Courtyard at Mt Tabor Pavilion

Last inspection

December 11, 2025

Inspections

7, 17 deficiencies cited

Substantiated abuse

0

Substantiated licensing violations

8

Regulatory actions

1

Current owner since

November 6, 2019

License conditions and other regulatory actions

• May 26, 2023 to February 6, 2024: License Condition, Failed to use an ABST RCFCD23-00690; incident: OR0003980300
  The facility failed to fully implement an Acuity Based Staffing Tool in accordance with OAR 411-054-0036(1)
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)

Inspections

• December 11, 2025: Kitchen, 2 deficiencies cited report
  • C0150: Facility Administration: Operation severity level 2, scope L2 Widespread
  • 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
• February 4, 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
• January 31, 2024: State Licensure, 0 deficiencies cited report
  • C0000: Comment severity level 0
• January 30, 2024: Validation, 10 deficiencies cited report
  • C0000: Comment severity level 0
  • C0260: Service Plan: General severity level 2, scope L2 Pattern, corrected April 2, 2024
  • C0295: Infection Prevention & Control severity level 2, scope L2 Widespread, corrected April 2, 2024
  • C0310: Systems: Medication Administration severity level 2, scope L2 Pattern, corrected April 2, 2024
  • C0365: Staffing Rqmt and Training: Training Rqmts severity level 2, scope L2 Widespread, corrected April 2, 2024
  Show all 11

  • C0372: Training Within 30 Days: Direct Care Staff severity level 2, scope L2 Pattern, corrected April 2, 2024
  • C0555: Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable severity level 2, scope L2 Widespread, corrected April 2, 2024
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected April 2, 2024
  • Z0155: Staff Training Requirements severity level 2, scope L2 Pattern, corrected April 2, 2024
  • Z0162: Compliance With Rules Health Care severity level 2, scope L2 Pattern, corrected April 2, 2024
  • Z0173: Secure Outdoor Recreation Area severity level 2, scope L2 Widespread, corrected April 2, 2024
• November 9, 2023: Complaint Investig., 2 deficiencies cited report
  • C0152: Facility Administration: Required Postings severity level 2, scope L2 Isolated
  • C0260: Service Plan: General severity level 2, scope L2 Isolated
• March 28, 2023: Complaint Investig., 1 deficiency cited report
  • C0010: Licensing Complaint Investigation severity level 2, scope L2 Isolated
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Widespread
• January 26, 2023: State Licensure, 0 deficiencies cited report
  • C0000: Comment severity level 0

Substantiated licensing violations

• May 21, 2026: Failed to staff as indicated by ABST Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  State’s findings

  Based on interview and record review, the facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. The facility’s failure is a violation of Oregon Administrative Rules.

• February 26, 2025: Failed to provide safe environment Licensing Violation; Level 2 - Minor harm or potential for moderate harm; 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

  Alleged Victim (AV) relies on the facility for his/her care. On or about February 26, 2025, AV was signed out of the secure unit by Alleged Perpetrator 2 (AP2) at 10:45 am. AV was brought to the exercise class in the unsecure part of the building where AV resides. While under the care of AP2, AV visited the apartment of Witness 4 (W4) and Witness 5 (W5). AV was not accompanied by AP2. While visiting W5, AV was responsible for a physical injury to W5. AP2 was provided with training in regard to supervision of memory care residents and understood that there was an expectation that maintaining a line of sight with AV was necessary to fulfill the monitoring expectation. AP2 failed to assure resident was safe, which is neglect of care and constitutes abuse. The facility failed to assure resident was safe, which is a violation of Oregon Administrative Rules.

• December 23, 2024: Failed to provide service 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 allegedly failed to provide service for the Alleged Victim, which is a violation of Oregon Administrative Rule.

• July 27, 2024: Failed to provide safe environment Licensing Violation; Level 2 - Minor harm or potential for moderate harm; 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

  Alleged Victim (AV) relies on the facility for his/her care. On or about July 27, 2024, AV exited the facility and was intercepted on the sidewalk fifteen to twenty feet from the entrance by an off-duty staff member. Alleged Perpetrator 2 (AP2) had entered the building through the secure door and failed to note the presence of AV and failed to slow and wait for the door to latch behind them. This allowed AV to exit the secure part of the facility and access the sidewalk outside of the building. AP2 was aware of AV’s exit seeking behaviors, noting that AV is always at the door, trying to get out. AP2 failed to provide a safe environment to AV, which is neglect of care and constitutes abuse. The facility failed to provide a safe environment to AV, which is a violation of Oregon Administrative Rules.

• May 17, 2024: Failed to provide service 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 allegedly failed to provide service for the Alleged Victim, 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 29 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.