Kinsington Place

Last inspection

October 21, 2024

Inspections

4, 21 deficiencies cited

Substantiated abuse

1

Substantiated licensing violations

3

Regulatory actions

0

Fines assessed

$500.00 (1 violation)

Current owner since

January 17, 2011

Inspections

• October 21, 2024: 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
• July 29, 2024: Re-Licensure, 16 deficiencies cited report
  • C0000: Comment severity level 0
  • C0150: Facility Administration: Operation severity level 3, scope L3 Isolated, corrected November 21, 2024
  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Isolated, corrected November 21, 2024
  • C0260: Service Plan: General severity level 2, scope L2 Isolated, corrected November 21, 2024
  • C0262: Service Plan: Service Planning Team severity level 2, scope L2 Pattern, corrected November 21, 2024
  Show all 18

  • C0270: Change of Condition and Monitoring severity level 3, scope L3 Isolated, corrected November 21, 2024
  • C0295: Infection Prevention & Control severity level 2, scope L2 Isolated, corrected November 21, 2024
  • C0305: Systems: Resident Right to Refuse severity level 2, scope L2 Isolated, corrected November 21, 2024
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Pattern, corrected November 21, 2024
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread, corrected November 21, 2024
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Pattern, corrected April 11, 2025
  • H1518: Individual Door Locks: Key Access severity level 2, scope L2 Widespread, corrected November 21, 2024
  • H1580: Limitations: Threats to Health and Safety severity level 2, scope L2 Widespread, corrected November 21, 2024
  • Z0142: Administration Compliance severity level 3, scope L3 Isolated, corrected November 21, 2024
  • Z0155: Staff Training Requirements severity level 2, scope L2 Pattern, corrected April 11, 2025
  • Z0162: Compliance With Rules Health Care severity level 3, scope L3 Isolated, corrected November 21, 2024
  • Z0163: Nutrition and Hydration severity level 2, scope L2 Isolated, corrected November 21, 2024
  • Z0164: Activities severity level 2, scope L2 Isolated, corrected November 21, 2024
• December 19, 2023: State Licensure, 0 deficiencies cited report
  • C0000: Comment severity level 0
• September 14, 2022: 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 January 1, 2023
  • C0295: Infection Prevention & Control severity level 2, scope L2 Widespread, corrected October 1, 2022
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread, corrected January 1, 2023
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected January 1, 2023

Substantiated abuse or neglect

• June 18, 2024: Failed to provide a safe medication administration system 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); 411-054-0055 (Medications and Treatments)
  State’s findings

  The Alleged Victim (AV) had a medication change on or about June 19, 2024. AV's medication had changed from 40 mg once per day to 40 mg twice per day. Facility staff thought they had faxed the order to the pharmacy, however, the fax went to AV's physician instead. It was not discovered that AV was not receiving his/her medication until staff noticed that AV had gained 15 lbs in one week. AV missed his/her medication from June 19, 2024 until June 26, 2024. On or about June 26, 2024, AV was transferred to the hospital with shortness of breath. The facility's failure to provide a safe medication administration system and provide AV's medication as ordered, placed AV at risk for serious harm. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• October 14, 2024: Failed to administer medication as ordered 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 orders as prescribed which is a violation of Oregon Administrative Rule.

• July 22, 2024: 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); 411-054-0030 (Resident Services); 411-054-0055 (Medications and Treatments)
  State’s findings

  On or about August 30, 2024, it was determined by staff that the Alleged Victim's (AV) medication amount was off. A facility investigation determined that the medication administration system and the narcotic log did not match. According to the narcotic log, AV missed on dose of his/her medication. AV did not have any adverse reaction to missing the medication. The facility's failure to ensure a safe medication administration system is a violation of Oregon Administrative Rules.

• June 24, 2024: 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)
  State’s findings

  According to the documentation, the Alleged Perpetrator 2 (AP2) failed to provide a safe environment by leaving the Alleged Victim (AV) alone outside in hot weather. On or about June 20, 2024, the AP2 took the AV who is diagnosed with cognitive impairment outside the locked memory care facility for a walk. AP2 later returned to the facility without the AV. Approximately 36 minutes later, the AV was returned to the facility by a neighbor of the facility. The failure resulted in the AP2 not ensuring a safe environment for the AV, which is a violation of resident rights is considered neglect of care and constitutes abuse. The facility failed to provide a safe environment which 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 16 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.