Bayberry Commons Assisted Living

Last inspection

September 19, 2025

Inspections

8, 40 deficiencies cited

Substantiated abuse

12

Substantiated licensing violations

29

Regulatory actions

3

Fines assessed

$33,188.00 (13 violations)

Current owner since

October 1, 2024

License conditions and other regulatory actions

• March 12, 2026 to July 1, 2026: License Condition, Failed to use an ABST ALFCD26-00091; 3 incidents: CALMS - 00103634, CALMS - 00103633, CALMS - 00103631
  The facility failed to ensure resident service plans reflect the residents needs as identified in evaluation and resident preference; when a resident experiences a significant change of condition the service plan must be reviewed and updated as needed in accordance with OAR 411-054-0036(1-4);
  Rules: 411-054-0025 (Facility Administration); 411-054-0036 (Service Plan – General); 411-054-0037 (Acuity-Based Staffing Tool)
• October 25, 2022 to November 9, 2023: License Condition, Failed to provide safe environment ALFCD22-00929; incident: CALMS - 00033251
  Pursuant to ORS 441.736(2)(d) and OAR 411-054-0110(4), DHS notifies Respondent that it intends to issue an Order Imposing License Condition in the immediate future, based on the following statement of violations. Please note that this Notice is a precursor to any Order Imposing License Condition, and consequently the conditions proposed below are not yet in effect.
  Rules: 411-054-0020; 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0030 (Resident Services); 411-054-0034 (Resident Move-In and Evaluation); 411-054-0036 (Service Plan – General); 411-054-0040 (Change of Condition and Monitoring); 411-054-0045 (Resident Health Services); 411-054-0050 (Infection Prevention and Control); 411-054-0055 (Medications and Treatments); 411-054-0070 (Staffing Requirements and Training); 411-054-0090 (Fire and Life Safety); 411-054-0300 (Assisted Living Facility Building Requirements)
• August 12, 2022 to April 2, 2024: License Condition, Failed to use an ABST ALFCD22-00755; incident: OR0003672604
  The facility failed to fully implement and update an acuity based staffing tool (ABST) in accordance with OAR 411-054-0037.
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)

Inspections

• September 19, 2025: Change of Owner, 2 deficiencies cited report
  • C0360: Staffing Requirements and Training: Staffing severity level 3, scope L3 Isolated
  • C0613: General Building: Doors-Walls, Cleanable severity level 2, scope L2 Widespread
• April 16, 2025: Kitchen, 1 deficiency cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread
• May 17, 2024: Complaint Investig., 2 deficiencies cited report
  • C0260: Service Plan: General severity level 2, scope L2 Isolated
  • C0613: General Building: Doors-Walls, Cleanable severity level 2, scope L2 Isolated
• January 10, 2023: Complaint Investig., 2 deficiencies cited report
  • C0010: Licensing Complaint Investigation severity level 2, scope L2 Isolated
  • C0260: Service Plan: General severity level 2, scope L2 Isolated
  • C0360: Staffing Requirements and Training: Staffing severity level 2, scope L2 Isolated
• November 15, 2022: Complaint Investig., 5 deficiencies cited report
  • C0010: Licensing Complaint Investigation severity level 2, scope L2 Isolated
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Isolated
  • C0260: Service Plan: General severity level 2, scope L2 Isolated
  • C0360: Staffing Requirements and Training: Staffing severity level 3, scope L3 Isolated
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Widespread
  • C0380: Involuntary Move-Out Criteria severity level 2, scope L2 Isolated

Substantiated abuse or neglect

• June 17, 2024: Failed to provide appropriate staffing Abuse: Neglect; 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); 411-054-0036 (Service Plan – General); 411-054-0045 (Resident Health Services); 411-054-0055 (Medications and Treatments)
  State’s findings

  Under the prior ownership Alleged Perpetrator 1 (AP1/Facility) is responsible for AV's Medication Administration. AV has doctor's orders for PRN [benzodiazepine medication] for anxiety and insomnia. AV’s care plan permits alcohol consumption, and physician's orders did not state to withhold the medication if intoxicated. On or about June 17, 2024, around midnight, AV allegedly returned to the facility intoxicated. AV requested AV's PRN [benzodiazepine]. AP1 staff contacted AP2 whom is a non-licensed medical professional for further guidance. AP2 directed AP1 staff to withhold the medication due to safety concerns, citing risks associated with alcohol and benzodiazepine interaction. AP1 Staff withheld AV's PRN [benzodiazepine] due to suspected intoxication, causing AV distress, crying, and fear of a panic attack. AP1 staff lacked resources to consult a licensed medical professional or training for medication guidance, leading to the decision to withhold AV's medication without proper consultation. AP1 neglected AV by failing to provide staff with resources to consult a medical professional for medication guidance, resulting in AV's discomfort.

• June 17, 2024: Failed to answer call light in a timely manner Abuse: Neglect; 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); 411-054-0036 (Service Plan – General)
  State’s findings

  Under the prior ownership: Alleged Victim's (AV)'s Care Plan indicates AV does not require scheduled safety checks, uses call light to request assistance, is a low fall risk with occasional assistance with ambulation, transfers independently. On or about May 06, 2024, AV was attempting to transfer from AV's bed to AV's power wheelchair and fell. AV used AV's Call Light pendant to notify AP1 staff of AV's fall and to request help, AP1 Staff did not respond to AV's Call Light pendant. AV used AV's Life Alert pendant to notify emergency services of AV's fall and request help. AP1 Staff did not respond to AV's Call Light pendant request until AP1 Staff saw emergency services enter AP1 and go to AV's room. AV was on the ground for 1:02:20 (1 Hour, 2 Minutes, 20 Seconds) before AP1 staff responded per the call light log. AP1 does not have a call light response policy in place, however staff report a reasonable response time to a call light is 10-15 minutes. AP1 Failed to answer call light in a timely manner to provide basic care, resulting in AV suffering unreasonable discomfort

• March 31, 2024: Failed to provide a safe medication administration system Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $188.00; report
  Rules: 411-054-0025 (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

  According to the documentation, the facility failed to provide a safe medication administration system for the Alleged Victim (AV) by not having medications available. On or about March 31, 2024, through April 7, 2024, the AV did not receive their scheduled eye drop medication which resulted in unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• September 14, 2023: Failed to provide a safe medication administration system Abuse: Neglect; 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

  According to the documentation, the facility failed to provide a safe medication administration system to ensure medication did not go missing. The facility did not have an accurate narcotic log which lead to the Alleged Victim (AV) to lose approximately 3.5ml of narcotic medication, which is a violation of Oregon Administrative Rules.

• May 25, 2023: Failed to follow care plan 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); 411-054-0036 (Service Plan – General)
  State’s findings

  According to the documentation, the facility failed to follow the care plan to provide supervision when the Alleged Victim (AV) is outside the facility. The failure resulted in the AV to wander from the building without staff intervention or knowledge they had left, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• June 10, 2026: Failed to properly plan care Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0036 (Service Plan – General)
  State’s findings

  The facility allegedly failed to properly plan care for the Alleged Victim. An investigation determined this is a violation of Oregon Administrative Rules.

• June 10, 2026: Failed to follow care plan Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0025 (Facility Administration)
  State’s findings

  The facility allegedly failed to ensure overall oversight of proper care service planning to ensure the Alleged Victim needs. An investigation determined this is a violation of Oregon Administrative Rules.

• May 19, 2026: 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 care needs. Inconsistencies were identified between the resident care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules.

• August 23, 2025: Failed to make facility or resident records accessible Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0105 (Inspections and Investigations)
  State’s findings

  Based on interview and record review, the facility failed to provide records to the Department upon request. The facility’s failure is a violation of Oregon Administrative Rules.

• April 20, 2025: Failed to provide a safe medication administration system 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 04/20/2025 Alleged Perpetrator 2 (AP2) administered Alleged Victim (AV) another residents’ medications. AV was placed on alert charting. The facility failed to provide a safe medication administration system for the AV. According to an investigation, AV experienced no negative outcome. The failure is a violation of Oregon Administrative Rules. The allegation that AP2 failed to provide a safe medication administration system for the AV was investigated and determined to be not substantiated.

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 62 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.