Alderwood ALF

Last inspection

May 20, 2026

Inspections

5, 15 deficiencies cited

Substantiated abuse

5

Substantiated licensing violations

14

Regulatory actions

0

Fines assessed

$1,376.00 (5 violations)

Current owner since

August 1, 2021

Inspections

• May 20, 2026: Kitchen, 1 deficiency cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
• July 12, 2024: Complaint Investig., 1 deficiency cited report
  • C0362: Acuity Based Staffing Tool - Abst Time severity level 2, scope L2 Widespread
• February 21, 2024: 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 April 21, 2024
• June 12, 2023: Validation, 11 deficiencies cited report
  • C0000: Comment severity level 0
  • C0252: Resident Move-In and Eval: Res Evaluation severity level 2, scope L2 Pattern, corrected August 13, 2023
  • C0262: Service Plan: Service Planning Team severity level 2, scope L2 Pattern, corrected August 13, 2023
  • C0305: Systems: Resident Right to Refuse severity level 2, scope L2 Isolated, corrected August 13, 2023
  • C0330: Systems: Psychotropic Medication severity level 2, scope L2 Pattern, corrected August 13, 2023
  Show all 12

  • C0340: Restraints and Supportive Devices severity level 2, scope L2 Isolated, corrected August 13, 2023
  • C0370: Staffing Requirements and Training – Pre-Serv severity level 2, scope L2 Pattern, corrected August 13, 2023
  • C0372: Training Within 30 Days: Direct Care Staff severity level 2, scope L2 Pattern, corrected August 13, 2023
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread, corrected August 13, 2023
  • C0422: Fire and Life Safety: Training For Residents severity level 2, scope L2 Widespread, corrected August 13, 2023
  • C0610: General Building Exterior severity level 2, scope L2 Widespread, corrected August 13, 2023
  • C0613: General Building: Doors-Walls, Cleanable severity level 2, scope L2 Widespread, corrected August 13, 2023
• January 18, 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 March 1, 2023

Substantiated abuse or neglect

• June 17, 2025: Failed to provide a safe medication administration system Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $188.00; report
  Rules: 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0055 (Medications and Treatments)
  State’s findings

  Alleged Victim’s (AV’s) care plan indicates that the facility is responsible for AV’s medication management. AV did not receive AV’s prescribed Xifaxan from June 1st to June 11, 2025. AV missed five (5) doses of Lactulose from June 5, 2025, to June 9, 2025. There is no documentation of AV being put on alert charting or increased monitoring due to running out of AV’s Xifaxan medication from June 1, 2025, to June 11, 2025. The facility did not note attempts to refill AV’s Xifaxan until June 7, 2025. The facility could not explain why the contact to the pharmacy and PCP was not made until June 7, 2025, when AV ran out of medication on June 1, 2025. As a result, AV was sent to the hospital on June 11, 2025, due to showing signs of possible stroke. Respondent failed to provide a safe medication administration system, to ensure the safety of AV. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

• April 22, 2025: Failed to maintain a safe physical 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); 411-054-0300 (Assisted Living Facility Building Requirements)
  State’s findings

  The Alleged Victim (AV) relies on the facility to provide a safe physical environment and for assistance with cares. According to an investigation, on or about April 20, 2025, the facility call system was not operating. There were not specific instructions for re-setting the call system and staff on shift were not able restore the operation of the call system. The AV called for assistance, the call was not received and the AV attempted to transfer independently and fell. The AV was not found on the floor by staff until approximately an hour later. The AV experienced unreasonable discomfort, skin tears, and bruising. The facility failed to ensure the call system was operational and that staff were instructed on how to address system outages, which is a violation of resident’s rights, is neglect of care, and constitutes abuse

• November 13, 2022: Failed to follow care plan Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $250.00; report
  Rules: 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

  On or about November 13, 2022, Alleged Perpetrator 2 (AP2) failed to follow The Alleged Victim (AV) care plan to provide assistance with toileting. The failure resulted in AV being found in wet briefs by another staff member and experiencing a loss of dignity. AP2's actions is a violation of resident rights, is considered neglect of care and constitute abuse. The facility failed to ensure care plans were followed, which is a violation of Oregon Administrative Rules.

• August 13, 2022: Failed to administer medication as ordered Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $250.00; report
  Rules: 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0055 (Medications and Treatments)
  State’s findings

  The facility failed to administer medication as ordered for the Alleged Victim’s (AV). AV is to be given insulin daily depending on blood sugar levels. According to documentation H/S went without the medication from on or about August 03, 2022, and August 13, 2022, putting AV at risk of serious harm. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

• July 8, 2022: Failed to provide oversight and monitoring of change of condition Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $500.00; report
  Rules: 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 08, 2022, the facility failed to ensure the Alleged Perpetrator 2 (AP2) assessed, intervened, and monitored the Alleged Victim (AV) when he/she experienced a change of condition. AV experienced abdominal pain from on or about May 1, 2022- July 11th, 2022. According to documentation, AV was transported to hospice for care on or about July 11, 2022. AP2’s actions are considered neglect of care and constitutes abuse. The facility failed to ensure oversight was appropriately conducted, which is a violation of Oregon Administrative Rules.

Substantiated licensing violations

• June 17, 2025: Failed to provide a safe medication administration system Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0055 (Medications and Treatments)
  State’s findings

  Based on interviews and record review, conducted during a site visit on 04/28/26, the facility’s failure to have a safe medication and treatment system was substantiated, which is a violation of Oregon Administrative Rules.

• April 12, 2024: Failed to administer medication as ordered 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); 411-054-0030 (Resident Services); 411-054-0055 (Medications and Treatments)
  State’s findings

  On or about APril 12, 2024 • Alleged Perpetrator 2 (AP2) administered AV medication that belonged to another resident causing unreasonable discomfort resulting in AV being transported to the hospital for evaluation and treatment. AP2’s actions are a violation of resident rights, are considered neglect of care and constitutes abuse. The facility failed to administer medication as ordered which is a violation of Oregon Administrative Rules.

• May 24, 2023: Failed to administer medication as ordered Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare)
  State’s findings

  Alleged Perpetrator 2 (AP2) failed to provide a safe medication administration system to ensure the Alleged Victim’s (AV) medications were administered as ordered. On or about May 24, 2023, AP2 failed to administered AV'S medication causing unreasonable discomfort and placing him/her at risk of serious harm. AP2's actions are considered neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.

• May 24, 2023: Failed to administer medication as ordered Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare)
  State’s findings

  Alleged Perpetrator 2 (AP2) failed to provide a safe medication administration system to ensure the Alleged Victim’s (AV) medications were administered as ordered. On or about May 24, 2022, AP2 failed to administered AV'S medication causing unreasonable discomfort and placing him/her at risk of serious harm. AP2's actions are considered neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.

• May 24, 2023: Failed to administer medication as ordered Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare)
  State’s findings

  Alleged Perpetrator 2 (AP2) failed to provide a safe medication administration system to ensure the Alleged Victim’s (AV) medications were administered as ordered. On or about May 24, 2023, AP2 failed to administered AV'S medication causing unreasonable discomfort and placing him/her at risk of serious harm. AP2's actions are considered neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system which 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 64 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.