Arbor House of Grants Pass

Last inspection

November 6, 2023

Inspections

2, 16 deficiencies cited

Substantiated abuse

1

Substantiated licensing violations

4

Regulatory actions

0

Fines assessed

$375.00 (1 violation)

Current owner since

February 1, 2022

• Every deficiency from the November 6, 2023 inspection was corrected by January 7, 2024

Inspections

• November 6, 2023: Validation, 16 deficiencies cited report
  • C0000: Comment severity level 0
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread, corrected January 7, 2024
  • C0242: Resident Services: Activities severity level 2, scope L2 Widespread, corrected January 7, 2024
  • C0260: Service Plan: General severity level 2, scope L2 Pattern, corrected January 7, 2024
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Pattern, corrected January 7, 2024
  Show all 17

  • C0280: Resident Health Services severity level 3, scope L3 Isolated, corrected January 7, 2024
  • C0295: Infection Prevention & Control severity level 2, scope L2 Widespread, corrected January 7, 2024
  • C0310: Systems: Medication Administration severity level 2, scope L2 Pattern, corrected January 7, 2024
  • C0340: Restraints and Supportive Devices severity level 3, scope L3 Isolated, corrected January 7, 2024
  • C0360: Staffing Requirements and Training: Staffing severity level 2, scope L2 Widespread, corrected January 7, 2024
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Widespread, corrected January 7, 2024
  • C0545: Plumbing Systems severity level 2, scope L2 Widespread, corrected January 7, 2024
  • H1518: Individual Door Locks: Key Access severity level 2, scope L2 Pattern, corrected January 7, 2024
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected January 7, 2024
  • Z0155: Staff Training Requirements severity level 2, scope L2 Pattern, corrected January 7, 2024
  • Z0162: Compliance With Rules Health Care severity level 3, scope L3 Isolated, corrected January 7, 2024
  • Z0164: Activities severity level 2, scope L2 Pattern, corrected January 7, 2024
• November 21, 2022: State Licensure, 0 deficiencies cited report
  • C0000: Comment severity level 0

Substantiated abuse or neglect

• July 31, 2025: Failed to provide safe environment 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) is dependent on the facility to meet his/her safety needs, resides in a secured unit and has a history of wandering behavior. According to an investigation, on or about July 31, 2025, AV eloped from the facility after being left unattended by staff on the front porch. AV left the facility grounds and was found on the ground by a neighbor after tripping and falling, resulting in a fractured wrist and other skin injuries. Staff reported leaving AV unattended on the front porch was a common and accepted practice. The facility failed to ensure AV's service planned need for supervision was provided and provide a safe environment for AV which is a violation of resident rights, is neglect of care which constitutes abuse.

Substantiated licensing violations

• April 3, 2026: Failed to provide safe environment 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 failed to protect the Alleged Victim (AV) from potential harm. According to an investigation, AV experienced a fall resulting in the risk of harm. The failure is a violation of Oregon Administrative Rules. The allegation that Alleged Perpetrator 2 (AP2) neglected AV was investigated and determined to be substantiated.

• August 2, 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

  The facility failed to provide a safe medication administration system for the Alleged Victim (AV). According to an investigation, AV experienced no negative outcome. The failure is a violation of Oregon Administrative Rules. The allegation that AP2 neglected AV was investigated and determined to be not substantiated.

• May 8, 2025: Failed to administer medication as ordered Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0055 (Medications and Treatments)
  State’s findings

  The facility allegedly failed to administer medications as ordered for the Alleged Victim (AV). According to an investigation, AV experienced no negative outcome. The failure is a violation of Oregon Administrative Rules. The allegation that AP2 neglected AV was investigated and determined to be not substantiated.

• August 1, 2022: Failed to submit timely or adequate staffing documentation Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-061-0010
  State’s findings

  On or about August 1, 2022, the Oregon Health Authority reported to the Department that Respondent failed to comply with weekly reporting requirements of vaccinated individuals, residents and staff, to the proper authority as required by law. This failure has been ongoing from July 1, 2022 to July 31, 2022, for a total of 30 days.

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 15 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.