Inspection Report
Census: 15
Capacity: 20
Deficiencies: 26
Nov 25, 2025
Visit Reason
State-compiled facility profile showing 6 inspections from 2022 to 2025 with deficiency history and compliance findings.
Findings
Across multiple inspections from 2022 to 2025, the facility demonstrated numerous deficiencies including failure to ensure resident dignity and respect, inadequate infection prevention and control, incomplete individualized activity and nutrition plans, and kitchen sanitation issues. Several administrative and compliance failures were also noted, with many deficiencies remaining uncorrected as of the latest inspections.
Complaint Details
The complaint investigation conducted on 12/07/2023 documented findings related to compliance with OARs 411 Division 54 and 57, including failure to adopt an acuity-based staffing tool and other compliance issues.
Severity Breakdown
Not Corrected: 22
Corrected: 9
Deficiencies (26)
| Description | Severity |
|---|---|
| C0200 - Resident Rights and Protection - General: Failed to ensure residents were treated with dignity and respect during meal service. | Not Corrected |
| C0242 - Resident Services: Activities: Failed to provide a daily program of social and recreational activities based on individual and group interests and needs. | Not Corrected |
| C0295 - Infection Prevention & Control: Failed to maintain effective infection prevention and control protocols related to dining services. | Not Corrected |
| C0303 - Systems: Treatment Orders: Failed to ensure physician orders were carried out as prescribed for a sampled resident. | Not Corrected |
| C0513 - Doors, Walls, Elevators, Odors: Failed to ensure all interior materials and surfaces were kept clean. | Not Corrected |
| H1510 - Individual Rights Settings: Privacy, Dignity: Failed to ensure residents were treated with dignity and respect related to meal service. | Not Corrected |
| H1517 - Individual Privacy: Own Unit: Failed to provide privacy in shared units for multiple residents. | Not Corrected |
| Z0142 - Administration Compliance: Failed to comply with licensing rules for the facility. | Not Corrected |
| Z0162 - Compliance with Rules Health Care: Failed to provide health care services in accordance with licensing rules. | Not Corrected |
| Z0163 - Nutrition and Hydration: Failed to provide a daily meal program based on resident preferences and needs. | Not Corrected |
| Z0164 - Activities: Failed to provide meaningful activities and individualized activity plans for residents. | Not Corrected |
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to maintain kitchen in a sanitary manner and ensure food was prepared and served according to Food Sanitation Rules. | Not Corrected |
| C0010 - Licensing Complaint Investigation: Findings documented from complaint investigation. | Not Corrected |
| C0361 - Acuity-Based Staffing Tool: Failed to adopt an acuity-based staffing tool addressing all required ADLs and staffing needs. | Not Corrected |
| C0252 - Resident Move-In and Eval: Res Evaluation: Failed to ensure evaluations were reviewed and updated quarterly and after significant changes for a sampled resident. | Corrected |
| C0260 - Service Plan: General: Failed to ensure service plans reflected current care needs and provided clear direction to staff for sampled residents. | Corrected |
| C0262 - Service Plan: Service Planning Team: Failed to ensure service plans were developed by a service planning team including required members. | Corrected |
| C0270 - Change of Condition and Monitoring: Failed to evaluate and develop interventions for short term changes of condition for a sampled resident. | Corrected |
| C0280 - Resident Health Services: Failed to ensure RN assessments were completed following severe weight loss and decline for a sampled resident. | Corrected |
| C0310 - Systems: Medication Administration: Failed to ensure MARs were accurate and included resident specific parameters for PRN medications for sampled residents. | Corrected |
| C0340 - Restraints and Supportive Devices: Failed to ensure thorough assessment and caregiver instruction for use of siderails for a sampled resident. | Corrected |
| C0420 - Fire and Life Safety: Safety: Failed to ensure fire drills were conducted according to Oregon Fire Code with proper documentation. | Corrected |
| Z0155 - Staff Training Requirements: Failed to ensure newly hired staff completed required pre-service orientation and demonstrated competency within required timeframes. | Corrected |
| Z0163 - Compliance With Rules Health Care: Failed to provide health care services in accordance with licensing rules, referencing multiple citations. | Corrected |
| Z0164 - Nutrition and Hydration: Failed to ensure individualized nutrition and hydration plans were developed and included in service plans for sampled residents. | Corrected |
| Z0165 - Behavior: Failed to provide individualized service plan for behavioral symptoms for a sampled resident. | Corrected |
Report Facts
Inspections on page: 6
Total deficiencies: 31
Total surveys: 6
Licensed beds: 20
Census: 15
Missed medication administrations: 43
Staff needed per day: 7.73
Weight loss percentage: 19.2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Memory Care Administrator / Executive Director | Named in multiple findings including dignity, infection control, staffing tool, and compliance acknowledgments |
| Staff 2 | Administrator / Memory Care Administrator | Named in multiple findings including dignity, infection control, staffing tool, and compliance acknowledgments |
| Staff 3 | RN / Memory Care Community Administrator | Named in multiple findings including dignity, infection control, medication administration, and compliance acknowledgments |
| Staff 6 | Caregiver | Reported resident food preferences during 2025 inspection |
| Staff 9 | Medication Technician | Reported availability of alternate desserts during 2025 inspection |
| Staff 10 | Medication Technician | Observed feeding resident during 2025 inspection |
| Staff 11 | Caregiver | Observed feeding resident and interviewed during 2025 inspection |
| Staff 16 | Caregiver | Observed feeding resident during 2025 inspection |
| Staff 7 | Caregiver | Named in staff training deficiency in 2022 inspection |
| Staff 13 | Caregiver | Named in staff training deficiency in 2022 inspection |
| Staff 5 | Executive Chef | Acknowledged kitchen sanitation issues in 2022 inspection |
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