Grande Ronde Retirement Residence

Last inspection

June 22, 2026

Inspections

6, 42 deficiencies cited

Substantiated abuse

16

Substantiated licensing violations

24

Regulatory actions

1

Fines assessed

$4,563.00 (14 violations)

Current owner since

October 1, 2026

License conditions and other regulatory actions

• March 20, 2025 to February 5, 2026: License Condition, Failed to provide safe environment ALFCD25-00119; incident: CALMS - 00074955
  The following statement of violations stem from evidence and interviews collected from the initial ODHS re-licensure survey #RL003416.Upon completion of the survey, this condition will be amended to include additional violations and terms of this condition.
  Rules: 411-054-0025 (Facility Administration); 411-054-0045 (Resident Health Services)

Inspections

• June 22, 2026: Kitchen, 1 deficiency cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
• March 24, 2025: Re-Licensure, 29 deficiencies cited report
  • C0150: Facility Administration: Operation severity level 4, scope L4 Isolated
  • C0154: Facility Administration: Policy & Procedure severity level 2, scope L2 Widespread
  • C0156: Facility Administration: Quality Improvement severity level 2, scope L2 Widespread
  • C0200: Resident Rights and Protection - General severity level 3, scope L3 Isolated
  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Pattern
  Show all 29

  • C0243: Resident Services: ADLS severity level 3, scope L3 Isolated
  • C0252: Resident Move-in & Evaluation: Res Evaluation severity level 2, scope L2 Isolated
  • C0260: Service Plan: General severity level 2, scope L2 Pattern
  • C0270: Change of Condition and Monitoring severity level 3, scope L3 Isolated
  • C0280: Resident Health Services severity level 4, scope L4 Isolated
  • C0290: Res Hlth Srvc: On- and Off-Site Health Srvc severity level 2, scope L2 Pattern
  • C0295: Infection Prevention & Control severity level 2, scope L2 Widespread
  • C0300: Systems: Medications and Treatments severity level 2, scope L2 Pattern
  • C0302: Systems: Tracking Control Substances severity level 2, scope L2 Pattern
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Pattern
  • C0305: Systems: Resident Right to Refuse severity level 2, scope L2 Pattern
  • C0310: Systems: Medication Administration severity level 2, scope L2 Pattern
  • C0325: Systems: Self-Administration of Meds severity level 2, scope L2 Isolated
  • C0340: Restraints and Supportive Devices severity level 2, scope L2 Isolated
  • C0360: Staffing Requirements and Training: Staffing severity level 2, scope L2 Widespread
  • C0361: Acuity Based Staffing Tool - Elements severity level 2, scope L2 Pattern
  • C0362: Acuity Based Staffing Tool - ABST Time severity level 2, scope L2 Pattern
  • C0363: Acuity Based Staffing Tool - Updates & Staffing Plan 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
  • C0610: General Building Exterior severity level 2, scope L2 Widespread
  • C0613: General Building: Doors-Walls, Cleanable severity level 2, scope L2 Widespread
  • H1510: Individual Rights Settings: Privacy, Dignity severity level 2, scope L2 Isolated
  • H1517: Individual Privacy: Own Unit severity level 2, scope L2 Pattern
• December 3, 2024: Complaint Investig., 1 deficiency cited report
  • C0260: Service Plan: General severity level 2, scope L2 Isolated
• August 14, 2024: Complaint Investig., 3 deficiencies cited report
  • C0155: Facility Administration: Records severity level 2, scope L2 Isolated
  • C0260: Service Plan: General severity level 2, scope L2 Isolated
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Isolated
• December 18, 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 April 28, 2024
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread, corrected April 28, 2024
• May 16, 2022: Validation, 7 deficiencies cited report
  • C0000: Comment severity level 0
  • C0160: Reasonable Precautions severity level 2, scope L2 Isolated, corrected July 17, 2022
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread, corrected April 26, 2023
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Isolated, corrected July 17, 2022
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread, corrected July 17, 2022
  Show all 9

  • C0422: Fire and Life Safety: Training For Residents severity level 2, scope L2 Widespread, corrected July 17, 2022
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread, corrected April 26, 2023
  • C0611: General Building Interior severity level 2, scope L2 Widespread, corrected July 17, 2022
  • C0613: General Building: Doors-Walls, Cleanable severity level 2, scope L2 Widespread, corrected July 17, 2022

Substantiated abuse or neglect

• March 5, 2026: Failed to properly plan care Abuse: Neglect; Level 3 - Moderate harm or potential for serious 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); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General)
  State’s findings

  On or about March 5, 2026, facility staff observed Witness 1 (W1) and Alleged Victim (AV) involved in a resident-to-resident altercation in which W1 and AV were observed in an intimate embrace in which AV was observed trying to pull away from W1. At time of incident, both W1 and AV were residents under the care and supervision of the Respondent's facility. Based on facility documentation and interviews, at time of incident, W1 was observed preventing AV from pulling away by grabbing a hold of AV in which W1 then gestured towards W1's genital area and encouraged AV to touch W1 in which AV reluctantly touched W1 on his/her genital area. W1 had a documented history of inappropriate conduct, including two prior incidents, first incident was on February 20, 2026, and second incident was on March 5, 2026, the same day as the incident but at an earlier time. Although an ISP was initiated after the first incident, the facility did not update W1’s care plan, strengthen supervision, or implement additional safeguards following the second incident. Despite evidence of increased risk, the facility failed to implement sufficient interventions to protect AV from W1’s inappropriate conduct which caused AV unreasonable discomfort and emotional harm. This constitutes abuse by neglect under OAR 411-020-0002(1)(b)(A)(i).

• June 13, 2025: Failed to follow care plan 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); 411-054-0036 (Service Plan – General)
  State’s findings

  On or about June 13, 2025, Alleged Perpetrator 2 (AP2) failed to follow the Alleged Victim’s (AV) care plan by attempting a one-person transfer, despite AV being designated as a two-person assist. According to facility documentation and staff interviews, AP2 initially called for assistance when AV needed to be transferred. However, when no one responded to AP2's call for assistance, AP2 proceeded to transfer AV alone from the recliner to the wheelchair. AP2 knowingly performed the transfer with the knowledge that AV was a two-person assist. During the transfer, the wheelchair, which was unlocked at the time of incident, moved causing AV to fall and sustain scrapes to his/her lower back and left hip. When assistance arrived, AV was found on the floor with AP2. AV sustained physical injury resulting in unreasonable discomfort. AP2’s actions are considered neglect of care, which constitutes abuse. The facility failed to ensure that AP2 was adequately trained to provide appropriate care for AV, particularly in situations where staff were not available to assist upon request. The facility is responsible for the supervision, training, and overall conduct of AP2 while acting within the scope of their employment duties. This failure to provide proper training and oversight caused AV unreasonable discomfort a result of AP2 not following AV's care plan which is a violation of resident rights, is considered neglect of care which constitutes abuse.

• November 11, 2024: Failed to provide a safe medication administration system 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); 411-054-0055 (Medications and Treatments)
  State’s findings

  On or about November 11, 2024, the facility failed to provide a safe medication administration system to ensure The Alleged Victim’s (AV) medications were administered as ordered which resulted in AV experiencing a migraine, nausea, and trouble falling asleep. The facility's failure resulted in unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• July 23, 2024: Failed to answer call light in a timely manner Abuse: Neglect; Level 3 - Moderate harm or potential for serious 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); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General); 411-054-0037 (Acuity-Based Staffing Tool); 411-054-0300 (Assisted Living Facility Building Requirements)
  State’s findings

  The Alleged Victim (AV) has limited use of his/her left side following a medical event years prior. AV is a 2-person assist with transfers. On or about July 23, 2024 at approximately 9:30 pm, AV used his/her call button to request staff assistance. AV's call was cleared from the call system, however, no staff showed up to assist AV. AV was on the floor for approximately two hours waiting assistance. At approximately 11:20 pm, a staff member heard AV's calls for help and assisted AV from the ground. AV suffered a laceration to their elbow, bruising on their back and a bump on the back of their head. The facility was unable to provide an accurate list of caregivers that worked that evening and no indication of who cleared the calls from the call system. The facility's failure to answer the call light in a timely manner caused AV to suffer continued pain and unreasonable discomfort. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

• March 5, 2024: Failed to provide or assist with hygiene 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)
  State’s findings

  On or about March 5, 2024, the Alleged Victim (AV) was found with a bad rash to his/her groin and chest area. It was discovered that AV previously had a rash which was found in early February and AV's rash continued through the month of February. AV had not received a shower since February 21, 2024, as AV routinely refuses showers, however, staff are to re-approach and encourage AV to take showers. AV did not receive a shower for approximately two weeks, leading to the spread of AV's rash. The facility's failure to provide hygiene assistance to AV is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• June 18, 2025: Failed to provide safe environment Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0070 (Staffing Requirements and Training)
  State’s findings

  Based on interview and record review, conducted during a site visit on 04/21/26 and 04/22/26, the facility’s failure to ensure prior to beginning their job responsibilities, all employees must complete orientation training was substantiated for 2 of 2 sampled direct care staff (#s 7 and 8) whose training records were reviewed. Findings include but are not limited to: A review of the facility’s Staff List dated 04/21/26 indicated Staff 8 was hired 04/01/26 and Staff 7 was hired on 07/21/25. A review of staff’s training records revealed Staff 8 did not complete pre-service orientation training on the following required topics: · An approved Home and Community-Based Services (HCBS) course; · An approved LGBTQIA2S+ training course; and · An approved Pre-service dementia training. A review of staff’s training records revealed Staff 7 did not complete pre-service orientation training on the following required topics: · An approved Pre-service dementia training. During exit interview Staff 1 and Staff 2 both reviewed the training documents for Staff 7 and Staff 8 and confirmed missed training. The facility failed to ensure prior to beginning their job responsibilities, all employees must complete orientation training which is a violation of Oregon Administrative Rules.

• June 13, 2025: 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 interview and record review, conducted during a site visit on 04/21/26 and 04/22/26, the facilities failure to ensure the implementation of services through evaluation and resident preference was substantiated for 1 of 1 sampled resident (# 1). Findings include, but are not limited to: A record review of Resident 1’s service plan dated 09/23/25 indicated: · Resident 1 required two-person assistance for transferring in and out for bathing; · Required two-person assistance for commode both during the day and at night; · For mobility and ambulation Resident 1 required two-person with bed mobility and repositioning; and · Resident 1 required two staff members to move in recliner. A record review of Resident 1’s service plan dated 09/23/25 indicated: · Resident 1 fall intervention stated two person assistance using a gait belt for transfers; · Resident 1 required two-person assistance for transferring in and out for bathing; · Required two-person assistance for commode both during the day and at night; · For mobility and ambulation Resident 1 required two-person with bed mobility and repositioning; and · Resident 1 required two staff members to move in recliner. A record review of Resident 1’s incident report dated 06/13/25 indicated: · One care staff transferred Resident 1 into the wheelchair from the recliner. Resident 1 feet slipped and the wheelchair moved back and Resident 1 had a fall. In an interview with Staff 9 and Resident 1. Resident 1 is a two-person transfer. The facility failed to ensure the implementation of services through evaluation and resident preference which is a violation of Oregon Administrative Rules.

• April 3, 2025: 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); 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) high blood pressure medication was administered as ordered. Based on facility documentation and interviews, AV missed a dose of his/her high blood pressure medication at 8pm on 4/1/25, 4/2/25, and 4/3/25, and 8am on 4/3/25. AV did not experience any negative outcome as a result of the missed medication. The facility failed to ensure a safe medication administration system for AV which is a violation Oregon Administrative Rules.

• April 2, 2025: 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); 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. Based on facility documentation and interviews, AV was given another resident's medication in addition to the AV's prescribed medication. This error was done by a staff member in training. AV was observed to have no adverse side effects or any deviation from baseline, there was also no deviation from AV's daily routine as a result of the error. However, the facility did fail to provide a safe medication system which is a violation of Oregon Administrative Rules.

• February 26, 2025: 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); 411-054-0055 (Medications and Treatments)
  State’s findings

  On or about February 26, 2025, Alleged Perpetrator 2 (AP2) failed to dispense the correct medication to the Alleged Victim (AV) resulting in unreasonable discomfort to AV. Based on facility documentation and interviews, at time of incident, the AV had been given another resident's medication and had not been given his/her pain medication as ordered which resulted in the AV experiencing minor gastrointestinal discomfort. AP2's action is considered neglect of care which constitutes abuse. The facility is responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of his or her employment duties. The facility failed to provide a safe medication administration system for AV 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 76 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.