Junction City Retirement and Assisted Living Residence

Last inspection

May 16, 2025

Inspections

5, 14 deficiencies cited

Substantiated abuse

8

Substantiated licensing violations

5

Regulatory actions

0

Fines assessed

$3,064.00 (8 violations)

Current owner since

February 1, 2024

Inspections

• May 16, 2025: Kitchen, 1 deficiency cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
• December 11, 2023: State Licensure, 3 deficiencies cited report
  • C0000: Comment severity level 0
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread, corrected April 1, 2024
  • C0295: Infection Prevention & Control severity level 2, scope L2 Widespread, corrected February 9, 2024
  • C0370: Staffing Requirements and Training – Pre-Serv severity level 2, scope L2 Isolated, corrected February 9, 2024
• August 17, 2023: Complaint Investig., 1 deficiency cited report
  • C0010: Licensing Complaint Investigation severity level 2, scope L2 Isolated
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Isolated
• May 30, 2023: Validation, 7 deficiencies cited report
  • C0000: Comment severity level 0
  • C0260: Service Plan: General severity level 2, scope L2 Pattern, corrected August 31, 2023
  • C0262: Service Plan: Service Planning Team severity level 2, scope L2 Pattern, corrected August 31, 2023
  • C0305: Systems: Resident Right to Refuse severity level 2, scope L2 Isolated, corrected August 31, 2023
  • C0370: Staffing Requirements and Training – Pre-Serv severity level 2, scope L2 Pattern, corrected August 31, 2023
  Show all 8

  • C0372: Training Within 30 Days: Direct Care Staff severity level 2, scope L2 Pattern, corrected August 31, 2023
  • C0610: General Building Exterior severity level 2, scope L2 Widespread, corrected August 31, 2023
  • C0613: General Building: Doors-Walls, Cleanable severity level 2, scope L2 Widespread, corrected August 31, 2023
• December 21, 2022: State Licensure, 2 deficiencies cited report
  • C0000: Comment severity level 0
  • C0200: Resident Rights and Protection - General severity level 2, scope L2 Widespread, corrected March 20, 2023
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread, corrected March 20, 2023

Substantiated abuse or neglect

• April 16, 2025: Failed to provide a safe medication administration system 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); 411-054-0055 (Medications and Treatments)
  State’s findings

  The Alleged Victim (AV) relies on the facility to provide AV with medication administration and management. According to an investigation, in April of 2025 the AV several days where AV went without multiple scheduled medications, resulting in AV feeling anxious, lethargic, agitated and weak. The facility failed to provide a safe medication administration system, which is a violation of resident rights, is neglect of care and constitutes abuse. The allegation that Alleged Perpetrator 2 (AP2) neglected AV was investigated and determined to be not substantiated.

• April 22, 2024: Failed to provide a safe medication administration system 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); 411-054-0055 (Medications and Treatments)
  State’s findings

  The facility failed to provide a safe medication administration system. According to an investigation, on or about April 15, 2024, it was discovered some of the Alleged Victim's (AV) narcotic pain medication was missing. As a result, AV did not receive two doses of medication, causing ongoing pain and financial exploitation, by way of theft. An unknown Alleged Perpetrator 2 (AP2) was responsible for financial exploitation, which constitutes abuse. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

• April 22, 2024: Failed to provide a safe medication administration system Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $375.00; 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

  The facility failed to provide a safe medication administration system. According to an investigation, on or about April 3, 2024, it was discovered approximately six of the Alleged Victim's (AV) narcotic pain PRN medication were missing, resulting in financial exploitation, by way of theft. An unknown Alleged Perpetrator 2 (AP2) was responsible for financial exploitation, which constitutes abuse. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

• November 17, 2022: Failed to provide a safe medication administration system Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $188.00; 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); 411-054-0055 (Medications and Treatments)
  State’s findings

  The Alleged Victim (AV) has a blood sugar condition which requires multiple medications. AV returned from the hospital with some changes to his/her medication. The facility failed to implement all the changes correctly, which resulted in AV missing medication for approximately a week. The facility's failure to provide a safe medication administration system is a violation of resident rights, is considered neglect of care and constitutes abuse.

• September 13, 2022: Failed to provide service 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); 411-054-0055 (Medications and Treatments)
  State’s findings

  The Alleged Victim (AV) receives insulin injections several times a day, along with blood sugar checks, which includes poking AV's finger to draw blood, which caused anxiety to AV. In late August of 2022, AV received a prescription for a dexacom unit, which would allow AV's blood sugar to be checked electronically and not receive finger pokes multiple times per day. AV waited for over two months for the unit to be applied, causing further anxiety for AV. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• February 15, 2024: Failed to provide medical treatment as ordered 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 an investigation, Alleged Perpetrator 2 (AP2) failed to follow policy and/or procedure when he/she discontinued the order for the Alleged Victim’s (AV) bandages and wraps to be changed, which resulted in wounds taking longer to heal and posing a serious risk of harm. AP2's actions are considered neglect and constitutes abuse. The facility failed to ensure medical treatment was followed as ordered, which is a violation of Oregon Administrative Rules.

• July 11, 2023: 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

  The facility failed to carry out medication and treatment orders as prescribed per complaint that the facility administered the wrong dosage, 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.

• June 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 June 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 May 1, 2022 to May 31, 2022, for a total of 30 days.

• May 29, 2022: 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); 411-054-0027 (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 May 26, 2022, the Alleged Victim (AV) was sent to the hospital with trouble breathing. AV was prescribed medication for his/her condition, including an antibiotic. On May 27, 2022, AV returned to the hospital due to shortness of breath and chest pain. It was determined that AV was allergic to the antibiotic. AV returned to the facility and notified them that AV was allergic to the medication. AV's record was updated to show not to give the medication to AV. On or about May 29, 2022, Alleged Perpetrator #2 (A2) gave the antibiotic to AV, placing AV at risk for harm. AP2's actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility's failure to provide a safe medication administration system 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 36 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.