Inspection Reports for Stephanie Gardens
19751 SE Stark St, Portland, OR 97233, OR, 97233
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Inspection Report
Complaint Investigation
Capacity: 52
Deficiencies: 26
Jul 9, 2025
Visit Reason
State-compiled facility profile showing 4 inspections from 2022-2025 with deficiency history and enforcement actions.
Findings
Across all inspections, the facility demonstrated multiple deficiencies including failure to complete timely service plans, inadequate reporting and investigation of abuse, incomplete resident evaluations and care plans, failure to follow physician orders, and environmental maintenance issues. Some deficiencies were corrected in follow-up visits, but several remained uncorrected as of the latest inspections.
Complaint Details
Complaint investigation conducted on 2025-07-09 regarding failure to complete quarterly service plans and other licensure complaints.
Deficiencies (26)
| Description |
|---|
| C0260 - Service Plan: General: Failure to complete quarterly service plans for 1 of 1 sampled resident. |
| C0000 - Comment: Findings documented for change of ownership survey and re-licensure survey compliance. |
| C0231 - Reporting & Investigating Abuse-Other Action: Failed to report injuries of unknown cause as suspected abuse and to promptly investigate reports of abuse for 1 of 3 sampled residents. |
| C0260 - Service Plan: General: Service plans not reflective of current care needs and lacking clear directions for 2 of 4 sampled residents. |
| C0270 - Change of Condition and Monitoring: Failed to evaluate, document, and communicate changes of condition for 3 of 4 sampled residents. |
| C0280 - Resident Health Services: Failed to complete significant change of condition assessment by RN for 1 of 2 sampled residents. |
| C0303 - Systems: Treatment Orders: Failed to ensure physician orders were carried out as prescribed for 3 of 4 sampled residents. |
| C0325 - Systems: Self-Administration of Meds: Failed to evaluate resident's ability and obtain physician order for self-administration for 1 of 2 sampled residents. |
| C0330 - Systems: Psychotropic Medication: Failed to ensure written resident-specific parameters and non-pharmacological interventions prior to PRN psychotropic medication for 1 sampled resident. |
| C0513 - Doors, Walls, Elevators, Odors: Failed to keep interior materials and surfaces clean and in good repair. |
| Z0142 - Administration Compliance: Failed to follow licensing rules for Residential Care and Assisted Living Facilities. |
| Z0162 - Compliance With Rules Health Care: Failed to provide health care services in accordance with licensing rules. |
| C0000 - Comment: Findings of kitchen inspection and revisits documented. |
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to maintain kitchen in accordance with Food Sanitation Rules; repeat citation. |
| C0455 - Inspections and Investigation: Insp Interval: Failed to ensure kitchen survey plan of correction was implemented and satisfied the Department. |
| Z0142 - Administration Compliance: Failed to follow licensing rules; repeat citation related to kitchen inspection. |
| C0000 - Comment: Findings of initial licensure survey and revisit documented. |
| C0231 - Reporting & Investigating Abuse-Other Action: Failed to thoroughly investigate incidents to rule out suspected abuse or neglect for 1 of 2 sampled residents. |
| C0252 - Resident Move-In and Eval: Res Evaluation: Failed to ensure move-in evaluations addressed all required components for 1 of 2 sampled residents. |
| C0270 - Change of Condition and Monitoring: Failed to evaluate and refer changes of condition for 1 of 3 sampled residents. |
| C0513 - Doors, Walls, Elevators, Odors: Failed to ensure all materials and surfaces were clean and in good repair. |
| C0555 - Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable: Failed to ensure exit doors had alarming devices or acceptable alert systems. |
| Z0142 - Administration Compliance: Failed to follow licensing rules; referenced multiple citations. |
| Z0162 - Compliance With Rules Health Care: Failed to follow licensing rules; referenced multiple citations. |
| Z0163 - Nutrition and Hydration: Failed to develop individualized nutrition and hydration plan for 1 of 3 sampled residents. |
| Z0164 - Activities: Failed to develop individualized activity plans and provide meaningful activities for 3 of 3 sampled residents. |
Report Facts
Inspections on page: 4
Total deficiencies: 23
Licensing violations: 7
Abuse violations: 0
Notices: 0
Licensed beds: 52
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Executive Director | Named in multiple findings including service plan failures, abuse reporting, and medication management |
| Staff 2 | Regional Director of Operations | Named in multiple findings related to service plans and compliance |
| Staff 3 | Regional RN | Named in multiple findings related to nursing and clinical compliance |
| Staff 4 | Regional Director of Training | Named in findings related to staff training and compliance |
| Staff 5 | RN | Named in findings related to resident assessments and medication administration |
| Staff 7 | Resident Care Coordinator | Named in findings related to care coordination and compliance |
| Staff 8 | Maintenance Director | Named in findings related to facility maintenance and environment |
| Staff 11 | Medication Technician | Named in findings related to psychotropic medication administration |
| Staff 16 | Medication Technician | Named in findings related to medication administration |
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