Deficiencies per Year
36
27
18
9
0
Unclassified
Inspection Report
Re-Inspection
Census: 33
Capacity: 49
Deficiencies: 36
Oct 27, 2025
Visit Reason
State-compiled facility profile showing 5 inspections from 2020 to 2025 with detailed deficiency history and enforcement findings.
Findings
Across multiple inspections, the facility demonstrated numerous deficiencies including failures in administrative oversight, service plan accuracy, abuse reporting, medication administration, staff training, fire and life safety, and environmental maintenance. Many deficiencies remained uncorrected at follow-up visits.
Complaint Details
Based on interview and observation, a complaint investigation in 2020 found the facility failed to exercise reasonable precautions against conditions threatening resident health and safety, including staff sleeping on duty.
Deficiencies (36)
| Description |
|---|
| C0150 - Facility Administration: Operation: Failed to provide effective administrative oversight to ensure quality of care and services rendered in the facility. |
| C0152 - Facility Administration: Required Postings: Failed to ensure required postings were in a routinely accessible and conspicuous location to residents and visitors. |
| C0231 - Reporting & Investigating Abuse-Other Action: Failed to ensure an unwitnessed fall was promptly investigated and reported to local SPD as needed. |
| C0260 - Service Plan: General: Failed to ensure service plans reflected residents' current care needs and provided clear directions to staff. |
| C0270 - Change of Condition and Monitoring: Failed to determine and document actions or interventions for changes of condition and update service plans as needed. |
| C0282 - RN Delegation and Teaching: Failed to ensure delegation and teaching was provided and documented by a RN in accordance with Oregon Administrative Rules. |
| C0303 - Systems: Treatment Orders: Failed to ensure medication and treatment orders were carried out as prescribed and documented. |
| C0305 - Systems: Resident Right to Refuse: Failed to notify physician/practitioner when residents refused consent to orders. |
| C0340 - Restraints and Supportive Devices: Failed to instruct caregivers on correct use and precautions, document use, and evaluate devices quarterly. |
| C0362 - Acuity Based Staffing Tool - ABST Time: Failed to accurately capture care time and care elements provided to residents. |
| C0363 - Acuity Based Staffing Tool - Updates & Staffing Plan: Failed to ensure ABST was updated no less than quarterly for most residents. |
| C0420 - Fire and Life Safety: Safety: Failed to provide fire and life safety instruction to staff on alternate months as required. |
| C0455 - Inspections and Investigation: Insp Interval: Failed to ensure relicensure survey plan of correction was implemented and satisfied the Department. |
| C0513 - Doors, Walls, Elevators, Odors: Failed to ensure interior materials and surfaces were kept clean and in good repair. |
| H1517 - Individual Privacy: Own Unit: Failed to ensure each individual had privacy in own unit due to shared bathrooms without privacy measures. |
| H1518 - Individual Door Locks: Key Access: Failed to ensure residents were provided keys to their units. |
| Z0142 - Administration Compliance: Failed to comply with licensing rules for the facility and Chapter 411, Division 57. |
| Z0155 - Staff Training Requirements: Failed to ensure newly hired and long-term staff completed required orientation, dementia, and LGBTQIA2S+ training within required timeframes. |
| Z0162 - Compliance with Rules Health Care: Failed to provide health care services in accordance with licensing rules. |
| Z0163 - Nutrition and Hydration: Failed to ensure individualized daily meal program based on resident preferences and needs documented in service plans. |
| Z0164 - Activities: Failed to ensure activity evaluations addressed required components and individualized activity plans were developed. |
| Z0173 - Secure Outdoor Recreation Area: Failed to ensure perimeter fences met height requirements and outdoor furniture was of sufficient weight and stability. |
| C0000 - Comment (2024 inspection): Kitchen inspection findings documented; facility in substantial compliance with food sanitation rules. |
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to maintain kitchen in good repair including broken tiles, leaking pipe, rusted shelves, and malfunctioning refrigerators/freezers. |
| C0000 - Comment (2023 inspection): Kitchen inspection findings documented; facility in substantial compliance with food sanitation rules. |
| C0000 - Comment (2022 inspection): Change of Owner re-licensure survey findings documented; facility in substantial compliance. |
| C0252 - Resident Move-In and Eval: Res Evaluation: Failed to ensure move-in evaluations addressed all required elements for sampled resident. |
| C0260 - Service Plan: General (2022): Failed to ensure service plans were reflective and provided clear instruction to staff. |
| C0282 - Rn Delegation and Teaching (2022): Failed to ensure delegation and supervision of nursing tasks in accordance with OSBN Division 47 rules. |
| C0303 - Systems: Treatment Orders (2022): Failed to ensure written, signed physician orders documented and followed. |
| C0310 - Systems: Medication Administration: Failed to ensure MARs were complete, accurate, and provided clear instructions for medication administration. |
| C0340 - Restraints and Supportive Devices (2022): Failed to ensure supportive devices were assessed, documented, and instructions provided to staff. |
| C0420 - Fire and Life Safety: Safety (2022): Failed to ensure fire drills and staff instruction met Oregon Fire Code requirements. |
| C0422 - Fire and Life Safety: Training For Residents: Failed to ensure fire and life safety training for residents and documentation. |
| C0510 - General Building Exterior: Failed to ensure exterior pathways and accesses were maintained in good repair to prevent fall hazards. |
| C0160 - Reasonable Precautions (2020 complaint): Failed to exercise reasonable precautions against conditions threatening resident health and safety including staff sleeping on duty. |
Report Facts
Inspections on page: 5
Total deficiencies: 33
Total licensing violations: 16
Total abuse violations: 0
Total notices: 0
Facility licensed beds: 49
Facility census: 33
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Debra Brown | Administrator | Named as facility administrator in facility information |
| Staff 1 | Director of Nursing | Named in multiple findings related to administrative oversight, delegation, and training |
| Staff 2 | Executive Director | Named in multiple findings related to facility operations and findings acknowledgments |
| Staff 7 | Medication Technician | Named in abuse reporting and medication administration findings |
| Staff 8 | Medication Technician | Named in RN delegation and teaching deficiency |
| Staff 9 | Medication Technician | Named in RN delegation and teaching deficiency |
| Staff 15 | Medication Technician | Named in RN delegation and teaching deficiency |
| Staff 18 | Facilities Manager | Named in environmental and outdoor recreation area findings |
| Staff 12 | Activities Director | Named in activities deficiency |
| Staff 17 | Business Office Manager | Named in staff training findings |
| Staff 19 | Executive Director | Named in staff training findings |
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