Brookdale Oswego Springs - Portland

Last inspection

August 5, 2026

Inspections

6, 26 deficiencies cited

Substantiated abuse

3

Substantiated licensing violations

4

Regulatory actions

1

Fines assessed

$813.00 (3 violations)

Current owner since

August 5, 2010

License conditions and other regulatory actions

• July 27, 2023 to February 26, 2025: License Condition, Failed to use an ABST ALFCD23-00446; incident: OR0004023900
  The facility failed to fully implement an Acuity Based Staffing Tool in accordance with OAR 411-054-0037.
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)

Inspections

• August 5, 2026: Re-Licensure, 1 deficiency cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
• January 7, 2026: Re-Licensure, 1 deficiency cited report
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread
• February 6, 2024: Complaint Investig., 1 deficiency cited report
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Isolated
• December 15, 2023: State Licensure, 1 deficiency cited report
  • C0000: Comment severity level 0
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread, corrected March 25, 2024
• April 20, 2023: Complaint Investig., 1 deficiency cited report
  • C0010: Licensing Complaint Investigation severity level 2, scope L2 Isolated
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Isolated
• December 6, 2022: Validation, 21 deficiencies cited report
  • C0000: Comment severity level 0
  • C0150: Facility Administration: Operation severity level 2, scope L2 Widespread, corrected May 15, 2023
  • C0154: Facility Administration: Policy & Procedure severity level 2, scope L2 Pattern, corrected May 15, 2023
  • C0200: Resident Rights and Protection - General severity level 2, scope L2 Pattern, corrected May 15, 2023
  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Pattern, corrected May 15, 2023
  Show all 24

  • C0252: Resident Move-In and Eval: Res Evaluation severity level 2, scope L2 Pattern, corrected May 15, 2023
  • C0260: Service Plan: General severity level 2, scope L2 Pattern, corrected May 15, 2023
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Pattern, corrected May 15, 2023
  • C0280: Resident Health Services severity level 2, scope L2 Pattern, corrected May 15, 2023
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Pattern, corrected September 9, 2023
  • C0310: Systems: Medication Administration severity level 2, scope L2 Pattern, corrected May 15, 2023
  • C0325: Systems: Self-Administration of Meds severity level 2, scope L2 Isolated, corrected September 9, 2023
  • C0330: Systems: Psychotropic Medication severity level 2, scope L2 Pattern, corrected May 15, 2023
  • C0360: Staffing Requirements and Training: Staffing severity level 2, scope L2 Pattern, corrected May 15, 2023
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Pattern, corrected January 31, 2025
  • C0370: Staffing Requirements and Training – Pre-Serv severity level 2, scope L2 Pattern, corrected May 15, 2023
  • C0372: Training Within 30 Days: Direct Care Staff severity level 2, scope L2 Pattern, corrected May 15, 2023
  • C0374: Annual and Biennial Inservice For All Staff severity level 2, scope L2 Pattern, corrected May 15, 2023
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread, corrected May 15, 2023
  • C0422: Fire and Life Safety: Training For Residents severity level 2, scope L2 Widespread, corrected May 15, 2023
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread, corrected January 31, 2025
  • C0613: General Building: Doors-Walls, Cleanable severity level 2, scope L2 Widespread, corrected May 15, 2023
  • C0622: Common Use Areas: Social severity level 2, scope L2 Widespread, corrected May 15, 2023
  • C0640: Heating and Ventilation severity level 2, scope L2 Widespread, corrected May 15, 2023

Substantiated abuse or neglect

• January 2, 2024: Failed to provide a safe medication administration system Abuse: Neglect; Level 2 - Minor harm or potential for moderate 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); 411-054-0055 (Medications and Treatments)
  State’s findings

  According to the documentation, the facility failed to provide a safe medication administration system by failing to administer medications as ordered to the Alleged Victim (AV). On approximately December 26, 2023, the facility realized the AV was not being administered an injectable medication to treat their skin condition. This medication was in the fridge and was from approximately March of 2023. There was no documented evidence the AV received their skin medication from approximately March through December 26, 2023, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• January 28, 2023: Failed to provide a safe medication administration system Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $188.00; report
  Rules: 411-054-0027 (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 facility failed to provide a safe medication administration system to ensure the Alleged Victim’s (AV) pain medication was administered as ordered. According to documentation On or about January 28,2023 and January 29, 2023, AV was administered a higher dose of pain medication resulting in AV showing symptoms hallucinations and experiencing unreasonable discomfort. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. According to documentation, the Alleged Perpetrator (AP2) administered a higher quantity then prescribed On or about January 28, 2023. AP2’s actions are considered neglect of care and constitutes abuse, which is a violation of Oregon Administrative Rules. According to documentation, the Alleged Perpetrator (AP3) administered a higher quantity then prescribed On or about January 28, 2023. AP3's actions are considered neglect of care and constitutes abuse, which is a violation of Oregon Administrative Rules. According to documentation, the Alleged Perpetrator (AP4) administered a higher quantity then prescribed On or about January 29, 2023. AP4's actions are considered neglect of care and constitutes abuse, which is a violation of Oregon Administrative Rules.

• May 1, 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. On or about May 5, 2022, AV had fallen and sustained significant bruising on the right side of his/her face. The facilities failure resulted in AV experiencing injury and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• November 2, 2025: Failed to follow care plan 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); 411-054-0036 (Service Plan – General)
  State’s findings

  The Alleged Victim (AV) has a history of believing that interactions with staff of the opposite sex are intimate when they are not. AV is care planned for staff to only give AV side hugs to avoid confusion. On or about November 2, 2025, Alleged Perpetrator #2 (AP2) gave AV a full front hug, causing AV to be confused and causing discomfort to AV. AP2 failed to follow the care plan, causing unreasonable emotional harm, which is a violation of resident rights, is considered neglect of care and constitutes emotional abuse. The facility's failure to ensure the care plan was followed is a violation of Oregon Administrative Rules.

• October 16, 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).

• May 2, 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 May 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 April 1, 2022 to April 30, 2022, for a total of 30 days.

• April 20, 2022: Failed to follow care plan Licensing Violation; Level 2 - Minor harm or potential for moderate harm; 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

  On or about April 21, 2022, Alleged Perpetrator 2 (AP2) failed to review the Alleged Victim's (AV) care plan, and updates. AP2 worked and cared for AV without reviewing the care plan. AP2's actions are considered neglect of care and constitute abuse. The facility failure 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.” 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.