Holly Residential Care Center

Last inspection

June 3, 2024

Inspections

4, 5 deficiencies cited

Substantiated abuse

0

Substantiated licensing violations

3

Regulatory actions

0

Current owner since

November 1, 2026

• No deficiencies cited at the last 2 inspections (June 2023 to April 2024)

Inspections

• June 3, 2024: Validation, 0 deficiencies cited report
  • C0000: Comment severity level 0
• April 5, 2024: State Licensure, 0 deficiencies cited report
  • C0000: Comment severity level 0
• June 14, 2023: State Licensure, 0 deficiencies cited report
  • C0000: Comment severity level 0
• June 1, 2022: Validation, 5 deficiencies cited report
  • C0000: Comment severity level 0
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread, corrected August 1, 2022
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Isolated, corrected August 1, 2022
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread, corrected September 30, 2022
  • C0422: Fire and Life Safety: Training For Residents severity level 2, scope L2 Widespread, corrected August 1, 2022
  • C0513: Doors, Walls, Elevators, Odors severity level 2, scope L2 Widespread, corrected September 30, 2022

Substantiated licensing violations

• November 8, 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

  Based on interview and record review, conducted during an investigation on 11/08/25, the facility’s failure to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident and use the results of an Acuity-Based Staffing Tool (ABST) to develop and routinely update the facility's posted staffing plan was substantiated. Findings include, but are not limited to: The facility’s posted staffing plan indicated: · For Day shift, 8 direct care staff; · For Swing shift, 7 direct care staff; and · For Night shift, 5 direct care staff. A review of the facility’s ABST care times as of 11/08/25 indicated: · For Day shift, 8.39, or a minimum of 8.5 direct care staff; · For Swing shift, 8.03, or a minimum of 8.5 direct care staff; and · For Night shift, 4.63, or a minimum of 5 direct care staff. The facility’s staffing schedule indicated: · For Day shift, 7 direct care staff; · For Swing shift, 7.5 direct care staff; and · For Night shift, 5 direct care staff. The facility’s staffing schedule, dated 11/08/25, indicated the facility was not staffing to its posted staffing plan for 1 of 6 shifts reviewed. The facility’s staffing schedule, dated 11/08/25, indicated the facility was not staffing to its ABST care times for 2 of 6 shifts reviewed. The facility's posted staffing plan did not exceed ABST care times for 2 of 6 shifts reviewed. The facility’s failure to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident and use the results of an Acuity-Based Staffing Tool (ABST) to develop and routinely update the facility's posted staffing plan is a violation of Oregon Administrative Rules.

• June 10, 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

  Based on interview and record review, conducted during an investigation on 09/01/26, the facility’s failure to use the results of an Acuity-Based Staffing Tool (ABST) to develop and routinely update the facility's posted staffing plan was substantiated. Findings include, but are not limited to: A review of the facility’s ABST care times as of 06/10/25 indicated: · For Day shift, 7.78, or a minimum of 8 direct care staff; · For Swing shift, 7.17, or a minimum of 7.5 direct care staff; and · For Night shift, 4.57, or a minimum of 5 direct care staff. The facility’s staffing schedule indicated: · For Day shift, 8 direct care staff; · For Swing shift, 7 direct care staff; and · For Night shift, 4.5 direct care staff. The facility’s failure to use the results of an Acuity-Based Staffing Tool (ABST) to develop and routinely update the facility's posted staffing plan is a violation of Oregon Administrative Rules.

• October 11, 2022: Failed to submit timely or adequate staffing documentation Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-061-0010
  State’s findings

  On or about October 1, 2022, the Oregon Health Authority reported to the Department that Respondent failed to comply with weekly reporting requirements of vaccinated individuals, residents and staff, to the proper authority as required by law. This failure has been ongoing from September 1, 2022 to September 30, 2022, for a total of 30 days.

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 42 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.