Awbrey Place Memory Care

Last inspection

January 15, 2025

Inspections

5, 15 deficiencies cited

Substantiated abuse

3

Substantiated licensing violations

3

Regulatory actions

0

Fines assessed

$1,188.00 (3 violations)

Current owner since

April 28, 2021

Inspections

• January 15, 2025: Kitchen, 2 deficiencies cited report
  • C0370: Staffing Requirements and Training ? Pre-service severity level 2, scope L2 Pattern
  • Z0142: Administration Compliance severity level 2, scope L2 Pattern
• April 8, 2024: State Licensure, 0 deficiencies cited report
  • C0000: Comment severity level 0
• January 8, 2024: Validation, 8 deficiencies cited report
  • C0000: Comment severity level 0
  • C0242: Resident Services: Activities severity level 2, scope L2 Widespread, corrected May 25, 2024
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Widespread, corrected March 25, 2024
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread, corrected March 25, 2024
  • C0422: Fire and Life Safety: Training For Residents severity level 2, scope L2 Widespread, corrected March 25, 2024
  Show all 10

  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread, corrected May 25, 2024
  • C0513: Doors, Walls, Elevators, Odors severity level 2, scope L2 Widespread, corrected March 25, 2024
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected May 25, 2024
  • Z0155: Staff Training Requirements severity level 2, scope L2 Pattern, corrected May 25, 2024
  • Z0164: Activities severity level 2, scope L2 Pattern, corrected March 25, 2024
• May 4, 2023: State Licensure, 2 deficiencies cited report
  • C0000: Comment severity level 0
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread, corrected July 5, 2023
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected July 5, 2023
• May 11, 2022: Initial Licensure, 3 deficiencies cited report
  • C0000: Comment severity level 0
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread, corrected July 12, 2022
  • C0530: Housekeeping and Laundry severity level 2, scope L2 Widespread, corrected July 12, 2022
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected July 12, 2022

Substantiated abuse or neglect

• August 24, 2025: Failed to provide a safe medication administration system Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $500.00; 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); 411-054-0055 (Medications and Treatments)
  State’s findings

  The Alleged Victim (AV) relied on the facility for care and medication administration. According to an investigation, there were multiple medication and documentation errors in AV's pain patch administration by multiple facility staff between August 6, 2025, and August 15, 2025. On or about August 12, 2025, AV displayed out of character aggravation and irritation after missing their fentanyl patch change scheduled for that day. The facility failed to provide a safe medication administration system, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• January 29, 2024: Failed to provide safe environment Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $500.00; 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) is a known fall risk and has suffered multiple falls with and without injury. AV suffered 4 falls within a week, with and without injury. The facility's failure to provide a safe environment from falls and properly supervise AV is a violation of resident rights, is considered neglect of care and constitutes abuse.

• November 14, 2023: 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) is a known fall risk and has had multiple falls with and without injury. AV is care planned to have a caregiver provide standby assistance while ambulating, however, AV will ambulate without assistance, requiring immediate intervention by staff. AV suffered three falls, November 14, 2023, November 25, 2023 and November 26, 2023, two of those falls causing injury. The facility's failure to ensure oversight of AV while ambulating placed AV at risk for serious harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• September 24, 2025: Failed to protect resident from financial exploitation 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)
  State’s findings

  The Alleged Victim (AV) relies on facility staff to ensure resident’s rights. According to an investigation, on or about September 15, 2025, the Alleged Perpetrator 2 (AP2) borrowed approximately $500.00 from AV, and refused to pay them back. AP2's actions are considered financial exploitation and constitutes abuse. The facility did not keep AV free from financial exploitation, which is a violation of Oregon Administrative rules.

• June 11, 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 to ensure the Alleged Victim’s (AV) medications were available onsite and administered as ordered. According to documentation, AV experienced no negative outcome. The failure is a violation of Oregon Administrative Rules.

• December 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 December 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 November 1, 2022 to November 30, 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 26 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.