Clackamas Heights Senior Living

Last inspection

May 19, 2025

Inspections

6, 17 deficiencies cited

Substantiated abuse

2

Substantiated licensing violations

10

Regulatory actions

0

Fines assessed

$438.00 (2 violations)

Current owner since

May 1, 2023

• No deficiencies cited at the last inspection (May 2025)

Inspections

• May 19, 2025: Complaint Investig., 0 deficiencies cited report
  • C0010: Licensing Complaint Investigation severity level 0
• February 20, 2025: Kitchen, 1 deficiency cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
• February 12, 2025: Change of Owner, 7 deficiencies cited report
  • C0372: Training Within 30 Days of Hire ? Direct Care Staff severity level 2, scope L2 Pattern
  • C0374: Annual and Biennial Inservice for All Staff severity level 2, scope L2 Pattern
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread
  • C0422: Fire and Life Safety: Training for Residents severity level 2, scope L2 Widespread
  • C0530: Housekeeping and Laundry severity level 2, scope L2 Widespread
  • C0545: Plumbing Systems severity level 2, scope L2 Widespread
  • C0555: Call Sys, Exit Dr Alarm, Phones, TV, or Cable severity level 2, scope L2 Widespread
• December 1, 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 January 30, 2024
• March 24, 2023: Complaint Investig., 7 deficiencies cited report
  • C0010: Licensing Complaint Investigation severity level 2, scope L2 Isolated
  • C0151: Facility Administration: Criminal History severity level 2, scope L2 Isolated
  • C0243: Resident Services: Adls severity level 2, scope L2 Isolated
  • C0252: Resident Move-In and Eval: Res Evaluation severity level 2, scope L2 Isolated
  • C0295: Infection Prevention & Control severity level 2, scope L2 Isolated
  Show all 8

  • C0360: Staffing Requirements and Training: Staffing severity level 2, scope L2 Isolated
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Widespread
  • C0513: Doors, Walls, Elevators, Odors severity level 2, scope L2 Isolated
• August 31, 2022: Complaint Investig., 1 deficiency cited report
  • C0010: Licensing Complaint Investigation severity level 2, scope L2 Isolated
  • C0151: Facility Administration: Criminal History severity level 2, scope L2 Isolated

Substantiated abuse or neglect

• August 5, 2022: Failed to provide safe environment 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)
  State’s findings

  The facility failed to provide a safe environment for Alleged Victim (AV) by failing to provide oversight of Alleged Perpetrator 2's (AP2) criminal background clearance which placed AV and other residents at the facility at risk for harm. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse. Alleged Perpetrator 2 (AP2) allegedly sexually abused AV. An investigation determined no abuse occurred.

• October 19, 2021: 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

  On or about October 19, 2021, the facility discovered that Alleged Victim's (AV) 30 Tab Narcotic HCL 5 MG Tablets delivered to the facility on September 24, 2021, went missing. An investigation determined that an Unknown Alleged Perpetrator 2 (AP2) wrongfully took AV's narcotic medication. AP's actions is financial exploitation which constitutes abuse. The facility failed to take preventive measures to prevent the loss or theft of AV's narcotic medication creating a risk of harm to AV. The facility's failure to provide a safe medication administration system is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• November 12, 2022: Failed to assure resident rights Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0034 (Resident Move-In and Evaluation)
  State’s findings

  The facility failed to contact the emergency contact. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action not taken due to change in ownership.

• November 12, 2022: 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 have an Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action not taken due to change in ownership.

• November 12, 2022: Failed to provide infection control Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0050 (Infection Prevention and Control)
  State’s findings

  The facility failed to establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action not taken due to change in ownership.

• August 31, 2022: Failed to provide safe environment 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 submit a background check to the department for a criminal fitness determination on all subject individuals. An investigation determined this is a violation of Oregon Administrative Rules.

• April 25, 2022: Failed to provide infection control 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 exercise reasonable precautions against any condition that may threaten the health, safety, and welfare of the residents. An investigation determined the facility violated 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 40 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.