Inspection Reports for The Springs at Clackamas Woods
14404 SE Webster Rd, Milwaukie, OR 97267, United States, OR, 97267
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Inspection Report
Re-Inspection
Capacity: 58
Deficiencies: 12
Jan 8, 2025
Visit Reason
State-compiled facility profile showing 3 inspections from 2022-2025 with deficiency history and enforcement violations.
Findings
Across all inspections, the facility demonstrated multiple deficiencies including failure to complete resident move-in evaluations, infection prevention protocol lapses, incomplete psychotropic medication documentation, inaccurate acuity-based staffing tools, and inadequate staff training. Some deficiencies were corrected over time, but several remained uncorrected as of the most recent inspection.
Deficiencies (12)
| Description |
|---|
| C0252 - Resident Move-in & Evaluation: Res Evaluation: Failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident. |
| C0295 - Infection Prevention & Control: Failed to maintain infection prevention and control protocols during meal service. |
| C0330 - Systems: Psychotropic Medication: Failed to ensure PRN medications had documented non-drug interventions attempted prior to administration for 1 of 1 sampled resident. |
| C0362 - Acuity Based Staffing Tool - ABST Time: Failed to complete ABST evaluation before resident move-in and inaccurate staffing time for another resident. |
| C0370 - Staffing Requirements and Training – Pre-service: Failed to ensure 2 of 4 staff completed infectious disease prevention training prior to job start. |
| C0372 - Training Within 30 Days of Hire – Direct Care Staff: Failed to ensure 2 of 3 newly hired direct care staff demonstrated knowledge and performance in required areas within 30 days. |
| C0000 - Comment: Kitchen inspection findings documented; facility in substantial compliance on revisit. |
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to ensure kitchen practices and protocols met Food Sanitation Rules. |
| C0160 - Reasonable Precautions: Failed to exercise reasonable precautions against conditions threatening resident health and safety, including unlocked chemical storage and improper glove use. |
| C0420 - Fire and Life Safety: Safety: Failed to ensure fire drills and life safety instruction were conducted and documented per Oregon Fire Code. |
| C0422 - Fire and Life Safety: Training For Residents: Failed to document resident instruction on fire and life safety procedures within required timeframes. |
| C0610 - General Building Exterior: Failed to maintain exterior pathways in good repair, creating fall hazards. |
Report Facts
Inspections on page: 3
Total deficiencies: 12
Total surveys: 3
Licensed beds: 58
Licensing violations: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Executive Director | Named in multiple findings including resident move-in evaluation, infection prevention, psychotropic medication, ABST, and staff training deficiencies |
| Staff 2 | Health Services Administrator | Named in multiple findings including resident move-in evaluation, infection prevention, psychotropic medication, ABST, and staff training deficiencies |
| Staff 5 | Resident Services Coordinator | Named in multiple findings including resident move-in evaluation, infection prevention, psychotropic medication, ABST, and staff training deficiencies |
| Staff 8 | Caregiver | Named in infection prevention deficiency related to meal service |
| Staff 10 | Caregiver | Named in staffing training deficiencies for infectious disease prevention and training within 30 days of hire |
| Staff 11 | Prep Cook | Named in staffing training deficiency for infectious disease prevention |
| Staff 7 | Caregiver | Named in training within 30 days of hire deficiency |
| Staff 2 | Health Services Director | Named in ABST deficiency interview |
| Staff 7 | Plant Operations Director | Named in fire and life safety deficiencies |
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