Courtyard at Mt Tabor Garden House

Last inspection

December 11, 2025

Inspections

6, 26 deficiencies cited

Substantiated abuse

5

Substantiated licensing violations

2

Regulatory actions

2

Fines assessed

$1,626.00 (5 violations)

Current owner since

August 31, 2018

License conditions and other regulatory actions

• May 3, 2024 to August 26, 2024: License Condition, Failed to provide safe environment RCFCD24-00464; incident: CALMS - 00055832
  The facility allegedly failed to operate is substantial compliance with Oregon Administrative Rules.
  Rules: 411-054-0036 (Service Plan – General); 411-054-0040 (Change of Condition and Monitoring); 411-057-0140 (Responsibilities of Administration); 411-057-0160 (Resident Services in a Memory Care Community)
• September 7, 2023 to January 9, 2024: License Condition, Failed to use an ABST RCFCD23-01118; incident: CALMS - 00046561
  The facility failed to implement an acuity-based staffing tool (ABST) which met the regulation.
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)

Inspections

• December 11, 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
• February 27, 2025: Complaint Investig., 1 deficiency cited report
  • C0010: Licensing Complaint Investigation severity level 2, scope L2 Isolated
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Isolated
• December 26, 2024: Kitchen, 2 deficiencies cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread
• January 31, 2024: State Licensure, 0 deficiencies cited report
  • C0000: Comment severity level 0
• August 7, 2023: Validation, 21 deficiencies cited report
  • C0000: Comment severity level 0
  • C0152: Facility Administration: Required Postings severity level 2, scope L2 Widespread, corrected January 21, 2024
  • C0154: Facility Administration: Policy & Procedure severity level 2, scope L2 Widespread, corrected January 21, 2024
  • C0156: Facility Administration: Quality Improvement severity level 2, scope L2 Widespread, corrected June 1, 2024
  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Pattern, corrected June 1, 2024
  Show all 31

  • C0252: Resident Move-In and Eval: Res Evaluation severity level 2, scope L2 Pattern, corrected October 10, 2023
  • C0260: Service Plan: General severity level 2, scope L2 Pattern, corrected June 1, 2024
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Pattern, corrected June 1, 2024
  • C0280: Resident Health Services severity level 2, scope L2 Isolated, corrected June 1, 2024
  • C0282: Rn Delegation and Teaching severity level 4, scope L4 Isolated, corrected October 10, 2023
  • C0295: Infection Prevention & Control severity level 2, scope L2 Pattern, corrected October 10, 2023
  • C0300: Systems: Medications and Treatments severity level 2, scope L2 Pattern, corrected June 1, 2024
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Isolated, corrected January 21, 2024
  • C0305: Systems: Resident Right to Refuse severity level 2, scope L2 Isolated, corrected June 1, 2024
  • C0310: Systems: Medication Administration severity level 2, scope L2 Pattern, corrected June 1, 2024
  • C0330: Systems: Psychotropic Medication severity level 2, scope L2 Isolated, corrected June 1, 2024
  • C0350: Administrator Qualification and Requirements severity level 2, scope L2 Widespread, corrected January 21, 2024
  • C0360: Staffing Requirements and Training: Staffing severity level 2, scope L2 Pattern, corrected October 10, 2023
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Widespread, corrected October 10, 2023
  • C0372: Training Within 30 Days: Direct Care Staff severity level 2, scope L2 Pattern, corrected January 21, 2024
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread, corrected October 10, 2023
  • C0422: Fire and Life Safety: Training For Residents severity level 2, scope L2 Widespread, corrected October 10, 2023
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread, corrected June 1, 2024
  • C0530: Housekeeping and Laundry severity level 2, scope L2 Widespread, corrected January 21, 2024
  • Z0140: Administration Responsibilities severity level 2, scope L2 Widespread, corrected June 1, 2024
  • Z0142: Administration Compliance severity level 2, scope L2 Pattern, corrected June 1, 2024
  • Z0155: Staff Training Requirements severity level 2, scope L2 Pattern, corrected January 21, 2024
  • Z0162: Compliance With Rules Health Care severity level 4, scope L4 Isolated, corrected June 1, 2024
  • Z0163: Nutrition and Hydration severity level 2, scope L2 Isolated, corrected June 1, 2024
  • Z0164: Activities severity level 2, scope L2 Pattern, corrected January 21, 2024
  • Z0165: Behavior severity level 2, scope L2 Isolated, corrected January 21, 2024
• January 26, 2023: State Licensure, 0 deficiencies cited report
  • C0000: Comment severity level 0

Substantiated abuse or neglect

• February 5, 2025: Failed to properly plan care 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); 411-054-0036 (Service Plan – General)
  State’s findings

  Alleged Victim (AV) relies on the facility for his/her care needs. AV experienced at least nine (9) unwitnessed falls in the period from December 10yth, 2024, through February 5th, 2025. Despite AV’s repeated falls, AV was not service e planned for any safety checks until AV’s service plan was updated. As a result of the falls, AV experienced a laceration to their elbow on or about January 31, 2025, and February 3, 2025, and AV experienced a cut to his/her head on or about February 5, 2025. The facility failed to adequately care plan around AV’s known history of falls, which is a violation of resident rights, is neglect of care and constitutes abuse.

• May 24, 2024: Failed to provide a safe medication administration system Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $500.00; report
  Rules: 411-054-0027 (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

  Alleged Victim (AV) relies on the facility to administer his/her medications. On or about May 23rd and 24th, 2024, AV was administered (blood pressure medication #1) and (blood pressure medication #2). The order to discontinue (blood pressure medication #1) was misplaced and was located after AV had already received blood pressure medication #1 in error on or about May 23rd and 24th, 2024. As a result, AV had a fall on May 23rd and 24th, 2024, in which AV sustained injuries. AV’s primary care team discontinued both blood pressure medications due to AV having side effects and resulting in falls. The facility failed to provide a safe medication administration system, which is a violation of resident rights, is neglect of care and constitutes abuse.

• May 24, 2024: 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

  Alleged Victim (AV) is care planned to require a standby assist during all showers. On or about May 23rd and 24th, 2024, AV was left alone in the shower room which resulted in AV sustaining falls with injury on both days. The facility failed to follow the care plan around AV shower needs, which is a violation of resident rights, is neglect of care and constitutes abuse.

• April 3, 2024: Failed to provide safe environment Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $250.00; 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)
  State’s findings

  The Alleged Victim (AV) is a known fall risk, typically sliding from his/her wheelchair onto the floor. On or about April 3, 2024, staff noticed multiple bruises on AV and sent him/her out to the hospital for evaluation. AV had bruising on his/her chest, shoulder, right arm and both knees. AV was also noted to have a broken bed, where staff could not lower the bed to the lowest position, it was stuck at the highest position. AV's bed was to be in the lowest position and could not be due to it being broken. The facility failed to provide a safe environment for AV, resulting in bruises to his/her body. Respondent failed to ensure a safe environment. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

• October 7, 2023: 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); 411-054-0030 (Resident Services)
  State’s findings

  On or about October 7, 2023, the Alleged Victim (AV) was able to exit the facility through a locked exit door by holding the door for over 20 seconds, which unlocks the door automatically. Staff heard the alarm sound, however, when going to investigate, staff didn't see anyone and assumed that the alarm had malfunctioned. Staff were not trained on what to do if an alarm sounded. AV returned to the facility approximately 30 minutes later, after walking across the street to get groceries. Respondent failed to ensure resident safety, placing AV at risk for harm. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(ii).

Substantiated licensing violations

• March 6, 2026: Failed to make facility or resident records accessible Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0105 (Inspections and Investigations)
  State’s findings

  Based on interview and record review, conducted during an investigation on 04/14/26, the facility’s failure to provide records to the Department upon request was substantiated, which is a violation of Oregon Administrative Rules.

• September 17, 2022: Failed to intervene when resident's condition changed Licensing Violation; Level 3 - Moderate harm or potential for serious harm; report
  Rules: 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0040 (Change of Condition and Monitoring)
  State’s findings

  On or about September 17, 2022, the Alleged Victim (AV) was noted to be expressing pain to his/her right arm and was given pain medication by Alleged Perpetrator #2 (AP2). AP2 did not do a pain assessment on AV at that time. On or about September 18, 2022, Alleged Perpetrator 3 (AP3) was notified by a staff member of AV’s pain and the need for AP3 to assess AV. AP3 did not observe or assess AV for any injuries that morning. AV’s physician was called in the afternoon by AV’s spouse and it was decided to take AV to the hospital where he/she was diagnosed with a dislocated shoulder and a fractured arm. AP2 and AP3’s actions are a violation of resident rights, 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.