Inspection Reports for Waverly Place
2853 SE Salem Ave, Albany, OR 97321, United States, OR, 97321
Back to Facility ProfileDeficiencies per Year
32
24
16
8
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Inspection Report
Kitchen
Capacity: 20
Deficiencies: 29
Nov 12, 2025
Visit Reason
State-compiled facility profile showing 6 inspections from 2021 to 2025 with detailed deficiency history and enforcement actions
Findings
Across multiple inspections from 2021 to 2025, the facility exhibited numerous deficiencies including failures in food sanitation, resident care evaluations, medication administration, staff training, fire and life safety, and compliance with licensing rules. Deficiencies were noted in resident health services, activity programming, abuse reporting, and environmental maintenance.
Complaint Details
Complaint investigation on 2025-06-09 substantiated failure to fully implement and update Acuity-Based Staffing Tool (ABST) for 1 sampled resident. Licensing violation confirmed.
Deficiencies (29)
| Description |
|---|
| C0240 - Resident Services Meals, Food Sanitation Rule: Facility failed to maintain kitchen and kitchenette in sanitary condition and ensure proper food temperatures and handling |
| Z0142 - Administration Compliance: Facility failed to follow licensing rules for Residential Care and Assisted Living Facilities |
| C0363 - Acuity Based Staffing Tool - Updates & Plan: Facility failed to fully implement and update Acuity-Based Staffing Tool |
| C0150 - Facility Administration: Operation: Licensee failed to provide effective oversight to ensure quality of care and services |
| C0231 - Reporting & Investigating Abuse-Other Action: Facility failed to promptly investigate and report incidents and injuries of unknown cause to local SPD |
| C0242 - Resident Services: Activities: Facility failed to provide daily program of social and recreational activities based on resident needs |
| C0252 - Resident Move-in & Evaluation: Res Evaluation: Facility failed to conduct initial resident evaluation prior to move-in |
| C0260 - Service Plan: General: Service plans were not reflective of resident needs, lacked clear direction, and were inconsistently implemented |
| C0270 - Change of Condition and Monitoring: Facility failed to ensure short term changes of condition were monitored and interventions evaluated |
| C0280 - Resident Health Services: Facility failed to ensure timely RN assessments for residents with significant changes of condition |
| C0290 - Res Hlth Srvc: On- and Off-Site Health Srvc: Facility failed to coordinate on-site health services with outside providers and implement recommendations |
| C0300 - Systems: Medications and Treatments: Facility failed to ensure safe medication system and adequate professional oversight |
| C0302 - Systems: Tracking Control Substances: Facility failed to have system for accurately tracking controlled substances |
| C0303 - Systems: Treatment Orders: Facility failed to ensure physician orders were carried out as prescribed and documented |
| C0310 - Systems: Medication Administration: Facility failed to maintain accurate MARs including resident-specific parameters for PRN medications |
| C0330 - Systems: Psychotropic Medication: Facility failed to ensure PRN psychotropic medications had resident-specific parameters and non-pharmacological interventions |
| C0340 - Restraints and Supportive Devices: Facility failed to ensure assessments were completed for supportive devices with restraining qualities |
| C0362 - Acuity Based Staffing Tool - ABST Time: Facility failed to accurately capture care time and care elements in ABST |
| C0363 - Acuity Based Staffing Tool - Updates & Staffing Plan: Facility failed to update ABST entries quarterly and with significant changes |
| C0372 - Training Within 30 Days of Hire – Direct Care Staff: Facility failed to ensure direct care staff were trained in First Aid and abdominal thrust within 30 days of hire |
| C0420 - Fire and Life Safety: Safety: Facility failed to conduct fire drills according to Oregon Fire Code and document required elements |
| C0422 - Fire and Life Safety: Training for Residents: Facility failed to instruct residents in fire and life safety procedures within 24 hours of admission and annually |
| C0455 - Inspections and Investigation: Insp Interval: Facility failed to ensure re-licensure survey plan of correction was implemented and satisfied the Department |
| C0510 - General Building Exterior: Facility failed to maintain courtyard surfaces and pathways in good repair |
| C0513 - Doors, Walls, Elevators, Odors: Facility failed to maintain environment clean and in good repair |
| H1510 - Individual Rights Settings: Privacy, Dignity: Facility failed to ensure residents' right to freedom from restraints |
| H1517 - Individual Privacy: Own Unit: Facility failed to ensure privacy due to no locks on shared bathroom doors |
| H1518 - Individual Door Locks: Key Access: Facility failed to provide all residents with keys to their units |
| L0252 - Resident Move-in & Evaluation: Res Evaluation: Facility failed to conduct initial resident evaluation prior to move-in |
Report Facts
Inspections on page: 6
Total deficiencies: 59
Total licensing violations: 10
Total notices: 1
Licensed beds: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Executive Director | Named in multiple findings related to oversight, investigations, and compliance |
| Staff 6 | Memory Care Coordinator | Named in multiple findings related to investigations, training, and compliance |
| Staff 2 | Business Office Manager | Named in findings related to staff training records and medication documentation |
| Staff 24 | Regional Director of Operations | Named in findings related to oversight and compliance |
| Staff 26 | Health Services Director/RN | Named in findings related to resident health services and medication administration |
| Staff 27 | Assisted Living RN | Named in findings related to resident care and service plans |
| Witness 1 | RN Consultant | Named in findings related to resident health assessments |
| Staff 4 | Assisted Living RCC | Named in findings related to resident service plans and activities |
| Staff 3 | Maintenance Director | Named in findings related to fire and life safety and environmental maintenance |
| Staff 25 | Culinary Services Director | Named in findings related to food sanitation and staff training |
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