Inspection Reports for The Lodge at Vista View
2205 Gilman Dr., Oregon City, OR 97045, OR, 97045
Back to Facility ProfileDeficiencies per Year
32
24
16
8
0
Unclassified
Inspection Report
Complaint Investigation
Capacity: 101
Deficiencies: 31
Jul 16, 2025
Visit Reason
State-compiled facility profile showing multiple inspections from 2022 to 2025 with detailed deficiency history and enforcement actions.
Findings
Across multiple inspections from 2022 through 2025, the facility exhibited numerous deficiencies including failures in service planning, medication administration, infection control, staffing, resident rights, and building maintenance. Several citations were repeat findings with ongoing corrective plans.
Complaint Details
Multiple complaint investigations conducted on 1/5/2023 and 7/29/2024 related to licensure complaints and service plan deficiencies.
Deficiencies (31)
| Description |
|---|
| C0000 - Comment: General comments on survey findings and compliance status. |
| C0150 - Facility Administration: Operation: Failed to provide effective oversight to ensure quality of care and services. |
| C0154 - Facility Administration: Policy & Procedure: Failed to implement effective methods to respond to and resolve resident complaints. |
| C0200 - Resident Rights and Protection - General: Failed to ensure residents' right to dignity, respect, privacy, and homelike environment. |
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to ensure a clean kitchen environment per Food Sanitation Rules. |
| C0243 - Resident Services: Adls: Deficiencies related to activities of daily living services. |
| C0252 - Resident Move-In and Eval: Res Evaluation: Failed to ensure move-in evaluations addressed all required elements and were updated quarterly or after significant changes. |
| C0260 - Service Plan: General: Failed to ensure service plans reflected residents' needs, were clear, updated quarterly, and implemented. |
| C0262 - Service Plan: Service Planning Team: Failed to ensure service plans were developed by a service planning team including resident and staff. |
| C0270 - Change of Condition and Monitoring: Failed to determine, communicate, and monitor actions/interventions for changes of condition. |
| C0280 - Resident Health Services: Failed to ensure RN significant change of condition assessments were completed for residents with significant weight changes. |
| C0295 - Infection Prevention & Control: Failed to have a trained Infection Control Specialist and maintain effective infection control protocols. |
| C0302 - Systems: Tracking Control Substances: Failed to have an accurate system for tracking controlled substances administered. |
| C0303 - Systems: Treatment Orders: Failed to carry out medication and treatment orders as prescribed and document accordingly. |
| C0304 - Systems: Medication and Treatment Review: Deficiencies related to medication and treatment review processes. |
| C0305 - Systems: Resident Right to Refuse: Failed to notify physician/practitioner when resident refused medications or treatments. |
| C0310 - Systems: Medication Administration: Failed to ensure accurate MARs with medication-specific instructions and documentation. |
| C0325 - Systems: Self-Administration of Meds: Failed to ensure residents had physician orders and evaluations for self-administering medications. |
| C0355 - Administrator: Administrator Requirements: Administrator failed to provide evidence of current Residential Care Facility Administrator license. |
| C0360 - Staffing Requirements and Training: Staffing: Failed to have sufficient staff to meet resident needs and ensure staff training compliance. |
| C0361 - Acuity-Based Staffing Tool: Failed to fully implement and update acuity-based staffing tool. |
| C0370 - Staffing Requirements and Training – Pre-Serv: Failed to ensure newly hired staff completed required pre-service orientation and dementia training. |
| C0372 - Training Within 30 Days: Direct Care Staff: Failed to ensure newly hired staff demonstrated competency within 30 days of hire. |
| C0374 - Annual and Biennial Inservice For All Staff: Failed to ensure long-term staff completed required annual in-service and infectious disease training. |
| C0420 - Fire and Life Safety: Safety: Failed to conduct fire drills per Oregon Fire Code and provide fire and life safety instruction on alternate months. |
| C0422 - Fire and Life Safety: Training For Residents: Failed to instruct residents on fire and life safety upon admission and annually. |
| C0455 - Inspections and Investigation: Insp Interval: Failed to ensure relicensure survey plan of correction was implemented and satisfied the Department. |
| C0455 - Inspections and Investigation: Insp Interval: Referenced deficiencies C150, C200, C252, C260, C262, C270, C280, C305, C420, C613. |
| C0613 - General Building: Doors-Walls, Cleanable: Failed to keep all interior and exterior materials and surfaces clean and in good repair. |
| C0615 - Resident Units: Failed to provide lockable storage space with keys for residents' small valuables and funds. |
| H1517 - Individual Privacy: Own Unit: Failed to ensure residents' rights of privacy in their own unit. |
Report Facts
Total inspections: 10
Total deficiencies: 46
Licensing violations: 10
Notices: 3
Date range of inspections: From 2022-09-13 to 2025-07-16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Interim Executive Director | Named in multiple findings and acknowledgments across inspections |
| Staff 2 | RN, Health Services Director | Named in multiple findings and acknowledgments across inspections |
| Staff 3 | Resident Care Coordinator (RCC) | Named in multiple findings and acknowledgments across inspections |
| Staff 5 | Regional Vice President of Operations | Named in multiple findings and acknowledgments across inspections |
| Staff 6 | RN Consultant | Named in multiple findings and acknowledgments across inspections |
| Staff 17 | Medication Technician / RCC Assistant | Named in multiple findings and acknowledgments across inspections |
| Staff 26 | Executive Director | Named in multiple findings and acknowledgments across inspections |
| Staff 4 | Environmental Director | Named in fire and life safety and building maintenance findings |
| Staff 9 | Medication Technician | Named in medication and self-administration findings |
| Staff 15 | Medication Technician | Named in medication administration findings |
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