5
Inspections
21
Deficiencies
27
Abuse Violations
34
Licensing Violations
3
Regulatory Actions
In plain language
- The most recent inspection was on October 29, 2025 (re-licensure visit) and found 6 deficiencies.
- Across 5 inspections since 2022, inspectors cited 21 deficiencies in total. 13 of them have a correction date recorded; the state lists no correction date for the other 8.
- There are 27 substantiated abuse violations on record.
- The provider also has 34 substantiated licensing violations — rule breaches that did not involve abuse.
- The state has taken 3 regulatory actions against this license, such as fines or conditions on the license.
Deficiencies are rule violations noted by a state inspector. Most are minor and get corrected quickly; the sections below show exactly what was found and how the provider responded.
Provider Information
Status
Open
Type
Assisted Living Facility
County
Columbia
Licensed Since
March 21, 2003
Classification
Not listed
Phone
503-728-2744
Email
gcrichton@sapphirehealthservices.com
Administrator
Gelissa Crichton
Accepts Medicaid
Yes
Memory Care
Yes
Inspections
5 records10/29/2025 Re-Licensure · Event RL007564 Re-Licensure6 deficiencies ▼
Deficiencies cited (6)
C0260 Service Plan: General Severity 2 ▼
Visit 1 · 10/29/2025 · Scope: L2 Pattern
No correction date recorded
Regulation (OAR)
OAR 411-054-0036 (1-4) Service Plan: General
(1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan.
(2) SERVICE PLAN.
The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence.
(a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations.
(b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services.
(c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided.
(d) Changes and entries made to the service plan must be dated and initialed.
(e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed.
(f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative.
(g) The facility administrator is responsible for ensuring the implementation of services.
(h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements.
(3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN.
(a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident.
(b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences.
(c) Staff must document and date adjustments or changes as applicable.
(4) QUARTERLY SERVICE PLAN REQUIREMENTS.
(a) Service plans must be completed quarterly after the resident moves into the facility.
(b) The quarterly evaluation is the basis of the resident's quarterly service plan.
(c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained.
Findings
Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs and preferences and provided clear direction regarding the delivery of services for 2 of 3 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to:
1. Resident 1 moved into the community in 05/2025 with diagnoses including dementia and unspecified sleep disorder.
The resident’s clinical record was reviewed, including the 10/20/25 service plan, observations were made, and interviews were conducted. The following was identified:
The 09/04/25 service plan was not reflective of the resident’s current care needs and did not give clear direction to the staff in the following areas:
* Number of staff and amount of assistance required with dressing, toileting/incontinence care, and transfers;
* Preference of hospital bed to sleep;
* Use of side rails, hospital bed, and alternating pressure mattress; and
* Frequency of weights.
The need for the facility to ensure residents’ current service plans were reflective of current care needs and status and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 1 (Executive Director), Staff 2 (Director of Health Services), Staff 6 (Regional Operations Specialist), Staff 7 (Regional Nurse), and Staff 8 (Regional Director of Operations) on 10/29/25 at 1:55 pm. They acknowledged the findings.
2. Resident 2 moved into the community in 12/2012 with diagnoses including psoriatic arthritis mutilans and chronic obstructive pulmonary disease.
The resident’s clinical record was reviewed, including the 10/20/25 service plan, observations were made, and interviews were conducted. The following was identified:
The service plan was not reflective of the resident’s current care needs and did not give clear direction to staff in the following areas:
* Fall history;
* Use of walker for ambulation inside the apartment;
* The resident’s inability to self-administer treatments; and
* Hourly safety checks.
The need for the facility to ensure service plans were reflective of the resident’s current care needs and status and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 1 (Executive Director), Staff 2 (Director of Health Services), Staff 6 (Regional Operations Specialist), Staff 7 (Regional Nurse), and Staff 8 (Regional Director of Operations) on 10/29/25 at 2:30 pm. They acknowledged the findings.
Plan of Correction
1. Resident 1 and Resident 2 Service Plans have been re-reviewed to ensure all information from their evaluation is reflected on their service plans and current care needs.
2. Resident Care Coordinator (RCC) and Registered Nurse (RN) will receive additional education on the New Admission Evaluation and SP steps. The RCC and RN will complete new move in evaluations and then the Administrator will audit to confirm these areas are reflected on the service plans.
3. All New Admission Service Plans, and 3 quarterly service plans will be audited as part of our monthly Quality Audit for 3 months, and if no errors are found then this will be audited quarterly, as well as needed when service plans occur.
4. Resident Care Coordinator, Registered Nurse, and Administrator will all be responsible to ensure completion of the processes and that corrections are monitored.
Visit 2 · 1/13/2026 · Scope: L2 Pattern
No correction date recorded
Regulation (OAR)
OAR 411-054-0036 (1-4) Service Plan: General
(1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan.
(2) SERVICE PLAN.
The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence.
(a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations.
(b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services.
(c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided.
(d) Changes and entries made to the service plan must be dated and initialed.
(e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed.
(f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative.
(g) The facility administrator is responsible for ensuring the implementation of services.
(h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements.
(3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN.
(a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident.
(b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences.
(c) Staff must document and date adjustments or changes as applicable.
(4) QUARTERLY SERVICE PLAN REQUIREMENTS.
(a) Service plans must be completed quarterly after the resident moves into the facility.
(b) The quarterly evaluation is the basis of the resident's quarterly service plan.
(c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained.
C0303 Systems: Treatment Orders Severity 2 ▼
Visit 1 · 10/29/2025 · Scope: L2 Pattern
No correction date recorded
Regulation (OAR)
OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders
(f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order.
Findings
Based on interview and record review, it was determined the facility failed to ensure physician's orders were carried out as prescribed for 2 of 3 sampled residents (#s 1 and 3) whose orders were reviewed. Findings include, but are not limited to:
1. Resident 3 moved into the community in 08/2025 with diagnoses including dementia with behavioral disturbance and chronic kidney disease.
Resident 3’s MAR, dated 10/01/25 through 10/27/25, and current physician's orders, dated 09/23/25, were reviewed, and the following was identified:
a. Resident 3 had a physician’s order for polyethylene glycol to give 17 grams by mouth every 24 hours as needed for constipation.
Review of the MAR revealed the polyethylene glycol was scheduled to be given 17 grams by mouth daily.
b. Physician's orders indicated rosuvastatin (calcium) oral tablet 25 mcg to be given by mouth one time a day.
Review of the MAR revealed rosuvastatin was listed twice to be administered at 8:00 pm and 9:00 pm and was initialed as administered twice five times during the 10/01/25 through 10/27/25 period.
In an interview with Staff 2 (Director of Health Services) on 10/29/25 at 9:55 am, she stated it was likely an error with the pharmacy.
The need to ensure physicians' orders were carried out as prescribed was discussed with Staff 1 (ED), Staff 2, Staff 6 (Regional Operations Specialist), Staff 7 (Regional Nurse), and Staff 8 (Regional Director of Operations) on 10/29/25 at 2:25 pm. They acknowledged the findings.
2. Resident 1 moved into the community in 05/2025 with diagnoses including dementia and constipation.
Review of the MAR, dated 10/01/25 through 10/27/25, and current physician's orders, dated 10/27/25, identified the following:
Resident 1 had a physician's order to weigh resident daily on day shift before breakfast.
From 10/01/25 to 10/24/25 and on 10/26/25 and 10/27/25, the MAR was marked as “Other/see nurses notes.” There was no corresponding documentation in the Progress Notes to indicate why resident was not weighed.
In an interview on 10/28/25 at 11:05 am, Staff 2 (Director of Health Services) stated the daily weights should have been discontinued.
The need to ensure physicians' orders were carried out as prescribed was discussed with Staff 1 (ED), Staff 2, Staff 6 (Regional Operations Specialist), Staff 7 (Regional Nurse), and Staff 8 (Regional Director of Operations) on 10/29/25 at 1:50 pm. They acknowledged the findings.
Plan of Correction
1. Orders have been reviewed for resident 3 and resident 1's primary care providers and orders have been clairified and updated. MARS on these residents were updated to align with Physician orders.
2. New Orders Triple Check system education will happen with the RCC, RN and Med Techs. Additionally,RCC, RN and Med Techs will be educated on how to appropriately document in the progress notes when marking "Other/see nurses notes" and the reason they need to complete the circle of documentation. Registered Nurse will Audit Point Click Care to verify that all "Other/see nurses notes" have follow up in the chart. We will utilize a triple check system where the RN, RCC, and Administrator check that the medication orders are put in correctly.
3. New orders will be audited M-F during our Clinical Meetings for the next month, then audited monthly as part of our Quality Audit.
4. Registered Nurse, Resident Care Coordinator, and Administrator will be responsible to see that corrections and systems are followed and monitored.
Visit 2 · 1/13/2026 · Scope: L2 Pattern
No correction date recorded
Regulation (OAR)
OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders
(f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order.
C0310 Systems: Medication Administration Severity 2 ▼
Visit 1 · 10/29/2025 · Scope: L2 Pattern
No correction date recorded
Regulation (OAR)
OAR 411-054-0055 (2) Systems: Medication Administration
(2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication.
Findings
Based on interview and record review, it was determined the facility failed to ensure resident-specific parameters and instructions were included for PRN medications and failed to ensure the MAR included the correct dosage of medication for 2 of 3 sampled residents (#s 1 and 2) whose MARs were reviewed. Findings include, but are not limited to:
1. Resident 2 moved into the community in 12/2012 with diagnoses including psoriatic arthritis mutilans and chronic obstructive pulmonary disease.
The resident’s MAR, dated 10/01/25 to 10/27/25, was reviewed, and the following orders were noted:
a. The resident had orders for two PRN medications for pain that did not have parameters for order of administration by unlicensed staff:
* Acetaminophen 500 mg, two tablets every six hours; and
* Hydromorphone HCl 4 mg tablet every four hours.
b. The resident had three orders for PRN medications for constipation that did not have parameters for order of administration by unlicensed staff:
* PEG 3350 powder 238 gm, mix 17 g in liquid;
* Senna 8.6 mg, one tablet daily; and
* Senna 8.6 mg, two tablets if no bowel movement in three days, not to exceed two tablets per day.
In an interview with Staff 15 (MT) on 10/28/25 at 2:35 pm, s/he stated, “I would probably give the Senna,” if the resident complained of constipation, “but actually, I would text the nurse just to make sure.”
The need to ensure resident-specific parameters and instructions for PRN medications were included on the MAR was reviewed with Staff 1 (Executive Director), Staff 2 (Director of Health Services), Staff 6 (Regional Operations Specialist), Staff 7 (Regional Nurse), and Staff 8 (Regional Director of Operations) on 10/29/25 at 2:30 pm. They acknowledged the findings.
2. Resident 1 moved into the community in 05/2025 with diagnoses including dementia and constipation.
The resident’s MAR, dated 10/01/25 to 10/27/25, was reviewed, and the following orders were noted:
a. The resident had orders for two PRN medications for pain that lacked parameters for order of administration by unlicensed staff:
* Acetaminophen 325 mg two tablets daily as needed for pain; and
* Morphine sulfate 20 mg/ml 0.25 to 0.5 ml every four hours as needed for pain.
b. The resident had two orders for PRN medications for constipation that lacked parameters for order of administration by unlicensed staff:
* Bisacodyl rectal suppository 10 mg rectally every 24 hours as needed for constipation; and
* Polyethylene glycol 17 grams as needed for bowel care.
c. The following medications lacked the specific dosage to administer:
* Morphine sulfate 20 mg/ml 0.25 to 0.5 ml every four hours as needed for pain; and
* Lorazepam 0.5 to 1 mg every four hours as needed for anxiety or shortness of breath.
In an interview on 10/28/25 at 11:00 am, Staff 2 (Director of Health Services) confirmed the lack of PRN parameters for the pain and bowel medications, as well as the ranges of the dosage of medications on the October MAR.
The need to ensure resident-specific parameters and instructions for PRN medications were included on the MAR and all medications had the correct dosage to administer was reviewed with Staff 1 (Executive Director), Staff 2, Staff 6 (Regional Operations Specialist), Staff 7 (Regional Nurse), and Staff 8 (Regional Director of Operations) on 10/29/25 at 1:55 pm. They acknowledged the findings.
Plan of Correction
1. All errors in parameters related to the bowel meds and to pain meds have been fixed with Resident 1 and Resident 2.
2. The Med Techs will be educated on clear parameters for PRN meds and education if an order is found to not have clear parameters. The Registered Nurse will review PRN orders for accurate Parpameters in MARS as a part of the new order review process.
3. We will audit new PRN medication orders M-F during clinical meetings for 4 weeks, if no issues are found we will audit PRNs monthly as part of our Quality Assurance process.
4. Registered Nurse, Resident Care Coordinator, and Administrator.
Visit 2 · 1/13/2026 · Scope: L2 Pattern
No correction date recorded
Regulation (OAR)
OAR 411-054-0055 (2) Systems: Medication Administration
(2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication.
C0340 Restraints and Supportive Devices Severity 2 ▼
Visit 1 · 10/29/2025 · Scope: L2 Isolated
No correction date recorded
Regulation (OAR)
OAR 411-054-0060 Restraints and Supportive Devices
Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07
Findings
Based on observation, interview, and record review, it was determined the facility failed to ensure a thorough RN, PT, or OT assessment was completed prior to the use of a supportive device with restraining qualities, failed to document other less restrictive alternatives were evaluated prior to the use of the device, and failed to instruct caregivers on the correct use and precautions related to the use of the device for 1 of 1 sampled resident (# 1) who used a supportive device with restraining qualities. Findings include, but are not limited to:
Resident 1 moved into the community in 05/2025 with diagnoses including dementia and unspecified sleep disorder.
Observations of the resident and interviews with staff indicated the resident had a quarter-length side rail on both sides of his/her bed. The side rails were in good repair and flush with the mattress.
There was no documented evidence other less restrictive alternatives were evaluated prior to the use of the device. Staff reported the resident was primarily bedbound and received the hospital bed with side rails from the hospice provider.
On 10/28/25 at 11:25 am, Staff 2 (Director of Health Services) confirmed an assessment of the side rails was not completed prior to survey entry.
The need to ensure supportive devices with restraining qualities were assessed by an RN, PT, or OT and were included in the resident's service plan was discussed with Staff 1 (ED), Staff 2, Staff 6 (Regional Operations Specialist), Staff 7 (Regional Nurse), and Staff 8 (Regional Director of Operations) on 10/29/25 at 1:55 pm. They acknowledged the findings.
Plan of Correction
1. Resident 1 assistive devices assessment was completed by Registered Nurse while survey was still in the community.
2. The Registered Nurse and RCC will do full physical walk through to ensure all potentially restrictive devices are identified and have appropriate assessments in place. Moving forward, each new device, including hospital beds, will be assessmented by the Registered Nurse for restraining qualities.
3. Desiginated staff will complete weekly walk through for 1 month for any further assistive devices, and monthly for 1 quarter. The Administrator will pull device audit monthly during QA to ensure all assessments are in place and compliant. If no errors are found in three months, then this will be audited quarterly as part of our Service Plan system.
4. Registered Nurse and Administrator are responsible to verify completion and monitoring of system.
Visit 2 · 1/13/2026 · Scope: L2 Isolated
No correction date recorded
Regulation (OAR)
OAR 411-054-0060 Restraints and Supportive Devices
Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07
Z0162 Compliance with Rules Health Care Severity 2 ▼
Visit 1 · 10/29/2025 · Scope: L2 Pattern
No correction date recorded
Regulation (OAR)
OAR 411-057-0160(2b) Compliance with Rules Health Care
(b) Health care services provided in accordance with the licensing rules of the facility.
Findings
Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:
Refer to C 260, C303, C310, and C340.
Plan of Correction
1. Refer to above C260, C303, C310, C340
2. Refer to above C260, C303, C310, C340
3. Refer to above C260, C303, C310, C340
4. Refer to above C260, C303, C310, C340
Visit 2 · 1/13/2026 · Scope: L2 Pattern
No correction date recorded
Regulation (OAR)
OAR 411-057-0160(2b) Compliance with Rules Health Care
(b) Health care services provided in accordance with the licensing rules of the facility.
Z0164 Activities Severity 2 ▼
Visit 1 · 10/29/2025 · Scope: L2 Pattern
No correction date recorded
Regulation (OAR)
OAR 411-057-0160(2d) Activities
(d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities.
Findings
Based on interview and record review, it was determined the facility failed to ensure meaningful activities that promote or help sustain the physical and emotional well-being of residents and activities were person centered and available during residents ' waking hours for sampled residents (#s 1 and 3) and multiple unsampled residents, and failed to ensure an individualized activity plan was developed for each resident, based on an activity evaluation, for 2 of 2 sampled residents (#s 1 and 3) who resided in the memory care unit. Findings include, but are not limited to:
1. Observations were made throughout the survey in the memory care unit and revealed a lack of meaningful activities for the residents.
On 10/28/25 during observations in the memory care unit, an activity was scheduled at 11:00 am titled “Music Hour.” In an interview with Staff 10 (CG) at 11:15 am on 10/28/25, he stated “typically” during music hour they will put music on the television for the residents to listen to together. Observations at 11:15 am revealed a cat show on the television with two residents watching and another resident looking at a magazine in the common area. The scheduled activity did not take place.
An interview with Staff 12 (CG) on 10/28/25 at 2:40 pm confirmed care staff were primarily responsible for conducting activities. Staff 12 stated there will be an activity title on the calendar “like reminiscing time”; however, she stated they did not have instructions on how to do the activity.
The following activities were scheduled for 10/29/25 in the memory care unit:
* 10:00 am – Reminiscing Time
* 11:00 am – Card Game
* 1:00 pm – Relaxation Afternoon
Observations made on 10/29/25 revealed that none of the above activities took place as scheduled.
Throughout the survey residents were observed remaining in their rooms or sitting at tables in the common area of the memory care unit coloring and/or watching television.
The need to ensure the facility provided meaningful activities that promote or help sustain the physical and emotional well-being of residents, and to ensure that activities were person centered and available during residents' waking hours was discussed with Staff 1 (ED), Staff 2 (Director of Health Services), Staff 6 (Regional Operations Specialist), Staff 7 (Regional Nurse), and Staff 8 (Regional Director of Operations) on 10/29/25 at 2:30 pm. They acknowledged the findings.
2. Resident 1 and 3’s current service plans, dated 09/04/25 and 09/15/25, respectively, and “Activity Evaluation” questionnaires were reviewed. There was no documented evidence the facility had evaluated and developed individualized plans based on each resident’s:
* Past and/or current interest;
* Current abilities and skills;
* Emotional and social needs and patterns;
* Physical abilities and limitations; and
* Adaptations necessary for the resident to participate; and
* Identification of activities for behavioral interventions.
The need to ensure each resident was evaluated for activities and an individualized activity plan was developed was discussed with Staff 1 (ED), Staff 2 (Director of Health Services), Staff 6 (Regional Operations Specialist), Staff 7 (Regional Nurse), and Staff 8 (Regional Director of Operations) on 10/29/25 at 2:25 pm. They acknowledged the findings.
Plan of Correction
1. Activity calendar will be audited for implementation of resident directed activities. Staff has been educated on the importance of following through on the activities on the calendar and Resident Care Coordinator and Activities Director are checking for execution of the activities.
Resident 1 and Resident 3's activity evaluations have been updated to reflect past/current interest, current ability and skill, emotional and social needs and patterns, physical ability and limitations and adaptations necessary for the resident to participate and identification of activities for behavioral intervention.
2. Staff education on the importance and method of completing each activity with checks by the Resident Care Coordinator, Administrator, or Activities Director occurring daily. Regional Director has come and taught staff about our Radiance program and how to implement and execute activities. Activity Director and Administrator audited all memory care activity evaluations to ensure they match each resident. Each new resident's Activity Evaluation will be completed by the Activity Director and double checked by Administrator.
3. Activity program execution will be evaluated as part of Quality Assurance each month, as well as spot checks completed daily by the Activities Director.
New move in and quarterly activity evaluations will be completed by Activity Director and Administrator will review to ensure accuracy for 6 months. Then audited quarterly during Quality Assurance and Activity Focused audits.
4. Activities Director, Administrator, Resident Care Coordinator, Caregivers, and Medication Techs.
Visit 2 · 1/13/2026 · Scope: L2 Pattern
No correction date recorded
Regulation (OAR)
OAR 411-057-0160(2d) Activities
(d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities.
1/4/2024 State Licensure · Event WO1W State LicensureNo deficiencies ▼
No deficiencies cited
This inspection closed without citations.
11/29/2022 Complaint Investig. · Event 36S5 Complaint Investig.2 deficiencies ▼
Deficiencies cited (2)
C0361 Acuity-Based Staffing Tool Severity 2 ▼
Visit 1 · 11/29/2022 · Scope: Isolated/Minimal harm or potential for moderate harm
No correction date recorded
C0550 Wiring Systems Severity 2 ▼
Visit 1 · 11/29/2022 · Scope: Isolated/Minimal harm or potential for moderate harm
No correction date recorded
Inspection notes
C0010 Licensing Complaint Investigation Severity 2 ▼
Visit 1 · 11/29/2022 · Scope: Isolated/Minimal harm or potential for moderate harm
No correction date recorded
Findings
Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes. This report reflects the findings of the complaint investigation conducted 11/29/2022. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:
Abbreviations possibly used in this document:
ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day
10/3/2022 Complaint Investig. · Event H1ZD Complaint Investig.No deficiencies ▼
No deficiencies cited
This inspection closed without citations.
6/21/2022 Validation · Event 68Q4 Validation13 deficiencies ▼
Deficiencies cited (13)
C0240 Resident Services Meals, Food Sanitation Rule Severity 2 ▼
Visit 1 · 6/23/2022 · Scope: Widespread/Minimal harm or potential for moderate harm
No correction date recorded
Regulation (OAR)
2. Two sampled residents who were interviewed during the survey reported not liking the food. One of the residents went on to state, "It all tastes pre-made. There isn't a lot of fresh fruits and vegetables. [The facility] has gone with the cheapest supplier and I can taste it."
A test tray was requested from Staff 5 (Dietary Manager) on 06/22/22 at 11:35 am.
The test tray was served to the surveyor team at 11:57 am. The meal was served uncovered and consisted of a soft shelled beef taco, corn with tomatoes and peppers, Spanish rice and banana pudding.
The ground beef used in the soft shelled taco did not taste seasoned and the beef had overcooked pieces which made it dry, crunchy and chewy.
The Spanish rice did not taste seasoned and was overcooked to a mechanical soft like texture.
The need to ensure the meals served were palatable was discussed with Staff 1 (Administrator), Staff 3 (Regional Director of Operations) and Staff 4 (Regional Nurse Consultant) on 06/23/22. They acknowledged the findings.
Findings
Based on observation and interview, it was determined the facility failed to ensure nutritious and palatable meals and snacks were provided in accordance with the United States Department of Agriculture (USDA) guidelines, and facility kitchen was kept clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:
1. The kitchen was toured on 06/21/22 with Staff 5 (Dietary Manager). The following was observed to be in need of cleaning or repair:
* The tile flooring underneath the warewashing machine had deep grooves and gouges; * The tile baseboard underneath the warewashing machine had fallen off the wall and was lying on the floor; * The floor tile had black matter build up; * The tiles along food prep and stove were cracked; * The ceiling tile above the hood range had a gouge exposing raw material; * The green exit door in kitchen had scuffs and rust colored spots; * The cabinets in coffee bar had scuffs and scrapes across the front; and * The ceiling tiles in dry storage above shelves had black scuff marks.
The need to ensure the kitchen was clean and in good repair was discussed with Staff 1 (Administrator) and Staff 3 (Regional Director of Operations) on 06/22/22. They acknowledged the findings.
Plan of Correction
1. Kitchen cleaning and damage repair to noted area of tile, kitchen door, coffee bar cabinet and ceiling tiles above hood and storage will take place.
Meals will be prepared using the new recipes and menu guides, and will be sampled for quality control to ensure residents are served palatable meals
2. Dietary staff will use the work order system for repairs, cleaning schedules and weekly walk throughs to ensure ongoing compliance.
ED/designee to sample meals to ensure quality of meals, and resident feedack to be obtained via weekly dining comment cards and monthly Dining Committee for the previous 3 months.
3. ED and Dietary Manager to conduct weekly kitchen walk throughs to ensure compliance
ED/designee to sample 2 meals weekly and provide feedback to dietary manager. Dining Committee shall meet monthly ongoing as a part of the QA process.
4. ED, RDO, Dietary Manager, Maintenance
Visit 2 · 9/14/2022 · Scope: Widespread/Minimal harm or potential for moderate harm
Corrected 8/22/2022
There are no detail notes for this visit.
C0260 Service Plan: General Severity 2 ▼
Visit 1 · 6/23/2022 · Scope: Pattern/Minimal harm or potential for moderate harm
No correction date recorded
Findings
Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs, updated with changes, and provided clear direction to staff regarding the delivery of services for 2 of 3 sampled residents (#s 2 and 4) whose service plans were reviewed. Findings include, but are not limited to:
1. Resident 2 was admitted to the facility in 05/2021 with diagnoses including history of stroke and major depressive disorder.
Review of the current service plan, dated 06/12/22, observations of the resident and interviews with the resident and caregiving staff indicated the service plan lacked the following information:
* Clear instruction to staff regarding compression stocking use, including use of lotion and treatments; and * Instruction to staff regarding care needs after tooth extraction.
2. Resident 4 was admitted to the facility in 04/2015 with diagnoses including rheumatoid arthritis.
Review of the current service plan, dated 03/08/22, indicated handwritten changes regarding side rail use and instructions to staff were not dated and initialed.
The need to ensure service plans were reflective of the residents' status, updated, and provided clear direction to staff was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (Regional Director of Operations) and Staff 4 (Regional Nurse Consultant) on 06/23/22. They acknowledged the findings.
Plan of Correction
1. Resident #2 and #4 SP updated to reflect missing resident specific items and SP conference to be held.
2. ED to conduct inservice with staff on the proper service planning process and to review OAR with the service planning team. Evaluation tool in PCC was updated to cover OAR areas and to feed directly to the service plan
3 . As part of the monthly internal QA process, community will audit 2 SPs for accuracy
4. RN and ED or designee are responsible
Visit 2 · 9/14/2022 · Scope: Pattern/Minimal harm or potential for moderate harm
Corrected 8/22/2022
There are no detail notes for this visit.
C0270 Change of Condition and Monitoring Severity 2 ▼
Visit 1 · 6/23/2022 · Scope: Pattern/Minimal harm or potential for moderate harm
No correction date recorded
Regulation (OAR)
2. Resident 3 was admitted to the facility in 02/2019 with diagnosis including diabetes and cognitive impairment.
The resident's medical record was reviewed and interviews were conducted. The following lacked documented evidence of monitoring through resolution:
a. On 06/02/22, a progress note stated Resident 3 had returned from the hospital after sustaining a fall out of bed that resulted in rib fractures and a pelvic fracture. The resident did not need surgical interventions for the fractures.
Per the facility's "alert charting and audit tool", a return admission from the hospital would constitute 72 hours of monitoring. The facility lacked documented evidence the return from the hospital and Resident 3's fractures had been monitored through resolution.
b. On 06/07/22, the resident had an increase in Hydrocodone (for pain). There was no documented evidence the change in medication had been monitored through resolution.
The need to ensure residents' short term changes of condition had documentation of weekly monitoring through resolution was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (Regional Director of Operations) and Staff 4 (Regional Nurse Consultant) on 06/23/22. They acknowledged the findings.
Findings
Based on interview and record review, it was determined the facility failed to determine what actions or interventions were needed for short term changes of condition, communicate those changes to staff on each shift and failed to monitor changes through resolution for 2 of 3 sampled residents (#s 2 and 3) who were reviewed with changes of condition. Findings include, but are not limited to:
1. Resident 2 was admitted to the facility in 05/2021 with diagnoses including stroke and major depressive disorder.
Resident 2's medical record was reviewed. Multiple changes of condition were identified with the following deficiencies:
a. No actions or intervention developed, no communication to staff on each shift or evidence of monitoring for the following changes of condition:
* Tooth extraction; and * Urinary tract infection.
b. Lack of weekly monitoring for:
* Left ankle wounds; * Wound under left knee; * Red rash to bilateral legs; and * Red rash/burn to top of both hands.
c. Lack of monitoring through resolution for:
* New medication on alert charting 04/01/22; and * Skin abrasion to forehead.
The need to ensure all changes of condition were evaluated, had interventions developed, were communicated to staff on each shift and monitored weekly for effectiveness through resolution was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (Regional Director of Operations), and Staff 4 (Regional Nurse Consultant) on 06/23/22. They acknowledged the findings.
Plan of Correction
1. Resident #2 and #3- Change of Condition were reviewed and documentation completed reflecting the changes and SP to be updated as needed.
2. 24 hour process will be reviewed and retraining as needed will be provided to Med Techs and RN to ensure that communication from staff regarding visualized changes are being documented for further follow up. RN, ED will review in clinical meeting and address/document accordingly.
3. Review of 24 hour binder and audit tool will be conducted M-F during clinical meetings. Monthly QA Audit of the 24 Hour process will be conducted ongoing as a part of conitnued compliance.
4. ED and RN or designee are responsible
Visit 2 · 9/14/2022 · Scope: Pattern/Minimal harm or potential for moderate harm
Corrected 8/22/2022
There are no detail notes for this visit.
C0290 Res Hlth Srvc: On- and Off-Site Health Srvc Severity 2 ▼
Visit 1 · 6/23/2022 · Scope: Isolated/Minimal harm or potential for moderate harm
No correction date recorded
Findings
Based on interview and record review, it was determined the facility failed to coordinate on-site health services with outside providers for 1 of 2 sampled residents (#2) who received services from outside providers. Findings include, but are not limited to:
Resident 2 was admitted to the facility in 05/2021 with diagnoses including history of stroke and major depressive disorder.
Review of outside provider communications in the resident's record indicated the following recommendations were made:
* 03/31/22: "Adaptive handle for motorized chair so s/he can reach lever to rotate chair for transfers," recommended by HHPT on Health Professional Communication form;
* 05/09/22: "Edema can be treated with ...restriction of dietary sodium intake and diuretics," on Patient Handout from dermatology Nurse Practitioner;
* 06/02/22: "Monitor bilateral circulation," recommended by HHRN on Health Professional Communication form; and
* 06/08/22: "Please remove Unna boot in 4 days - on 06/12/22 and apply Triamcinolone cream thereafter 1 time a day under compression socks," from dermatology Nurse Practitioner handwritten note on day of service.
There was no documented evidence these recommendations were communicated to staff or implemented as appropriate.
The need to ensure coordination between the facility and outside service providers was reviewed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (Regional Director of Operations), and Staff 4 (Regional Nurse Consultant) on 06/23/22. They acknowledged the findings.
Plan of Correction
1. Resident #2 home health notes have been reviewed and documentation completed reflecting outside provider reccomendations. Staff have been made aware of changes, via tsp and service plan to be updated as needed. Resident # 2 was reassessed with no negative outcome.
2. 24hr process to be reviewed with staff to ensure communication regarding New outside provider notes or reccomendations. RN and ED will review any outside provider notes M-F in clinical meetings.
3. Review of outside provider binder, including audit, will be conducted Monday through Friday during clinical meeting ongoing.
4. RN and ED responsible
Visit 2 · 9/14/2022 · Scope: Isolated/Minimal harm or potential for moderate harm
Corrected 8/22/2022
There are no detail notes for this visit.
C0303 Systems: Treatment Orders Severity 2 ▼
Visit 1 · 6/23/2022 · Scope: Isolated/Minimal harm or potential for moderate harm
No correction date recorded
Findings
Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed for 1 of 2 sampled residents (#2) whose orders were reviewed. Findings include, but are not limited to:
Resident 2's signed physician orders and 06/01/2022 through 06/21/22 MAR/TAR were reviewed. The following orders were not carried out as prescribed:
* Triamcinolone cream - one time a day under compression socks was ordered on 06/08/22. The facility failed to implement the new order, continuing to administer Triamcinolone cream bid;
* Mupirocin 2% ointment - "apply to wounds on legs every day until resolved" was ordered on 04/29/22. Leg wounds were resolved 05/09/22 per progress note and Staff 2 (RN) interview. The 06/01/22 through 06/21/22 TAR indicated Mupirocin was still being administered; and
* Six treatments lacked documented evidence of administration on the 06/01/22 through 06/21/22 TAR.
The need to ensure all medications and treatments were administered as prescribed by the physician was reviewed with Staff 1 (Administrator), Staff 2, Staff 3 (Regional Director of Operations), and Staff 4 (Regional Nurse Consultant) on 06/23/22. They acknowledged the findings.
Plan of Correction
1. Comprehensive physican's order review was conducted for resident #2, in addition 10 residents physican orders will be reviewed for accuracy by date of compliance
2. Inservice all facility Med Techs on order processing and review
3. Audit new Physician orders alongside the MAR weekly for 6 weeks and then monthly after during 24 hour review process. Bring any findings to internal QA meeting monthly
4. ED and RN responsible
Visit 2 · 9/14/2022 · Scope: Isolated/Minimal harm or potential for moderate harm
Corrected 8/22/2022
There are no detail notes for this visit.
C0305 Systems: Resident Right to Refuse Severity 2 ▼
Visit 1 · 6/23/2022 · Scope: Isolated/Minimal harm or potential for moderate harm
No correction date recorded
Findings
Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner when a resident refused to consent to medication and treatment orders for 1 of 1 sampled resident (#2) who had documented treatment refusals. Findings include, but are not limited to:
Resident 2's 06/01/22 through 06/21/22 MAR/TAR was reviewed. The record showed 10 instances of treatment refusal.
There was no documented evidence the facility notified the physician each time the resident refused to consent to orders.
The need to ensure the facility notified physicians of medication and treatment refusals was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (Regional Director of Operations), and Staff 4 (Regional Nurse Consultant) on 06/23/22. They acknowledged the findings.
Plan of Correction
1. Resident #2 orders to be updated to reflect MD preference for notifcation when medication is refused.
2. Inservice Med Techs on proper notification of refused medications.
3. Lead Med Tech/RN/ED or designee to check for refused medications M-F and ensure proper notifications were made x4 weeks and then spot check 2 times per month as part of internal QA process. Bring findings to monthly internal QA meetings
4. ED, RN and Lead Med Tech or designee responsible
Visit 2 · 9/14/2022 · Scope: Isolated/Minimal harm or potential for moderate harm
Corrected 8/22/2022
There are no detail notes for this visit.
C0310 Systems: Medication Administration Severity 2 ▼
Visit 1 · 6/23/2022 · Scope: Pattern/Minimal harm or potential for moderate harm
No correction date recorded
Findings
Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included medication specific instructions including significant side effects and when to call the prescriber or nurse and failed to ensure resident-specific parameters for PRN medications for 2 of 3 sampled residents (#s 2 and 3) whose medications were reviewed. Findings include, but are not limited to:
1. Resident 3 was admitted to the facility in 02/2019 with diagnoses including diabetes and cognitive impairment. The resident's 06/01/22 through 06/21/22 MAR and TAR was reviewed and revealed the following:
* Two PRN bowel medications to treat constipation lacked parameters on when to initiate treatment and what medication to administer first; and * Scheduled and PRN blood glucose monitoring was lacking resident specific instructions on when to notify the prescriber or nurse relating to high blood sugar readings.
There was an entry on Resident 3's TAR to notify the prescriber monthly of any medication refusals. There was an entry on 06/13/22 which prompted to "Other / See Nurse Notes." There was no documented evidence of a corresponding nurse note.
The need to ensure residents' MARs and TARs were accurate and provided clear instruction to unlicensed staff was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (Regional Director of Operations) and Staff 4 (Regional Nurse Consultant) on 06/23/22. They acknowledged the findings.
2. Resident 2 was admitted to the facility in 05/2021 with diagnoses including history of stroke and major depressive disorder. The resident's 06/01/22 through 06/21/22 MAR/TAR was reviewed and the following deficiencies were identified.
a. The medication record contained no medication specific instructions, if applicable, including significant side effects. Resident 2 was on alert charting beginning 04/30/22 for new medications, including Doxycycline. A progress note dated 05/13/22 stated "resident is on alert for red rash/burn to the top of both hands, right hand appears to be swollen. Resident is complaining of pain and states that it burns. Resident believes that the Doxycycline is what's causing the redness to [resident's] hands."
b. There were no parameters for two PRN pain medications: acetaminophen and hydrocodone/APAP; and
c. There were 36 entries on TAR that indicated either "Hold/See Nurse Notes" or "Other/See Nurse Notes." There was no documented evidence of corresponding nurse notes.
The need to ensure MARs/TARs were complete and accurate was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (Regional Director of Operations), and Staff 4 (Regional Nurse Consultant) on 06/23/22. They acknowledged the findings.
Plan of Correction
1 - Resident #3 medications reviewed to include specific instructions for staff. Resident #2 medications were reviewed and corrected to address parameters. All resident orders to be reviewed and ensure resident specific instructions and/or parameters are in place
2 - Training to be provided to health services team regarding order confirmation, clarification of orders and proper parameters
3 - Audit orders for parameters and instructions as new orders are received during the clinical meeting, and 2 at random monthly as a part of QA process
4 - Lead Med Tech, RN, ED or designee responsible
Visit 2 · 9/14/2022 · Scope: Pattern/Minimal harm or potential for moderate harm
Corrected 8/22/2022
There are no detail notes for this visit.
C0370 Staffing Requirements and Training – Pre-Serv Severity 2 ▼
Visit 1 · 6/23/2022 · Scope: Pattern/Minimal harm or potential for moderate harm
No correction date recorded
Findings
Based on interview and record review, it was determined the facility failed to ensure pre-service dementia care training had been completed, with certification, prior to staff providing direct care to residents for 3 of 3 newly-hired direct care staff (#s 9, 10 and 14). Findings include, but are not limited to:
The facility's training records were reviewed on 06/22/22 and 6/23/22.
Staff 9 (CG), hired 12/09/21, Staff 10 (CG), hired 01/18/22, and Staff 14 (CG), hired 04/05/22, lacked documented evidence they had completed the required pre-service dementia training prior to providing direct care to residents.
The need to ensure all newly hired, direct care staff had the required pre-service dementia training prior to providing care to residents was reviewed with Staff 1 (Administrator) and Staff 3 (Regional Director of Operations) on 06/23/22. They acknowledged the findings.
Plan of Correction
1. All employee files to be audited for the presence of all required preservice dementia training.
2. New employee onboarding process to be reviewed/ completed with ED to ensure that new hire checklist is completed and accurate for all new employees with documented evidence.
3. Employee Training Grid to be used to track all employee pre-service dementia training. ED to audit 3 files/month for accuracy and completeness.
Audit findings to be brought to internal QA meeting
4. ED, RDO responsible
Visit 2 · 9/14/2022 · Scope: Pattern/Minimal harm or potential for moderate harm
Corrected 8/22/2022
There are no detail notes for this visit.
C0420 Fire and Life Safety: Safety Severity 2 ▼
Visit 1 · 6/23/2022 · Scope: Widespread/Minimal harm or potential for moderate harm
No correction date recorded
Findings
Based on interview and record review, it was determined the facility failed to ensure fire and life safety instructions to staff was provided on alternate months and failed to ensure written fire drill records included all required components. Findings include, but are not limited to:
On 06/22/22 fire and life safety records for 12/21/2021 through 05/15/2022 were reviewed.
1. Fire and life safety training was not consistently being provided to staff on alternating months of fire drills.
2. The facility was not consistently evacuating or relocating residents during fire drills. Fire drill documentation was lacking or incomplete regarding:
* Escape route used; * Evacuation time-period required; * Number of occupants evacuated; and * Evidence alternate routes were used during fire drills.
The need to ensure staff received all required fire and life safety training and fire drills included all required components was discussed with Staff 1 (Administrator) and Staff 3 (Regional Director of Operations) on 06/22/22. They acknowledged the findings.
Plan of Correction
1. Fire drill form with appropriate Fire Life Safety requirements to be reviewed with maintenance director with immediate corrections and will be in compliance by compliance date. Documented evacuations that include residents, as well as alternating saftey training will be adequately documented with clear instructions on routes and procedures.
2. Fire drills, evacuations and staff safety training to be conducted on company standardized forms which address all needed requirements per OAR to include resident/ staff training, involvment and adequate documentation with proper filing.
3. Fire drills/training to be reviewed during internal QA meeting monthly to ensure compliance.
4. ED responsible
Visit 2 · 9/14/2022 · Scope: Widespread/Minimal harm or potential for moderate harm
Corrected 8/22/2022
There are no detail notes for this visit.
C0422 Fire and Life Safety: Training For Residents Severity 2 ▼
Visit 1 · 6/23/2022 · Scope: Widespread/Minimal harm or potential for moderate harm
No correction date recorded
Findings
Based on interview and record review, it was determined the facility failed to re-instruct residents, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. Findings include, but are not limited to:
On 06/22/22 at 10:48 am, Staff 6 (Maintenance) confirmed the facility had not been providing annual fire and life safety training to residents.
The need to ensure fire and life safety instruction was provided to residents at least annually was reviewed with Staff 1 (Administrator) and Staff 3 (Regional Director of Operations) on 06/22/22. They acknowledged the findings.
Plan of Correction
1.Facilty has implemented and scheduled annual fire evacuation training that will be conducted before 8/22/22.
2. All residents to be trained on fire safety, fire roles and responsibities, and evacuation upon move in and annually per the new schedule.
3. Fire drills/training to be reviewed during internal QA meeting to ensure compliance monthly
4. ED responsible
Visit 2 · 9/14/2022 · Scope: Widespread/Minimal harm or potential for moderate harm
Corrected 8/22/2022
There are no detail notes for this visit.
C0610 General Building Exterior Severity 2 ▼
Visit 1 · 6/23/2022 · Scope: Widespread/Minimal harm or potential for moderate harm
No correction date recorded
Findings
Based on observation and interview, it was determined the facility failed to ensure the exterior pathways and accesses to the facility common use areas, entrance and exit ways were maintained in good repair. Findings include, but are not limited to:
The facility grounds and sidewalks were observed on 06/21/22 and the following was identified:
* Outside the facility entrance the green wicker chair left arm rest was fraying; * The enclosed eaves to the left of the front door had a hole; * Drop-offs at approximately three to seven inches in height along sidewalks; and * The walkway next to mechanical room had hole measuring approximately 20 inches by 30 inches and was deep enough that the surveyor was unable to visualize the bottom. The hole was covered with wood creating an uneven surface.
The drop-offs and hole created potential tripping hazards for residents.
The need to ensure the exterior pathways and accesses to the facility common use areas was discussed with Staff 1 (Administrator) and Staff 3 (Regional Director of Operations) on 06/22/22. They acknowledged the findings.
Plan of Correction
1. Wicker chair was removed and hole in eave and sidewalk drop offs in back of communiity, have been scheduled for repair. Project completion estimated for 08/22/22. While awaiting completetion, caution tape has been put into place to prevent resident access.
2. All staff to be inserviced to the workorder process for repairs and maintenance.
3. ED and Maintenance Director to conduct weekly walk throughs, as well as internal QA meetings to review building maintenance audits. RDO to complete quarterly building walk through
4. RDO, ED, Maintenance Director responsible
Visit 2 · 9/14/2022 · Scope: Widespread/Minimal harm or potential for moderate harm
Corrected 8/22/2022
There are no detail notes for this visit.
C0613 General Building: Doors-Walls, Cleanable Severity 2 ▼
Visit 1 · 6/23/2022 · Scope: Widespread/Minimal harm or potential for moderate harm
No correction date recorded
Findings
Based on observation and interview, it was determined the facility failed to keep all interior and exterior surfaces clean and in good repair. Findings include, but are not limited to:
The interior and exterior of the building were toured on 06/21/22. The following areas needed cleaning or repair:
a. Facility Wide * Multiple resident rooms, facility doors and door frames had scuffs, scratches and gouges; * The carpet throughout the facility had stains; and * Multiple walls throughout the facility had gouges and scuffs.
b. First Floor * The front desks left corner was chipped exposing wood underneath; * The elevator panels had gouges and scuff marks; and * The carpet baseboard was fraying where it attached to wood baseboard in dining room next to the salon and staff lounge.
c. Housekeeping / Hopper Room * The corner had a gouge in wall exposing material underneath; * The hopper had debris around the rim and sides; and * The power outlet plate was broken next to the door.
d. Laundry Room * The vinyl tiles were broken and missing underneath the left dryer exposing wood; * The ceiling tiles had rust color stains and one was missing; * The cabinets had scuff marks along the front; and * The chair seat on the brown chair had white and black stains.
e. Dining Room * The pillar had gouges and scuff marks; * The screen was bent in the left window; and * The vinyl flooring was cracked and did not connect around the gold floor cleanout cover creating a hole.
f. Ice Cream Bar * The grout to tile countertop had black debris build up; and * The baseboards had black debris on the top.
g. Second Floor * The carpet was fraying at the second-floor threshold into the elevator; * The black tables in the Activity Room had gouges exposing wood; and * The carpet baseboard had white debris on it in the Activity Room.
The areas needing cleaning and repair were shown to and discussed with Staff 1 (Administrator) and Staff 3 (Regional Director of Operations) on 06/22/22 at 1:05 pm. They acknowledged the findings.
Plan of Correction
1. Interior and Exterior deficiencies noted in the 2567 will be reviewed and repaired.
2. All staff to be trained on utilizing work order system to ensure needed repairs are addressed timely.
3. ED and Maintenance Director to conduct weekly walk throughs, as well as monthly QA meeting audits. RDO to complete quarterly communitiy walk though to ensure compliance.
4. RDO, ED and Maintenance Director
Visit 2 · 9/14/2022 · Scope: Widespread/Minimal harm or potential for moderate harm
Corrected 8/22/2022
There are no detail notes for this visit.
C0640 Heating and Ventilation Severity 2 ▼
Visit 1 · 6/23/2022 · Scope: Widespread/Minimal harm or potential for moderate harm
No correction date recorded
Findings
Based on observation and interview, it was determined the facility failed to ensure that covers, grates, or screens of wall heaters did not exceed 120 degrees Fahrenheit (F) when installed in locations that were subject to incidental contact by individuals. Findings include, but are not limited to:
During an environmental walk-through on 06/21/22, the following was identified:
Fireplaces were observed turned off during the survey.
* The Surveyor turned on the lobby fireplace via a wall timer at 1:50 pm. The surveyor measured the front glass covering at 1:54 pm, it measured 212 degrees F with the surveyor's thermometer.
* The Surveyor turned on the Activity Room fireplace via a wall timer at 2:22 pm. The surveyor measured the front glass covering using the surveyor's thermometer at 2:28 pm, it measured 174 degrees F.
The need to ensure residents could not come into incidental contact with fireplace elements that exceeded 120 degrees F was discussed with Staff 1 (Administrator) and Staff 3 (Regional Director of Operations) on 06/22/22. They acknowledged the findings.
Plan of Correction
1. Immediate action was taken for the safety of our residents. The fireplaces were turned off and disabled until the new fireplace screens arrived that week. screens were secured in place.
2. Ongoing checks to ensure the screens are in place and to ensure the residents cannot come in contact with the hot surface.
3. ED and Maintenance Director to ensure proper placement of safety screens weekly during walk throughs and monthly temps will be conducted.
4. ED and Maintenance Director are responsible
Visit 2 · 9/14/2022 · Scope: Widespread/Minimal harm or potential for moderate harm
Corrected 8/22/2022
There are no detail notes for this visit.
Inspection notes
C0000 Comment Severity 0 ▼
Visit 1 · 6/23/2022
No correction date recorded
Findings
The findings of the re-licensure survey conducted 06/21/22 through 06/23/22 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.
Abbreviations possibly used in this document:
ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI: quality improvement RCC: Resident Care Coordinator RN: Registered Nurse TAR: Treatment Administration Record tid: three times a day
Visit 2 · 9/14/2022
No correction date recorded
Findings
The findings of the first re-visit to the re-licensure survey of 06/23/22, conducted 09/13/22 through 09/14/22, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.
Abuse Violations
27 records2/16/2026 Failed to provide safe environment · 00458081-AP-410244 Level 2Substantiated ▼
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0025(1)(a) and (b), 411-054-0027(1)(g) and (s), 411-054-0028(2)
Findings
The Alleged Victim (AV) relies on the facility to provide a safe environment. AV was sharing a room with Witness 1 (W1) who is known to have aggressive behaviors towards other residents. W1 admitted to punching AV in the face for not turning out the lights in the room. The facility failed to provide a safe environment for AV, resulting in AV getting injured by W1 which is neglect of care and constitutes abuse.
Sanction
ALFCP26-00174 $250.00 fine assessed
12/17/2021 Failed to assure timely medical treatment · 00175244-AP-139150 Level 3Substantiated ▼
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious harm
Rules violated (OAR)
411-054-0027(1)(f) and (r)
411-054-0028(2)
411-054-0036(2)(g)
Findings
On or about November 26, 2021, Alleged Victim (AV) was discharged to the facility from the hospital with a doctor’s order for facility to follow-up with AV’s primary physician to ensure AV received continued medical care and oversight to address AV’s change in medical condition. AV was not seen by his/her primary physician until December 22, 2021. The facility’ failure to ensure that AV received necessary medical treatment according to hospital’s discharge medical orders, left AV without necessary care, which is a is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction
ALFCP22-00555 $500.00 fine assessed
12/7/2021 Failed to follow care plan · 00174958-AP-138931 Level 3Substantiated ▼
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious harm
Rules violated (OAR)
411-054-0027(1)(f) and (r)
411-054-0028(2)
411-054-0036(2)(g)
411-054-0040(2)(a)
Findings
Alleged Victim (AV) relies on the facility for his/her care. AV was care planned for treatment of ulcer/skin impairment. On or about, December 7, 2021, AV was sent to the hospital where he/she presented with a pressure injury that was in various stages of injury. According to witnesses and documentation, the facility, failed to follow the care plan, resulting in AV experiencing pain and skin breakdown, which is a violation of resident rights, is neglect of care which constitutes abuse.
Sanction
ALFCP22-00487 $1500.00 fine assessed
1/20/2021 Failed to protect resident from mental or emotional abuse · 00121165-AP-094018 Level 2Substantiated ▼
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0025(1)(a) and (b)
411-054-0027(1)(f)(g) and (r)
411-054-0028(2)
Findings
On or about January 20, 2021, the Alleged Victim (AV) was getting a shower from staff when he/she fell. Staff were unable to lift AV and called in other staff to assist, however, the staff were unsure how to lift AV and staff felt it was very awkward and did not protect AV's personal dignity. The facility failed to preserve AV's personal dignity during care, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction
ALFCP21-01587 $250.00 fine assessed
8/4/2020 Failed to properly plan care · 00096074-AP-072697 Level 3Substantiated ▼
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious harm
Rules violated (OAR)
411-054-0025(1)(a) and (b)
411-054-0027(1)(f) and (r)
411-054-0028(2)
411-054-0030(1)(e)(I)
411-054-0036(2)(g)
411-054-0040(1)(b) and (c)
Findings
The facility failed to appropriately care plan and provide care for the Alleged Victim (AV) after his/her change of condition. AV was having issues eating and swallowing an was sent to the hospital for aspiration. The facility failed to update his/her care plan, causing him/her to have to visit the hospital multiple times, as staff were not aware of the issue and were not caring for AV as he/she should have been cared for. Staff were not assisting AV as they should have, AV's condition worsened, causing unreasonable discomfort. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction
ALFCP21-01112 $500.00 fine assessed
10/24/2018 Failure to provide a system that prevents theft or misuse of medication · ST180858 Level 3Substantiated ▼
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious harm
Rules violated (OAR)
411-054-0025(1)(a) and (b)
411-054-0055(1)(a) and (d); (4)(b), (A)(B)
Findings
AP neglected AV as defined in OAR 4110200002(1)(b)(A)(i) by medication being missing and/or unaccounted for, which resulted in risk of serious harm. Facility did not selfreport.
8/1/2018 Failed to protect resident from financial exploitation · 00011682AP-008392 Level 2Substantiated ▼
Type
Abuse: Financial abuse
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0027(1)(f)
411-054-0028(2)
411-054-0055(1)(a)
Findings
AP financially exploited AV as defined in OAR 4110200002(1)(e)(A)by missing narcotic pain medications, which resulted in financial loss to AV.
Sanction
ALFCP19-178 $250.00 fine assessed
6/14/2018 Failed to provide or assist with hygiene · ST188626 Level 3Substantiated ▼
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious harm
Rules violated (OAR)
411-054-0027(1)(f) and (r)
411-054-0028(2)
411-054-0030(1)(e)(B)
411-054-0036(2)(g)
411-054-0040(2)(a)
Findings
The facility failed to provide appropriate care to RV.
Sanction
ALFCP18-199 $1500.00 fine assessed
6/11/2018 Failed to provide or assist with hygiene · ST188573B Level 3Substantiated ▼
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious harm
Rules violated (OAR)
411-054-0027(1)(f) and (r)
411-054-0030(1)(e)(B)(G) and (H)
411-054-0036(2)(g)
411-054-0040(2)(a)
Findings
AP neglected AV as defined in OAR 4110200002(1)(b)(A)(i) by failing to provideappropriate hygiene care toAV as ordered, which resulted in risk of serious harm.
Sanction
ALFCP18-184 $1500.00 fine assessed
2/25/2017 Failed to provide a safe medication administration system · ST179957 Level 3Substantiated ▼
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious harm
Rules violated (OAR)
411-054-0027(1)(f) and (r)
411-054-0055(1)(a) and (f)
Findings
Failure to properly administer medications.
Sanction
ALFCP17-066 $400.00 fine assessed
5/2/2016 Failed to provide safe environment · CO16148 Level 3Substantiated ▼
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious harm
Rules violated (OAR)
411-054-0025
411-054-0034
411-054-0036
411-054-0040
411-054-0045
411-054-0055
411-054-0065
411-054-0070
Findings
Condition
Sanction
ALFCD16-006 $0.00 fine assessed
2/1/2016 Failed to follow care plan · ST164458 Level 2Substantiated ▼
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0025(1)(a) and (b)
411-054-0027(1)(f) and (r)
411-054-0036(1)(b), (c) and (g)
Findings
Failure to protect resident from harm.
2/1/2016 Failed to provide a safe medication administration system · ST164468 Level 2Substantiated ▼
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0025(1)(a) and (b)
411-054-0027(1)(f) and (r)
411-054-0055(1)(a) and (f)
Findings
Failure to provide a safe medication administration system.
12/23/2015 Failed to have medication available · ST154020 Level 3Substantiated ▼
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious harm
Rules violated (OAR)
411-054-0027(1)(f) and (r)
411-054-0030(1)(e)(I)
411-054-0055(1)(a) and (f)
Findings
Failure to provide safe medication administration.
Sanction
ALFCP16-020 $300.00 fine assessed
10/13/2015 Failed to follow care plan · ST153851 Level 2Substantiated ▼
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0025(1)(a) and (b)
411-054-0027(1)(f) and (r)
411-054-0030(1)(e)(B) and (g)
411-054-0036(1)(b), (c) and (g)
Findings
Failure to provide appropriate care to resident.
10/13/2015 Failed to provide appropriate skin care · ST153897 Level 2Substantiated ▼
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0025(1)(a) and (b)
411-054-0027(1)(f) and (r)
411-054-0036(1)(b), (c) and (g)
Findings
Facility failed to provide appropriate care.
8/24/2015 Failed to adequately care plan related to falls · ST152567 Level 2Substantiated ▼
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0025(1)(a) and (b)
411-054-0027(1)(f) and (r)
411-054-0036(1)(b), (c) and (g)
Findings
Failure to protect resident from harm.
1/26/2015 Failed to follow care plan · ST150041 Level 2Substantiated ▼
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0025(1)(a) and (b)
411-054-0027(1)(f) and (r)
411-054-0030(1)(e)(B)
411-054-0036(1)(b), (c) and (g)
Findings
Failure to protect resident from harm.
1/13/2015 Failed to adequately care plan related to falls · ST150236 Level 3Substantiated ▼
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious harm
Rules violated (OAR)
411-054-0027(1)(f) and (r)
411-054-0036(1)(b), (c) and (g)
411-054-0070(1)(d), (e), (f) and (i)(A) and (B)
Findings
Facility failed to protect resident from harm.
Sanction
ALFCP15-043 $300.00 fine assessed
7/10/2014 Failed to follow care plan · ST147699 Level 3Substantiated ▼
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious harm
Rules violated (OAR)
411-054-0027(1)(f) and (r)
411-054-0036(1)(g)
411-054-0070(1)(d), (e) and (f)
Findings
Facility failed to maintain a safe environment.
Sanction
ALFCP14-075 $300.00 fine assessed
6/28/2014 Failed to adequately care plan related to falls · ST148524 Level 2Substantiated ▼
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0025(1)(a) and (b)
411-054-0027(1)(f) and (r)
411-054-0036(1)(g)
411-054-0070(1), (2) and (3)
Findings
Facility failed to maintain a safe environment.
4/2/2014 Failed to provide safe environment · ST146594 Level 2Substantiated ▼
Type
Abuse: Financial abuse
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0025(1)(b)
411-054-0027(1)(r)
411-054-0028(1), (2) and (3)
Findings
Facility failed to prevent resident loss of property.
3/15/2012 Failed to provide safe environment · ST129505 Level 2Substantiated ▼
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0027(1)(r)
411-054-0030(1)(e)(I)
411-054-0036(1)(g)
411-054-0040(2)(a)
Findings
The facility failed to provide a safe environment.
1/16/2012 Failed to provide safe environment · ST128960 Level 2Substantiated ▼
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0027(1)(r)
411-054-0028(2)
411-054-0030(1)(e)(I)
411-054-0040(2)(a)
Findings
The facility failed to provide a safe environment.
8/15/2011 Failed to intervene when resident's condition changed · ST117758 Level 3Substantiated ▼
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious harm
Rules violated (OAR)
411-054-0027(1)(f) and (r)
411-054-0028(2)
411-054-0040(1)(b) and (c) and (2)(c)
411-054-0045(1)(f)(A)
Findings
Facility failed to assess and intervene.
Sanction
ALFCP12-004 $300.00 fine assessed
6/5/2010 Failed to assure resident was safe · ST104783 Level 2Substantiated ▼
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0027(1)(f)
411-054-0028(2)
Findings
The facility failed to assess and intervene.
2/20/2010 Failed to intervene when resident's condition changed · ST103593 Level 2Substantiated ▼
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0027(1)(f)
411-054-0028(2)
411-054-0036(1)(g)
411-054-0040(1)(b) and (c)
411-054-0045(1)(f)(A)
Findings
The facility failed to assess and intervene to prevent a resident to resident altercation.
Licensing Violations
34 records12/21/2021 Failed to provide appropriate staffing · OR0003361300 Level 1Substantiated ▼
Type
Licensing Violation
Level
1 - No harm or potential for minor harm
Rules violated (OAR)
411-054-0070(1)
Findings
The allegation that the facility failed to have sufficient staff to meet the scheduled and scheduled needs of the residents in accordance with OAR 411-054-0070(1) per complaint that there is an ongoing staff shortage and the nurse is covering shifts for other employees was verified.
12/21/2021 Failed to provide safe environment · OR0003361302 Level 1Substantiated ▼
Type
Licensing Violation
Level
1 - No harm or potential for minor harm
Rules violated (OAR)
411-054-0200(4)(i)
Findings
The allegation that the facility failed to keep all equipment in good repair in accordance with OAR 411-054-0200(4)(i) per complaint of drywall that is not repaired and pipes are exposed was verified.
12/11/2020 Failed to provide a therapeutic diet · OR0002761200 Level 1Substantiated ▼
Type
Licensing Violation
Level
1 - No harm or potential for minor harm
Rules violated (OAR)
411-054-0030(1)(a)(A)
Findings
The facility failed to provide modified special diets that are appropriate to residents' needs and choices.
11/2/2020 Failed to assure resident rights · OR0002715800 Level 2Substantiated ▼
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0090(1)(a)
Findings
The facility failed to conduct fire drill per the Oregon Fire Code. An investigation determined this is a violation of Oregon Administrative Rules.
11/2/2020 Failed to assure resident rights · OR0002715801 Level 2Substantiated ▼
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0025(4)
Findings
Facility failure to exercise reasonable precautions against any condition that may threaten the health, safety, or welfare of residents. An investigation determined this is a violation of Oregon Administrative Rules.
9/27/2020 Failed to provide safe environment · 00104670-AP-079854 Level 2Substantiated ▼
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0027(1)(r)
411-054-0300(4)(i)
Findings
The facility failed to provide safe environment for the Alleged Victim (AV). On or about September 27, 2020, AV was smoking in his/her room and caught him/herself on fire. The smoke detector and/or the sprinkler system did not activate to alert staff. AV suffered burns to his/her body and later passed at the hospital due to burns from the event. An investigation determined no facility abuse occurred, however the facility did fail to provide a safe environment by not ensuring the fire alarm was set to alert staff to a fire, which is a violation of Oregon Administrative Rules.
9/27/2020 Failed to provide safe environment · OR0002662702 Level 1Substantiated ▼
Type
Licensing Violation
Level
1 - No harm or potential for minor harm
Rules violated (OAR)
411-054-0025(7)(e)
Findings
Facility failure to have a policy on smoking in residents rooms. The allegation was substantiated.
9/27/2020 Failed to assure resident was safe · OR0002662704 Level 1Substantiated ▼
Type
Licensing Violation
Level
1 - No harm or potential for minor harm
Rules violated (OAR)
411-054-0025(4)
Findings
Facility failure to provide reasonable precautions against any condition that may threaten the health, safety, or welfare of residents . The allegation that PPE masks were not being worn properly is confirmed.
8/1/2018 Failed to report potential or suspected abuse · SR19136 Level 3Substantiated ▼
Type
Licensing Violation
Level
3 - Moderate harm or potential for serious harm
Rules violated (OAR)
411-054-0028(2)
411-054-0120(4)(a)(E)
Findings
Facility failed to report suspected abuse.
Sanction
ALFCP19-180 $1000.00 fine assessed
6/18/2018 Failed to provide appropriate housekeeping services · OR0001526700 Level 1Substantiated ▼
Type
Licensing Violation
Level
1 - No harm or potential for minor harm
Findings
Facility failed to provide household services to resident's unit pursuant to OAR 4110540030(1)(g).
6/18/2018 Failed to provide appropriate housekeeping services · OR0001526701 Level 1Substantiated ▼
Type
Licensing Violation
Level
1 - No harm or potential for minor harm
Findings
Facility failed to keep resident's unit free of an unpleasant urine odor pursuant to OAR 4110540300(4)(h).
6/18/2018 Failed to properly plan care · OR0001526702 Level 1Substantiated ▼
Type
Licensing Violation
Level
1 - No harm or potential for minor harm
Findings
Facility failed to update and properly follow resident's service plan pursuant to OAR 4110540036(2).
6/18/2018 Failed to provide or assist with hygiene · OR0001526705 Level 1Substantiated ▼
Type
Licensing Violation
Level
1 - No harm or potential for minor harm
Findings
Facility failed to provide resident showers regularly pursuant to OAR 4110540030(1)(e)(B).
6/18/2018 Falsified records · OR0001526706 Level 1Substantiated ▼
Type
Licensing Violation
Level
1 - No harm or potential for minor harm
Findings
Facility failed to comply with facility administration requirements in accordance with OAR 4110540025(8)(a). The facility is allegedly falsifying records to state services were provided to a resident which were not.
6/14/2018 Failed to report potential or suspected abuse · SR18078 Level 2Substantiated ▼
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0028(2)
411-054-0120(4)(a)(E)
Findings
Failure to selfreport.
Sanction
ALFCP18-200 $1000.00 fine assessed
6/11/2018 Failed to report potential or suspected abuse · SR18070 Level 3Substantiated ▼
Type
Licensing Violation
Level
3 - Moderate harm or potential for serious harm
Rules violated (OAR)
411-054-0028(2)
411-054-0120(4)(a)(E)
Findings
Failure to selfreport.
Sanction
ALFCP18-185 $750.00 fine assessed
6/11/2018 Failed to assure timely medical treatment · ST188573A Level 2Substantiated ▼
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0027(1)(r)
411-054-0030(2)(a)
411-054-0040(1)(a) and (d);(2)(b) and (c)
Findings
AP neglected AV as defined in OAR 4110200002(1)(b)(A)(i) by failing to protect AV from harm as ordered, which resulted in risk of serious harm.
3/19/2018 Failed to provide safe environment · ST186812 Level 2Substantiated ▼
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0027(1)(r)
411-054-0036(2)(g)
Findings
Facility Self Reported: The facility failed to provide a safe environment.
2/26/2018 Failed to provide safe environment · ST186376 Level 2Substantiated ▼
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0027(1)(r)
411-054-0030(1)(e)(I)
Findings
The facility failed to protect residents from harm.
10/31/2017 Failed to provide or assist with hygiene · ST174214 Level 2Substantiated ▼
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0027(1)(r)
411-054-0040(1)(c)(B),(2)(a) and (d)
Findings
The facility failed to provide appropriate care to RV.
4/19/2016 Failed to provide a safe medication administration system · ST165581 Level 2Substantiated ▼
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0025(1)(a) and (b)
411-054-0027(1)(r)
411-054-0055(1)(a) and (f) and (2)
Findings
Facility failed to protect resident from harm.
3/23/2016 Falsified records · OR0001081700 Level 1Substantiated ▼
Type
Licensing Violation
Level
1 - No harm or potential for minor harm
Rules violated (OAR)
411-054-0025(8)(a)
Findings
Substitue one resident's narcotics for another resident's narcotics4110540025(8)(a)On April 1, 2016, Compliance Specialist (CS) interviewed Staff 2 to determine if the facility has a policy that prohibits falsification of records. Staff 2 indicated his/her staff will not compromise safety of residents, all staff know medication cannot be substituted when facility is running short on medications for a particular resident.On April 1, 2016, CS interviewed Resident 1 who indicated he/she takes narcotics for pain. Resident 1 also indicated he/she has never been informed the facility has run out of his/her narcotics before.On April 1, 2016, CS interviewed Resident 2 who indicated he/she receives their medication (narcotics for pain) regularly and has not been informed recently of the facility running out of his/her medication.On April 1, 2016, CS interviewed Resident 3 who indicated he/she takes narcotics for pain. Resident 1 also indicated he/she has never been informed the facility has run out of his/her narcotics before.On April 7, 2016, CS received Medical Administration Records (MARs) for 3 Sample Residents (Residents 1, 2 & 3) to determine if documentation were appropriate. Notations in Resident 2 ' s December 2015 MAR appeared inconsistent because Resident 2 ' s MAR did not match his/her pill count in the facility ' s Narcotic Log; there were inaccurate pill counts for 7 dates (3rd, 5th, 14th, 17th, 21st, 25th & 27th) in December. Resident 2 ' s January 2016 MAR also appear inconsistent because Resident 2 ' s MAR did not match his/her pill count in the facility ' s Narcotic Log; were inaccurate pill counts for 4 dates (4th, 11th, 30th & 31st) in January.On April 19, 2016, CS was contacted by Staff 4 via phone. Staff 4 indicated Staff 1 worked the floor the night before and applied another resident ' s pain cream to Resident 4 when Resident 4 was complaining of pain. Resident 4 had an adverse reaction to the topical medication and had to be admitted into the hospital later that night. On April 20, 2016, CS was contacted again via phone by Staff 4 who stated medical staff located an empty box for pain topical cream in the Medical Room trash can that morning. It was a box for Resident 5 ' s pain medication. Staff 4 took a picture of the box of medication and emailed it to CS for review. CS asked Staff 4 if they ' ve located the missing medication and Staff 4 indicated Resident 4 took the medication that was applied to his/her back with him/her to the hospital. On April 26, 2016, CS reentered the facility and interviewed Staff 1 about incident involving Resident 4. Staff 1 indicated he/she applied a topical pain reliever to Resident 4 ' s back. Staff 1 indicated he/she also had a topical pain relieving creamResident 5 ' s topical pain medication) in his/her possession when he/she applied a topical pain relieving cream prescribed for R4 Staff 1 also said he/she mistakenly left Resident 5 ' s topical pain medication on counter in Resident 4 ' s room.On April 26, 2016, CS interviewed Staff 3 about the incident involving Resident 4. Staff 3 stated he/she was informed by Staff 6 that Staff 1 put topical pain medication on Resident 4 and soon after Resident 4 ' s pulse accelerated and Resident 4 started feeling badly. Staff 3 further indicated Resident 4 has a doctor ' s order on file for a topical pain relieving cream but was told by staff that Staff 1 used Resident 5 ' s topical pain relieving cream instead. Staff 3 confirmed staff believes Resident 4 has Resident 5 ' s topical pain relieving cream in his/her possession.On April 26, 2016, CS secured a copy of Resident 5 ' s April 2016 MAR that showed an order for a different topical pain relieving cream than resident 4s . CS went to the Medical Room where Staff 4 was on duty and asked to see where Resident 5 ' s medication is kept. Staff 4 showed where current medication for Resident 5 is kept and also showed where medication Resident 5 is no longer using is kept. There was one unused/unopened box of topical pain relieving cream in that drawer. Staff 4 indicated prior to the incident involving Resident 4, there were two unused/unopened boxes of topical pain relieving cream in that drawer.On April 26, 2016, CS interviewed Staff 5 who indicated he/she was working on April 19, 2016 when Resident 4 had to go to the hospital. Staff 5 was told by Resident 4 he/she was not feeling well and had back pain. Staff 5 indicated he/she was told by Resident 4 that Staff 1 applied a topical cream that increased (not relieved) his/her back pain.On April 26, 2016, CS visited Resident 4 in a rehabilitation center. Resident 4 indicated Staff 1 applied a cream to his/her back on April 20th and he/she had a bad reaction to it. Resident 4 indicated it was not his/her topical pain medication and handed CS a tube of topical pain relieving cream. Resident 4 indicated Staff 1 used this topical pain relieving cream on him/her and left it behind.
3/7/2016 Failed to provide a safe medication administration system · ST164892 Level 2Substantiated ▼
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0055(1)(a) and (f)
Findings
Failure to provide safe medication administration system.
3/3/2016 Failed to properly plan care · OR0001071200 Level 1Substantiated ▼
Type
Licensing Violation
Level
1 - No harm or potential for minor harm
Rules violated (OAR)
411-054-0036(4)
Findings
Failure to permit family member (POA) to participate in Service Plan Meeting4110540036 On March 9, 2016, Compliance Specialist (CS) interviewed Staff 1 who indicated Witness 1 was not Resident 1's Power of Attorney (POA). Staff 1 insisted Witness 1 was not Resident 1's POA and indicated there was no paperwork in Resident 1's file indicating such. Staff 1 went further to say Resident 1 did not ask Witness 1 to participate in his Service Plan. CS informed Staff 1 of the requirement under OAR 4110540036(4) requiring the facility to give Resident 1 & Resident 1 ' s representative proper notice of the Service Plan meeting and provide the resident (or any other family member) an opportunity to participate in it.On March 9, 2016, CS also interviewed Resident 1 to determine if Complainant was his/her POA. Resident 1 indicated Complainant was indeed his POA; referencing his/her working history as reason why he/she had Witness 1 as his/her POA. Resident 1 also disagreed with Staff 1's statement that he/she did not ask Witness 1 to participate in his/her Service Plan. Resident 1 indicated he/she had no prior notice of the Service Plan meeting and was totally surprised when Staff 1 approached him and asked him to sign new Service Plan document.On March 16, 2016, CS interviewed Staff 1. This time CS informed Staff 1 that on March 8, 2016, CS obtained a copy of a Department of Human Services document indicating Witness 1 was financial responsible party for Resident 1 and asked Staff 1 if he/she was aware that Witness 1 was Resident 1's POA? Staff 1 indicated he/she was not informed by Resident 1.
2/4/2016 Failed to assure resident rights · ST165267 Level 2Substantiated ▼
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0025(1)(a) and (b)
411-054-0027(1)(a) and (r)
Findings
Facility failed to provide appropriate care to residents.
12/2/2015 Failed to provide a safe medication administration system · OR0001034701 Level 1Substantiated ▼
Type
Licensing Violation
Level
1 - No harm or potential for minor harm
Rules violated (OAR)
411-054-0055(2)
Findings
Failure to keep an accurate Medication Administration Record (MAR) on all medications that are ordered by a legally recognized prescriber and are administered by the facility4110540055(2)Staff 1 was interviewed on December 16, 2015 and indicated that Resident 1's MAR count was inaccurate on November 23, 2015. When this was discovered, Staff 6 called Staff 1 who immediately drove into work & conducted an internal investigation. The internal investigation yielded an inaccurate narcotic count for Resident 1's medication. Staff 5 was the only staff assigned to administer medication to Resident 1. Resident 1 via interview on December 16, 2015 confirmed that from October 26, 2015 November 22, 2015, he did not receive any medication from Staff 5 although MAR states so.
12/2/2015 Failure to provide a system that prevents theft or misuse of medication · OR0001034702 Level 1Substantiated ▼
Type
Licensing Violation
Level
1 - No harm or potential for minor harm
Rules violated (OAR)
411-054-0055(1)(e )
Findings
Failure to maintain a system for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administrered by the facility.4110540055(1)(e) On December 4, 2015, Staff 2 was interviewed to determine if there were any licensing systemic issues that led to errors in the reporting and documentation of narcotic medications. Staff 2 admitted that Staff 3 (who resigned on December 4, 2015) and Staff 1 were having challenges that contributed to overall oversight issues. Medication were not being administered to Resident 1 but were missing from Resident 1's MAR & medication cart. Since the discovery of missing medication, Staff 2 was sent from corporate office to assist Staff 1 in their internal investigation, narcotic audit and retraining of existing and replacement staff. Both Staff 1 & 2 have retrained all facility medical aides via inservice training and meetings in November 2015. On December 4, 2015, Staff 4 was interviewed and then shadowed during medication administration before lunch. Staff 4 explained that both Staff 1 & 2 have done oneoneone training with all medical aides in November 2015 to cover the basics and rules; reminding medical aides to sign medication out as they are administering them; reminding medical aides where to stand to observe residents taking medication; how to properly dispense medication; what to do with unused, old or partially used medication; how to properly document everything.Compliance Specialist (CS) observed Staff 4 administer all medications required before lunch and then observed Staff 4's record keeping and refilling medical cart with medication. On December 4, 2015, Staff 3 was interviewed and shared that this was his/her last day as he/she resigned. Staff 3 while clearing his/her office, accepted the interview and shared differences in opinions between Staff 3 and Staff 1. It became clear that both Staff 3 & 1 have been clashing for some time and as a result, gaps in communication and reporting ensued. Once the facility became aware medications were missing, Staff 1 selfreported the issue. Staff 2 was sent from corporate to help with an internal investigation, narcotic audit & retraining staff. Staff 1 & 3's differences could not be resolved so Staff 3 announced his/her resignation. Both Staff 1 & 3 point to each other as causes of the rift between them. This rift, helped create an opportunity (according to facility's internal investigation) for Staff 5 to steal Resident 1's medication for a period of time before thefts were discovered and reported.On December 16, 2015 Staff 1 & 2 were interviewed again to determine where the facility was with hiring someone to replace Staff 3. CS was informed that facility has been using someone from corporate to cover part time until a replacement was secured. A replacement has been hired but he/she is going through training through the end of December 2015. Staff 1 was also interviewed separately to determine all steps taken to prevent a systemwide breakdown that occurred in November 2015. Staff 1 indicated that Staff 5 resigned and has been replaced by fully trained staff; other medical aides were retrained on an oneonone basis; additionally, all medical aides pariticipated in a meeting where all oneonone training points were reviewed and discussed again.CS believes a new system is now in place for medication control and administering medication with clearer reporting lines should any medication disappear or is unaccounted for.
11/24/2015 Failed to provide a safe medication administration system · ST153728 Level 2Substantiated ▼
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0025(1)(a) and (b)
411-054-0055(1)(a) and (2)
Findings
Failure to provide safe medication administration system.
9/22/2015 Failed to provide medical treatment as ordered · ST152908 Level 2Substantiated ▼
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0025(1)(a) and (b)
411-054-0036(1)(b), (c) and (g)
411-054-0055(3)
Findings
Failure to provide a safe environment.
8/31/2015 Failed to provide proper food/nutrition · OR0000998000 Level 1Substantiated ▼
Type
Licensing Violation
Level
1 - No harm or potential for minor harm
Rules violated (OAR)
411-054-0030(1)(a)(A)(B)
Findings
RV states that after change in administration, the food is cold & there is no protein in meals4110540030(1)(a)(A) & (B)On September 1, 2015, Compliance Specialist (CS) interviwed Resident 1 who indicated his/her food is usually cold whenever he/she sit down to eat in facility dining room. Resident 1 also indicated he/she is not getting enough protein from facility meals. CS asked Resident 1 to describe what food he/she is not getting (lack of protein) and Resident 1 responded: "bacon." Resident 1 is under the impression this is the only source of protein he/she can receive during breakfast. On September 1, 2015, CS interviewed Staff 2 and informed him/her of food complaints. Staff 2 indicated the first he/she heard of this issue was the day before. CS informed Staff 2 that Resident 1's Capillary Blood Glucose (CBGs) are taken before every meal.. Staff 2 indicated he/she will coordinate with medical staff to serve Resident 1's food after CBGs are taken. Staff 2 also indicated that the facility normally offers sausage as a bacon substitute but Resident 1 does not like sausage. Staff 2 agreed to now substitute an egg for protein whenever the menu's protein item is not liked by Resident 1Staff 2 lastly informed CS the residents have formed a Food Council and copies of those minutes are disseminated to the cook and administration so they are aware of food grievances. However, Staff 2 indicates, the food is improving however, it is impossible to satisfy everyone. On September 1, 2015, CS interviewed Staff 1 who indicated most residents eat what is on the menu. Staff 1 admitted that breakfast menu became static but indicated going forward, menu items shall change and rotate. Staff 1 further indicated he/she just learned of Resident 1's food complaint and will ensure better coordination with staff to serve Resident 1's food after his/her CBGs have been taken.On September 1, 2015, CS interviewed Resident 2 who indicated Staff 2 is new and sometimes serves tasty and nutritious meals. However, sometimes food is overcooked though. Resident 2 further indicated some dishes are full of starch & light on protein.On September 1, 2015, CS observed lunch being served at the facility. The lunch menu today was well rounded, served warm/hot and did provide protein.
8/31/2015 Failed to provide or assist with hygiene · OR0000998003 Level 1Substantiated ▼
Type
Licensing Violation
Level
1 - No harm or potential for minor harm
Rules violated (OAR)
411-054-0030(1)(e )(B)
Findings
RV stated the living room areas are unclean and trash is not taken out.4110540330(1)(g)On September 1, 2015, Compliance Specialist (CS) interviewed Resident 1 and he/she clarified he/she was referring to his/her apartment not getting cleaned once per week nor trash taken out. CS walked around Resident 1's apartment and found only Resident 1's shower not farely clean. Resident 1 indicated housekeeping vacuums his/her apartment but does not clean the bathroom.On September 1, 2015, CS interviewed Staff 1 who indicated the facility call lights are down so the facility is forced to rearrange staff and perform 30 minute checks of all residents. Due to this unanticipated emergency, the facility housekeeper has been reassigned to help on the floor with caregiving. The facility is now utilizing a caregiver to serve in temporary housekeeping role. Staff 1 acknowledges the temporary housekeeper is not doing too well and will be replaced once facility's call lights are repaired. Staff 1 assures CS call lights issue will be resolved very soon.On September 16, 2015, Staff 1 faxed a copy of the invoice for call light repair indicating the call lights were repaired on September 3, 2015 and staff were moved back into their former familiar roles.
8/13/2015 Failed to provide service · ST152484 Level 2Substantiated ▼
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0025(1)(a) and (b)
411-054-0027(1)(r)
411-054-0030(1)(e)(G)
411-054-0036(1)(b), (c) and (g)
Findings
Failed to proved a safe environment.
6/7/2013 Failed to address resident's behavior · ST133687 Level 2Substantiated ▼
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0025(1)(a) and (b)
411-054-0027(1)(r)
411-054-0030(1)(e)(I)
411-054-0036(1)(g)
411-054-0040(2)(a)
Findings
Facility failed to provide a safe environment.
10/18/2010 Failed to provide safe environment · ST105508 Level 2Substantiated ▼
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0027(1)(a) and (r)
Findings
The facility failed to provide a safe environment.
Regulatory Actions
3 recordsALFCD26-00052 Failed to update staffing plan based on ABST · 2/5/2026 → 3/9/2026 License Condition ▼
Type
License Condition
Effective date
2/5/2026 to 3/9/2026
Reference number
CALMS - 00101245
Rules violated (OAR)
411-054-0037(1-7) and 411-054-0070(1)
Description
The following statement of violations stem from evidence and interviews collected from Substantiated Licensing Complaint Unit Report #LCU-00097950 and LCU-00097951 completed January 27, 2026.
Findings
Facility failed to properly post and maintain daily staffing documentation
ALFCD23-00096 Failed to use an ABST · 2/10/2023 → 3/7/2023 License Condition ▼
Type
License Condition
Effective date
2/10/2023 to 3/7/2023
Reference number
OR0003883601
Rules violated (OAR)
411-054-0037(3)
Description
The facility failed to fully implement and update an Acuity Based Staffing Tool (ABST) in accordance with OAR 411-054-0037.
Findings
Facility failed to use an ABST
ALFCD23-00096 Failed to provide or maintain resident care equipment · 2/10/2023 → 3/7/2023 License Condition ▼
Type
License Condition
Effective date
2/10/2023 to 3/7/2023
Reference number
OR0003883602
Rules violated (OAR)
411-054-0200(10)(a)
Description
The facility failed to maintain wiring systems in good repair in accordance with OAR 411-054-0200 (10) (a) per observation the wiring was exposed near the bed of a resident.
Findings
Facility failed to provide or maintain resident care equipment