Brookdale Bend

Last inspection

February 9, 2026

Inspections

6, 21 deficiencies cited

Substantiated abuse

4

Substantiated licensing violations

7

Regulatory actions

2

Fines assessed

$1,688.00 (5 violations)

Current owner since

February 17, 2009

License conditions and other regulatory actions

• November 6, 2025 to November 21, 2025: License Condition, Failed to provide a safe medication administration system RCFCD25-01316; incident: CALMS - 00093076
  Rules: 411-054-0027 (Resident Rights and Protections); 411-054-0055 (Medications and Treatments)
• January 22, 2024 to March 31, 2025: License Condition, Failed to use an ABST RCFCD23-01613; incident: OR0003979200
  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)

Inspections

• February 9, 2026: Kitchen, 2 deficiencies cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread
• November 6, 2025: Re-Licensure, 3 deficiencies cited report
  • C0300: Systems: Medications and Treatments severity level 4, scope L4 Pattern
  • C0302: Systems: Tracking Control Substances severity level 3, scope L3 Pattern
  • Z0162: Compliance with Rules Health Care severity level 4, scope L4 Pattern
• February 22, 2024: 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 April 22, 2024
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected April 22, 2024
• February 1, 2024: Complaint Investig., 1 deficiency cited report
  • C0010: Licensing Complaint Investigation severity level 2, scope L2 Isolated
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Isolated
• September 27, 2023: Complaint Investig., 1 deficiency cited report
  • C0010: Licensing Complaint Investigation severity level 2, scope L2 Widespread
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Widespread
• June 6, 2022: Validation, 12 deficiencies cited report
  • C0000: Comment severity level 0
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread, corrected February 20, 2023
  • C0260: Service Plan: General severity level 2, scope L2 Pattern, corrected November 24, 2022
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Pattern, corrected February 20, 2023
  • C0280: Resident Health Services severity level 2, scope L2 Pattern, corrected September 7, 2022
  Show all 14

  • C0290: Res Hlth Srvc: On- and Off-Site Health Srvc severity level 2, scope L2 Isolated, corrected November 24, 2022
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Isolated, corrected September 7, 2022
  • C0330: Systems: Psychotropic Medication severity level 2, scope L2 Isolated, corrected February 20, 2023
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread, corrected February 20, 2023
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected February 20, 2023
  • Z0162: Compliance With Rules Health Care severity level 2, scope L2 Pattern, corrected February 20, 2023
  • Z0163: Nutrition and Hydration severity level 2, scope L2 Isolated, corrected September 7, 2022
  • Z0164: Activities severity level 2, scope L2 Pattern, corrected September 7, 2022
  • Z0165: Behavior severity level 2, scope L2 Isolated, corrected September 7, 2022

Substantiated abuse or neglect

• May 11, 2023: Failed to provide a safe medication administration system Abuse: Neglect; Level 3 - Moderate harm or potential for serious 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

  According to the documentation, the facility failed to provide a safe medication administration system for the Alleged Victim (AV) by administering more medication than prescribed. On or about March 20, 2023, the AV suffered an injury fall which required hospitalization. While at the hospital, the AV underwent some tests and was found to have an abnormally high phenytoin/Dilantin of 46.8 and had to undergo detoxification to reduce the levels to a normal range of 4.6. The AV had to detox for approximately a week before their levels returned to normal, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• November 5, 2022: Failed to provide safe environment 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); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General)
  State’s findings

  The facility failed to provide a safe environment to the Alleged Victim (AV) according to H/H needs. The failure resulted in AV eloping the secured building, without staff knowledge, placing H/H at risk of harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• January 30, 2022: Failed to properly plan care 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); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General)
  State’s findings

  The facility failed to implement interventions and appropriately care plan related to the Alleged Victim’s (AV) fall history. The failure resulted in AV experiencing injury and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• October 27, 2021: Failed to properly plan care Abuse: Neglect; Level 2 - Minor harm or potential for moderate 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); 411-054-0036 (Service Plan – General)
  State’s findings

  The facility failed to implement interventions and appropriately care plan related to the Alleged Victim’s (AV) fall history. On or about October 27, 2021, AV suffered an unwitnessed fall, resulting in AV breaking h/h collar bone. The failure resulted in AV experiencing pain and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• November 4, 2025: Failed to protect resident from financial exploitation Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0027 (Resident Rights and Protections); 411-054-0055 (Medications and Treatments)
  State’s findings

  The Alleged Victim (AV) relies on the facility to manage their medications. The pharmacy delivered medications for AV, which were signed for by Alleged Perpetrator 2 (AP2) but not put in the medication cart. The facility was unable to locate medications and AP2 was cited for theft 3 by local law enforcement. The facility failed to protect AV from financial abuse, which is a violation of resident rights and Oregon Administrative Rule. The allegation that AP2 financially abused AV was investigated and determined to be substantiated.

• November 4, 2025: Failed to protect resident from financial exploitation Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0027 (Resident Rights and Protections); 411-054-0055 (Medications and Treatments)
  State’s findings

  The facility failed to protect the Alleged Victim (AV) from financial exploitation, which is a violation of Oregon Administrative Rule. The Alleged Perpetrator 2(AP2) signed for AV's medication when delivered by the pharmacy, but the medication was not put in the med cart, and the facility staff were unable to locate the medication. The allegation that AP2 financially exploited AV was investigation and determined to be substantiated.

• November 4, 2025: Failed to protect resident from financial exploitation Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0027 (Resident Rights and Protections); 411-054-0055 (Medications and Treatments)
  State’s findings

  The Alleged Victim (AV) relies on the facility for medication management and to protect them from financial exploitation. On 11/4/25 the pharmacy delivered medications for AV to the facility, and they were signed for by Alleged Perpetrator 2 (AP2). AP2 never logged the medications in the medication system, and the facility was unable to locate them. The facility failed to protect AV from financial exploitation due to loss of AV's medication, which a violation of Oregon Administrative Rule. The allegations against AP2 were investigated and substantiated for abuse.

• December 20, 2023: Failed to submit timely or adequate staffing documentation Licensing Violation; Level 2 - Minor harm or potential for moderate harm; fine $250.00; report
  Rules: 411-061-0010
  State’s findings

  On or about December 1, 2023, 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, 2023 to November 30, 2023, for a total of 30 days.

• November 30, 2023: 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); 411-054-0200 (Residential Care Facility Building Requirements)
  State’s findings

  The Alleged Victim (AV) relies on the facility for all care. On or about November 30, 2023, Alleged Perpetrator #2 (AP2) opened AV's window to alleviate a strong urine odor in the room. AP2 was told to close the window by other staff and use alternative methods to alleviate the odors in the room. AP2 left his/her shift and didn't close AV's window. The temperature outside was between 28 and 37 degrees Fahrenheit. AV was found in his/her room unresponsive and stiff. AV was transported to the hospital and diagnosed with COVID, dehydration and a body temperature of 88.7 degrees. AP2's actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility's failure to ensure a safe environment is a violation of Oregon Administrative Rules.

• November 5, 2023: 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 failed to carry out medication orders as prescribed in accordance with OAR 411-054-0055(1)(f).

• November 4, 2023: 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); 411-054-0055 (Medications and Treatments)
  State’s findings

  The Alleged Victim (AV) is administered his/her medication by the facility. On or about November 4, 2023, Alleged Perpetrator #2 (AP2) failed to administer medication to AV as ordered. AV did not experience any adverse effects from not receiving the medication, however, AV was placed at risk for harm by not receiving medication as ordered. AP2's actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility's failure to ensure a safe medication administration system 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 59 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.