Calaroga Terrace Senior Living

Last inspection

July 16, 2026

Inspections

6, 43 deficiencies cited

Substantiated abuse

13

Substantiated licensing violations

20

Regulatory actions

2

Fines assessed

$15,563.00 (13 violations)

Current owner since

April 1, 2026

License conditions and other regulatory actions

• April 26, 2024 to October 2, 2024: License Condition, Failed to provide safe environment RCFCD24-00415; incident: CALMS - 00055185
  Re-Licensure Survey (8V4B11): On April 1, 2024, through April 4, 2024, ODHS conducted a Re-Licensure Survey (8V4B11) which confirmed the facility was out of compliance with 22 Oregon Administrative Rules.
  Rules: 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General); 411-054-0040 (Change of Condition and Monitoring); 411-054-0045 (Resident Health Services); 411-054-0055 (Medications and Treatments)
• September 6, 2023 to October 2, 2023: License Condition, Failed to use an ABST RCFCD23-01094; incident: OR0004068100
  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

• July 16, 2026: Change of Owner, 8 deficiencies cited report
  • C0295: Infection Prevention & Control severity level 2, scope L2 Pattern
  • C0370: Staffing Requirements and Training ? Pre-service severity level 2, scope L2 Pattern
  • C0372: Training Within 30 Days of Hire ? Direct Care Staff severity level 2, scope L2 Pattern
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread
  • C0510: General Building Exterior severity level 2, scope L2 Widespread
  Show all 8

  • C0513: Doors, Walls, Elevators, Odors severity level 2, scope L2 Widespread
  • C0555: Call Sys, Exit Dr Alarm, Phones, TV, or Cable severity level 2, scope L2 Pattern
  • L0370: Staffing Requirements and Training ? Pre-service severity level 2, scope L2 Pattern
• July 30, 2025: Complaint Investig., 2 deficiencies cited report
  • C0362: Acuity Based Staffing Tool - Abst Time severity level 2, scope L2 Widespread
  • C0363: Acuity Based Staffing Tool - Updates & Plan severity level 2, scope L2 Widespread
• May 27, 2025: Kitchen, 1 deficiency cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
• April 1, 2024: Validation, 22 deficiencies cited report
  • C0000: Comment severity level 0
  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Pattern, corrected June 3, 2024
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread, corrected June 3, 2024
  • C0260: Service Plan: General severity level 2, scope L2 Pattern, corrected June 3, 2024
  • C0270: Change of Condition and Monitoring severity level 3, scope L3 Isolated, corrected June 3, 2024
  Show all 23

  • C0282: Rn Delegation and Teaching severity level 2, scope L2 Pattern, corrected June 3, 2024
  • C0290: Res Hlth Srvc: On- and Off-Site Health Srvc severity level 2, scope L2 Pattern, corrected June 3, 2024
  • C0302: Systems: Tracking Control Substances severity level 2, scope L2 Isolated, corrected June 3, 2024
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Pattern, corrected June 3, 2024
  • C0305: Systems: Resident Right to Refuse severity level 2, scope L2 Pattern, corrected June 3, 2024
  • C0310: Systems: Medication Administration severity level 2, scope L2 Pattern, corrected June 3, 2024
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Pattern, corrected June 3, 2024
  • C0370: Staffing Requirements and Training – Pre-Serv severity level 2, scope L2 Pattern, corrected June 3, 2024
  • C0372: Training Within 30 Days: Direct Care Staff severity level 2, scope L2 Pattern, corrected June 3, 2024
  • C0374: Annual and Biennial Inservice For All Staff severity level 2, scope L2 Pattern, corrected June 3, 2024
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread, corrected June 3, 2024
  • C0422: Fire and Life Safety: Training For Residents severity level 2, scope L2 Widespread, corrected June 3, 2024
  • C0510: General Building Exterior severity level 2, scope L2 Widespread, corrected June 3, 2024
  • C0511: General Building Interior severity level 2, scope L2 Widespread, corrected June 3, 2024
  • C0513: Doors, Walls, Elevators, Odors severity level 2, scope L2 Widespread, corrected June 3, 2024
  • C0515: Resident Units severity level 2, scope L2 Pattern, corrected June 3, 2024
  • C0530: Housekeeping and Laundry severity level 2, scope L2 Widespread, corrected June 3, 2024
  • C0555: Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable severity level 2, scope L2 Widespread, corrected June 3, 2024
• July 13, 2023: Complaint Investig., 3 deficiencies cited report
  • C0010: Licensing Complaint Investigation severity level 2, scope L2 Isolated
  • C0290: Res Hlth Srvc: On- and Off-Site Health Srvc severity level 2, scope L2 Isolated
  • C0360: Staffing Requirements and Training: Staffing severity level 2, scope L2 Isolated
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Widespread
• September 6, 2022: Complaint Investig., 7 deficiencies cited report
  • C0010: Licensing Complaint Investigation severity level 2, scope L2 Isolated
  • C0160: Reasonable Precautions severity level 2, scope L2 Isolated
  • C0260: Service Plan: General severity level 2, scope L2 Isolated
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Widespread
  • C0310: Systems: Medication Administration severity level 2, scope L2 Isolated
  Show all 8

  • C0360: Staffing Requirements and Training: Staffing severity level 2, scope L2 Widespread
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Widespread
  • C0513: Doors, Walls, Elevators, Odors severity level 2, scope L2 Isolated

Substantiated abuse or neglect

• July 19, 2023: Failed to provide a safe medication administration system Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $1,125.00; 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) medications were administered as ordered. On or about July 19, 2023, AV was given medication of another resident while out of the facility on an outing. As a result of the medication error, AV required hospitalization. The facility's failure resulted in unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse. Alleged Perpetrator 2 (AP2) and Alleged Perpetrator 3 (AP3) allegedly neglected AV. An investigation determined no abuse occurred by AP2 and AP3.

• July 18, 2023: Failed to provide safe environment 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)
  State’s findings

  On or about July 18, 2023, Alleged Victim's (AV) personal property, $200.00 cash, went missing from his/her wallet that was located in AV's room. Based on facility documentation and interviews, an employee whose employment was terminated on July 6, 2023, trespassed into the facility on July 18, 2023, and was later observed speaking to AV in his/her room. AV reported the cash missing shortly after the terminated employee (Witness 6, W6) left the facility. Upon discovery of AV's missing personal property, it was discovered that Witness 4 (W4), who is a current employee at the facility, let W6 into the facility. W4 later reported that he/she was not trained or made aware that terminated employees could not access the facility after termination of employment. The facility's failure to provide a safe environment and to ensure staff are properly trained in facility's safety protocols resulted in loss of funds for AV which is a violation of resident rights, is considered neglect of care and constitutes abuse. Alleged Perpetrator 2 (AP2) allegedly financially exploited AV. An investigation determined that abuse did not occur by AP2.

• June 11, 2023: Failed to follow care plan 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); 411-054-0036 (Service Plan – General)
  State’s findings

  The facility failed to provide appropriate services according to the Alleged Victim’s (AV) care needs as noted in his/her care plan. Based on facility documentation and interviews, the facility failed to respond timely to AV's call light when AV reached out for assistance with his/her Activities of Daily Living. AV's call light log shows an activation on June 11, 2023 at 4:43am with 41-minute response time causing AV unreasonable discomfort due to the facility's lack of timely response. Based on facility documentation and interviews, AV is temperature sensitive and gets cold easily. AV experiences discomfort when AV does not have adequate bedding to keep warm. On June 18, 2023, AV was observed to be without appropriate bedding to keep warm which caused AV unreasonable discomfort. The facility's failure to follow AV's care plan is a violation of resident rights, is considered neglect of care and constitutes abuse.

• May 15, 2023: Failed to provide a safe medication administration system 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); 411-054-0055 (Medications and Treatments)
  State’s findings

  The facility failed to provide a safe medication administration system to ensure The Alleged Victim’s (AV) blood sugar levels were monitored as ordered. Based on facility documentation and interviews, AV's blood sugar was not checked on May 15, 2023 which led to AV falling resulting in a black eye. AV returned to the facility early from a vacation and staff observed AV in the common area on the evening of May 14, 2023. During the evening shift on May 14, 2023, staff did not conduct safety checks, nor offered AV a snack as designated on AV's MAR which resulted in AV blacking out around 5:30am on May 15, 2023, due to his/her blood sugar levels being low. AV was transported to the hospital for treatment. The facility's failure resulted in unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• July 13, 2022: Failed to provide safe environment 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

  The facility failed to properly care plan according to W1s needs and behaviors. The failure resulted in repeated resident to resident altercations resulting in physical injury, unreasonable discomfort and loss of dignity to multiple residents. The facility’s actions are a violation of resident rights, are considered neglect of care and constitute abuse.

Substantiated licensing violations

• July 14, 2026: Failed to provide safe environment Licensing Violation; Level 3 - Moderate harm or potential for serious harm; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections)
  State’s findings

  On or about July 14, 2026, Witness 1 (W1) reported multiple unauthorized withdrawals from the Alleged Victim’s (AV) bank account totaling $2,226.18. Based on facility documentation and interviews, AV’s bank statements showed transfers to an online payment application registered to Alleged Perpetrator 2 (AP2), along with ATM withdrawals and in-store purchases made the same day. AP2, an employee who regularly provides care to AV, worked in AV’s area on July 13, 2026. AP2 also helps sort undeliverable mail, giving AP2 access to residents’ financial documents such as debit cards and bank correspondence. Bank records showed transfers to AP2’s online payment account, additional cash withdrawals at a local financial institution (s), and purchases at a nearby grocery store, all close to AP2’s residence. Store surveillance from July 13, 2026, captured AP2 making a purchase matching the amount withdrawn from AV’s account. AP2 wrongfully obtained funds from AV through deceit, fraud, and trickery by taking AV’s debit card and making unauthorized withdrawals from AV’s bank account. AP2's actions is considered financial exploitation which is considered abuse. The facility failed to protect AV from financial exploitation which is a violation of Oregon Administrative Rules.

• June 14, 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

  Based on record review and interview, conducted during a site visit on 08/11/26, the facility’s failure to ensure the implementation of services was substantiated for 1 of 1 sampled resident (#1). Findings include, but are not limited to: Review of Resident 1’s service plan dated 06/17/26, physician’s report dated 08/12/25, charting notes dated 05/07/26 through 08/11/26, and incident investigation report dated 06/23/26 indicated the following: Resident 1 was diagnosed with major neurocognitive disorder; Resident 1 was diagnosed as confused/disoriented; Resident 1 had cognitive impairments; Resident 1 was not able to leave the facility unassisted; Resident 1 left the facility unassisted on 6/13/26; Resident 1 fell asleep at a bus stop and could not find their way home; and Resident 1 was returned to the facility by a public transportation employee on 06/14/26. Resident 1 stated in an interview that they were new to the facility, it was a new neighborhood, they got disoriented and the bus driver had to bring them back to the facility. In separate interviews, Staff 2, Staff 3, Staff 4, Staff 5, and Staff 6 each stated Resident 1 leaves the facility unassisted on a regular basis; they also stated there was an incident in 06/2026 where resident 1 left the facility unassisted, got disoriented, and the resident needed assistance from a community member to get back to the facility. In an interview, Staff 2 and Staff 3 acknowledged the physician’s report dated 08/12/25 and Resident 1’s service plan dated 06/17/26 indicated the resident was not able to leave the facility unassisted. Because Resident 1’s service plan stated they were not able to leave the facility unassisted and the Resident left the facility unassisted on 06/13/26, the facility’s failure to ensure the implementation of services is a violation of Oregon Administrative Rules.

• June 2, 2026: Failed to staff as indicated by ABST Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)
  State’s findings

  Based on interview and record review, conducted during an investigation on 08/11/26, the facility's failure to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident and use the results of an ABST to develop and routinely update the facility’s posted staffing plan, and complete or update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly, as required, was substantiated. Findings include, but are not limited to: The ABST was reviewed for the alleged event date of 06/02/26. The facility’s posted staffing plan indicated: Day shift: 7 direct care staff; Swing shift: 6 direct care staff; and Night shift: 3 direct care staff. A review of the facility's ABST "minimum time needed based on acuity" indicated: Day shift: 7.2 direct care staff; Swing shift: 6.2 direct care staff; and Night shift: 1.7 direct care staff. The facility staffing plan was below the ABST required minimum hours based on acuity for day and swing shift. The facility direct care staff schedule for 05/27/26 through 06/02/26 indicated: The facility was not staffing to its posted staffing plan for 06/21 shifts reviewed; and The facility was staffed below the ABST minimum time needed based on acuity for 12/21 shifts reviewed. The facilities census was 75. A review of the facility’s last ABST evaluation update per resident indicated 5 of 75 residents had not been updated quarterly as required. The facility’s failure to use the results of an ABST to develop and routinely update the facility’s posted staffing plan and have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident, and complete or update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly, as required, is a violation of Oregon Administrative Rules.

• December 8, 2024: 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)
  State’s findings

  On or about December 8, 2024, around 10:00 AM, Alleged Perpetrator 2 (AP2) administered Alleged Victim (AV) the wrong morning medications. AV is a resident of the facility. Based on facility documentation and interviews, as a result of AP2's medication administration error, AV experienced dizziness, lightheadedness, blurred vision, and low blood pressure. Although trained in proper medication administration, AP2 failed to perform required verification checks. AP2's actions caused physical harm and serious risk to AV, which is considered neglect of care and constitutes abuse. The facility also failed to maintain a safe medication administration system for AV, violating Oregon Administrative Rules.

• September 21, 2023: 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 fully implement and update an Acuity Based Staffing Tool (ABST) in accordance with OAR 411-054-0037, which 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 105 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.