Holi Senior Living

Last inspection

June 17, 2026

Inspections

6, 70 deficiencies cited

Substantiated abuse

6

Substantiated licensing violations

18

Regulatory actions

1

Fines assessed

$3,438.00 (6 violations)

Current owner since

September 1, 2021

License conditions and other regulatory actions

• August 10, 2022 to May 5, 2023: License Condition, Failed to use an ABST RCFCD22-01243; incident: CALMS - 00030492
  Based on preliminary evidence and interviews collected from Survey #2EHY11 initiated on August 8, 2022, the facility is not in substantial compliance with Oregon Administrative Rules for Residential Care Facilities and the Facilitys non-compliance places residents in immediate jeopardy.Concerns are related to lack of Registered Nurse (RN) and Administrator oversight.On August 18, 2022, the results from the Re-licensure Survey confirmed the immediate jeopardy finding and that the facility had approximately thirty-nine (39) citations, which were out of compliance. DHS now issues this Amended Notice and Order Imposing License Condition, to include additional recommendations and assist the facility in reaching substantial compliance. Respondents license is subject to the following conditions effective August 26, 2022.
  Rules: 411-004-0020; 411-054-0025 (Facility Administration); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0034 (Resident Move-In and Evaluation); 411-054-0035 (Designated Contact Person); 411-054-0037 (Acuity-Based Staffing Tool); 411-054-0040 (Change of Condition and Monitoring); 411-054-0045 (Resident Health Services); 411-054-0055 (Medications and Treatments); 411-054-0060 (Restraints and Supportive Devices); 411-054-0070 (Staffing Requirements and Training); 411-054-0090 (Fire and Life Safety); 411-054-0200 (Residential Care Facility Building Requirements); 411-057-0140 (Responsibilities of Administration); 411-057-0160 (Resident Services in a Memory Care Community); 411-057-0170 (Physical Design, Environment, and Safety)

Inspections

• June 17, 2026: Kitchen, 4 deficiencies cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
  • C0370: Staffing Requirements and Training ? Pre-service severity level 2, scope L2 Pattern
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread
  • Z0155: Staff Training Requirements severity level 2, scope L2 Pattern
• December 11, 2025: Re-Licensure, 20 deficiencies cited report
  • C0200: Resident Rights and Protection - General severity level 2, scope L2 Pattern
  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Isolated
  • C0252: Resident Move-in & Evaluation: Res Evaluation severity level 2, scope L2 Pattern
  • C0260: Service Plan: General severity level 2, scope L2 Pattern
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Isolated
  Show all 22

  • C0295: Infection Prevention & Control severity level 2, scope L2 Widespread
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Pattern
  • C0305: Systems: Resident Right to Refuse severity level 2, scope L2 Isolated
  • C0310: Systems: Medication Administration severity level 2, scope L2 Pattern
  • C0330: Systems: Psychotropic Medication severity level 2, scope L2 Pattern
  • C0340: Restraints and Supportive Devices severity level 2, scope L2 Pattern
  • C0363: Acuity Based Staffing Tool - Updates & Staffing Plan severity level 2, scope L2 Widespread
  • 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
  • C0435: Emergency and Disaster Planning severity level 2, scope L2 Widespread
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread
  • C0513: Doors, Walls, Elevators, Odors severity level 2, scope L2 Widespread
  • H1510: Individual Rights Settings: Privacy, Dignity severity level 2, scope L2 Pattern
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread
  • Z0155: Staff Training Requirements severity level 2, scope L2 Pattern
  • Z0162: Compliance with Rules Health Care severity level 2, scope L2 Pattern
  • Z0164: Activities severity level 2, scope L2 Pattern
• March 12, 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 24, 2024: Complaint Investig., 3 deficiencies cited report
  • C0010: Licensing Complaint Investigation severity level 0
  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Isolated
  • C0260: Service Plan: General severity level 2, scope L2 Isolated
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Isolated
• November 14, 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 January 13, 2024
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected January 13, 2024
• August 8, 2022: Initial Licensure, 39 deficiencies cited report
  • C0000: Comment severity level 0
  • C0150: Facility Administration: Operation severity level 4, scope L4 Widespread, corrected November 24, 2022
  • C0154: Facility Administration: Policy & Procedure severity level 2, scope L2 Widespread, corrected November 24, 2022
  • C0156: Facility Administration: Quality Improvement severity level 2, scope L2 Widespread, corrected November 24, 2022
  • C0160: Reasonable Precautions severity level 2, scope L2 Widespread, corrected November 24, 2022
  Show all 41

  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Pattern, corrected November 24, 2022
  • C0242: Resident Services: Activities severity level 2, scope L2 Widespread, corrected November 24, 2022
  • C0252: Resident Move-In and Eval: Res Evaluation severity level 2, scope L2 Pattern, corrected November 24, 2022
  • C0260: Service Plan: General severity level 2, scope L2 Pattern, corrected April 8, 2023
  • C0262: Service Plan: Service Planning Team severity level 2, scope L2 Pattern, corrected November 24, 2022
  • C0270: Change of Condition and Monitoring severity level 3, scope L3 Pattern, corrected November 24, 2022
  • C0280: Resident Health Services severity level 3, scope L3 Pattern, corrected November 24, 2022
  • C0282: Rn Delegation and Teaching severity level 4, scope L4 Isolated, corrected November 24, 2022
  • C0290: Res Hlth Srvc: On- and Off-Site Health Srvc severity level 2, scope L2 Pattern, corrected November 24, 2022
  • C0300: Systems: Medications and Treatments severity level 3, scope L3 Pattern, corrected November 24, 2022
  • C0302: Systems: Tracking Control Substances severity level 2, scope L2 Pattern, corrected November 24, 2022
  • C0303: Systems: Treatment Orders severity level 3, scope L3 Pattern, corrected April 8, 2023
  • C0310: Systems: Medication Administration severity level 2, scope L2 Pattern, corrected April 8, 2023
  • C0315: Systems: Treatment Administration severity level 2, scope L2 Pattern, corrected November 24, 2022
  • C0325: Systems: Self-Administration of Meds severity level 2, scope L2 Pattern, corrected November 24, 2022
  • C0340: Restraints and Supportive Devices severity level 2, scope L2 Pattern, corrected November 24, 2022
  • C0360: Staffing Requirements and Training: Staffing severity level 2, scope L2 Pattern, corrected November 24, 2022
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Widespread, corrected November 24, 2022
  • C0370: Staffing Requirements and Training – Pre-Serv severity level 2, scope L2 Pattern, corrected November 24, 2022
  • C0372: Training Within 30 Days: Direct Care Staff severity level 2, scope L2 Pattern, corrected April 8, 2023
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread, corrected April 8, 2023
  • C0422: Fire and Life Safety: Training For Residents severity level 2, scope L2 Widespread, corrected November 24, 2022
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread, corrected April 8, 2023
  • C0510: General Building Exterior severity level 2, scope L2 Widespread, corrected November 24, 2022
  • C0513: Doors, Walls, Elevators, Odors severity level 2, scope L2 Widespread, corrected November 24, 2022
  • C0530: Housekeeping and Laundry severity level 2, scope L2 Widespread, corrected November 24, 2022
  • C0540: Heating and Ventilation severity level 2, scope L2 Widespread, corrected November 24, 2022
  • C0555: Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable severity level 2, scope L2 Widespread, corrected November 24, 2022
  • H1518: Individual Door Locks: Key Access severity level 2, scope L2 Pattern, corrected November 24, 2022
  • H1523: Individual Freedom: Access to Food Any Time severity level 2, scope L2 Widespread, corrected November 24, 2022
  • Z0142: Administration Compliance severity level 4, scope L4 Widespread, corrected April 8, 2023
  • Z0162: Compliance With Rules Health Care severity level 4, scope L4 Isolated, corrected April 8, 2023
  • Z0163: Nutrition and Hydration severity level 2, scope L2 Pattern, corrected November 24, 2022
  • Z0164: Activities severity level 2, scope L2 Pattern, corrected November 24, 2022
  • Z0168: Outside Area severity level 2, scope L2 Widespread, corrected November 24, 2022
  • Z0173: Secure Outdoor Recreation Area severity level 2, scope L2 Widespread, corrected November 24, 2022

Substantiated abuse or neglect

• December 17, 2025: Failed to assist with toileting 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

  The Alleged Victim (AV) relies on the facility for assistance with toileting and incontinence care. According to an investigation, on or about December 18, 2025, AV did not receive timely assistance with incontinence care, resulting in AV experiencing unreasonable discomfort and embarrassment from sitting in soiled undergarments for an extended period of time. AP1 did not ensure same gendered staff were available to provide care, per AV's care plan, resulting in AV experiencing unreasonable discomfort. The facility failed to provide appropriate or timely care, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• April 4, 2025: Failed to provide service 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) relies on the facility for his/her care. AV's care planned fall interventions included for staff to conduct regular inspections of AV's living areas to identify and mitigate any fall hazards and maintain clear pathways. According to an investigation, on or about April 4, 2025, AV's room had boxes on the floor near the door and AV fell near the door after tripping, resulting in multiple facial fractures and skin injuries. The facility failed to follow the care plan, which is a violation of resident’s rights, is neglect of care and constitutes abuse.

• March 11, 2025: Failed to properly plan care Abuse: Neglect; Level 3 - Moderate harm or potential for serious 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

  The Alleged Victim (AV) has cognitive deficits that impact memory, a history of falls, severe visual impairment and relies on the facility for his/her care. AV's care plan provided direction that AV could walk with a walker and stand-by assistance of one staff, AV was a high fall risk and should not be walking by themselves. The care plan included fall interventions of having signs in AV's room to remind AV to call for assistance and use their call light. According to an investigation, on or about March 10, 2025, AV was found on the floor in the hallway outside of AV's room, resulting in a hip fracture. The facility failed to properly plan care and follow the care plan, which is a violation of resident’s rights, is neglect of care and constitutes abuse.

• February 14, 2024: Failed to properly plan care 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); 411-054-0036 (Service Plan – General)
  State’s findings

  The Alleged Victim (AV) has a known documented preexisting condition that can cause decrease ability to see clearly, write, speak, or walk. On or about February 14, 2024, the AV was found down on the floor by facility staff with no explanation as to how s/he got there. AV complained of chest pain and trouble breathing. AV was helped off the floor by facility staff, AV continued to complain of chest pain. However, due to facility staff still seeing no visible injuries they monitored AV and reported the fall to the oncoming care staff, the nurse, AV’s family, and the AV’s PCP via fax. AV continued to complain of chest pain throughout the day, and eventually taken to the hospital and diagnosed with a sternum fracture. AV sustained a total of 3 falls which occurred on or about February 02, 2024, February 04, 2024, and February 14, 2024. AV’s most recent fall is the one that is believed to have caused AV’s sternum fracture. The same interventions from the AV’s February 02, 2024, service plan were the same ones added to the AV’s February 14, 2024, service plan. There also appears to be no progressive intervention planning that took place after the AV’s fall on February 02, 2024, other than monitor for latent injuries. An intervention of grip socks was verbally mentioned as a progressive precaution, this intervention never made it to any of the provided documentation from the facility as proof that this put into practice. The facility failed to appropriately care plan and implement reasonable interventions to address AV’s falls, which resulted in AV sustaining 3 falls from February 02, 2024, to February 14, 2024, and resulting in AV having an injury fall with a fractured sternum, which is violation of resident rights, is considered neglect of care and constitutes abuse.

• July 2, 2023: Failed to provide safe environment Abuse: Neglect; Level 3 - Moderate harm or potential for serious 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)
  State’s findings

  The Alleged Victim (AV) was a known fall risk with a history of falls. According to an investigation, on or about July 2, 2023, AV was found next to his/her bed with a laceration under his/her right eye, which resulted in AV being sent to the hospital. The facility failed to provide a safe environment, which is considered neglect of care and constitutes abuse.

• September 8, 2022: Failed to provide safe environment Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $188.00; report
  Rules: 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0030 (Resident Services)
  State’s findings

  Alleged Victim (AV) had a known elopement risk. The facility failed to provide a safe environment. On or about September 8, 2022, AV eloped from the facility and was gone for about twenty minutes before being located, leaving AV at risk for serious harm. Staff discovered the facility courtyard was unlocked and the alarm was not working. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• March 23, 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

  The facility failed to provide records to the Department upon request. The facility’s failure is a violation of Oregon Administrative Rules.

• November 11, 2025: Failed to staff as indicated by 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 implement and maintain an Acuity-Based Staffing Tool. The facility’s failure is a violation of Oregon Administrative Rules.

• September 15, 2025: 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); 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 to meet his/her daily needs and was care-planned as being at risk for falls. According to an investigation, on or about September 15, 2025, the Alleged Perpetrator 2 (AP2) failed to follow the care plan when leaving AV on the toilet and closing the door, resulting in AV being exposed to potential harm. AP2's actions are considered neglect and constitute abuse. The facility failed to provide a safe environment, which violates Oregon Administrative Rules.

• August 18, 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 implement and maintain an Acuity-Based Staffing Tool. The facility’s failure is a violation of Oregon Administrative Rules.

• June 23, 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. 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 90 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.