Kelly Gardens Residential Care

Last inspection

April 16, 2025

Inspections

4, 13 deficiencies cited

Substantiated abuse

6

Substantiated licensing violations

20

Regulatory actions

1

Fines assessed

$4,951.00 (6 violations)

Current owner since

June 1, 2023

License conditions and other regulatory actions

• September 16, 2025 to November 13, 2025: License Condition, Failed to provide safe environment RCFCD25-01036; 2 incidents: CALMS - 00088081, CALMS - 00087830
  The facility failed to exercise reasonable precautions against any condition that may threaten the health, safety, or welfare of residents in accordance with OAR 411-054-0025(4); per a complaint the elevator at the facility has not been working resulting in residents from upper floors not having access to the lower floors, and a resident smoking in their room.
  Rules: 411-054-0025 (Facility Administration); 411-054-0030 (Resident Services)

Inspections

• April 16, 2025: Change of Owner, 3 deficiencies cited report
  • C0305: Systems: Resident Right to Refuse severity level 2, scope L2 Pattern
  • C0363: Acuity Based Staffing Tool - Updates & Staffing Plan severity level 2, scope L2 Widespread
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread
  • C0510: General Building Exterior severity level 2, scope L2 Widespread
• April 8, 2025: Complaint Investig., 3 deficiencies cited report
  • C0360: Staffing Requirements and Training: Staffing severity level 2, scope L2 Widespread
  • C0362: Acuity Based Staffing Tool - Abst Time severity level 2, scope L2 Widespread
  • C0363: Acuity Based Staffing Tool - Updates & Plan severity level 2, scope L2 Widespread
• December 5, 2023: State Licensure, 0 deficiencies cited report
  • C0000: Comment severity level 0
• July 18, 2022: Initial Licensure, 7 deficiencies cited report
  • C0000: Comment severity level 0
  • C0310: Systems: Medication Administration severity level 2, scope L2 Isolated, corrected January 26, 2023
  • C0330: Systems: Psychotropic Medication severity level 2, scope L2 Isolated, corrected January 26, 2023
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Widespread, corrected September 18, 2022
  • C0372: Training Within 30 Days: Direct Care Staff severity level 2, scope L2 Pattern, corrected January 26, 2023
  Show all 10

  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Pattern, corrected January 26, 2023
  • C0555: Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable severity level 2, scope L2 Widespread, corrected September 18, 2022
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected January 26, 2023
  • Z0155: Staff Training Requirements severity level 2, scope L2 Pattern, corrected January 26, 2023
  • Z0162: Compliance With Rules Health Care severity level 2, scope L2 Isolated, corrected January 26, 2023

Substantiated abuse or neglect

• October 8, 2024: 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 facility failed to provide appropriate services according to the Alleged Victim’s (AV) care needs when AV took smoke breaks outside. Based on facility documentation and interviews, facility staff are instructed to escort AV to and from his/her smoke breaks and to check on AV every ten minutes while AV is outside or to remain directly with AV while AV is smoking. It was determined that the facility failed to provide clear direction regarding the delivery of AV's services, which resulted in AV being continually left outside for extended periods of time during inclement weather conditions between October 8, 2024, and October 25, 2024. The facility failed to provide appropriate training and oversight to ensure staff do not leave Alleged Victim (AV) outside for prolonged periods of time, resulting in AV's unreasonable discomfort due to exposure to inclement weather conditions, emotional harm due to feelings of being forgotten causing anxiety and panic, and serious loss of person dignity. The facility's failure is a moderate violation of resident rights, is considered neglect of care, and constitutes abuse.

• September 17, 2024: Failed to provide a safe medication administration system Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $1,013.00; 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

  Alleged Victim (AV) is under the care of the facility and AV is care planned for pain medication management. On September 15, 2024, September 16, 2024, and September 17, 2024, AV suffered an increased in pain due to the facility not reordering AV's narcotic pain medication in a timely manner. Based on facility documentation and interviews, staff were pulling AV's narcotic pain medications from incorrect cards which caused staff to not accurately track when AV's narcotic pain medication needed to be reordered to ensure availability. The facility's failure to provide a safe medication administration system to ensure AV's narcotic pain medications were administered as ordered. The failure resulted in AV experiencing pain lasting more than 24 hours, causing unnecessary unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• April 4, 2024: Failed to provide safe environment Abuse: Neglect; Level 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance; fine $2,500.00; 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); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General)
  State’s findings

  The Alleged Victim (AV) is a resident of the facility and receives care due to short-term memory loss, which places AV at risk of harm because of difficulty recalling information and susceptibility to manipulation. Alleged Perpetrator 2 (AP2), employed as a caregiver at the facility, entered into an inappropriate and prohibited relationship with AV. AP2 was discovered in AV’s bed by a member of facility management and was immediately suspended. During the internal investigation, both AV and AP2 denied any inappropriate relationship. AP2 was later reinstated but restricted from working on AV’s floor or providing care to AV. Despite these restrictions, AP2 continued visiting AV’s room and maintained communication via text messages. While AV was hospitalized between March 16, 2024, and March 27, 2024, AP2 disclosed to Alleged Perpetrator 3 (AP3) that AP2 had “kissed” AV. Between February 13, 2024, and April 2, 2024, AP2 engaged in a texting relationship with AV that included: sexual photos and explicit language; use of pet names and inappropriate emojis; and manipulative language when AV did not respond. When AV stopped responding, AP2 continued sending inappropriate messages. AV was initially reluctant to discuss the relationship but later disclosed that it was intimate, both physically and emotionally, and expressed that AP2 was “playing mind games.” AV stated he/she ended the relationship when he/she no longer wished to continue. Although the facility provides mandatory reporting training and all interviewed staff confirmed completion, multiple staff members were aware of and uncomfortable with AP2’s actions yet failed to report or adequately follow up. This indicates that the training was insufficient to ensure timely intervention and prevention of inappropriate conduct. AP2's actions caused AV significant emotional harm. AP2's actions is considered sexual abuse. The facility’s failure to properly monitor AP2 while caring for residents and failing to train staff on proper mandatory reporting guidelines resulting in sexual abuse by AP2 is a violation of resident rights is considered neglect of care and constitutes abuse. Given AV’s cognitive impairment and the inherent power imbalance between resident and caregiver, this situation presents an elevated risk of further harm. Alleged Perpetrator 3 (AP3) failed to follow mandatory reporting requirements when informed of inappropriate intimate physical contact made by AP2 towards AV, resulting in ongoing sexual abuse by AP2. AP3's action is considered neglect of care which constitutes abuse. Alleged Perpetrator 4 (AP4) and Alleged Perpetrator 5 (AP5) allegedly neglected AV. An investigation determined no abuse occurred by AP4 and AP5.

• February 27, 2024: Failed to provide a safe medication administration system 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); 411-054-0055 (Medications and Treatments)
  State’s findings

  On or about February 27, 2024, the facility failed to provide a safe medication administration system to ensure the Alleged Victim’s (AV) medications were administered as ordered. The failure resulted in unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse. Alleged Perpetrator 2 (AP2) allegedly neglected AV. An investigation determined no abuse occurred by AP2.

• December 11, 2023: Failed to meet the scheduled and unscheduled needs of residents 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); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General); 411-054-0037 (Acuity-Based Staffing Tool)
  State’s findings

  During the overnight shift of December 11, 2023, Alleged Victim (AV) pushed AV's call button several times, to request support with his/her Activities of Daily Living for night care as care planned. AV needed transfer assistance with incontinence care and to smoke a cigarette, PRN medication to manage his/her pain, and a drink of water for relief to quench thirst. As a result of facility's staffing levels not being sufficient at the time of incident, AV soiled his/her bed and was left in his/her soiled bed "all night". Based on facility documentation and interviews, the facility was unable to provide evidence as requested for investigation to show staffing levels at time of incident were sufficient to meet the scheduled and unscheduled needs of residents. The facility is licensed for 61 beds. During the overnight shift of December 11, 2023, when this incident occurred, there were only three staff taking care of the entire facility needs. At time of incident, AV was care planned as a two-person assist in a Hoyer lift. The facility's failure to provide adequate staffing support, resulted serious emotional harm due to staff not being able to adequately address AV's nighttime support needs and requests. Alleged Perpetrator 2 (AP2) allegedly neglected AV at time of incident. An investigation inconclusively determined no licensing violation or abuse occurred by AP2.

• April 20, 2023: Failed to provide safe environment Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $188.00; report
  State’s findings

  The facility failed to provide appropriate supervision to the Alleged Victim (AV) according to his/her needs. The failure resulted in AV eloping the secured building, without staff knowledge, placing him/her at risk of harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• February 18, 2026: 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

  On or about February 18, 2026, the facility failed to ensure Medication and treatment orders were carried out as prescribed. The facility's failure is a violation of Oregon Administrative Rules.

• February 18, 2026: 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 have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules.

• January 16, 2026: 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 07/08/26, the facility’s failure to complete or update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly as required was substantiated. Findings include, but are not limited to: The facility’s census was 31. A review of the facility’s last ABST evaluation update per resident indicated 15 of 31 residents had not been updated quarterly as required as of 01/16/26. The facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules.

• October 15, 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 failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules.

• September 5, 2025: Failed to provide safe environment 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.

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 61 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.