Brookdale Wilsonville

Last inspection

June 24, 2026

Inspections

7, 23 deficiencies cited

Substantiated abuse

4

Substantiated licensing violations

8

Regulatory actions

1

Fines assessed

$1,188.00 (4 violations)

Current owner since

August 5, 2010

License conditions and other regulatory actions

• March 15, 2023 to February 26, 2025: License Condition, Failed to meet the scheduled and unscheduled needs of residents RCFCD23-00236; 3 incidents: OR0003872005, OR0003872004, OR0003872003
  The facility failed to carry out medications and treatment orders in accordance with OAR 411-054-0055(1)(f) per a complaint that a resident has not received their medication as prescribed.
  Rules: 411-054-0037 (Acuity-Based Staffing Tool); 411-054-0055 (Medications and Treatments); 411-054-0070 (Staffing Requirements and Training)

Inspections

• June 24, 2026: Re-Licensure, 3 deficiencies cited report
  • C0160: Reasonable Precautions severity level 2, scope L2 Pattern
  • C0370: Staffing Requirements and Training ? Pre-service severity level 2, scope L2 Pattern
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread
• May 1, 2025: Kitchen, 1 deficiency cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
• November 8, 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 10, 2024
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread, corrected March 10, 2024
• September 13, 2023: Complaint Investig., 4 deficiencies cited report
  • C0010: Licensing Complaint Investigation severity level 2, scope L2 Isolated
  • C0155: Facility Administration: Records severity level 2, scope L2 Isolated
  • C0360: Staffing Requirements and Training: Staffing severity level 2, scope L2 Isolated
  • C0370: Staffing Requirements and Training – Pre-Serv severity level 2, scope L2 Isolated
  • C0613: General Building: Doors-Walls, Cleanable severity level 2, scope L2 Isolated
• April 11, 2023: Validation, 10 deficiencies cited report
  • C0000: Comment severity level 0
  • C0200: Resident Rights and Protection - General severity level 2, scope L2 Isolated, corrected June 12, 2023
  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Isolated, corrected June 12, 2023
  • C0243: Resident Services: Adls severity level 2, scope L2 Isolated, corrected June 12, 2023
  • C0252: Resident Move-In and Eval: Res Evaluation severity level 2, scope L2 Isolated, corrected June 12, 2023
  Show all 12

  • C0262: Service Plan: Service Planning Team severity level 2, scope L2 Pattern, corrected June 12, 2023
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Isolated, corrected September 3, 2023
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Widespread, corrected January 31, 2025
  • C0370: Staffing Requirements and Training – Pre-Serv severity level 2, scope L2 Pattern, corrected June 12, 2023
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread, corrected June 12, 2023
  • C0422: Fire and Life Safety: Training For Residents severity level 2, scope L2 Widespread, corrected June 12, 2023
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread, corrected January 31, 2025
• December 20, 2022: Complaint Investig., 3 deficiencies cited report
  • C0010: Licensing Complaint Investigation severity level 2, scope L2 Isolated
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Isolated
  • C0360: Staffing Requirements and Training: Staffing severity level 2, scope L2 Widespread
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Widespread
• September 28, 2022: 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 November 7, 2022

Substantiated abuse or neglect

• April 16, 2024: Failed to properly plan care 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); 411-054-0036 (Service Plan – General)
  State’s findings

  According to the documentation, the facility failed to properly care plan appropriate interventions for the Alleged Victim’s (AV) known fall history. On or about April 15, 2024, the AV experienced an unwitnessed fall causing a skin tear. There was no documented evidence the facility implemented appropriate fall interventions, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• January 22, 2024: Failed to properly plan care 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 implement interventions and appropriately care plan related to the Alleged Victim’s (AV) fall history. On or about January 22, 2024, AV suffered an unwitnessed fall, resulting in an injury to H/H head. 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.

• October 27, 2022: Failed to administer medication as ordered Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $375.00; 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 properly administer the Alleged Victim’s (AV) medications. According to documentation, on or about October 06, 2022- October 28, 2022, AV was not administered h/h Furosemide. AV experienced rapid weight gain of approximately ten – fourteen pounds causing pain and unreasonable discomfort. The facility failed to Administer Medication as ordered which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• November 1, 2021: Failed to administer medication as ordered 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); 411-054-0055 (Medications and Treatments)
  State’s findings

  The facility failed to provide a safe medication administration system to ensure Alleged Victim (AV) medication for pain was administered. On or about November 01, 2021, He/she did not receive the pain medication as requested, putting AV at risk of harm. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• August 14, 2024: Failed to follow care plan Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-020-0002 (Definitions)
  State’s findings

  According to the documentation, the Alleged Perpetrator 2 (AP2) failed to follow the service plan to secure the Alleged Victim (AV) into their wheelchair. On or about August 14, 2024, the AP2 failed to secure the AV into a seatbelt when they were placed in the back of the bus. Due to the seatbelt not being engaged, the result was the AV falling out of the wheelchair sustaining multiple injuries including bruising and head laceration, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to ensure the service plan was being followed which is a violation of Oregon Administrative Rules.

• April 17, 2024: Failed to provide safe environment 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 fully implement and update an acuity-based staffing tool in accordance with OAR 411-054-0037.

• December 4, 2023: Failed to keep medication record current or accurate 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 and treatment orders as prescribed. An investigation determined this is a violation of Oregon Administrative Rules.

• February 6, 2023: Failed to provide service Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0070 (Staffing Requirements and Training)
  State’s findings

  The facility failed to have a training program that includes methods to determine competency of direct care in accordance with OAR 411-054-0070(2-4) and (6).

• February 6, 2023: Failed to provide service Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0025 (Facility Administration)
  State’s findings

  The facility failed to implement a written policy that prohibits the falsification of records in accordance with OAR 411-054-0025(8)(a).

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.