Deficiencies (last 5 years)
Deficiencies (over 5 years)
16.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
148% worse than Oregon average
Oregon average: 6.7 deficiencies/yearDeficiencies per year
28
21
14
7
0
Inspection Report
Kitchen
Capacity: 85
Deficiencies: 2
Jul 24, 2025
Visit Reason
Facility failed to maintain kitchen in accordance with Oregon Food Sanitation Rules with food spills, debris, and needed repairs noted. Administration compliance issues also noted. Deficiencies were not corrected on revisits.
Findings
Facility failed to maintain kitchen in accordance with Oregon Food Sanitation Rules with food spills, debris, and needed repairs noted. Administration compliance issues also noted. Deficiencies were not corrected on revisits.
Deficiencies (2)
| Description |
|---|
| OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules). This Rule is not met as evidenced by: Facility failed to ensure kitchen was maintained in accordance with Oregon Food Sanitation Rules. |
| OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. Facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. |
Inspection Report
Change Of Owner
Capacity: 85
Deficiencies: 19
Jul 15, 2024
Visit Reason
Change of ownership survey identified multiple deficiencies including failure to comply with fire and life safety, heating and ventilation, abuse reporting, change of condition monitoring, resident health services, infection prevention, medication orders, staffing, and facility maintenance. Several deficiencies were corrected on revisit, some remained uncorrected.
Findings
Change of ownership survey identified multiple deficiencies including failure to comply with fire and life safety, heating and ventilation, abuse reporting, change of condition monitoring, resident health services, infection prevention, medication orders, staffing, and facility maintenance. Several deficiencies were corrected on revisit, some remained uncorrected.
Deficiencies (19)
| Description |
|---|
| OAR 411-054-0090 Fire and Life Safety; and OAR 411-054-0020 (8) Heating and Ventilation Systems. Facility failed to comply with fire and life safety and heating/ventilation requirements. |
| OAR 411-054-0028 Reporting & Investigating Abuse. Facility failed to ensure all incidents of abuse or suspected abuse were immediately reported and investigated. |
| OAR 411-054-0040 Change of Condition and Monitoring. Facility failed to refer significant changes of condition to the nurse and monitor changes appropriately. |
| OAR 411-054-0045 Resident Health Services. Facility failed to ensure RN assessments for significant changes of condition. |
| OAR 411-054-0295 Infection Prevention & Control. Facility failed to maintain infection prevention protocols. |
| OAR 411-054-0303 Systems: Treatment Orders. Facility failed to ensure physician orders were carried out as prescribed. |
| OAR 411-054-0360 Staffing Requirements and Training: Staffing. Facility failed to provide sufficient caregiving staff to meet resident needs. |
| OAR 411-054-0420 Fire and Life Safety: Safety. Facility failed to conduct fire drills and provide fire safety training as required, and lacked evacuation plans for residents. |
| OAR 411-054-0455 Inspections and Investigation: Insp Interval. Facility failed to ensure plan of correction was implemented and satisfied the Department. |
| OAR 411-054-0510 General Building Exterior. Facility failed to secure poisons, chemicals, and maintain grounds free of litter and refuse. |
| OAR 411-054-0513 Doors, Walls, Elevators, Odors. Facility failed to keep interior materials and surfaces clean and in good repair. |
| OAR 411-054-0530 Housekeeping and Laundry. Facility failed to ensure washing machines had minimum rinse temperature or chemical disinfectant. |
| OAR 411-054-0540 Heating and Ventilation. Facility failed to keep heating equipment in good repair and safe temperature. |
| OAR 411-057-1510 Individual Rights Settings: Privacy, Dignity. Facility failed to ensure privacy and dignity related to accessible information. |
| OAR 411-057-1517 Individual Privacy: Own Unit. Facility failed to provide individual privacy in resident units. |
| OAR 411-057-1518 Individual Door Locks: Key Access. Facility failed to ensure residents had keys to their units. |
| OAR 411-057-0140 (2) Administration Compliance. Facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. |
| OAR 411-057-0155 Staff Training Requirements. Facility failed to ensure newly hired staff completed required dementia training and competencies. |
| OAR 411-057-0162 Compliance With Rules Health Care. Facility failed to provide health care services in accordance with licensing rules. |
Inspection Report
State Licensure Other
Capacity: 85
Deficiencies: 1
Jul 3, 2024
Visit Reason
Kitchen inspection found the facility in substantial compliance with applicable food sanitation rules. No deficiencies corrected or noted.
Findings
Kitchen inspection found the facility in substantial compliance with applicable food sanitation rules. No deficiencies corrected or noted.
Deficiencies (1)
| Description |
|---|
| C0000 - Comment |
Inspection Report
Complaint Investigation
Capacity: 85
Deficiencies: 8
Jun 17, 2024
Visit Reason
Complaint investigation identified failures in abuse reporting, service plan implementation, health services coordination, medication administration, staffing, secure outdoor recreation, and medication pass. Multiple deficiencies not corrected on revisit.
Findings
Complaint investigation identified failures in abuse reporting, service plan implementation, health services coordination, medication administration, staffing, secure outdoor recreation, and medication pass. Multiple deficiencies not corrected on revisit.
Deficiencies (8)
| Description |
|---|
| OAR 411-054-0028 Reporting & Investigating Abuse. Facility failed to immediately notify department of abuse or suspected abuse incidents. |
| OAR 411-054-0260 Service Plan: General. Facility failed to ensure implementation of services as per service plan. |
| OAR 411-054-0290 Resident Health Services: On- and Off-Site Health Services. Facility failed to coordinate with off-site health services. |
| OAR 411-054-0300 Systems: Medications and Treatments. Facility failed to ensure safe medication administration system. |
| OAR 411-054-0360 Staffing Requirements and Training: Staffing. Facility failed to provide sufficient staff to meet resident needs. |
| OAR 411-054-0510 General Building Exterior. Facility failed to maintain secure storage of chemicals and toxic materials. |
| OAR 411-054-0513 Doors, Walls, Elevators, Odors. Facility failed to keep environment clean and in good repair. |
| OAR 411-057-0173 Secure Outdoor Recreation Area. Facility failed to provide a secure outdoor recreation area. |
Inspection Report
Complaint Investigation
Capacity: 85
Deficiencies: 24
Apr 20, 2023
Visit Reason
Complaint investigation revealed numerous deficiencies including failure in facility administration, abuse reporting, service plan accuracy, change of condition monitoring, medication administration, staffing, fire and life safety, resident rights, and compliance with health care rules. Many deficiencies were not corrected on revisit.
Findings
Complaint investigation revealed numerous deficiencies including failure in facility administration, abuse reporting, service plan accuracy, change of condition monitoring, medication administration, staffing, fire and life safety, resident rights, and compliance with health care rules. Many deficiencies were not corrected on revisit.
Deficiencies (24)
| Description |
|---|
| OAR 411-054-0010 Licensing Complaint Investigation. Facility failed to operate in compliance with applicable laws and regulations. |
| OAR 411-054-0150 Facility Administration: Operation. Facility failed to supervise and train staff adequately. |
| OAR 411-054-0154 Facility Administration: Policy & Procedure. Facility failed to develop and implement smoking policy. |
| OAR 411-054-0155 Facility Administration: Records. Facility failed to prohibit falsification of records. |
| OAR 411-054-0200 Resident Rights and Protection - General. Facility failed to protect privacy and dignity. |
| OAR 411-054-0231 Reporting & Investigating Abuse. Facility failed to immediately notify local department of abuse or suspected abuse. |
| OAR 411-054-0243 Resident Services: ADLs. Facility failed to assist with toileting and bladder management. |
| OAR 411-054-0260 Service Plan: General. Facility failed to ensure service plans were available and updated. |
| OAR 411-054-0270 Change of Condition and Monitoring. Facility failed to monitor and report changes of condition. |
| OAR 411-054-0300 Systems: Medications and Treatments. Facility failed to ensure safe medication administration. |
| OAR 411-054-0301 Systems: Medication Administration. Facility failed to keep medications secure. |
| OAR 411-054-0303 Systems: Treatment Orders. Facility failed to administer medications as ordered. |
| OAR 411-054-0360 Staffing Requirements and Training: Staffing. Facility failed to provide sufficient staff. |
| OAR 411-054-0361 Acuity-Based Staffing Tool. Facility failed to fully implement staffing tool. |
| OAR 411-054-0365 Staffing Rqmt and Training: Training Rqmts. Facility failed to train direct care staff timely. |
| OAR 411-054-0370 Staffing Requirements and Training – Pre-Serv. Facility failed to have pre-service orientation and training. |
| OAR 411-054-0372 Training Within 30 Days: Direct Care Staff. Facility failed to document competency of staff. |
| OAR 411-054-0457 Inspect and Investigations: Posting Surveys. Facility failed to post current inspection report. |
| OAR 411-054-0513 Doors, Walls, Elevators, Odors. Facility failed to keep interior and exterior materials clean and in good repair. |
| OAR 411-057-0155 Staff Training Requirements. Facility failed to ensure newly hired staff completed required training. |
| OAR 411-057-0162 Compliance With Rules Health Care. Facility failed to provide health care services in accordance with licensing rules. |
| OAR 411-057-0163 Nutrition and Hydration. Facility failed to ensure individualized nutrition and hydration plans. |
| OAR 411-057-0164 Activities. Facility failed to ensure individualized activity plans and meaningful activities. |
| OAR 411-057-0165 Behavior. Facility failed to evaluate behavioral symptoms and develop behavior plans. |
Inspection Report
Validation Re Licensure
Capacity: 85
Deficiencies: 28
May 2, 2022
Visit Reason
Re-licensure survey identified numerous deficiencies including failure in facility administration, abuse reporting, service plan development, change of condition monitoring, resident health services, medication administration, staffing, fire and life safety, facility maintenance, and compliance with licensing rules. Many deficiencies remained uncorrected on revisit.
Findings
Re-licensure survey identified numerous deficiencies including failure in facility administration, abuse reporting, service plan development, change of condition monitoring, resident health services, medication administration, staffing, fire and life safety, facility maintenance, and compliance with licensing rules. Many deficiencies remained uncorrected on revisit.
Deficiencies (28)
| Description |
|---|
| OAR 411-054-0000 Comment. Findings documented for re-licensure survey and first revisit. |
| OAR 411-054-0150 Facility Administration: Operation. Facility failed to provide effective administrative oversight. |
| OAR 411-054-0231 Reporting & Investigating Abuse. Facility failed to ensure timely and thorough investigation and reporting of abuse. |
| OAR 411-054-0240 Resident Services Meals, Food Sanitation Rule. Facility failed to maintain kitchen and kitchenettes in accordance with food sanitation rules. |
| OAR 411-054-0252 Resident Move-In and Eval: Res Evaluation. Facility failed to ensure timely and complete resident evaluations. |
| OAR 411-054-0260 Service Plan: General. Facility failed to ensure service plans were reflective, clear, and followed. |
| OAR 411-054-0262 Service Plan: Service Planning Team. Facility failed to ensure service plans were developed by a service planning team. |
| OAR 411-054-0270 Change of Condition and Monitoring. Facility failed to monitor and document changes of condition and notify RN. |
| OAR 411-054-0280 Resident Health Services. Facility failed to conduct RN assessments for significant changes of condition. |
| OAR 411-054-0282 RN Delegation and Teaching. Facility failed to maintain RN delegation documentation. |
| OAR 411-054-0290 Resident Health Services: On- and Off-Site Health Services. Facility failed to coordinate on-site health services with outside providers. |
| OAR 411-054-0300 Systems: Medications and Treatments. Facility failed to ensure safe medication and treatment system and professional oversight. |
| OAR 411-054-0303 Systems: Treatment Orders. Facility failed to ensure physician orders were carried out as prescribed. |
| OAR 411-054-0310 Systems: Medication Administration. Facility failed to maintain accurate MARs with reasons for use and clear instructions. |
| OAR 411-054-0330 Systems: Psychotropic Medication. Facility failed to ensure PRN psychotropic medications had resident-specific parameters and staff knowledge. |
| OAR 411-054-0372 Training Within 30 Days: Direct Care Staff. Facility failed to ensure newly hired staff demonstrated competency. |
| OAR 411-054-0420 Fire and Life Safety: Safety. Facility failed to meet fire and life safety requirements including drills, training, and evacuation plans. |
| OAR 411-054-0422 Fire and Life Safety: Training For Residents. Facility failed to provide and document resident fire safety training. |
| OAR 411-054-0455 Inspections and Investigation: Insp Interval. Facility failed to implement and satisfy plan of correction. |
| OAR 411-054-0460 Conditions. Facility failed to provide sufficient caregiving staff to meet conditions placed by DHS. |
| OAR 411-054-0510 General Building Exterior. Facility failed to secure chemicals and toxic materials. |
| OAR 411-054-0513 Doors, Walls, Elevators, Odors. Facility failed to maintain environment clean and in good repair. |
| OAR 411-057-0140 (2) Administration Compliance. Facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. |
| OAR 411-057-0155 Staff Training Requirements. Facility failed to ensure newly hired staff completed required training and competencies. |
| OAR 411-057-0162 Compliance With Rules Health Care. Facility failed to provide health care services in accordance with licensing rules. |
| OAR 411-057-0163 Nutrition and Hydration. Facility failed to ensure individualized nutrition and hydration plans. |
| OAR 411-057-0164 Activities. Facility failed to ensure individualized activity plans and meaningful activities. |
| OAR 411-057-0165 Behavior. Facility failed to evaluate behavioral symptoms and develop behavior plans. |
Inspection Report
Complaint Investigation
Capacity: 85
Deficiencies: 1
Jan 5, 2021
Visit Reason
Complaint investigation found facility failed to ensure reasonable precautions for infection control including staff wearing masks improperly and allowing COVID positive staff to work. Deficiency not corrected on revisit.
Findings
Complaint investigation found facility failed to ensure reasonable precautions for infection control including staff wearing masks improperly and allowing COVID positive staff to work. Deficiency not corrected on revisit.
Deficiencies (1)
| Description |
|---|
| OAR 411-054-0160 Reasonable Precautions. Facility failed to ensure reasonable infection control precautions. |
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