff |
| C0270 - Change of Condition and Monitoring: Failed to identify, evaluate, communicate, and monitor changes of condition |
| C0280 - Resident Health Services: Failed to ensure RN assessments for significant changes of condition |
| C0290 - Res Hlth Srvc: On- and Off-Site Health Srvc: Failed to inform staff of new interventions and adjust service plans accordingly |
| C0295 - Infection Prevention & Control: Failed to comply with masking requirements and have a trained Infection Control Specialist |
| C0300 - Systems: Medications and Treatments: Failed to ensure safe medication system and professional oversight |
| C0301 - Systems: Medication Administration: Failed to ensure medications were documented by the person administering them |
| C0302 - Systems: Tracking Control Substances: Failed to accurately track controlled substances |
| C0303 - Systems: Treatment Orders: Failed to carry out physician orders as prescribed and document properly |
| C0304 - Systems: Medication and Treatment Review: Failed to ensure pharmacist or RN reviewed medications every 90 days |
| C0305 - Systems: Resident Right to Refuse: Failed to notify physician of resident refusals |
| C0325 - Systems: Self-Administration of Meds: Failed to evaluate residents' ability to self-administer and obtain physician approval |
| C0330 - Systems: Psychotropic Medication: Failed to document reason for use, side effects, and non-pharmacological interventions for psychotropic medication |
| C0370 - Staffing Requirements and Training – Pre-Serv: Failed to document required pre-service orientation and infectious disease training |
| C0372 - Training Within 30 Days: Direct Care Staff: Failed to verify and document competency of newly hired direct-care staff |
| C0420 - Fire and Life Safety: Safety: Failed to conduct and document required fire drills properly |
| C0422 - Fire and Life Safety: Training For Residents: Failed to instruct residents on fire and life safety procedures upon admission and annually |
| C0455 - Inspections and Investigation: Insp Interval: Failed to implement and satisfy re-licensure survey plan of correction |
| C0613 - General Building: Doors-Walls, Cleanable: Failed to keep interior materials and surfaces clean and in good repair |
| C0615 - Resident Units: Failed to ensure residents had keys to lockable storage spaces |
| C0630 - House Keeping and Sanitation: Failed to ensure soiled clothing and linens were laundered properly |
| C0655 - Call System: Failed to ensure exit doors had alarms to alert staff when residents exited |
Report Facts
Inspections on page: 7
Total deficiencies: 52
Licensing violations: 10
Notices: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| ERIC BEVINS | Administrator | Named in multiple findings and plans of correction related to administrative oversight and medication errors |
| Staff 1 | Administrator or Executive Director | Named in multiple findings related to medication errors, infection control, and administrative oversight |
| Staff 2 | RN or Nurse Consultant | Named in findings related to medication administration and infection control |
| Staff 3 | RCC or Nurse Consultant | Named in findings related to service plans, medication administration, and abuse reporting |
| Staff 5 | Kitchen Manager | Named in findings related to kitchen sanitation and infection control |
| Staff 6 | Resident Care Coordinator | Named in findings related to acuity-based staffing tool and training |
| Staff 7 | Finance | Named in findings related to staff training documentation |
| Staff 8 | CG or Caregiver | Named in findings related to medication administration and resident care |
| Staff 9 | CG | Named in findings related to laundry process |
| Staff 10 | MT or Medication Technician | Named in findings related to medication administration documentation |
| Staff 12 | MT | Named in findings related to controlled substance tracking |
| Staff 23 | RCC Assistant | Named in findings related to service plan accuracy |
| Staff 24 | MT | Named in findings related to service plan availability |
| Staff 25 | MT | Named in findings related to medication administration |
| Staff 28 | Executive Director | Named in multiple findings related to administrative oversight and medication errors |
| Staff 29 | MT/CG | Named in findings related to medication administration documentation |
| Staff 31 | Regional Director | Named in findings related to medication administration and oversight |
| Staff 35 | MT | Named as designated Infection Control Specialist without required training |
| Staff 36 | MT | Named in medication administration findings |
| Staff 41 | LPN, Health and Wellness Director | Named in service plan findings |
| Staff 42 | RN, Director of Health Services | Named in service plan findings |
| Staff 43 | Consultant | Named in service plan findings |
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