Bayberry Commons Memory Care

Last inspection

July 29, 2026

Inspections

6, 35 deficiencies cited

Substantiated abuse

5

Substantiated licensing violations

17

Regulatory actions

3

Fines assessed

$35,188.00 (9 violations)

Current owner since

October 1, 2024

License conditions and other regulatory actions

• July 11, 2025 to September 5, 2025: License Condition, Failed to provide safe environment RCFCD25-00732; incident: CALMS - 00083102
  Based on preliminary information, received on or about July 9, 2025, a complaint investigation was received. ODHS concludes that Respondents acts or omissions create a situation where the residents of the facility and future residents are at risk of immediate jeopardy. Failure to comply with Oregon Administrative Rules constitutes a threat to the health, safety, and welfare of its residents
  Rules: 411-054-0025 (Facility Administration); 411-054-0055 (Medications and Treatments)
• March 1, 2023 to April 2, 2024: License Condition, Failed to use an ABST RCFCD23-00253; incident: OR0003958600
  The facility failed to fully implement an Acuity Based Staffing Tool in accordance with OAR 411-054-0036(1).
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)
• October 25, 2022 to November 9, 2023: License Condition, Failed to provide safe environment RCFCD22-01553; incident: CALMS - 00033259
  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); 411-054-0036 (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); 411-054-0200 (Residential Care Facility Building Requirements); 411-057-0140 (Responsibilities of Administration); 411-057-0150 (Staffing Requirements); 411-057-0160 (Resident Services in a Memory Care Community)

Inspections

• July 29, 2026: Re-Licensure, 2 deficiencies cited report
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Isolated
  • Z0162: Compliance with Rules Health Care severity level 2, scope L2 Isolated
• August 28, 2025: Change of Owner, 6 deficiencies cited report
  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Pattern
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Isolated
  • C0295: Infection Prevention & Control severity level 2, scope L2 Pattern
  • H1517: Individual Privacy: Own Unit severity level 2, scope L2 Pattern
  • H1580: Limitations: Threats To Health And Safety severity level 2, scope L2 Pattern
  • Z0164: Activities severity level 2, scope L2 Pattern
• April 16, 2025: Kitchen, 2 deficiencies 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
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread
• November 2, 2023: Complaint Investig., 1 deficiency cited report
  • C0010: Licensing Complaint Investigation severity level 2, scope L2 Isolated
  • C0513: Doors, Walls, Elevators, Odors severity level 2, scope L2 Isolated
• January 10, 2023: Complaint Investig., 1 deficiency cited report
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Widespread
• October 10, 2022: Validation, 23 deficiencies cited report
  • C0000: Comment severity level 0
  • C0150: Facility Administration: Operation severity level 2, scope L2 Widespread, corrected May 13, 2023
  • C0160: Reasonable Precautions severity level 2, scope L2 Widespread, corrected September 30, 2023
  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Pattern, corrected May 13, 2023
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread, corrected May 13, 2023
  Show all 25

  • C0260: Service Plan: General severity level 2, scope L2 Pattern, corrected May 13, 2023
  • C0262: Service Plan: Service Planning Team severity level 2, scope L2 Pattern, corrected May 13, 2023
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Pattern, corrected May 13, 2023
  • C0280: Resident Health Services severity level 3, scope L3 Isolated, corrected May 13, 2023
  • C0295: Infection Prevention & Control severity level 2, scope L2 Widespread, corrected May 13, 2023
  • C0302: Systems: Tracking Control Substances severity level 2, scope L2 Pattern, corrected May 13, 2023
  • C0310: Systems: Medication Administration severity level 2, scope L2 Pattern, corrected May 13, 2023
  • C0330: Systems: Psychotropic Medication severity level 2, scope L2 Pattern, corrected May 13, 2023
  • C0360: Staffing Requirements and Training: Staffing severity level 2, scope L2 Widespread, corrected May 13, 2023
  • C0372: Training Within 30 Days: Direct Care Staff severity level 2, scope L2 Pattern, corrected May 13, 2023
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread, corrected May 13, 2023
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread, corrected September 30, 2023
  • C0510: General Building Exterior severity level 2, scope L2 Widespread, corrected September 30, 2023
  • C0513: Doors, Walls, Elevators, Odors severity level 2, scope L2 Widespread, corrected May 13, 2023
  • C0555: Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable severity level 2, scope L2 Widespread, corrected May 13, 2023
  • Z0140: Administration Responsibilities severity level 2, scope L2 Widespread, corrected May 13, 2023
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected September 30, 2023
  • Z0155: Staff Training Requirements severity level 2, scope L2 Pattern, corrected May 13, 2023
  • Z0162: Compliance With Rules Health Care severity level 3, scope L3 Isolated, corrected May 13, 2023
  • Z0168: Outside Area severity level 2, scope L2 Widespread, corrected May 13, 2023

Substantiated abuse or neglect

• July 7, 2025: Failed to administer medication as ordered Abuse: Neglect; Level 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance; fine $2,500.00; 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); 411-054-0036 (Service Plan – General); 411-054-0055 (Medications and Treatments)
  State’s findings

  Alleged Victim (AV) has diagnosis of progressive cognitive impairment, memory loss, hypertension, atrial fibrillation, and congestive heart failure. AV is a resident of a locked memory care facility, which is responsible for providing care, including ordering, storing, and administering all medications to AV. Staff are to begin working on refills of a medication when a resident has seven days left of the medication. AP1 procedures instruct staff to place a resident on alert charting at the first dose of missed medication and to continue documenting attempts to obtain the medication. AP1 uses a computer system which emails a daily report of missed medications. AP1 management staff failed to review the missed medication report. AV is prescribed blood thinning medication twice a day. On or about June 22 and 23, 2025, AV missed the 8:00am dose of AV's blood thinning medication, and all doses from June 26, 2025, to July 7, 2025. AV missed the 8:00am of beta blocker medication from June 27, 2025, to July 2, 2025. During the period of June 22, 2025, to July 7, 2025, AV was not placed on alert charting for the missed blood thinning medication. AV was on alert charting for other missed medications. On or about July 7, 2025, AV began to show stroke-like symptoms and was sent to the hospital. While at the hospital, AV's blood was found to be out of intended therapeutic range of someone on blood thinning medication. AV returned to AP1 after being hospitalized but with significant deficits, including never regaining consciousness. AV passed away on July 12, 2025. The facility failed to provide a safe medication administration system and administer medication as ordered, which is a violation of resident rights is considered neglect of care and constitutes abuse.

• December 27, 2023: Failed to properly plan care 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); 411-054-0036 (Service Plan – General)
  State’s findings

  According to the documentation, the facility failed to implement appropriate fall interventions for the Alleged Victim’s (AV) known fall history. On or about December 22, 2023, the AV attempted to self-transfer and was found on the floor in their apartment with their arms looped in the wheelchair causing pain and bruising, which is a violation of resident rights, is considered neglect of are and constitutes abuse.

• May 1, 2022: Failed to properly plan care 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); 411-054-0036 (Service Plan – General)
  State’s findings

  The Alleged Victim (AV) has a history of unexplained bruising. During a 3 month span of time, from May 2022 until September 2022, AV was reported to have unexplained bruising on at least 10 different occasions. The facility did place tubi grips on AV's arms in August to protect AV from him/herself grabbing their arms, however, AV took them off regularly. AV's care plan was not updated sufficiently or quickly enough to address these bruising incidents, leaving AV at a risk for serious harm. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

• January 9, 2022: Failed to properly plan care Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $1,500.00; 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); 411-054-0036 (Service Plan – General)
  State’s findings

  The Alleged Victim (AV) resides in a room in the facility that shares a bathroom with another resident. The other resident wanders into AV's room, which is upsetting to AV. On or about January 8, 2022, AV was trying to alert staff that his/her neighbor was in his/her room, and AV suffered a fall, causing bruising to his/her back and shoulder. On or about January 9, 2022, AV fell again, hitting his/her head and suffering left hip pain, which resulted in AV being sent to the hospital and being diagnosed with a hip fracture. It is unclear if AV was trying to use the restroom or trying to notify staff of the neighbor in his/her room. The facility failed to properly care plan to reduce AV's falls, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• December 4, 2021: Failed to properly plan care 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); 411-054-0036 (Service Plan – General); 411-054-0040 (Change of Condition and Monitoring); 411-054-0045 (Resident Health Services)
  State’s findings

  On or about December 4, 2021, the Alleged Victim (AV) suffered a fall, causing bruising and an injury to his/her pinky finger, which was red, swollen and warm to the touch. AV has had previous falls, however, no fall interventions were put into place to ensure resident safety, and AV's care plan was out of date, with many incorrect citations in his/her care plan. Alleged Perpetrator #2 (AP2) was advised of the falls, however, did not complete any assessment of AV after his/her fall, nor did AP2 update AV's care plan. AP2's actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• January 20, 2026: Failed to make facility or resident records accessible Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  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.

• January 20, 2026: 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.

• January 20, 2026: 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

  The facility failed to make records available to the Department upon request. The facility’s failure is a violation of Oregon Administrative Rules.

• July 7, 2025: Failed to provide a safe medication administration system Licensing Violation; Level 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance; report
  Rules: 411-054-0055 (Medications and Treatments)
  State’s findings

  Based on interview and record review, conducted during a site visit on 07/15/25, the facility’s failure to ensure adequate professional oversight of the medication and treatment administration system was substantiated for 1 of 1 sampled resident (#1). This posed an immediate jeopardy situation, which put the health and safety of residents at risk. Findings include, but are not limited to: Administrative oversight of the medication and treatment administration system was found to be ineffective, based on deficiencies in the following areas: C0303: Systems: Medication and Treatment Orders. A review of the physician's orders dated 05/12/25 indicated the following: Eliquis oral tablet 2.5 mg, give one tablet by mouth twice a day for atrial fibrillation; and Metoprolol oral tablet extended release 24-hour 50 mg, give one tablet by mouth once daily for hypertension. A review of Resident 1’s MARs from 06/01/25 through 07/11/25 indicated the following: Eliquis 2.5 mg tablet for the 8:00 am dose had not been provided to the resident on 06/22/25, 06/23/25, and 06/26/25 through 07/07/25. On 07/03/25, the resident had not received his/her 8:00 pm dose. The resident missed a total of 15 doses of medication; and Metoprolol 50 mg had not been provided from 06/27/25 through 07/02/25. The resident missed a total of 6 doses of medication. The facility’s policy and procedure for medication and treatment orders dated 05/01/25, indicated the following: If a resident misses a medication due to the medication being unavailable, the med tech must document on the MAR the applicable medication and efforts to obtain them. Staff should attempt to obtain medication immediately and follow up until the issue has been resolved. Notify the Nurse, ED, and prescriber for medications not given due to being unavailable; Place the resident on alert charting and include what has been done or needs to be followed up on to get the medication in the community in the alert charting entry; Put an ISP in place to note what needs to be monitored by staff due to the missed medication; Refills must be ordered before a medication reaches a seven-day supply; Once refills have been requested, each shift must follow up until the medication arrives; Document all efforts made to obtain medications timely, including phone calls, faxes, non-coverage notices, and coordinate with the prescriber or pharmacy; Any medications requested but not received require immediate follow-up. A review of Resident 1’s progress notes dated 06/01/25 through 07/12/25 indicated the following: There had been no alert charting or monitoring for missed medications; There had been no chart notes indicating the facility's efforts to obtain the necessary medications; On 07/03/25, the med tech called the PCP’s office at 9:45 am regarding refills of the Eliquis and Metoprolol medication; On 07/03/25, the updated E-Rx was received for Metoprolol, MAR order was verified to match the E-script; On 07/08/25 the resident was sent out to the hospital on 07/07/25 with a confirmed stroke on 07/08/25; On 07/09/25, the resident returned from the hospital; and On 07/12/25, the resident had passed away on 07/11/25. Fax communication from the facility to the pharmacy and physician indicated the following: On 06/24/25, the facility inquired to refill Resident 1’s Metoprolol 50 mg prescription; On 06/25/25, the facility inquired to refill Resident 1’s Eliquis 2.5 mg prescription; and On 07/02/25, the facility followed up with the request to fill both Metoprolol 50 mg and Eliquis 2.5 mg. Stating, “Resident has been out for a week.” An incident report dated 07/09/25 indicated the facility nurse was notified by the med tech that the resident had been sent to the hospital for a possible stroke on 07/07/25. The nurse received an update from family/hospital regarding the resident's stroke when the evening shift med tech asked if his/her medications were related to the stroke. The nurse asked what the med tech meant. Med tech then stated that the resident had been missing [his/her] morning dose of 2.5mg Eliquis since 06/26/25. The nurse had not been notified that s/he was out of the medication. The resident was not placed on alert for the missed Eliquis. The resident's Eliquis order stated to give 2.5mg twice daily for anticoagulant therapy related to the atrial fibrillation diagnosis. ln addition to the missed Eliquis dose, the resident had missed Metoprolol 50mg tablet from 06/27/25 through 07/02/25 when it came back in stock. The resident was not placed on alert for missed doses of Metoprolol. Eliquis and Metoprolol both required a refill script from a primary care provider. Primary care provider had been faxed on 06/24/25, 06/25/25, and 07/02/25 for new scripts. Med tech called on 07/03/25 for a new script of Eliquis to be sent to the community. The resident had Eliquis available in the evening shift medication drawer and was receiving 2.5mg of Eliquis every day on swing shift until 07/06/25, which was the evening shift before being sent out to the hospital. During an interview, Staff 1 (Executive Director) confirmed that the facility had not made adequate efforts to obtain the resident’s medication. There had been no ISP or alert charting for the missed medication, and no monitoring of potential side effects as a result of missed medication. The facility nurse had not been notified until after the resident was sent to the hospital due to a stroke. The facility failed to provide a safe medication system by not re-ordering a resident's medication on time and not following up with the refill request to ensure it was filled. This resulted in the resident not receiving his/her medication for atrial fibrillation and required emergency medical care. On 07/15/25, at approximately 4:00 pm, the Department requested an immediate plan of correction. An acceptable plan of correction was received from the facility on 07/15/25 at approximately 5:07 pm. The immediate risk was addressed; however, the facility will need to evaluate the overall system failures associated with the licensing violation. The facility’s failure to ensure adequate professional oversight of the medication and treatment administration system was substantiated.

• July 7, 2025: Failed to administer medication as ordered Licensing Violation; Level 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance; report
  Rules: 411-054-0055 (Medications and Treatments)
  State’s findings

  Based on interview and record review, conducted during a site visit on 07/15/25, the facility’s failure to carry out medication and treatment orders as prescribed was substantiated for 1 of 1 sampled resident (#1). Findings include, but are not limited to: A review of the physician's orders dated 05/12/25 indicated the following: Eliquis oral tablet 2.5 mg, give one tablet by mouth twice a day for atrial fibrillation; and Metoprolol oral tablet extended release 24-hour 50 mg, give one tablet by mouth once daily for hypertension. A review of Resident 1’s MARs from 06/01/25 through 07/11/25 indicated the following: Eliquis 2.5 mg tablet for the 8:00 am dose had not been provided to the resident on 06/22/25, 06/23/25, and 06/26/25 through 07/07/25. On 07/03/25, the resident had not received his/her 8:00 pm dose. The resident missed a total of 15 doses of medication; and Metoprolol 50 mg had not been provided from 06/27/25 through 07/02/25. The resident missed a total of 6 doses of medication. The facility’s policy and procedure for medication and treatment orders dated 05/01/25, indicated the following: If a resident misses a medication due to the medication being unavailable, the med tech must document on the MAR the applicable medication and efforts to obtain them. Staff should attempt to obtain medication immediately and follow up until the issue has been resolved. Notify the Nurse, ED, and prescriber for medications not given due to being unavailable; Place the resident on alert charting and include what has been done or needs to be followed up on to get the medication in the community in the alert charting entry; Put an ISP in place to note what needs to be monitored by staff due to the missed medication; Refills must be ordered before a medication reaches a seven-day supply; Once refills have been requested, each shift must follow up until the medication arrives; Document all efforts made to obtain medications timely, including phone calls, faxes, non-coverage notices, and coordinate with the prescriber or pharmacy; Any medications requested but not received require immediate follow-up. A review of Resident 1’s progress notes dated 06/01/25 through 07/12/25 indicated the following: There had been no alert charting or monitoring for missed medications; There had been no chart notes indicating the facility's efforts to obtain the necessary medications; On 07/03/25, the med tech called the PCP’s office at 9:45 am regarding refills of the Eliquis and Metoprolol medication; On 07/03/25, the updated E-Rx was received for Metoprolol, MAR order was verified to match the E-script; On 07/08/25 the resident was sent out to the hospital on 07/07/25 with a confirmed stroke on 07/08/25; On 07/09/25, the resident returned from the hospital; and On 07/12/25, the resident had passed away on 07/11/25. Fax communication from the facility to the pharmacy and physician indicated the following: On 06/24/25, the facility inquired to refill Resident 1’s Metoprolol 50 mg prescription; On 06/25/25, the facility inquired to refill Resident 1’s Eliquis 2.5 mg prescription; and On 07/02/25, the facility followed up with the request to fill both Metoprolol 50 mg and Eliquis 2.5 mg. Stating, “Resident has been out for a week.” An incident report dated 07/09/25 indicated the facility nurse was notified by the med tech that the resident had been sent to the hospital for a possible stroke on 07/07/25. The nurse received an update from family/hospital regarding the resident's stroke when the evening shift med tech asked if his/her medications were related to the stroke. The nurse asked what the med tech meant. Med tech then stated that the resident had been missing his/her morning dose of 2.5mg Eliquis since 06/26/25. The nurse had not been notified that s/he was out of the medication. The resident was not placed on alert for the missed Eliquis. The resident's Eliquis order stated to give 2.5mg twice daily for anticoagulant therapy related to the atrial fibrillation diagnosis. ln addition to the missed Eliquis dose, the resident had missed Metoprolol 50mg tablet from 06/27/25 through 07/02/25 when it came back in stock. The resident was not placed on alert for missed doses of Metoprolol. Eliquis and Metoprolol both required a refill script from a primary care provider. Primary care provider had been faxed on 06/24/25, 06/25/25, and 07/02/25 for new scripts. Med tech called on 07/03/25 for a new script of Eliquis to be sent to the community. The resident had Eliquis available in the evening shift medication drawer and was receiving 2.5mg of Eliquis every day on swing shift until 07/06/25, which was the evening shift before being sent out to the hospital. During an interview with Staff 1 (Executive Director) confirmed that the facility had not made adequate efforts to obtain the resident’s medication. There had been no ISP or alert charting for the missed medication, and no monitoring of potential side effects as a result of missed medication. The facility nurse had not been notified until after the resident was sent to the hospital due to a stroke. The facility failed to provide a safe medication system by not re-ordering a resident's medication on time and not following up with the refill request to ensure it was filled. This resulted in the resident not receiving his/her medication for atrial fibrillation and required emergency medical care. The facility’s failure to carry out medication and treatment orders as prescribed was 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 14 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.