Inspection Report
Renewal
Census: 26
Capacity: 64
Deficiencies: 26
Jul 2, 2025
Visit Reason
State-compiled facility profile showing 6 inspections from 2021 to 2025 with deficiency history and enforcement actions
Findings
Across multiple inspections from 2021 to 2025, the facility demonstrated numerous deficiencies including failure to investigate and report abuse, inadequate service plans, insufficient staffing, incomplete staff training, fire and life safety violations, and issues with housekeeping and laundry. Several deficiencies were repeated and plans of correction were implemented but not always fully corrected at subsequent visits.
Complaint Details
Investigation conducted on 6/29/2023 related to acuity-based staffing tool compliance
Deficiencies (26)
| Description |
|---|
| C0231 - Reporting & Investigating Abuse-Other Action: Failed to ensure injuries of unknown cause were promptly investigated to rule out abuse and reported to local SPD |
| C0260 - Service Plan: General: Failed to ensure service plans were reflective of residents' needs and provided clear direction to staff |
| C0270 - Change of Condition and Monitoring: Failed to ensure short-term changes of condition were evaluated, monitored, and documented weekly until resolution |
| C0280 - Resident Health Services: Failed to ensure RN assessment was completed timely and documented for significant changes of condition |
| C0360 - Staffing Requirements and Training: Staffing: Failed to maintain sufficient direct care staff to meet residents' scheduled and unscheduled needs |
| C0362 - Acuity Based Staffing Tool - ABST Time: Failed to ensure ABST accurately captured care time and care elements provided to residents |
| C0420 - Fire and Life Safety: Safety: Failed to conduct fire drills according to Oregon Fire Code and provide fire and life safety instruction on alternate months |
| C0422 - Fire and Life Safety: Training for Residents: Failed to ensure residents were instructed on fire and life safety procedures within 24 hours of admission and annually |
| C0455 - Inspections and Investigation: Insp Interval: Failed to ensure re-licensure survey plan of correction was implemented and satisfied the Department |
| C0530 - Housekeeping and Laundry: Failed to ensure washers had minimum rinse temperature of 140°F unless chemical disinfectant was used |
| H1517 - Individual Privacy: Own Unit: Failed to ensure privacy and dignity related to absence of locks on shared bathroom doors |
| Z0142 - Administration Compliance: Failed to follow licensing rules for Residential Care and Assisted Living Facilities |
| Z0155 - Staff Training Requirements: Failed to ensure newly hired and long-term staff completed required orientation and annual training |
| Z0162 - Compliance with Rules Health Care: Failed to provide health care services in accordance with licensing rules |
| Z0164 - Activities: Failed to evaluate and develop individualized activity plans for residents |
| C0000 - Comment: Kitchen inspections documented findings related to food sanitation and compliance with OARs |
| C0200 - Resident Rights and Protection - General: Failed to ensure resident dignity with dining and honoring resident likes and preferences |
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to maintain kitchen in good repair and sanitary manner |
| C0370 - Staffing Requirements and Training – Pre-Serv: Failed to ensure food preparers had active food handler's certificates |
| C0361 - Acuity-Based Staffing Tool: Investigation conducted to determine compliance with staffing tool requirements |
| C0513 - Doors, Walls, Elevators, Odors: Failed to ensure environment was kept clean and in good repair |
| C0545 - Plumbing Systems: Failed to ensure hot water temperature was maintained within required range |
| C0310 - Systems: Medication Administration: Failed to ensure MARs included specific instructions for PRN medications |
| C0372 - Training Within 30 Days: Direct Care Staff: Failed to ensure newly hired staff completed abdominal thrust and First Aid training within 30 days |
| Z0163 - Nutrition and Hydration: Failed to ensure individualized nutrition and hydration plans were developed and followed |
| Z0165 - Behavior: Failed to provide individualized service plan for behavioral symptoms impacting resident or others |
Report Facts
Inspections on page: 6
Total deficiencies: 40
Total surveys: 6
Notices: 3
Licensing violations: 10
Residents census: 26
Licensed beds: 64
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Executive Director | Named in multiple findings including abuse reporting, staffing, service plans, and fire safety |
| Staff 3 | Wellness Director | Named in multiple findings including abuse reporting, service plans, staffing, and RN assessments |
| Staff 7 | Resident Services Director | Named in staffing and training findings |
| Staff 2 | Dining Services Director | Named in food service and kitchen sanitation findings |
| Staff 24 | Plant Operations Director | Named in fire safety and environmental maintenance findings |
| Staff 9 | Caregiver | Named in staff training and resident care findings |
| Staff 10 | Caregiver | Named in laundry and kitchen sanitation findings |
| Staff 14 | Caregiver | Named in resident care findings |
| Staff 20 | Caregiver | Named in staff training findings |
| Staff 22 | Medication Technician | Named in staff training findings |
| Staff 25 | Memory Care Administrator | Named in privacy and bathroom lock findings |
| Staff 26 | Wellness Director | Named in privacy and change of condition findings |
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