Conifer House Residential Care And Memory Care

Last inspection

March 10, 2025

Inspections

4, 17 deficiencies cited

Substantiated abuse

28

Substantiated licensing violations

7

Regulatory actions

0

Fines assessed

$18,000.00 (28 violations)

Current owner since

August 1, 2014

Inspections

• March 10, 2025: 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
• June 4, 2024: Licensure Complaint, 1 deficiency cited report
  • C0301: Systems: Medication Administration severity level 2, scope L2 Isolated
• December 22, 2023: 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 February 20, 2024
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected February 20, 2024
• December 12, 2022: Validation, 12 deficiencies cited report
  • C0000: Comment severity level 0
  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Isolated, corrected February 14, 2023
  • C0252: Resident Move-In and Eval: Res Evaluation severity level 2, scope L2 Pattern, corrected August 5, 2023
  • C0260: Service Plan: General severity level 2, scope L2 Pattern, corrected August 5, 2023
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Pattern, corrected February 14, 2023
  Show all 15

  • C0372: Training Within 30 Days: Direct Care Staff severity level 2, scope L2 Pattern, corrected February 14, 2023
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread, corrected February 14, 2023
  • C0422: Fire and Life Safety: Training For Residents severity level 2, scope L2 Widespread, corrected February 14, 2023
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Pattern, corrected August 5, 2023
  • C0510: General Building Exterior severity level 2, scope L2 Widespread, corrected February 14, 2023
  • C0555: Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable severity level 2, scope L2 Widespread, corrected February 14, 2023
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected February 14, 2023
  • Z0155: Staff Training Requirements severity level 2, scope L2 Isolated, corrected February 14, 2023
  • Z0162: Compliance With Rules Health Care severity level 2, scope L2 Pattern, corrected August 5, 2023
  • Z0164: Activities severity level 2, scope L2 Pattern, corrected August 5, 2023

Substantiated abuse or neglect

• April 28, 2026: Failed to follow care plan 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); 411-054-0036 (Service Plan – General)
  State’s findings

  The Alleged Victim (AV) relied on the facility for his/her care and was care planned for a nonslip pad to be under them while seated. On or about April 28, 2026, AV was found on the floor after falling out of the recliner resulting in a hematoma. According to an investigation, AV had been sitting in a recliner in their room all night, and despite multiple staff interacting with AV, no one moved AV's nonslip pad from their wheelchair to the recliner they were sitting in, contributing to the fall. The facility failed to follow AV care plan, which is a violation of resident’s rights is neglect of care and constitutes abuse as defined by OAR 411-020-0002(1)(b)(A)(i).

• March 1, 2026: Failed to provide service Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $1,500.00; 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); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General)
  State’s findings

  The Alleged Victim (AV) relied on the facility for care and had a history of falls when drinking. On or about March 1, 2026, while intoxicated, AV fell in their room, resulting in a head laceration and a hand fracture. According to an investigation, the service plan indicated staff were to provide AV with frequent safety checks and alert management when AV was observed to be intoxicated or drinking, but there were no interventions or instructions indicating how to prevent falls when AV was intoxicated. The facility also had documented that a managed risk agreement would be implemented after one of the previous falls, but this was never done. The facility failed to provide services, to include properly care planning and/or implementing interventions to mitigate AV's fall risk and to ensure resident safety, which is a violation of resident rights, is considered neglect of care and constitutes abuse as defined in OAR 411-020-0002(1)(b)(A)(i).

• September 5, 2025: Failed to provide service Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $1,125.00; 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 Alleged Victim (AV) relies on the facility for care and has a history of falls. On or about September 5, 2025, AV fell in the common area of the facility while attempting to ambulate on their own, resulting in fractured ribs. According to an investigation, despite AV's service plan adding interventions after previous falls, some interventions were contradicting, and/or weren't implemented. The facility failed to provide services, to include properly care planning and/or implementing interventions to mitigate AV's fall risk and to ensure resident safety, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• August 3, 2025: Failed to follow care plan 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); 411-054-0036 (Service Plan – General)
  State’s findings

  The Alleged Victim (AV) relies on the facility for care, is a known fall risk, and is care planned for ambulation using a wheelchair. On or about August 3, 2025, Alleged Perpetrator 2 (AP2) helped AV to the dining room by having AV walk with a walker. AV became dizzy and fell to their knees. AV stated their knees hurt a little bit. According to an investigation, it was discovered that AP2 was not properly trained regarding caring for residents, and therefore AP2 allegations were not substantiated. The facility failed to ensure residents care plan were followed, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• March 6, 2025: Failed to provide service 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); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General)
  State’s findings

  The Alleged Victim (AV) relies on the facility for care, supervision, and safety. On or about March 6, 2025, facility staff were alerted that AV was outside the facility at a nearby business, after the business called the police. AV had left the facility and crossed a busy road, without staff knowledge. The facility failed to provide appropriate services, regarding care planning and resident safety, which placed AV at risk of harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• June 30, 2026: 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. An investigation determined this is a violation of Oregon Administrative Rules.

• May 10, 2026: 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. An investigation determined this is a violation of Oregon Administrative Rules.

• April 28, 2026: Failed to update staffing plan based on ABST Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0037 (Acuity-Based Staffing Tool); 411-054-0070 (Staffing Requirements and Training)
  State’s findings

  The facility failed to fully implement and update an acuity-based staffing tool and staff accordingly. An investigation determined this is a violation of Oregon Administrative Rules.

• March 15, 2026: Failed to update staffing plan based on ABST Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0037 (Acuity-Based Staffing Tool); 411-054-0070 (Staffing Requirements and Training)
  State’s findings

  The facility failed to fully implement and update an acuity-based staffing tool and staff accordingly. An investigation determined this is a violation of Oregon Administrative Rules.

• February 28, 2026: Failed to update staffing plan based on ABST Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0037 (Acuity-Based Staffing Tool); 411-054-0070 (Staffing Requirements and Training)
  State’s findings

  The facility failed to fully implement and update an acuity-based staffing tool and staff accordingly. An investigation determined this is a violation of Oregon Administrative Rules.

• December 16, 2025: Failed to update staffing plan based on 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 develop, maintain, and implement an Acuity Based Staffing Tool. An investigation determined this is a violation of Oregon Administrative Rules.

• September 4, 2023: Failed to provide a safe medication administration system 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 ensure that the staff person who administers the medication must visually observe the resident take the medication. The facility’s 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.” This community is licensed for 51 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.