Heartwood Place

Last inspection

April 2, 2026

Inspections

7, 20 deficiencies cited

Substantiated abuse

8

Substantiated licensing violations

5

Regulatory actions

0

Fines assessed

$4,263.00 (8 violations)

Current owner since

May 2, 2014

Inspections

• April 2, 2026: Re-Licensure, 5 deficiencies cited report
  • C0295: Infection Prevention & Control severity level 2, scope L2 Isolated
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Pattern
  • C0362: Acuity Based Staffing Tool - ABST Time severity level 2, scope L2 Pattern
  • Z0142: Administration Compliance severity level 2, scope L2 Isolated
  • Z0162: Compliance with Rules Health Care severity level 2, scope L2 Pattern
• April 24, 2025: Licensure Complaint, 3 deficiencies cited report
  • C0360: Staffing Requirements and Training: Staffing severity level 2, scope L2 Isolated
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Isolated
  • C0363: Acuity Based Staffing Tool - Updates & Plan severity level 2, scope L2 Isolated
• March 7, 2024: State Licensure, 0 deficiencies cited report
  • C0000: Comment severity level 0
• May 30, 2023: Validation, 9 deficiencies cited report
  • C0000: Comment severity level 0
  • C0252: Resident Move-In and Eval: Res Evaluation severity level 2, scope L2 Isolated, corrected August 29, 2023
  • C0260: Service Plan: General severity level 2, scope L2 Pattern, corrected August 29, 2023
  • C0262: Service Plan: Service Planning Team severity level 2, scope L2 Pattern, corrected August 29, 2023
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Isolated, corrected August 29, 2023
  Show all 10

  • C0295: Infection Prevention & Control severity level 2, scope L2 Pattern, corrected August 29, 2023
  • C0372: Training Within 30 Days: Direct Care Staff severity level 2, scope L2 Pattern, corrected August 29, 2023
  • Z0142: Administration Compliance severity level 2, scope L2 Pattern, corrected August 29, 2023
  • Z0155: Staff Training Requirements severity level 2, scope L2 Pattern, corrected August 29, 2023
  • Z0162: Compliance With Rules Health Care severity level 2, scope L2 Pattern, corrected August 29, 2023
• May 17, 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
• May 17, 2023: Licensure Complaint, 2 deficiencies cited report
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Isolated
  • C0310: Systems: Medication Administration severity level 2, scope L2 Isolated
• February 9, 2023: State Licensure, 0 deficiencies cited report
  • C0000: Comment severity level 0

Substantiated abuse or neglect

• July 27, 2025: 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); 411-054-0036 (Service Plan – General)
  State’s findings

  The Alleged Victim (AV) is dependent on the facility to meet his/her safety needs and has a history of falls. According to an investigation, on or about July 27, 2025, AV was found on the floor in their apartment after an apparent fall from the wheelchair. AV's service plan, last updated July 26, 2025, did not include a risk of falls or have interventions for staff to follow to reduce the likelihood of falls. Previous fall interventions, identified in temporary service plans, had not been included in the current service plan. The facility did not develop or implement any known changes to AV's care plan following a fall on June 30, 2025. The facility failed to develop fall interventions to address AV’s fall risk, resulting in injury and a fractured right hand. The facility failed to properly plan care for AV, which is a violation of resident rights, is considered neglect of care which constitutes abuse.

• April 20, 2024: Failed to properly plan care 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

  According to the documentation, the facility failed to implement appropriate interventions for the Alleged Victim’s (AV) known fall history. The AV has a history of being non-compliant with current interventions by removing no skid socks and call pendant from their clothes. The facility failed to implement appropriate interventions to prevent future falls. On or about April 20, 2024, the AV was found in the hallway near their apartment. AV was able to bear weight and ambulate to their room. Later that day, the AV was complaining of hip pain and was sent to the hospital for assessment. The AV was diagnosed with a fractured femoral neck of AV’s left hip, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• February 16, 2024: Failed to properly plan care 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

  According to the documentation, the facility failed to properly care plan appropriate interventions for the Alleged Victim’s (AV) repeated falls. On or about January 21, 2024, the AV suffered a fall and sustained a fracture to their right arm and fell again approximately twelve (12) hours later, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• February 8, 2023: Failed to properly plan care Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $450.00; 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

  According to the documentation, the facility failed to properly care plan by implementing fall interventions to prevent injury falls. The failure resulted in the Alleged Victim (AV) suffering repeated falls with injury and needing to be sent to the hospital for evaluation, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• September 1, 2022: Failed to properly plan care 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); 411-054-0036 (Service Plan – General)
  State’s findings

  According to the documentation, the facility failed to properly care plan and implement interventions for Witness 1’s (W1) behaviors, including resident to resident altercations. The failure resulted in W1 hitting the Alleged Victim (AV) in the chin, causing pain and emotional discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• January 7, 2026: Failed to provide safe environment Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections)
  State’s findings

  The Alleged Victim (AV) relies on the facility for care and safety. On or about January 7, 2026, AV went to the door and started knocking. The Alleged Perpetrator 2 (AP2) opened the door, allowing AV to exit the secured unit. The facility was not aware AV had left the building, until they received a phone call that told them AV was not there, and that a person in the neighborhood had picked up AV and was going to drop AV back off to the facility. AV left the facility at 4:52 pm and was returned at 5:39 pm. AP2’s actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility failed to provide a safe environment which is a violation of Oregon Administrative rules.

• November 25, 2025: 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 allegedly failed to develop, maintain, and implement an Acuity Based Staffing Tool. An investigation determined this is a violation of Oregon Administrative Rules.

• February 10, 2023: 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 an Acuity Based Staffing Tool. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action not taken due to violation being abated by Survey June 1, 2023.

• October 8, 2022: 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

  Facility failure to carry out medication and treatment orders as prescribed. An investigation concluded a licensing violation occurred.

• October 8, 2022: 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

  Facility failure to keep an accurate Medication Administration Record (MAR) of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility. An investigation concluded a licensing violation occurred.

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 48 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.