Horton Plaza

Last inspection

August 17, 2023

Inspections

2, 6 deficiencies cited

Substantiated abuse

1

Substantiated licensing violations

3

Regulatory actions

0

Fines assessed

$250.00 (1 violation)

Current owner since

September 23, 2017

Inspections

• August 17, 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 December 31, 2024
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread, corrected December 31, 2024
• February 3, 2022: Validation, 5 deficiencies cited report
  • C0000: Comment severity level 0
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Isolated, corrected April 1, 2022
  • C0300: Systems: Medications and Treatments severity level 2, scope L2 Pattern, corrected April 1, 2022
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Isolated, corrected April 1, 2022
  • C0310: Systems: Medication Administration severity level 2, scope L2 Pattern, corrected April 1, 2022
  • C0330: Systems: Psychotropic Medication severity level 2, scope L2 Isolated, corrected April 1, 2022

Substantiated abuse or neglect

• September 21, 2022: Failed to provide safe environment 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)
  State’s findings

  Alleged Victim (AV) care plan states that private caregivers are to prevent falls to AV by providing support and assistance at all times, AV has 24/7 private caregivers. On or about September 9, 2022, a private caregiver was assisting AV transfer to a wheelchair and the brakes were not all the way "ON" causing the chair to slip away and AV sustaining a fall. On or about September 21, 2022, the private caregiver was suspected to have fallen asleep and AV was found on the floor next to their bed with the overnight caregiver nearby. AV was sent to the ER as a result of this fall. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Substantiated licensing violations

• December 16, 2022: Failed to follow care plan 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

  According to the documentation, Alleged Perpetrator (AP2) failed to follow Alleged Victim’s (AV) service plan in providing stand-by assistance with all transfers. The failure resulted in AV self-transferring and sustaining a fall with injury, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to ensure AV’s care plan was followed, which is a violation of Oregon Administrative Rules.

• October 1, 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.

• January 12, 2022: Failed to administer ordered medication Licensing Violation; Level 1 - No harm or potential for minor harm; report
  Rules: 411-054-0055 (Medications and Treatments)
  State’s findings

  The allegation that the facility failed to carry out medication orders as prescribed in accordance with OAR 411-054-0055(1)(f) per complaint that the facility did not administer resident's medication was verified.

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 18 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.