Deficiencies (last 5 years)
Deficiencies (over 5 years)
15 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
124% worse than Oregon average
Oregon average: 6.7 deficiencies/yearDeficiencies per year
28
21
14
7
0
Inspection Report
FEOS
Capacity: 30
Deficiencies: 4
Sep 11, 2025
Visit Reason
Facility failed to conduct investigations of injuries of unknown cause to rule-out abuse or report suspected abuse; failed to ensure medication and treatment orders were carried out as prescribed; failed to maintain accurate medication administration records; and failed to provide health care services in accordance with licensing rules.
Findings
Facility failed to conduct investigations of injuries of unknown cause to rule-out abuse or report suspected abuse; failed to ensure medication and treatment orders were carried out as prescribed; failed to maintain accurate medication administration records; and failed to provide health care services in accordance with licensing rules.
Deficiencies (4)
| Description |
|---|
| OAR 411-054-0028 — Reporting & Investigating Abuse-Other Action |
| OAR 411-054-0055 — Systems: Treatment Orders |
| OAR 411-054-0055 — Systems: Medication Administration |
| OAR 411-057-0160 — Compliance with Rules Health Care |
Inspection Report
Licensure Complaint, Complaint Investig.
Capacity: 30
Deficiencies: 1
May 7, 2025
Visit Reason
Facility failed to update and implement an acuity-based staffing tool (ABST) accurately reflecting residents' care needs for sampled residents.
Findings
Facility failed to update and implement an acuity-based staffing tool (ABST) accurately reflecting residents' care needs for sampled residents.
Deficiencies (1)
| Description |
|---|
| OAR 411-054-0362 — Acuity Based Staffing Tool - Abst Time |
Inspection Report
FEOS
Capacity: 30
Deficiencies: 3
Apr 23, 2025
Visit Reason
Facility failed to ensure timely training within 30 days of hire for direct care staff, failed administrative compliance, and failed staff training requirements.
Findings
Facility failed to ensure timely training within 30 days of hire for direct care staff, failed administrative compliance, and failed staff training requirements.
Deficiencies (3)
| Description |
|---|
| OAR 411-054-0070 — Training Within 30 Days of Hire – Direct Care Staff |
| OAR 411-057-0140 — Administration Compliance |
| OAR 411-057-0155 — Staff Training Requirements |
Inspection Report
Follow-up/Revisit, Other
Capacity: 30
Deficiencies: 25
May 13, 2024
Visit Reason
Multiple deficiencies including failure to implement policies for resident rights and protection, failure to investigate and report abuse, inadequate service plans, failure to monitor changes of condition, infection control issues, medication administration inaccuracies, and environmental maintenance problems. Some deficiencies were corrected by revisit date 7/14/2024.
Findings
Multiple deficiencies including failure to implement policies for resident rights and protection, failure to investigate and report abuse, inadequate service plans, failure to monitor changes of condition, infection control issues, medication administration inaccuracies, and environmental maintenance problems. Some deficiencies were corrected by revisit date 7/14/2024.
Deficiencies (25)
| Description |
|---|
| OAR 411-054-0200 — Resident Rights and Protection - General |
| OAR 411-054-0231 — Reporting & Investigating Abuse-Other Action |
| OAR 411-054-0252 — Resident Move-In and Eval: Res Evaluation |
| OAR 411-054-0270 — Change of Condition and Monitoring |
| OAR 411-054-0280 — Resident Health Services |
| OAR 411-054-0295 — Infection Prevention & Control |
| OAR 411-054-0310 — Systems: Medication Administration |
| OAR 411-054-0330 — Systems: Psychotropic Medication |
| OAR 411-054-0350 — Administrator Qualification and Requirements |
| OAR 411-054-0361 — Acuity-Based Staffing Tool |
| OAR 411-054-0365 — Staffing Rqmt and Training: Training Rqmts |
| OAR 411-054-0372 — Training Within 30 Days: Direct Care Staff |
| OAR 411-054-0420 — Fire and Life Safety: Safety |
| OAR 411-054-0510 — General Building Exterior |
| OAR 411-054-0513 — Doors, Walls, Elevators, Odors |
| OAR 411-054-0555 — Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable |
| OAR 411-004-1517 — Individual Privacy: Own Unit |
| OAR 411-004-1518 — Individual Door Locks: Key Access |
| OAR 411-004-1580 — Limitations: Threats to Health and Safety |
| OAR 411-057-0142 — Administration Compliance |
| OAR 411-057-0155 — Staff Training Requirements |
| OAR 411-057-0162 — Compliance With Rules Health Care |
| OAR 411-057-0164 — Activities |
| OAR 411-057-0165 — Behavior |
| OAR 411-057-0176 — Resident Rooms |
Inspection Report
Complaint Investig., Licensure Complaint
Capacity: 30
Deficiencies: 2
Sep 19, 2023
Visit Reason
Facility failed to fully implement and update an Acuity-Based Staffing Tool (ABST) and failed to conduct a licensing complaint investigation properly.
Findings
Facility failed to fully implement and update an Acuity-Based Staffing Tool (ABST) and failed to conduct a licensing complaint investigation properly.
Deficiencies (2)
| Description |
|---|
| OAR 411-054-0010 — Licensing Complaint Investigation |
| OAR 411-054-0361 — Acuity-Based Staffing Tool |
Inspection Report
State Licensure, Other
Capacity: 30
Deficiencies: 1
Aug 29, 2023
Visit Reason
Kitchen inspection found the facility in substantial compliance with relevant food sanitation rules.
Findings
Kitchen inspection found the facility in substantial compliance with relevant food sanitation rules.
Deficiencies (1)
| Description |
|---|
| OAR 411-054-0000 — Comment |
Inspection Report
Complaint Investig., Licensure Complaint
Capacity: 30
Deficiencies: 5
Nov 2, 2022
Visit Reason
Facility failed to update care plans quarterly, maintain infection prevention and control protocols, carry out medication and treatment orders as prescribed, maintain sufficient staffing, and ensure staff training and competency.
Findings
Facility failed to update care plans quarterly, maintain infection prevention and control protocols, carry out medication and treatment orders as prescribed, maintain sufficient staffing, and ensure staff training and competency.
Deficiencies (5)
| Description |
|---|
| OAR 411-054-0260 — Service Plan: General |
| OAR 411-054-0295 — Infection Prevention & Control |
| OAR 411-054-0303 — Systems: Treatment Orders |
| OAR 411-054-0360 — Staffing Requirements and Training: Staffing |
| OAR 411-054-0361 — Acuity-Based Staffing Tool |
Inspection Report
Complaint Investig., Licensure Complaint
Capacity: 30
Deficiencies: 8
Sep 7, 2022
Visit Reason
Facility failed to provide reasonable precautions, assist residents with ADLs, maintain accurate service plans, carry out medication and treatment orders as prescribed, maintain accurate MARs, provide non-pharmacological interventions prior to PRN psychotropic medications, maintain sufficient staffing, and maintain equipment in good repair.
Findings
Facility failed to provide reasonable precautions, assist residents with ADLs, maintain accurate service plans, carry out medication and treatment orders as prescribed, maintain accurate MARs, provide non-pharmacological interventions prior to PRN psychotropic medications, maintain sufficient staffing, and maintain equipment in good repair.
Deficiencies (8)
| Description |
|---|
| OAR 411-054-0160 — Reasonable Precautions |
| OAR 411-054-0243 — Resident Services: Adls |
| OAR 411-054-0260 — Service Plan: General |
| OAR 411-054-0303 — Systems: Treatment Orders |
| OAR 411-054-0310 — Systems: Medication Administration |
| OAR 411-054-0330 — Systems: Psychotropic Medication |
| OAR 411-054-0360 — Staffing Requirements and Training: Staffing |
| OAR 411-054-0361 — Acuity-Based Staffing Tool |
Inspection Report
State Licensure, Other
Capacity: 30
Deficiencies: 2
Jul 11, 2022
Visit Reason
Facility failed to ensure food sanitation compliance in kitchen and failed to maintain accurate service plans and evaluations. Some deficiencies were corrected by revisit date 9/11/2022.
Findings
Facility failed to ensure food sanitation compliance in kitchen and failed to maintain accurate service plans and evaluations. Some deficiencies were corrected by revisit date 9/11/2022.
Deficiencies (2)
| Description |
|---|
| OAR 411-054-0240 — Resident Services Meals, Food Sanitation Rule |
| OAR 411-057-0142 — Administration Compliance |
Inspection Report
Validation, Re-Licensure
Capacity: 30
Deficiencies: 24
Oct 4, 2021
Visit Reason
Facility failed to ensure safe medication systems, adequate professional oversight, quality improvement programs, reasonable precautions, timely investigations and reporting of abuse, accurate service plans and evaluations, coordination of health services, and fire and life safety compliance. Immediate jeopardy was identified and abated during the survey.
Findings
Facility failed to ensure safe medication systems, adequate professional oversight, quality improvement programs, reasonable precautions, timely investigations and reporting of abuse, accurate service plans and evaluations, coordination of health services, and fire and life safety compliance. Immediate jeopardy was identified and abated during the survey.
Deficiencies (24)
| Description |
|---|
| OAR 411-054-0055 — Systems: Medications and Treatments |
| OAR 411-054-0156 — Facility Administration: Quality Improvement |
| OAR 411-054-0160 — Reasonable Precautions |
| OAR 411-054-0231 — Reporting & Investigating Abuse-Other Action |
| OAR 411-054-0240 — Resident Services Meals, Food Sanitation Rule |
| OAR 411-054-0252 — Resident Move-In and Eval: Res Evaluation |
| OAR 411-054-0260 — Service Plan: General |
| OAR 411-054-0270 — Change of Condition and Monitoring |
| OAR 411-054-0280 — Resident Health Services |
| OAR 411-054-0290 — Res Hlth Srvc: On- and Off-Site Health Srvc |
| OAR 411-054-0300 — Systems: Medications and Treatments |
| OAR 411-054-0303 — Systems: Treatment Orders |
| OAR 411-054-0304 — Systems: Medication and Treatment Review |
| OAR 411-054-0310 — Systems: Medication Administration |
| OAR 411-054-0360 — Staffing Requirements and Training: Staffing |
| OAR 411-054-0372 — Training Within 30 Days: Direct Care Staff |
| OAR 411-054-0420 — Fire and Life Safety: Safety |
| OAR 411-054-0455 — Inspections and Investigation: Insp Interval |
| OAR 411-054-0513 — Doors, Walls, Elevators, Odors |
| OAR 411-054-0555 — Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable |
| OAR 411-057-0140 — Administration Responsibilities |
| OAR 411-057-0142 — Administration Compliance |
| OAR 411-057-0155 — Staff Training Requirements |
| OAR 411-057-0162 — Compliance With Rules Health Care |
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