Inspection Reports for St Anthony Village
3560 SE 79th Ave, Portland, OR 97206, OR, 97206
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Inspection Report
Re-Inspection
Census: 72
Capacity: 126
Deficiencies: 68
Oct 7, 2025
Visit Reason
State-compiled facility profile showing 4 inspections from 2022-2025 with detailed deficiency history and enforcement actions
Findings
Across multiple inspections from 2022 to 2025, the facility exhibited numerous deficiencies including failures in administration oversight, resident care, staff training, infection control, medication administration, staffing adequacy, fire and life safety, and facility maintenance. Several repeat citations and immediate threats to resident health and safety were identified.
Complaint Details
Complaint investigation conducted on 2025-02-10 substantiated failure to carry out medication and treatment orders as prescribed and failure to fully implement and update acuity-based staffing tool for sampled residents.
Deficiencies (68)
| Description |
|---|
| C0150 - Facility Administration: Operation: Failed to provide effective oversight for facility operation and quality of services rendered |
| C0152 - Facility Administration: Required Postings: Failed to ensure required postings were displayed in accessible and conspicuous locations |
| C0154 - Facility Administration: Policy & Procedure: Failed to develop and implement written smoking policy in accordance with Oregon Indoor Clean Air Act |
| C0155 - Facility Administration: Records: Failed to maintain complete and accurate resident records for multiple residents |
| C0156 - Facility Administration: Quality Improvement: Failed to conduct ongoing quality improvement program evaluating services, outcomes, and satisfaction |
| C0200 - Resident Rights and Protection - General: Failed to ensure residents' right to homelike environment and dignity due to offensive signage |
| C0231 - Reporting & Investigating Abuse-Other Action: Failed to immediately report resident-to-resident altercations to local SPD office |
| C0252 - Resident Move-in & Evaluation: Res Evaluation: Failed to ensure initial and quarterly evaluations addressed all required elements for multiple residents |
| C0260 - Service Plan: General: Failed to ensure service plans reflected current care needs, were accessible, and provided clear directions |
| C0262 - Service Plan: Service Planning Team: Failed to ensure service plans were developed by a proper service planning team including resident and licensed nurse |
| C0270 - Change of Condition and Monitoring: Failed to develop resident-specific interventions and monitor short-term changes of condition |
| C0280 - Resident Health Services: Failed to ensure RN assessment for significant change of condition |
| C0282 - RN Delegation and Teaching: Failed to ensure delegation and teaching by RN for medication administration |
| C0295 - Infection Prevention & Control: Failed to establish and maintain infection prevention protocols during ADL care and meal service |
| C0300 - Systems: Medications and Treatments: Failed to ensure safe medication system and professional oversight |
| C0302 - Systems: Tracking Control Substances: Failed to ensure accurate tracking of controlled substances |
| C0303 - Systems: Treatment Orders: Failed to ensure written, signed physician orders and administration as prescribed |
| C0330 - Systems: Psychotropic Medication: Failed to ensure resident-specific parameters and documentation of non-pharmacological interventions for PRN psychotropics |
| C0340 - Restraints and Supportive Devices: Failed to ensure thorough assessment and quarterly evaluation of supportive devices with restraining qualities |
| C0360 - Staffing Requirements and Training: Staffing: Failed to have sufficient direct care staff per Acuity-Based Staffing Tool and posted staffing plan |
| C0362 - Acuity Based Staffing Tool - ABST Time: Failed to accurately capture care time and care elements for residents in ABST |
| C0363 - Acuity Based Staffing Tool - Updates & Staffing Plan: Failed to update ABST with significant changes and at least quarterly |
| C0372 - Training Within 30 Days of Hire – Direct Care Staff: Failed to ensure direct care staff demonstrated competency and completed required training |
| C0420 - Fire and Life Safety: Safety: Failed to conduct and document fire drills per Oregon Fire Code and provide fire safety training on alternate months |
| C0422 - Fire and Life Safety: Training for Residents: Failed to instruct residents on fire and life safety procedures within 24 hours of admission and annually |
| C0427 - Fire and Life Safety: Egress, first aid: Failed to ensure emergency fire exits and stairwells were unobstructed |
| C0455 - Inspections and Investigation: Insp Interval: Failed to submit plan of correction that satisfied the Department |
| C0650 - Electrical Systems: Failed to prohibit use of extension cords |
| H1517 - Individual Privacy: Own Unit: Failed to ensure resident privacy during ADL care |
| H1518 - Individual Door Locks: Key Access: Failed to provide residents keys to their units |
| L0152 - Facility Administration: Required Postings: Failed to post Resident Rights and Protections and LGBTQIA2S+ nondiscrimination notice |
| L0252 - Resident Move-in & Evaluation: Res Evaluation: Failed to include pronouns and gender identity in initial evaluation |
| Z0142 - Administration Compliance: Failed to comply with licensing rules for Residential Care and Assisted Living Facilities and Memory Care Communities |
| Z0155 - Staff Training Requirements: Failed to ensure staff completed required orientation, dementia training, and competency evaluations |
| Z0162 - Compliance with Rules Health Care: Failed to provide health care services in accordance with licensing rules |
| Z0164 - Activities: Failed to ensure meaningful activity evaluations and individualized activity plans for residents |
| Z0168 - Outside Area: Failed to have written policy for resident access to outdoor recreation area and door locking |
| Z0173 - Secure Outdoor Recreation Area: Failed to maintain secure fencing around outdoor recreation area |
| C0010 - Licensing Complaint Investigation: Complaint investigation findings documented |
| C0303 - Systems: Treatment Orders (Complaint): Failure to carry out medication and treatment orders as prescribed |
| C0363 - Acuity Based Staffing Tool - Updates & Plan (Complaint): Failure to fully implement and update ABST |
| C0000 - Comment (2023): Findings of kitchen inspections and compliance with food sanitation rules |
| C0240 - Resident Services Meals, Food Sanitation Rule (2023): Failed to maintain kitchen in accordance with Food Sanitation Rules |
| C0455 - Inspections and Investigation: Insp Interval (2023): Failed to ensure re-licensure survey plan of correction was implemented and satisfied Department |
| C0156 - Facility Administration: Quality Improvement (2023): Failed to develop and conduct ongoing quality improvement programs |
| C0231 - Reporting & Investigating Abuse-Other Action (2023): Failed to promptly investigate injuries of unknown cause and notify SPD |
| C0242 - Resident Services: Activities (2023): Failed to provide activity program based on individual and group needs |
| C0260 - Service Plan: General (2023): Failed to ensure service plans were updated, reflective, and provided clear instructions |
| C0280 - Resident Health Services (2023): Failed to ensure timely RN assessment for significant change of condition |
| C0282 - RN Delegation and Teaching (2023): Failed to ensure delegation and supervision of nursing tasks per OSBN rules |
| C0290 - Res Hlth Srvc: On- and Off-Site Health Srvc (2023): Failed to coordinate on-site health services with outside providers |
| C0295 - Infection Prevention & Control (2023): Failed to have trained Infection Control Specialist |
| C0303 - Systems: Treatment Orders (2023): Failed to ensure signed physician orders and administration as prescribed |
| C0310 - Systems: Medication Administration (2023): Failed to ensure accurate MARs with resident-specific parameters |
| C0330 - Systems: Psychotropic Medication (2023): Failed to ensure non-pharmacological interventions documented prior to PRN psychotropic administration |
| C0340 - Restraints and Supportive Devices (2023): Failed to ensure informed consent, documentation, and instruction for supportive devices |
| C0361 - Acuity-Based Staffing Tool (2023): Failed to select and implement ABST and develop staffing plan accordingly |
| C0372 - Training Within 30 Days: Direct Care Staff (2023): Failed to ensure newly hired direct care staff completed required training |
| C0420 - Fire and Life Safety: Safety (2023): Failed to conduct fire drills per OFC and provide fire safety training on alternate months |
| C0422 - Fire and Life Safety: Training For Residents (2023): Failed to instruct residents on fire safety within 24 hours of admission and annually |
| C0455 - Inspections and Investigation: Insp Interval (2023): Failed to implement and satisfy plan of correction |
| C0610 - General Building Exterior (2023): Failed to maintain exterior pathways in good repair and secure chemicals |
| C0613 - General Building: Doors-Walls, Cleanable (2023): Failed to maintain interior materials and surfaces in good repair and clean |
| C0615 - Resident Units (2023): Failed to provide lockable storage and safe operable windows |
| C0645 - Plumbing Systems (2023): Failed to maintain hot water temperatures within required range |
| C0655 - Call System (2023): Failed to provide functional call system and emergency call devices in resident bathrooms and public restrooms |
| H1517 - Individual Privacy: Own Unit (2025): Failed to ensure privacy during ADL care for resident |
| H1518 - Individual Door Locks: Key Access (2025): Failed to provide keys to residents for their units |
Report Facts
Inspections on page: 4
Total deficiencies: 73
Total surveys: 4
Abuse violations: 0
Licensing violations: 10
Notices: 3
Residents in facility: 72
Licensed beds: 126
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E'Lan Calise | Administrator | Named in multiple findings and interviews related to facility oversight and plan of correction responsibility |
| Staff 1 | Administrator | Named in multiple findings and interviews related to deficiencies and acknowledgments |
| Staff 3 | LPN/Director of the Cottages | Named in findings related to abuse reporting and infection control |
| Staff 7 | Director of Care and Nursing | Named in findings related to staff training and quality improvement |
| Staff 9 | Maintenance Supervisor | Named in findings related to facility maintenance and fire safety |
| Staff 14 | CG/MT | Named in findings related to medication delegation |
| Staff 15 | MT | Named in findings related to medication delegation and staff training |
| Staff 23 | CG/MT | Named in findings related to medication delegation and staff training |
| Staff 24 | MT | Named in findings related to medication delegation and staff training |
| Staff 29 | MT | Named in findings related to medication delegation and staff training |
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