Pricing ranges from
    $5,329 – 6,927/month

    Klamath Falls Senior Living

    2130 N Eldorado Ave, Klamath Falls, OR 97601
    • Assisted Living

    Pricing

    Prices shown are estimates and subject to change. Contact your senior living advisor for current pricing.

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    Amenities

    Healthcare services

    • Activities of daily living assistance
    • Assistance with bathing
    • Assistance with dressing
    • Assistance with transfers
    • Medication management
    • Mental wellness program

    Healthcare staffing

    • 12-16 hour nursing
    • 24-hour call system
    • 24-hour supervision

    Meals and dining

    • Diabetes diet
    • Meal preparation and service
    • Special dietary restrictions

    Room

    • Air-conditioning
    • Cable
    • Fully furnished
    • Housekeeping and linen services
    • Kitchenettes
    • Private bathrooms
    • Telephone
    • Wifi

    Transportation

    • Community operated transportation
    • Transportation arrangement

    Common areas

    • Beauty salon
    • Computer center
    • Fitness room
    • Gaming room
    • Garden
    • Outdoor space
    • Small library
    • Wellness center

    Community services

    • Concierge services
    • Fitness programs
    • Move-in coordination

    Activities

    • Community-sponsored activities
    • Planned day trips
    • Resident-run activities
    • Scheduled daily activities

    Reviews

    4.65·(145)

    Overall rating

    1. 5
    2. 4
    3. 3
    4. 2
    5. 1
    • Care

      4.6
    • Staff

      4.6
    • Meals

      4.3
    • Amenities

      4.5
    • Value

      2.9

    Pros

    • Compassionate, resident-focused caregiving
    • Warm, welcoming front-desk and concierge service
    • Engaged and accommodating activities director
    • Wide range of social and recreational activities
    • Restaurant-style dining with varied menu options
    • In-room dining and flexible meal service
    • Spacious apartment layouts (studio, 1BR, 2BR)
    • Hotel-like amenities and well-kept common areas
    • Clean, well-maintained facility and grounds
    • Proximity to a local hospital
    • 24-hour on-site staffing
    • Helpful move-in coordination and transition support
    • Assistance with Medicaid and benefits enrollment
    • Pet-friendly policies and support
    • Responsive maintenance and timely repairs
    • Family-involved, team-oriented care approach
    • Small-community, family-like atmosphere
    • Regular events (birthday parties, live music, card games)
    • Knowledgeable and accessible administrative and sales staff
    • Demonstrated dementia-care rapport in individual cases

    Cons

    • Staff conduct and incident response
    • Gaps in clinical training and emergency preparedness
    • Inconsistent housekeeping and sanitation practices
    • Inadequate family communication and care notifications
    • Staffing instability and turnover
    • Inconsistent meal quality and service continuity
    • Personal-property safeguarding gaps
    • Weak end-of-life and hospice coordination
    • Perception of high cost and rigid long-term contract terms
    • Management effectiveness variability during ownership transition
    • Limited ground-floor accessibility and parking options

    Summary of reviews

    The reviews aggregate into a mixed but informative picture. Many families and residents praise the facility’s day-to-day strengths: a warm, resident-focused staff culture, an active activities program, restaurant-style dining with varied menus and in-room service, and spacious, hotel-like accommodations. Multiple accounts highlight a smooth move-in experience, helpful administrative and sales staff, responsive maintenance, Medicaid assistance, and a small-community atmosphere that supports socialization and engagement (bingo, live music, weekly events, gardening and patio spaces).

    Care quality impressions are divergent. Numerous reviewers describe compassionate, attentive caregiving, positive dementia support, collaborative communication with families, and a sense that residents are kept busy and safe. At the same time, there are significant operational concerns: complaints about delayed responses to personal-care needs, instances implying lapses in sanitation and timely bathing/assistance, and reported gaps in CPR/first-aid and emergency-preparedness training. A smaller number of accounts describe serious individual allegations involving staff conduct that prompted external involvement and regulatory attention; these items stand apart from routine service feedback and have influenced perceptions of the facility’s clinical oversight and incident-response processes.

    Staff and management receive mixed evaluations. Many reviewers single out individual staff — front-desk personnel, activities leadership, nurses, and administrators — as courteous, knowledgeable, and effective. Several comments document positive change under new or attentive leadership and praise specific team members for helping transitions and care coordination. Conversely, other reviewers describe inconsistent leadership, delayed or poor communication with families, punitive reactions to staff who raise concerns, and staffing shortages that have affected services such as dining and housekeeping. Ownership transition and management variability are recurring themes that appear to correlate with both improvements and declines in local practices depending on timing.

    Dining and activities are generally described as strengths, but with variability. Some reviewers describe high-quality, restaurant-style meals, flexible ordering, and accommodating dining staff; others report inconsistent meal quality, staffing-related interruptions, and concerns about nutrition at times. The activities program is consistently noted as engaging and beneficial to residents’ social and cognitive well-being.

    Facilities and logistics are frequently seen as positives: clean communal spaces, well-kept grounds, multiple apartment configurations, onsite 24-hour staff, and convenient proximity to a hospital. Contrasting comments point to intermittent housekeeping shortfalls, occasional communication delays regarding clinical changes (including hospice notifications), and limitations such as parking/accessibility and the absence of some on-site services (e.g., salon) in certain units.

    Notable patterns for prospective residents and families to consider: verify current leadership and turnover rates, ask about staff training and emergency protocols (CPR/first aid), review the facility’s procedures for property security and family notification, and clarify contractual terms and fees. The bulk of feedback emphasizes strong personal relationships, engaged activities, and appealing physical amenities; however, the presence of serious individual allegations and multiple operational concerns suggests that due diligence focused on clinical oversight, incident response, and management stability is warranted before making a placement decision.

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    Location

    Klamath Falls Senior Living is located at 2130 N Eldorado Ave, Klamath Falls, OR, 97601.

    About Klamath Falls Senior Living

    Klamath Falls Senior Living sits on an emerald hillside in Klamath Falls, surrounded by blossoming trees and garden views that just make people feel at home, and residents can choose from private or semi-private apartments in studio, one-bedroom, or two-bedroom layouts, with some ground-floor spaces offering patios that open into the garden. Apartments come with kitchenettes and private bathrooms, each fitted with walk-in, wheelchair-accessible showers, and all of them allow pets, so long as folks want to bring theirs along, and there's room service if anyone prefers a meal in their room. The building never feels stuffy since there's always someone in the restaurant-style dining room where chefs prepare meals each day, and there are housekeeping and laundry services, too, for anyone who'd rather spend time doing something else. People who like staying active can join in games, chair exercises, bingo, crafts, religious services, or garden socials, and the community calendar includes special events, like outings into town and holiday celebrations such as Easter with photos and goodie bags.

    There are full-time Assisted Living and temporary Respite Care services for those needing more help, and Memory Care supports people living with Alzheimer's or other forms of dementia, with a medical and nursing staff that folks often find patient, skilled, and easy to talk to. Seniors can get help with walking or wheelchairs, and the in-house skilled nursing is meant for those who need it, with regular health assessments for everyone's peace of mind. The staff, concierge, and reception teams are known to be approachable and helpful, working hard to keep things running smoothly and keeping an eye on residents' dignity and enjoyment. The setting feels safe and clean, and people say the busy schedule keeps everyone engaged and social, but there's still plenty of privacy in each well-equipped apartment. Klamath Falls Senior Living welcomes adults 55 and over and accepts both independent folks and those who need a little more care, and being part of the Pacifica Senior Living family means it follows state licensing rules, under license number 1364036202, which many find reassuring. There's on-site parking, transportation for field trips, a salon and spa right in the building, and modern amenities like internet, landline, and TV to round out daily life, so it's the kind of place where people can settle in with support for many different needs and lifestyles.

    About Pacifica Senior Living

    Klamath Falls Senior Living is managed by Pacifica Senior Living.

    Pacifica Senior Living, a division of Pacifica Companies (family-owned since 1978), was founded in 2008 and is headquartered in San Diego, California. Operating over 90 communities across 13-14 states with concentrations in California, Florida, and Arizona, Pacifica has grown to become the 13th largest overall senior care provider in the United States. The company ranks as the 5th largest memory care provider, 10th largest assisted living provider, and 21st largest independent living provider nationally, serving thousands of residents from coast to coast through their comprehensive care offerings.

    Pacifica's mission centers on creating a lifestyle of independence, security, and peace of mind for each individual and their family. The company provides personalized, compassionate care services through their signature Heartland™ Assisted Living and Legacies™ Memory Care programs, which focus on the individual while offering customized care plans that respect each resident's needs, preferences, and privacy. Their philosophy emphasizes striking a balance between assistance and independence, providing dignified and compassionate retirement experiences in environments that feel like home. Each community is managed individually, allowing for tailored support of unique resident profiles and communal character, with everything from scheduling to dining menus designed around residents' preferences.

    The company's specialized memory care programs demonstrate their expertise in dementia care. Their Legacies™ Memory Care program helps patients with Alzheimer's disease and other forms of memory loss feel safe and secure while providing memory-boosting activities. The innovative Amara Memory Support program creates welcoming and empowering environments that celebrate the essence of people rather than focusing on their diagnosis. Programming encompasses nine Focus Elements of Life: Recreation, Service, Spirituality, Movement, Sensory, Household Connection, Community, Exploration, and Creative Arts, delivered through stimulating activities including gardening, culinary adventures, musical experiences, creative artistic outlets, and mindfulness practices.

    Pacifica offers a comprehensive continuum of care including independent living, assisted living, memory care, respite care, skilled nursing, and adult day care services. All communities focus on promoting well-being by meeting care needs while facilitating social interactions, activities, and wellness programs. Despite recent financial challenges leading to the bankruptcy of one management entity affecting approximately 20 California facilities, the majority of Pacifica's nearly 100 communities continue operating, maintaining their commitment to advancing senior living and providing peace of mind to residents and families through warm, family-like communities where each resident receives individualized attention while maintaining dignity and independence.

    People often ask...

    Klamath Falls Senior Living offers competitive pricing, with rates starting at a cost of $5,329 per month.

    Klamath Falls Senior Living offers assisted living.

    There are 49 photos of Klamath Falls Senior Living on Mirador.

    The full address for this community is 2130 N Eldorado Ave, Klamath Falls, OR 97601.

    No, Klamath Falls Senior Living does not offer respite care. Respite care in assisted living communities provides temporary, short-term relief for primary caregivers by offering professional care for their loved ones. It allows individuals to stay in an assisted living community for a limited time, giving caregivers a break while ensuring residents receive necessary support and assistance with daily activities.

    Safety & Compliance

    In Oregon, the Department of Human Services' Aging & People with Disabilities program licenses assisted living and residential care facilities, conducting inspections, complaint investigations, and renewals.

    License number70M024
    StatusActive
    Facility typeAssisted Living Facility
    Capacity70 residents
    LicenseePacifica Sl Klamath Falls, LLC
    EffectiveApril 8th, 1997
    View the official license record

    Inspection Reports

    151

    Reports

    0

    Type A Citations

    0

    Type B Citations

    2

    Complaints

    16

    Years

    19 Aug 2026License Condition
    Concluded that the actions/omissions created a risk of immediate jeopardy to residents' health and safety due to failure to provide a safe environment. Found that needed/necessary services were not provided.
    • Regulatory Action—Failed to provide safe environment
    13 Aug 2026Inspection
    Investigated the allegation of failing to provide a safe environment and found a licensing violation.
    • Licensing—Failed to provide safe environment
    13 Aug 2026Inspection
    Investigated a staffing allegation and identified inconsistencies between ABST data and staffing schedules, indicating insufficient staffing levels to meet resident needs.
    • Licensing—Failed to staff as indicated by ABST
    12 Aug 2026Inspection
    Investigated and found a deficiency for failing to evaluate and document short term change of condition.
    • Licensing—Failed to intervene when resident's condition changed
    12 Aug 2026Inspection
    Investigated the allegation and found that medication and treatment orders were not carried out as prescribed.
    • Licensing—Failed to provide medical treatment as ordered
    11 Aug 2026Inspection
    Determined that a violation occurred due to failure to require residents to move out only for reasons stated in the involuntary move-out criteria.
    • Licensing—Failed to comply with move-out, transfer or discharge requirements
    05 Jul 2026Inspection
    Investigated the allegation and found failure to fully implement and update an acuity-based staffing tool.
    • Licensing—Failed to use an ABST
    08 Apr 2026Abuse: Neglect
    Investigated and found neglect with inadequate care planning and monitoring that led to skin breakdown and pain.
    • Abuse—Failed to provide service
    23 Mar 2026Abuse: Neglect
    Found neglect and abuse for failing to implement post-fall interventions, resulting in a second fall and hospital visit.
    • Abuse—Failed to properly plan care
    12 Feb 2026Inspection
    Investigated and found a failure to immediately report abuse or suspected abuse to the Department, AAA, or law enforcement and to promptly investigate all reports, violating Oregon administrative rules.
    • Licensing—Failed to report potential or suspected abuse
    12 Feb 2026Inspection
    Found a policy failure to refer residents who may be victims of acute sexual assault.
    • Licensing—Failed to assure resident rights
    05 Feb 2026Inspection
    Investigated and substantiated a medication safety violation. Staff did not visually observe residents taking their medications.
    • Licensing—Failed to provide a safe medication administration system
    04 Feb 2026Abuse: Neglect
    Investigated a complaint about medication safety and found a failure to provide a safe medication administration system, resulting in missing narcotics and evidence of neglect and abuse; a fine was assessed.
    • Abuse—Failed to provide a safe medication administration system
    30 Jan 2026Inspection
    Identified that service plans were not reflective of resident preferences and not implemented.
    • Licensing—Failed to properly plan care
    09 Jan 2026Inspection
    Investigated and found staffing levels were not consistently aligned with ABST indications. Inconsistencies existed between the staffing schedule and ABST data, and staff levels did not meet residents' scheduled and unscheduled needs.
    • Licensing—Failed to staff as indicated by ABST
    09 Jan 2026Inspection
    Investigated and found a failure to promptly report and investigate abuse, suspected abuse, and neglect.
    • Licensing—Failed to report potential or suspected abuse
    09 Jan 2026Inspection
    Determined that documentation was not provided as requested, constituting a violation.
    • Licensing—Failed to cooperate with an investigation
    09 Jan 2026Inspection
    Found a failure to develop and implement a policy for referring residents who may be victims of acute sexual assault.
    • Licensing—Failed to provide safe environment
    09 Jan 2026Inspection
    Investigated the allegation of failing to provide a safe environment and found a violation of Oregon Administrative Rules.
    • Licensing—Failed to provide safe environment
    09 Jan 2026License Condition
    Identified actions/omissions that created immediate jeopardy by failing to provide needed services and a safe environment.
    • Regulatory Action—Failed to provide safe environment
    09 Jan 2026Inspection
    Investigated and found a violation for failing to identify, evaluate, monitor, and document significant change of condition requirements.
    • Licensing—Failed to provide service
    09 Jan 2026Inspection
    Determined that service plans were not based on evaluations and reflective of residents' needs and preferences, and were not clearly directed, implemented, reviewed, updated, or readily available to staff.
    • Licensing—Failed to properly plan care
    09 Jan 2026Inspection
    Found that residents were not provided a safe and homelike environment.
    • Licensing—Failed to provide safe environment
    09 Jan 2026Inspection
    Investigated and found a failure to provide a safe environment.
    • Licensing—Failed to provide safe environment
    09 Jan 2026Inspection
    Identified a deficiency in the Acuity-Based Staffing Tool that did not reflect resident care needs, with inconsistencies between the roster, care plans, and ABST data.
    • Licensing—Failed to use an ABST
    09 Jan 2026Inspection
    Found staffing deficiencies inconsistent with ABST results and scheduled needs. Inconsistencies between the staffing schedule and ABST data indicated under-staffing for resident care.
    • Licensing—Failed to use an ABST
    09 Jan 2026Inspection
    Identified that the ABST was not updated to reflect resident needs, with inconsistencies between the roster, care plans, and ABST data.
    • Licensing—Failed to use an ABST
    08 Jan 2026Abuse: Neglect
    Investigated a neglect and abuse case; found that a resident with a history of inappropriate behavior roamed freely and entered another resident's apartment unsupervised, with care plans not followed.
    • Abuse—Failed to provide service
    31 Dec 2025Abuse: Neglect
    Investigated a neglect and abuse report involving failure to provide required care, resulting in emotional distress and risk of harm to a resident.
    • Abuse—Failed to provide service
    31 Dec 2025Abuse: Neglect
    Investigated a complaint and found violations for neglect and abuse; a $1,500 fine was assessed.
    • Abuse—Failed to provide service
    31 Dec 2025Inspection
    Investigated and found abuse and neglect occurred, with a fine assessed for failing to provide a safe environment.
    • Licensing—Failed to provide safe environment
    05 Sept 2025Inspection
    Found that a staff member kissed and rubbed a person receiving care, creating an unsafe environment. This conduct constituted a licensing violation.
    • Licensing—Failed to provide safe environment
    11 Aug 2025Abuse: Neglect
    Investigated a complaint of abuse and neglect; concluded there was a failure to provide adequate services and a safe environment after an incident of inappropriate sexual touching by a resident.
    • Abuse—Failed to provide service
    01 Aug 2025Abuse: Neglect
    Investigated found neglect and abuse due to failure to properly plan care after repeated falls, resulting in injuries and a $1500 fine assessed.
    • Abuse—Failed to properly plan care
    21 Jul 2025Inspection
    Investigated an allegation and found deficiencies in the medication administration system and documentation.
    • Licensing—Failed to keep medication record current or accurate
    01 Jul 2025Inspection
    Investigated allegation identified failure to administer medication as ordered.
    • Licensing—Failed to administer medication as ordered
    03 May 2025Abuse: Neglect
    Investigated a complaint of neglect resulting in a resident fall and hip fracture; found failures in care planning and fall-prevention interventions, with a fine assessed.
    • Abuse—Failed to provide service
    04 Mar 2025Abuse: Neglect
    Found violations of care planning and resident monitoring that contributed to a fall with injury.
    • Abuse—Failed to provide service
    28 Jan 2025Abuse: Neglect
    Investigated and found care planning failures and lack of fall-prevention interventions led to multiple falls and injuries, with a fine assessed.
    • Abuse—Failed to properly plan care
    28 Jan 2025Abuse: Neglect
    Found that the care plan was not followed, contributing to multiple falls and injuries, and assessed a $1125 fine.
    • Abuse—Failed to properly plan care
    19 Dec 2024Abuse: Neglect
    Found that safety interventions to prevent falls were not implemented after a resident at risk fell, creating a risk of harm. A $1,000 fine was assessed.
    • Abuse—Failed to provide service
    19 Dec 2024Abuse: Neglect
    Investigated neglect and abuse due to inadequate monitoring and failure to provide needed care, leading to a fall-related hip fracture and hospitalization.
    • Abuse—Failed to provide service
    19 Dec 2024Abuse: Neglect
    Investigated abuse/neglect findings identified failures in care and medication management, including missing oxygen orders, limited monitoring, and delayed nebulizer treatment, resulting in a monetary sanction.
    • Abuse—Failed to provide service
    17 Dec 2024Abuse: Neglect
    Found neglect and abuse due to failure to follow the care plan and monitor, leading to a resident lying in urine and risk of infection and skin breakdown; a fine was assessed.
    • Abuse—Failed to provide service
    20 Nov 2024Kitchen
    Found multiple lapses in food storage and kitchen sanitation, and administration compliance concerns were identified. Violations were noted for food safety rules and for administration oversight.
    • Deficiency—Resident Services Meals, Food Sanitation Rule
    • Deficiency—Administration Compliance
    16 Nov 2024Abuse: Neglect
    Investigated neglect alleging failure to provide required safety checks and monitoring for a resident. A fall occurred after checks were not performed for about 13 hours, indicating insufficient care.
    • Abuse—Failed to provide service
    30 Oct 2024Abuse: Neglect
    Found neglect due to failure to properly plan care to address increasing seizure and fall risk, leading to multiple hospital visits for injuries between Sept 25 and Oct 30, 2024; a $1,500 fine was assessed.
    • Abuse—Failed to properly plan care
    24 Oct 2024Licensure
    Identified widespread deficiencies across administration, resident rights, health services, staffing, and safety, indicating systemic failures in oversight and resident care.
    • Deficiency—Facility Administration: Operation
    • Deficiency—Facility Administration: Policy & Procedure
    • Deficiency—Facility Administration: Quality Improvement
    • Deficiency—Reasonable Precautions
    • Deficiency—Resident Rights and Protection - General
    • Deficiency—Reporting & Investigating Abuse-Other Action
    • Deficiency—Resident Move-in & Evaluation: Res Evaluation
    • Deficiency—Service Plan: General
    • Deficiency—Change of Condition and Monitoring
    • Deficiency—Resident Health Services
    • Deficiency—Infection Prevention & Control
    • Deficiency—Systems: Treatment Orders
    • Deficiency—Systems: Medication Administration
    • Deficiency—Systems: Self-Administration of Meds
    • Deficiency—Systems: Psychotropic Medication
    • Deficiency—Restraints and Supportive Devices
    • Deficiency—Staffing Requirements and Training: Staffing
    • Deficiency—Acuity Based Staffing Tool - Elements
    • Deficiency—Acuity Based Staffing Tool - ABST Time
    • Deficiency—Acuity Based Staffing Tool - Updates & Staffing Plan
    • Deficiency—Training Within 30 Days of Hire ? Direct Care Staff
    • Deficiency—Annual and Biennial Inservice for All Staff
    • Deficiency—Fire and Life Safety: Safety
    • Deficiency—Fire and Life Safety: Training for Residents
    • Deficiency—General Building Exterior
    • Deficiency—General Building: Doors-Walls, Cleanable
    • Deficiency—Individual Rights Settings Right to Freedom
    17 Oct 2024License Condition
    Found deficiencies for failing to meet residents' scheduled and unscheduled needs.
    • Regulatory Action—Failed to meet the scheduled and unscheduled needs of residents
    16 Oct 2024Complaint
    Investigated a complaint about resident health services and found no deficiencies.
    • Deficiency—Resident Health Services
    14 Oct 2024Inspection
    Found a staffing deficiency due to failure to provide an Oregon licensed nurse regularly scheduled onsite and available for phone consultation.
    • Licensing—Failed to provide appropriate staffing
    14 Oct 2024Abuse: Neglect
    Found neglect and abuse for failing to provide required care and planning for a resident, resulting in repeated UTIs and loss of dignity; a fine was assessed.
    • Abuse—Failed to provide service
    14 Oct 2024Abuse: Neglect
    Found neglect and abuse due to failure to provide necessary care and services after unwitnessed falls, causing pain and discomfort.
    • Abuse—Failed to provide service
    14 Oct 2024Inspection
    Found a deficiency for failing to provide a safe environment because there was no working elevator.
    • Licensing—Failed to provide safe environment
    12 Oct 2024Abuse: Neglect
    Investigated allegations of neglect found the care plan wasn't followed, leaving the resident soaked in urine and at risk of serious harm; a $1,500 fine was assessed.
    • Abuse—Failed to follow care plan
    12 Oct 2024Inspection
    Investigated staffing practices related to ABST. Found failure to fully implement and update ABST, violating Oregon Administrative Rules.
    • Licensing—Failed to update staffing plan based on ABST
    11 Oct 2024Abuse: Neglect
    Investigated a neglect allegation and found care planning shortcomings and delayed responses to call lights, with a $500 fine assessed.
    • Abuse—Failed to provide service
    11 Oct 2024Abuse: Neglect
    Investigated found a resident did not receive timely call light responses and safety checks were not followed, leading to discomfort and loss of dignity.
    • Abuse—Failed to provide service
    10 Oct 2024Abuse: Neglect
    Investigated the allegation of neglect and abuse and found failures in care planning and interventions that led to repeated injuries from falls, with a fine assessed.
    • Abuse—Failed to provide service
    09 Oct 2024Abuse: Neglect
    Identified neglect for failing to follow the care plan, resulting in AV sitting in soiled briefs daily with redness and skin injury; a $1,500 fine was assessed.
    • Abuse—Failed to follow care plan
    07 Oct 2024Abuse: Neglect
    Found neglect of care and abuse due to improper oxygen management that caused distress to a resident who depended on care. Staff repeatedly left portable oxygen canisters on and increased oxygen flow beyond orders, leading to distress and confinement until new canisters arrived.
    • Abuse—Failed to provide service
    01 Oct 2024Abuse: Neglect
    Determined neglect and abuse occurred due to a caregiver's inaction after a catheter was pulled, leading to hospital care, and found training deficiencies with a $1500 fine assessed.
    • Abuse—Failed to provide service
    01 Oct 2024Abuse: Neglect
    Investigated and found care planning failures led to repeated catheter removals and resulting discomfort, constituting neglect and abuse.
    • Abuse—Failed to properly plan care
    30 Sept 2024Abuse: Neglect
    Found neglect of care that left an individual in urine-soaked clothing for long periods, causing a rash and discomfort, with a fine assessed.
    • Abuse—Failed to provide service
    30 Sept 2024Abuse: Neglect
    Investigated a complaint and found deficiencies in care planning and fall prevention that led to unwitnessed falls and injuries; a fine was assessed.
    • Abuse—Failed to provide service
    20 Sept 2024Abuse: Neglect
    Investigated the allegation of abuse/neglect and found that inadequate care planning and interventions failed to mitigate falls and self-transfers, resulting in injuries; a $1,500 fine was assessed.
    • Abuse—Failed to provide service
    15 Sept 2024Abuse: Neglect
    Found neglect due to failure to follow the care plan, resulting in discomfort and risk to the resident. A $1,500 fine was assessed.
    • Abuse—Failed to follow care plan
    11 Sept 2024Abuse: Neglect
    Investigated and found neglect and abuse due to failure to provide needed services and care planning, resulting in a head injury; a $1,500 fine was assessed.
    • Abuse—Failed to provide service
    26 Aug 2024Abuse: Neglect
    Found that a resident did not receive care as planned, resulting in a severe health issue and neglect.
    • Abuse—Failed to provide service
    26 Aug 2024Abuse: Neglect
    Found neglect and abuse due to failures in care planning and following the care plan, with resulting injuries and a fine.
    • Abuse—Failed to provide service
    17 Jul 2024Abuse: Neglect
    Investigated a neglect allegation and found inadequate care planning and monitoring that led to a fall.
    • Abuse—Failed to provide service
    11 Jul 2024Abuse: Neglect
    Investigated and found substantiated neglect and abuse due to failure to provide services and to mitigate fall risk, resulting in an injury and a $1,500 fine assessed.
    • Abuse—Failed to provide service
    01 Jul 2024Abuse: Neglect
    Investigated deficiencies in care planning and staff training resulted in neglect, with a $500 fine assessed.
    • Abuse—Failed to provide service
    26 Apr 2024Abuse: Neglect
    Investigated and found neglect due to failure to plan care to mitigate fall risk; three falls occurred with skin tears and discomfort, and a fine was assessed.
    • Abuse—Failed to properly plan care
    20 Feb 2024Abuse: Neglect
    Identified a failure to obtain and administer medications as ordered after surgery, causing three ER visits; a $500 fine was assessed.
    • Abuse—Failed to provide a safe medication administration system
    29 Nov 2023Inspection
    Investigated a staffing allegation and found failure to provide an Oregon-licensed nurse regularly on site and available for phone consultation.
    • Licensing—Failed to provide appropriate staffing
    07 Nov 2023Abuse: Neglect
    Found violations for failing to follow the care plan and administer PRN medication, resulting in severe pain and hospitalization. A $3,000 fine was assessed.
    • Abuse—Failed to follow care plan
    07 Nov 2023Abuse: Neglect
    Concluded neglect and abuse from failing to assess a resident’s changing skin condition and to provide a safe medication administration system, resulting in ongoing pain and a worsening infection; a $3,000 fine was assessed.
    • Abuse—Failed to provide service
    03 Oct 2023Licensure
    Identified deficiencies in food storage and sanitation during the 10/03/2023 survey, with a 01/30/2024 revisit determining substantial compliance.
    • Deficiency—Comment
    • Deficiency—Resident Services Meals, Food Sanitation Rule
    14 Sept 2023Abuse: Neglect
    Found neglect and abuse due to failure to respond to AV's changing condition and skin breakdown, leading to ongoing licensed professional intervention.
    • Abuse—Failed to provide service
    14 Sept 2023Abuse: Neglect
    Investigated an allegation of unsafe environment and found staff were not monitored or following policy, risking resident safety. A $2,250 fine was assessed.
    • Abuse—Failed to provide safe environment
    01 Sept 2023Abuse: Neglect
    Investigated a complaint found failure to implement dietary-related interventions and care planning, risking serious harm to a resident. Substantiated abuse/neglect with a $500 fine assessed.
    • Abuse—Failed to properly plan care
    25 Jul 2023License Condition
    Investigated the allegation of failing to provide service; found the required transfer and two-person assist care planning were not implemented.
    • Regulatory Action—Failed to provide service
    25 Jul 2023License Condition
    Determined that an acuity-based staffing tool was not fully implemented. A deficiency was identified for not using an ABST.
    • Regulatory Action—Failed to use an ABST
    25 Jul 2023License Condition
    Determined a failure to report potential or suspected abuse promptly, and found a deficiency related to resident rights.
    • Regulatory Action—Failed to report potential or suspected abuse
    21 Jul 2023Inspection
    Investigated inconsistencies between the resident roster, care plans, and the Acuity-Based Staffing Tool. Determined this violates Oregon Administrative Rules.
    • Licensing—Failed to use an ABST
    06 Jun 2023Abuse: Neglect
    Investigated found neglect for failing to monitor a resident’s changing condition and follow the care plan, which contributed to a serious health decline and leg amputation.
    • Abuse—Failed to provide oversight and monitoring of change of condition
    04 May 2023Complaint
    Investigated and found multiple deficiencies: failure to report incidents to SPD, inadequate service plan implementation, missed medication orders, and overdue service plan reviews in the ABST.
    • Deficiency—Licensing Complaint Investigation
    • Deficiency—Reporting & Investigating Abuse-Other Action
    • Deficiency—Service Plan: General
    • Deficiency—Systems: Treatment Orders
    • Deficiency—Acuity-Based Staffing Tool
    26 Apr 2023Abuse: Neglect
    Concluded neglect occurred due to failure to monitor and respond to a resident's significant change in condition, resulting in serious harm. A fine was assessed.
    • Abuse—Failed to provide oversight and monitoring of change of condition
    10 Apr 2023Abuse: Neglect
    Investigated found a staff member coerced a resident to shower before an appointment after refusals, violating resident rights and constituting emotional abuse and neglect. A fine was assessed.
    • Abuse—Failed to assure resident rights
    29 Mar 2023Abuse: Neglect
    Found neglect for failing to provide two-person transfers per the care plan, resulting in a resident fall with injury.
    • Abuse—Failed to provide service
    03 Mar 2023Abuse: Neglect
    Found neglect and abuse due to failure to properly plan care, resulting in several injury falls and risk of serious harm. A $1,750 fine was assessed.
    • Abuse—Failed to properly plan care
    03 Mar 2023Abuse: Neglect
    Found neglect and abuse due to failure to provide CPAP care, risking infection.
    • Abuse—Failed to provide service
    11 Jan 2023Abuse: Neglect
    Investigated a medication safety complaint and found a safe administration system was not provided, resulting in about five days without medications and related discomfort.
    • Abuse—Failed to provide a safe medication administration system
    02 Oct 2022Abuse: Neglect
    Determined that verbal/emotional abuse and neglect occurred due to inadequate oversight of ambulation and hostile staff behavior. A $250 fine was assessed.
    • Abuse—Failed to protect resident from mental or emotional abuse
    12 Jul 2022Inspection
    Found neglect and failure to follow the care plan, resulting in loss of personal dignity and risk of harm.
    • Licensing—Failed to provide service
    05 Jun 2022Abuse: Neglect
    Found that staff did not provide needed services to the resident, causing pain and emotional discomfort and constituting neglect and abuse; a $500 fine was assessed.
    • Abuse—Failed to provide service
    10 May 2022License Condition
    Found that residents were at risk of immediate jeopardy due to failure to provide a safe environment, resulting in a license condition.
    • Regulatory Action—Failed to provide safe environment
    02 May 2022Validation
    Investigated a licensee's compliance during re-licensure; identified multiple deficiencies in oversight, care planning, medication management, infection control, staffing, and building safety, but reached substantial compliance.
    • Deficiency—Comment
    • Deficiency—Facility Administration: Operation
    • Deficiency—Facility Administration: Policy & Procedure
    • Deficiency—Facility Administration: Quality Improvement
    • Deficiency—Reasonable Precautions
    • Deficiency—Resident Move-In and Eval: Res Evaluation
    • Deficiency—Service Plan: General
    • Deficiency—Service Plan: Service Planning Team
    • Deficiency—Change of Condition and Monitoring
    • Deficiency—Resident Health Services
    • Deficiency—Rn Delegation and Teaching
    • Deficiency—Systems: Medications and Treatments
    • Deficiency—Systems: Treatment Orders
    • Deficiency—Systems: Medication and Treatment Review
    • Deficiency—Systems: Resident Right to Refuse
    • Deficiency—Systems: Medication Administration
    • Deficiency—Staffing Requirements and Training – Pre-Serv
    • Deficiency—Training Within 30 Days: Direct Care Staff
    • Deficiency—Annual and Biennial Inservice For All Staff
    • Deficiency—Fire and Life Safety: Safety
    • Deficiency—Fire and Life Safety: Training For Residents
    • Deficiency—Inspections and Investigation: Insp Interval
    • Deficiency—General Building Exterior
    • Deficiency—General Building: Doors-Walls, Cleanable
    • Deficiency—Heating and Ventilation
    29 Apr 2022Abuse: Neglect
    Identified neglect and abuse due to failure to properly plan for respiratory needs, leading to a significant medical event requiring an emergency room visit; a fine was assessed.
    • Abuse—Failed to properly plan care
    29 Apr 2022Abuse: Neglect
    Found abuse by neglect due to failure to monitor and respond to a significant change of condition, resulting in falls and ongoing pain.
    • Abuse—Failed to provide oversight and monitoring of change of condition
    24 Apr 2022Abuse: Neglect
    Found neglect due to failure to plan care after a change in condition, leading to approximately four unwitnessed falls and risk of serious harm.
    • Abuse—Failed to properly plan care
    21 Apr 2022Abuse: Neglect
    Found violations related to failure to plan care for a resident, resulting in falls and risk of ongoing harm. A $500 fine was assessed.
    • Abuse—Failed to properly plan care
    11 Apr 2022Inspection
    Investigated and found interior odors and interior materials and surfaces not kept clean, violating Oregon administrative rules.
    • Licensing—Failed to provide safe environment
    31 Mar 2022Inspection
    Identified a staffing deficiency due to RN not assessing all residents when changes in condition occurred.
    • Licensing—Failed to provide appropriate staffing
    30 Mar 2022Abuse: Neglect
    Found substantiated neglect for failing to monitor and respond to a change in condition, resulting in hospitalization for stroke and sepsis.
    • Abuse—Failed to provide oversight and monitoring of change of condition
    03 Jan 2022Abuse: Neglect
    Investigated abuse by neglect; found failures to assess, monitor, and respond to a resident's change in condition and to honor a hospital transfer request, risking serious harm.
    • Abuse—Failed to provide oversight and monitoring of change of condition
    29 Mar 2021Abuse: Neglect
    Found abuse by neglect for failing to respond to a resident’s change of condition and oversee staff; a $188 fine was assessed.
    • Abuse—Failed to provide oversight and monitoring of change of condition
    04 Jan 2021Abuse: Neglect
    Investigated and found failure to provide a safe medication administration system, leading to missing medications and discomfort, constituting neglect and abuse; a $500 fine was assessed.
    • Abuse—Failed to provide a safe medication administration system
    23 Dec 2020Abuse: Neglect
    Identified a deficiency for failing to protect a resident from theft, resulting in missing personal items and constituting abuse.
    • Abuse—Failed to protect resident from financial exploitation
    16 Dec 2020Inspection
    Identified a deficiency in assisting residents with activities of daily living around the clock.
    • Licensing—Failed to provide service
    21 Nov 2020Inspection
    Investigated an allegation of verbal abuse toward a resident and found staff yelled during care and failed to protect the resident from abuse.
    • Licensing—Failed to protect resident from verbal abuse
    16 Sept 2020Inspection
    Investigated and found a deficiency in safe medication administration; medication not given as prescribed.
    • Licensing—Failed to administer medication as ordered
    14 Sept 2020Inspection
    Found a failure to provide a safe medication administration system that left a resident without medication on about September 13, 2020.
    • Licensing—Failed to provide a safe medication administration system
    13 Sept 2020Inspection
    Determined that a safe medication administration system was not provided, resulting in a patient receiving a double dose and at risk of harm. This reflected neglect of care and abuse as identified in the findings.
    • Licensing—Failed to provide a safe medication administration system
    03 Sept 2020Inspection
    Found failure to administer medications as ordered, resulting in 10 missed doses.
    • Licensing—Failed to administer medication as ordered
    03 Sept 2020Abuse: Neglect
    Investigated and found a failure to provide a safe medication administration system, resulting in missed doses and extreme pain for a resident.
    • Abuse—Failed to provide a safe medication administration system
    01 Aug 2020Inspection
    Found violations related to failure to provide required services and protect a resident from neglect, resulting in a resident being left in a wet brief and experiencing loss of dignity.
    • Licensing—Failed to provide service
    22 Jul 2020Inspection
    Investigated and found inappropriate verbal comments toward a resident by staff and a failure to protect the resident from verbal abuse.
    • Licensing—Failed to protect resident from verbal abuse
    02 Jul 2020Abuse: Neglect
    Found failures to plan and monitor care according to needs and fall history, resulting in an unwitnessed fall with injury.
    • Abuse—Failed to properly plan care
    05 May 2020Inspection
    Investigated a complaint and found that medication orders were not followed as prescribed.
    • Licensing—Failed to administer medication as ordered
    22 Apr 2020Inspection
    Found that resident privacy and dignity were not protected.
    • Licensing—Failed to assure resident rights
    15 Feb 2020Inspection
    Found that a staff member wrongfully took medication from a resident after death and that the resident's belongings were not protected from theft.
    • Licensing—Failed to protect resident from financial exploitation
    29 Dec 2019Inspection
    Investigated a financial exploitation allegation and found a staff member engaged in sexual contact with a resident, and protections against abuse were inadequate.
    • Licensing—Failed to protect resident from financial exploitation
    30 Oct 2019Abuse: Neglect
    Investigated and found failures to implement interventions and care planning, resulting in multiple falls, injuries of unknown origin, poor hygiene, and lack of behavioral support.
    • Abuse—Failed to provide service
    30 Oct 2019Abuse: Neglect
    Investigated an allegation of physical abuse and neglect; found physical force used, causing fear and discomfort, and failure to protect or intervene for the resident, with a fine assessed.
    • Abuse—Failed to protect resident from physical abuse
    30 Oct 2019Abuse: Neglect
    Identified neglect due to failure to provide eating assistance, resulting in about 28 pounds of weight loss in two months. A $2,250 fine was assessed.
    • Abuse—Failed to provide service
    30 Oct 2019Abuse: Involuntary Seclusion
    Found a violation for involuntary seclusion constituting abuse and assessed a $2,250 fine.
    • Abuse—Failed to protect resident from involuntary seclusion
    14 Oct 2019Abuse: Neglect
    Found that care planning failed to address a resident's change in condition, resulting in inadequate transfer support and a fall with fracture, constituting abuse and neglect.
    • Abuse—Failed to properly plan care
    27 Sept 2019Inspection
    Found verbal abuse toward a resident and failure to protect the resident from abuse.
    • Licensing—Failed to protect resident from verbal abuse
    22 Jul 2019Abuse: Neglect
    Investigated an allegation of neglect that led to physical harm due to failure to provide basic care; a fine was assessed.
    • Abuse—Failed to assure resident was safe
    03 Jun 2019Inspection
    Found a deficiency in safe medication administration due to delays in refilling medications. This resulted in residents not receiving medications as prescribed.
    • Licensing—Failed to provide a safe medication administration system
    13 May 2017Abuse: Financial abuse
    Investigated an allegation of financial abuse and found a failure to protect a resident from theft by another resident.
    • Abuse—Failed to provide safe environment
    08 May 2017Condition
    Investigated a neglect allegation of failed to provide service and found condition deficiencies at relicensure.
    • Regulatory Action—Failed to provide service
    03 May 2017Abuse: Financial abuse
    Investigated and found that a resident was not protected from theft.
    • Abuse—Failed to provide safe environment
    19 Sept 2016Abuse: Neglect
    Investigated the neglect allegation and identified a failure to obtain a medical order that led to serious injury, with a $400 fine assessed.
    • Abuse—Failed to obtain medical order
    16 Sept 2016Abuse: Financial abuse
    Found a failure to protect a resident from theft, resulting in monetary loss.
    • Abuse—Failed to provide safe environment
    22 Apr 2016Inspection
    Found deficiencies in residents' meal choices and compliance with therapeutic diet requirements.
    • Licensing—Failed to provide a therapeutic diet
    22 Apr 2016Inspection
    Found that residents did not receive palatable meals.
    • Licensing—Failed to provide proper food/nutrition
    17 Mar 2015Abuse: Neglect
    Found that staff failed to assess and intervene when a resident's condition changed, resulting in severe injury requiring surgery.
    • Abuse—Failed to intervene when resident's condition changed
    04 Oct 2014Abuse: Neglect
    Found a safety deficiency after substantiating neglect; a $300 fine was assessed.
    • Abuse—Failed to intervene when resident's condition changed
    29 Aug 2014Abuse: Neglect
    Investigated an allegation of neglect and found that staff failed to assess and intervene when a resident's condition changed; a $300 fine was assessed.
    • Abuse—Failed to intervene when resident's condition changed
    13 Aug 2014Abuse: Neglect
    Determined neglect occurred due to failure to assess and intervene after a resident's condition changed; a $200 fine was assessed.
    • Abuse—Failed to intervene when resident's condition changed
    15 Jul 2014Abuse: Financial abuse
    Determined financial abuse occurred and residents were not protected from it.
    • Abuse—Failed to provide safe environment
    17 Jun 2014Abuse: Neglect
    Found that care was not provided according to plan, resulting in injury, and a $300 fine was assessed.
    • Abuse—Failed to follow care plan
    08 Apr 2014Abuse: Neglect
    Determined a failure to properly plan care, with a $300 fine assessed.
    • Abuse—Failed to properly plan care
    16 Nov 2013Abuse: Financial abuse
    Found that a resident's funds were not protected, creating a risk of theft.
    • Abuse—Failed to provide safe environment
    10 Jun 2013Abuse: Financial abuse
    Found that protections against theft were inadequate, resulting in the loss of property.
    • Abuse—Failed to provide safe environment
    28 Nov 2012Abuse: Neglect
    Cited for failing to follow a care plan and provide appropriate care, with a $300 fine assessed.
    • Abuse—Failed to follow care plan
    22 Dec 2011Inspection
    Found that a resident's pain medication was not administered as ordered.
    • Licensing—Failed to administer ordered medication
    03 Mar 2010Inspection
    Investigated and found a violation of resident rights due to harassment of a resident.
    • Licensing—Failed to assure resident rights

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