Inspection Report
Kitchen
Census: 31
Capacity: 85
Deficiencies: 44
Oct 24, 2025
Visit Reason
State-compiled facility profile showing 7 inspections from 2021 to 2025 with detailed deficiency history and enforcement actions.
Findings
Across multiple inspections from 2021 to 2025, the facility exhibited numerous deficiencies including failures in food sanitation, administration compliance, abuse reporting, resident health services, infection prevention, medication administration, staffing, fire and life safety, building maintenance, and staff training. Several deficiencies were repeat citations and some posed immediate threats to resident health and safety.
Complaint Details
Multiple complaint investigations documented failures in abuse reporting, resident care, medication administration, staffing, and facility operations with findings reviewed and acknowledged by facility staff.
Deficiencies (44)
| Description |
|---|
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to ensure the kitchen was maintained in accordance with Oregon Food Sanitation Rules including cleanliness and repair issues. |
| Z0142 - Administration Compliance: Failed to follow licensing rules for Residential Care and Assisted Living Facilities. |
| C0231 - Reporting & Investigating Abuse-Other Action: Failed to ensure incidents of abuse or suspected abuse were promptly reported and investigated. |
| C0270 - Change of Condition and Monitoring: Failed to refer significant changes of condition to the facility nurse and monitor residents appropriately. |
| C0280 - Resident Health Services: Failed to ensure RN assessments were completed for residents with significant changes of condition. |
| C0295 - Infection Prevention & Control: Failed to maintain infection prevention protocols including proper glove use and hand hygiene. |
| C0303 - Systems: Treatment Orders: Failed to ensure physician orders were carried out as prescribed. |
| C0360 - Staffing Requirements and Training: Staffing: Failed to have sufficient caregiving staff to meet resident needs and emergency evacuation requirements. |
| C0420 - Fire and Life Safety: Safety: Failed to conduct fire drills per Oregon Fire Code and provide fire safety instruction on alternate months; lacked evacuation plans for residents needing assistance. |
| C0455 - Inspections and Investigation: Insp Interval: Failed to ensure plan of correction from change of ownership survey was implemented and satisfied the Department. |
| C0510 - General Building Exterior: Failed to secure poisons, chemicals, and toxic materials and maintain grounds free of litter and refuse. |
| C0513 - Doors, Walls, Elevators, Odors: Failed to keep interior materials and surfaces clean and in good repair including walls, ceilings, flooring, and baseboard heaters. |
| C0530 - Housekeeping and Laundry: Failed to ensure washing machines had minimum rinse temperature or used chemical disinfectant when washing soiled linens. |
| C0540 - Heating and Ventilation: Failed to keep heating equipment in good repair and maintain safe temperatures on baseboard heaters. |
| H1510 - Individual Rights Settings: Privacy, Dignity: Failed to ensure privacy and dignity related to accessible information in common areas. |
| H1517 - Individual Privacy: Own Unit: Failed to provide individual privacy in residents' own units due to doors left open without resident preference. |
| H1518 - Individual Door Locks: Key Access: Failed to ensure residents and appropriate staff had keys to access units; repeat citation. |
| Z0155 - Staff Training Requirements: Failed to ensure newly hired staff completed required dementia training and demonstrated competencies within 30 days. |
| Z0162 - Compliance With Rules Health Care: Failed to provide health care services in accordance with licensing rules; referenced multiple other citations. |
| C0160 - Reasonable Precautions: Failed to ensure reasonable infection control precautions including proper mask use by staff. |
| C0010 - Licensing Complaint Investigation: Multiple deficiencies identified during complaint investigation. |
| C0150 - Facility Administration: Operation: Failed to supervise and train staff adequately; issues with staff marijuana use at work. |
| C0154 - Facility Administration: Policy & Procedure: Failed to develop and implement a smoking policy; staff violations documented. |
| C0155 - Facility Administration: Records: Failed to develop policy prohibiting falsification of records; training documents falsified. |
| C0200 - Resident Rights and Protection - General: Failed to protect privacy and dignity; staff violations with camera phone use. |
| C0243 - Resident Services: Adls: Failed to assist with toileting and bladder management leading to skin breakdown and infections. |
| C0260 - Service Plan: General: Failed to implement and maintain accurate and current service plans reflecting resident needs. |
| C0270 - Change of Condition and Monitoring: Failed to monitor and document changes of condition and notify RN timely. |
| C0280 - Resident Health Services: Failed to conduct RN assessments for significant changes of condition and update service plans. |
| C0300 - Systems: Medications and Treatments: Failed to ensure safe medication and treatment systems with adequate oversight. |
| C0301 - Systems: Medication Administration: Failed to keep medications secure between set-up and administration. |
| C0303 - Systems: Treatment Orders: Failed to administer medications as ordered by physician. |
| C0360 - Staffing Requirements and Training: Staffing: Failed to provide sufficient staff to meet resident needs; frequent no call-no shows. |
| C0361 - Acuity-Based Staffing Tool: Failed to fully implement and update acuity-based staffing tool. |
| C0365 - Staffing Rqmt and Training: Training Rqmts: Failed to train direct care staff within first 30 days. |
| C0370 - Staffing Requirements and Training – Pre-Serv: Failed to have pre-service orientation and training program for direct care staff. |
| C0372 - Training Within 30 Days: Direct Care Staff: Failed to document competency evaluations for new staff within 30 days. |
| C0457 - Inspect and Investigations: Posting Surveys: Failed to post current inspection report and conditions near main entrance. |
| C0460 - Conditions: Failed to provide sufficient caregiving staff to meet conditions placed by DHS. |
| C0510 - General Building Exterior: Failed to maintain locked storage for chemicals and toxic materials; repeat citation. |
| C0513 - Doors, Walls, Elevators, Odors: Failed to maintain environment clean and in good repair; repeat citation. |
| Z0163 - Nutrition and Hydration: Failed to develop individualized nutrition and hydration plans for residents. |
| Z0164 - Activities: Failed to develop individualized activity plans and provide meaningful activities for residents. |
| Z0165 - Behavior: Failed to evaluate behavioral symptoms and develop individualized behavior plans for residents. |
Report Facts
Inspections on page: 7
Total deficiencies: 73
Total surveys: 7
Licensing violations: 20
Notices: 7
Licensed beds: 85
Resident census: 31
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lauren Beard | Administrator | Named as facility administrator |
| Staff 1 | Executive Director | Named in multiple findings and interviews related to deficiencies and acknowledgments |
| Staff 2 | Registered Nurse | Named in multiple findings and interviews related to deficiencies and acknowledgments |
| Staff 3 | Business Office Manager | Named in findings related to complaint investigations and staff training |
| Staff 4 | Maintenance Director | Named in findings related to building maintenance and fire safety |
| Staff 6 | Residential Care Coordinator | Named in multiple findings and interviews related to deficiencies and acknowledgments |
| Staff 8 | Resident Care Coordinator | Named in findings related to resident care and medication administration |
| Staff 13 | Medication Technician | Named in medication administration findings |
| Staff 26 | Director of Operations | Named in fire safety and administrative findings |
| Staff 27 | Nurse Consultant | Named in multiple findings and interviews related to deficiencies and acknowledgments |
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