Adara Oaks Living

Last inspection

June 18, 2025

Inspections

4, 11 deficiencies cited

Substantiated abuse

7

Substantiated licensing violations

6

Regulatory actions

1

Fines assessed

$2,388.00 (7 violations)

Current owner since

November 1, 2021

License conditions and other regulatory actions

• June 10, 2025 to July 3, 2025: License Condition, Failed to provide safe environment RCFCD25-00602; incident: CALMS - 00080836
  On or about Saturday morning (6/7/25) at Adara Oaks, around 1:30 AM. A fire broke out after a resident lit a marijuana joint while on oxygen in her apartment. The resident sustained significant burns, was intubated on site, and transported to the hospital. She has since been transferred to the burn unit and may be discharged in the coming days.
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0036 (Service Plan – General)

Inspections

• June 18, 2025: Re-Licensure, 8 deficiencies cited report
  • C0252: Resident Move-in & Evaluation: Res Evaluation severity level 2, scope L2 Isolated
  • C0260: Service Plan: General severity level 2, scope L2 Pattern
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Isolated
  • C0362: Acuity Based Staffing Tool - ABST Time severity level 2, scope L2 Pattern
  • C0363: Acuity Based Staffing Tool - Updates & Staffing Plan severity level 2, scope L2 Widespread
  Show all 8

  • C0510: General Building Exterior severity level 2, scope L2 Widespread
  • C0513: Doors, Walls, Elevators, Odors severity level 2, scope L2 Widespread
  • L0252: Resident Move-in & Evaluation: Res Evaluation severity level 2, scope L2 Isolated
• December 9, 2024: Complaint Investig., 2 deficiencies cited report
  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Isolated
  • C0363: Acuity Based Staffing Tool - Updates & Plan severity level 2, scope L2 Isolated
• August 31, 2023: State Licensure, 1 deficiency cited report
  • C0000: Comment severity level 0
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread, corrected October 30, 2023
• May 23, 2022: Validation, 0 deficiencies cited report
  • C0000: Comment severity level 0

Substantiated abuse or neglect

• June 7, 2025: Failed to properly plan care Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $375.00; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0036 (Service Plan – General)
  State’s findings

  The Alleged Victim (AV) has a known history and pattern of unsafe smoking in his/her room, using an open flame while he/she is on a continuous oxygen nasal cannula. On or about June 7, 2025, staff responded to AV's room after they heard AV screaming for help. When staff opened AV's door, and the room was filled with smoke and observed visible flames. Staff called for assistance and removed AV from the room and evacuated all residents from the facility. AV's nasal cannula was melted to AV's face and AV's face was black from smoke. AV was taken to the hospital and diagnosed with second degree burns to his/her head and face. During the time leading up to this incident, staff had noticed smoke in AV's room, from AV engaging in smoking marijuana from a pipe and pre rolled joints with an open flame. AV's care plan does not contain preventative measures to address AV's known behaviors of unsafe smoking in AV's room. The facility's failure to address AV's risk of serious harm by using an open flame while using supplemental oxygen is a violation of resident rights, is considered neglect of care and constitutes abuse.

• January 17, 2024: Failed to follow care plan Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $250.00; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General)
  State’s findings

  The Alleged Victim (AV) and Witness #4 (W4) are known to have altercations and are to be in line of sight of staff when in the common areas. On or about January 17, 2024, AV and W4 were in the common area with no staff present. W4 was found hitting AV in the head with a closed fist by staff, and staff intervened quickly to stop the altercation and further assault of AV. The facility's failure to follow the care plan is a violation of resident rights, is considered neglect of care and constitutes abuse.

• July 21, 2023: Failed to provide safe environment Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $375.00; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0030 (Resident Services)
  State’s findings

  On or about July 20, 2023, Witness #3 (W3) had been drinking alcohol and is care planned to have increased monitoring when intoxicated. W3 went outside where the Alleged Victim (AV) was in the smoking area. W3 approached AV and engaged in an altercation, where AV sustained an injury to his/her hand. The facility failed to provide a safe environment by not monitoring W3 when he/she is outside of the facility. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

• December 10, 2022: Failed to provide safe environment Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $375.00; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0030 (Resident Services)
  State’s findings

  On or about December 10, 2022, the Alleged Victim (AV) was standing outside the facility front door smoking. Witness #1 (W1) approached AV asking for a cigarette, to which AV declined. W1 punched AV in the face and pulled AV to the ground, causing an abrasion to AV's knee. W1 is care planned for one on one monitoring for safety. The facility failed to monitor AV this day, resulting in a physical altercation. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

• November 23, 2022: Failed to follow care plan Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $375.00; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0036 (Service Plan – General)
  State’s findings

  According to the documentation, the facility failed to follow the care plan for the Alleged Victim (AV) to keep them in line-of-sight monitoring in common areas to prevent resident to resident altercations. The failure resulted in Witness 2 (W2) and AV getting in a physical altercation resulting in W2 hitting the AV in the head with a metal water bottle, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• October 3, 2022: Failed to follow care plan Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $450.00; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General)
  State’s findings

  On or about October 3, 2022, Witness #2 (W2) walked into AV's room while AV was sleeping and whispered inappropriate things to AV, causing AV unreasonable discomfort. Facility staff are to supervise W2 due to known sexualized behaviors exhibited by W2 towards other residents. The facility failed to follow the care plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• April 9, 2022: Failed to provide safe environment Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $188.00; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0030 (Resident Services)
  State’s findings

  The Alleged Victim (AV) and Witness #1 (W1) have been involved in many instances of verbal and physical aggression from July 2021 to April 2022. The facility failed to implement new meaningful interventions to reduce the amount of altercations between the two residents. The facility failed to provide a safe environment, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• July 5, 2025: Failed to provide appropriate staffing Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)
  State’s findings

  The facility failed to appropriately staff and indicated by their posted staffing plan. The facility's failure is a violation of Oregon administrative rules.

• June 7, 2025: Failed to use an ABST Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)
  State’s findings

  The facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules.

• October 8, 2024: Failed to use an ABST Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)
  State’s findings

  The facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules.

• January 13, 2023: Failed to use an ABST Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)
  State’s findings

  The facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules.

• April 25, 2022: Failed to assure resident rights Licensing Violation; Level 1 - No harm or potential for minor harm; report
  Rules: 411-054-0027 (Resident Rights and Protections)
  State’s findings

  the facility failed to ensure that residents receive services in a manner that protects privacy and dignity.

• April 17, 2022: Failed to protect resident from verbal abuse Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare)
  State’s findings

  The facility and Alleged Perpetrator #2 (AP2) failed to protect the Alleged Victim (AV) from verbal abuse. On or about April 17, 2022, AP2 used profanity towards AV while AV was exhibiting known behaviors requiring redirection. AP2's actions are a violation of resident rights, are considered neglect of care and constitute verbal abuse. the facility's failure is a violation of Oregon Administrative Rules.

Read the full record on the state’s site →

ODHS lists only substantiated violations: “either a substantiated instance of abuse or a licensing violation. Open investigations and complaints that are being appealed by the provider are not listed.” Oregon counts neglect as a form of abuse; see the state’s definitions of abuse. Each violation shows the level ODHS gives it, in the state’s words (for example “2 - Minor harm or potential for moderate harm”), and any fine ODHS assessed. Inspection citations show the state’s severity level and scope, and the date ODHS recorded the problem as corrected when it lists one. Rule names come from the Oregon Administrative Rules. ODHS: “Formal regulatory actions can range from a condition placed upon a license due to non-compliance or a notice to revoke a license.” This community is licensed for 60 residents; larger communities are inspected and reported on more often, so read counts with size in mind. Source: Oregon Department of Human Services, Long-Term Care Licensing, data as of October 15, 2026, showing the last five years. Always visit in person and ask the community about anything listed here.