Inspection Reports for Tierra Rose Care Center
4254 Weathers Street NE, OR, 97301
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
18.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
181% worse than Oregon average
Oregon average: 6.7 deficiencies/yearDeficiencies per year
32
24
16
8
0
Inspection Report
Complaint Investigation
Capacity: 76
Deficiencies: 2
Nov 13, 2025
Visit Reason
No deficiencies found during this complaint and re-licensure survey.
Findings
No deficiencies found during this complaint and re-licensure survey.
Deficiencies (2)
| Description |
|---|
| F0000 - INITIAL COMMENTS |
| M0000 - Initial Comments |
Inspection Report
Complaint Investigation
Capacity: 76
Deficiencies: 5
Oct 17, 2025
Visit Reason
Multiple deficiencies including failure to provide adequate treatment and services to prevent pressure ulcers, infection prevention and control issues, and medication storage and labeling problems. All cited deficiencies were corrected by 11/10/2025.
Findings
Multiple deficiencies including failure to provide adequate treatment and services to prevent pressure ulcers, infection prevention and control issues, and medication storage and labeling problems. All cited deficiencies were corrected by 11/10/2025.
Deficiencies (5)
| Description |
|---|
| F0000 - INITIAL COMMENTS |
| F0686 - Treatment/Svcs to Prevent/Heal Pressure Ulcer |
| F0880 - Infection Prevention & Control |
| M0000 - Initial Comments |
| M9999 - STATE OF OREGON ADMINISTRATIVE RULES |
Inspection Report
Complaint Investigation
Capacity: 76
Deficiencies: 2
Apr 16, 2025
Visit Reason
No deficiencies found during this complaint and licensure complaint survey.
Findings
No deficiencies found during this complaint and licensure complaint survey.
Deficiencies (2)
| Description |
|---|
| F0000 - INITIAL COMMENTS |
| M0000 - Initial Comments |
Inspection Report
Complaint Investigation
Capacity: 76
Deficiencies: 2
Dec 20, 2024
Visit Reason
No deficiencies found during this complaint and licensure complaint survey.
Findings
No deficiencies found during this complaint and licensure complaint survey.
Deficiencies (2)
| Description |
|---|
| F0000 - INITIAL COMMENTS |
| M0000 - Initial Comments |
Inspection Report
Complaint Investigation
Capacity: 76
Deficiencies: 9
Jun 28, 2024
Visit Reason
Multiple deficiencies including failure to provide appropriate foot care, accident hazard supervision, medication storage, food sanitation, resident records accuracy, essential equipment maintenance, and restorative care. Some deficiencies were corrected while others remained uncorrected at last visit.
Findings
Multiple deficiencies including failure to provide appropriate foot care, accident hazard supervision, medication storage, food sanitation, resident records accuracy, essential equipment maintenance, and restorative care. Some deficiencies were corrected while others remained uncorrected at last visit.
Deficiencies (9)
| Description |
|---|
| F0000 - INITIAL COMMENTS |
| F0687 - Foot Care |
| F0689 - Free of Accident Hazards/Supervision/Devices |
| F0761 - Label/Store Drugs and Biologicals |
| F0812 - Food Procurement,Store/Prepare/Serve-Sanitary |
| F0842 - Resident Records - Identifiable Information |
| F0908 - Essential Equipment, Safe Operating Condition |
| M0000 - Initial Comments |
| M9999 - STATE OF OREGON ADMINISTRATIVE RULES |
Inspection Report
Complaint Investigation
Capacity: 76
Deficiencies: 16
Apr 21, 2023
Visit Reason
Numerous deficiencies including failure to provide reasonable accommodations, develop comprehensive care plans, quality of care issues, sufficient nursing staff, medication regimen review, fall prevention, physician visits, and specialized rehab services. Many deficiencies were corrected but some remained uncorrected at last visit.
Findings
Numerous deficiencies including failure to provide reasonable accommodations, develop comprehensive care plans, quality of care issues, sufficient nursing staff, medication regimen review, fall prevention, physician visits, and specialized rehab services. Many deficiencies were corrected but some remained uncorrected at last visit.
Deficiencies (16)
| Description |
|---|
| F0000 - INITIAL COMMENTS |
| F0558 - Reasonable Accommodations Needs/Preferences |
| F0656 - Develop/Implement Comprehensive Care Plan |
| F0684 - Quality of Care |
| F0689 - Free of Accident Hazards/Supervision/Devices |
| F0712 - Physician Visits-Frequency/Timeliness/Alt NPP |
| F0725 - Sufficient Nursing Staff |
| F0756 - Drug Regimen Review, Report Irregular, Act On |
| F0758 - Free from Unnec Psychotropic Meds/PRN Use |
| F0803 - Menus Meet Resident Nds/Prep in Adv/Followed |
| F0804 - Nutritive Value/Appear, Palatable/Prefer Temp |
| F0806 - Resident Allergies, Preferences, Substitutes |
| F0825 - Provide/Obtain Specialized Rehab Services |
| M0000 - Initial Comments |
| M0185 - Bariatric Criteria and Services |
| M9999 - STATE OF OREGON ADMINISTRATIVE RULES |
Inspection Report
Complaint Investigation
Capacity: 76
Deficiencies: 22
Jan 11, 2023
Visit Reason
Multiple deficiencies including failure to ensure resident rights, safe environment, abuse and neglect prevention, comprehensive assessments, wound care, medication management, staffing, training, infection control, and quality assurance. Some deficiencies were corrected while others remained uncorrected at last visit.
Findings
Multiple deficiencies including failure to ensure resident rights, safe environment, abuse and neglect prevention, comprehensive assessments, wound care, medication management, staffing, training, infection control, and quality assurance. Some deficiencies were corrected while others remained uncorrected at last visit.
Deficiencies (22)
| Description |
|---|
| F0000 - INITIAL COMMENTS |
| F0552 - Right to be Informed/Make Treatment Decisions |
| F0584 - Safe/Clean/Comfortable/Homelike Environment |
| F0600 - Free from Abuse and Neglect |
| F0636 - Comprehensive Assessments & Timing |
| F0684 - Quality of Care |
| F0686 - Treatment/Svcs to Prevent/Heal Pressure Ulcer |
| F0689 - Free of Accident Hazards/Supervision/Devices |
| F0727 - RN 8 Hrs/7 days/Wk, Full Time DON |
| F0730 - Nurse Aide Peform Review-12 hr/yr In-Service |
| F0741 - Sufficient/Competent Staff-Behav Health Needs |
| F0802 - Sufficient Dietary Support Personnel |
| F0842 - Resident Records - Identifiable Information |
| F0865 - QAPI Prgm/Plan, Disclosure/Good Faith Attmpt |
| F0867 - QAPI/QAA Improvement Activities |
| F0880 - Infection Prevention & Control |
| F0946 - Compliance and Ethics Training |
| M0000 - Initial Comments |
| M0182 - Nursing Services:Minimum Licensed Nurse Staff |
| M0183 - Nursing Services: Minimum CNA Staffing |
| M0185 - Bariatric Criteria and Services |
| M9999 - STATE OF OREGON ADMINISTRATIVE RULES |
Inspection Report
Capacity: 76
Deficiencies: 3
May 3, 2022
Visit Reason
Deficiencies related to influenza and pneumococcal immunizations, COVID-19 vaccination of staff, and infection control. Some deficiencies were corrected while others remained uncorrected at last visit.
Findings
Deficiencies related to influenza and pneumococcal immunizations, COVID-19 vaccination of staff, and infection control. Some deficiencies were corrected while others remained uncorrected at last visit.
Deficiencies (3)
| Description |
|---|
| F0000 - INITIAL COMMENTS |
| F0883 - Influenza and Pneumococcal Immunizations |
| F0888 - COVID-19 Vaccination of Facility Staff |
Inspection Report
Complaint Investigation
Capacity: 76
Deficiencies: 32
Mar 28, 2022
Visit Reason
Extensive deficiencies including failure to ensure resident rights, timely assessments, care planning, wound care, medication management, infection control, staffing, training, quality assurance, and resident safety. Immediate jeopardy situations related to elopement and aspiration were identified and abated. Many deficiencies were corrected while others remained uncorrected at last visit.
Findings
Extensive deficiencies including failure to ensure resident rights, timely assessments, care planning, wound care, medication management, infection control, staffing, training, quality assurance, and resident safety. Immediate jeopardy situations related to elopement and aspiration were identified and abated. Many deficiencies were corrected while others remained uncorrected at last visit.
Deficiencies (32)
| Description |
|---|
| F0000 - INITIAL COMMENTS |
| F0550 - Resident Rights/Exercise of Rights |
| F0558 - Reasonable Accommodations Needs/Preferences |
| F0580 - Notify of Changes (Injury/Decline/Room, etc.) |
| F0600 - Free from Abuse and Neglect |
| F0609 - Reporting of Alleged Violations |
| F0610 - Investigate/Prevent/Correct Alleged Violation |
| F0636 - Comprehensive Assessments & Timing |
| F0637 - Comprehensive Assessment After Signifcant Chg |
| F0656 - Develop/Implement Comprehensive Care Plan |
| F0657 - Care Plan Timing and Revision |
| F0658 - Services Provided Meet Professional Standards |
| F0686 - Treatment/Svcs to Prevent/Heal Pressure Ulcer |
| F0688 - Increase/Prevent Decrease in ROM/Mobility |
| F0689 - Free of Accident Hazards/Supervision/Devices |
| F0690 - Bowel/Bladder Incontinence, Catheter, UTI |
| F0693 - Tube Feeding Mgmt/Restore Eating Skills |
| F0697 - Pain Management |
| F0698 - Dialysis |
| F0744 - Treatment/Service for Dementia |
| F0756 - Drug Regimen Review, Report Irregular, Act On |
| F0757 - Drug Regimen is Free from Unnecessary Drugs |
| F0804 - Nutritive Value/Appear, Palatable/Prefer Temp |
| F0812 - Food Procurement,Store/Prepare/Serve-Sanitary |
| F0825 - Provide/Obtain Specialized Rehab Services |
| F0849 - Hospice Services |
| F0867 - QAPI/QAA Improvement Activities |
| F0881 - Antibiotic Stewardship Program |
| F0919 - Resident Call System |
| M0000 - Initial Comments |
| M0183 - Nursing Services: Minimum CNA Staffing |
| M9999 - STATE OF OREGON ADMINISTRATIVE RULES |
Inspection Report
Capacity: 76
Deficiencies: 1
Sep 17, 2021
Visit Reason
No deficiencies found during this state licensure survey.
Findings
No deficiencies found during this state licensure survey.
Deficiencies (1)
| Description |
|---|
| M0000 - Initial Comments |
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