Lakeland Senior Living

Last inspection

June 4, 2026

Inspections

4, 22 deficiencies cited

Substantiated abuse

13

Substantiated licensing violations

32

Regulatory actions

1

Fines assessed

$5,376.00 (12 violations)

Current owner since

May 1, 2024

License conditions and other regulatory actions

• July 2, 2026: License Condition, Failed to provide safe environment ALFCD26-00255; incident: CALMS - 00114362
  On June 1, 2026, through June 4, 2026, Oregon Department of Human Services (ODHS) conducted a Re-licensure Survey (RL012255) which confirmed the facility is not in substantial compliance with Oregon Administrative Rules for Assisted Living Facilitiesand the Facilitys non-compliance places residents at risk of serious harm.
  Rules: 411-054-0025 (Facility Administration); 411-054-0036 (Service Plan – General); 411-054-0040 (Change of Condition and Monitoring); 411-054-0045 (Resident Health Services); 411-054-0055 (Medications and Treatments)

Inspections

• June 4, 2026: Re-Licensure, 10 deficiencies cited report
  • C0160: Reasonable Precautions severity level 4, scope L4 Isolated
  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Isolated
  • C0260: Service Plan: General severity level 2, scope L2 Pattern
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Pattern
  • C0290: Res Hlth Srvc: On- and Off-Site Health Srvc severity level 2, scope L2 Pattern
  Show all 10

  • C0295: Infection Prevention & Control severity level 2, scope L2 Pattern
  • C0300: Systems: Medications and Treatments severity level 3, scope L3 Isolated
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Pattern
  • C0340: Restraints and Supportive Devices severity level 2, scope L2 Isolated
  • C0372: Training Within 30 Days of Hire ? Direct Care Staff severity level 2, scope L2 Pattern
• March 27, 2026: Kitchen, 1 deficiency cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
• November 8, 2024: Change of Owner, 8 deficiencies cited report
  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Isolated
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
  • C0252: Resident Move-in & Evaluation: Res Evaluation severity level 2, scope L2 Pattern
  • C0260: Service Plan: General severity level 2, scope L2 Isolated
  • C0290: Res Hlth Srvc: On- and Off-Site Health Srvc severity level 2, scope L2 Isolated
  Show all 8

  • C0305: Systems: Resident Right to Refuse severity level 2, scope L2 Pattern
  • C0374: Annual and Biennial Inservice for All Staff severity level 2, scope L2 Isolated
  • C0613: General Building: Doors-Walls, Cleanable severity level 2, scope L2 Widespread
• December 1, 2022: Complaint Investig., 3 deficiencies cited report
  • C0010: Licensing Complaint Investigation severity level 2, scope L2 Isolated
  • C0360: Staffing Requirements and Training: Staffing severity level 2, scope L2 Isolated
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Isolated
  • C0435: Emergency and Disaster Planning severity level 2, scope L2 Isolated

Substantiated abuse or neglect

• March 29, 2026: Failed to provide safe environment Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $1,000.00; 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 Alleged Victim (AV) resides in the Respondent’s facility and relies on facility staff to ensure that AV’s basic care, safety, and supervision needs are met. AV has a documented history of falls, including an incident on March 1, 2026, when AV attempted to get out of bed and slipped, and another incident on March 21, 2026, when AV fell in the bathroom during the night and remained on the floor for several hours because AV did not have AV’s call pendant. AV’s service plan indicates that AV can appropriately use the call pendant, uses a cane or four-wheel walker for ambulation, and that nighttime staff will retrieve the urinal from the bathroom and place it within AV’s reach for nighttime use. After the fall on March 1, 2026, interventions included staff monitoring AV more closely and reminding AV that staff are available to assist as needed. Following the fall on March 21, 2026, AV was added to NOC shift rounds twice nightly. Despite these interventions, the facility failed to provide a safe environment and did not follow AV’s service plan or the interventions intended to mitigate AV’s fall risk. On or about March 28, 2026, AV was last seen at approximately 9:00 p.m. during medication pass. AV slipped, lost balance, and struck AV’s head on the floor while ambulating to the bathroom. AV remained on the floor for approximately six hours until activating the bathroom pull cord at around 3:00 a.m. on March 29, 2026. The Respondent failed to provide a safe environment and did not follow AV’s service plan or interventions. This constitutes abuse by neglect as defined in OAR 411-020-0002(1)(A)(i).

• January 18, 2026: Failed to provide safe environment 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); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General)
  State’s findings

  Alleged Victim (AV) resides in the Respondent’s facility and depends on facility staff for assistance with daily needs and safety. AV has a documented history of exiting the facility, becoming lost, and requiring assistance from local law enforcement and facility staff to return, with incidents occurring in June 2025, July 2025, and August 2025. AV’s service plan reflects poor recent and remote memory. Facility staff report that AV has cognitive impairments and requires redirection and cueing. On or about January 18, 2026, AV exited the facility without staff awareness. Local law enforcement and search and rescue were notified. AV was found approximately three miles away, on the highway, crawling on AV’s hands and knees. The Respondent failed to provide adequate supervision and a safe environment. This constitutes abuse by neglect as defined in OAR 411-020-0002(1)(b)(A)(ii).

• October 7, 2025: Failed to provide oversight and monitoring of change of condition 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); 411-054-0040 (Change of Condition and Monitoring); 411-054-0045 (Resident Health Services)
  State’s findings

  Alleged Victim (AV) lives at Respondent’s facility. AV has a history of high blood pressure. AV's service plan reflects AV is independent in taking medications and checking AV's blood pressure. On or about October 7, 2025, AV's blood pressure was too high, and facility staff called EMS. AV took AV's blood pressure medication prior to EMS arriving. EMS suggested the facility monitor AV's blood pressure throughout the night. However, the facility failed to assess, provide oversight, monitor and document residents change of condition, which constitutes abuse by neglect.

• June 29, 2025: Failed to provide safe environment 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); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General)
  State’s findings

  Witness 1 (W1) has a history of verbal and physical aggression towards residents. W1 is verbally aggressive to other residents in a bullying like behavior to the point of residents and staff being scared of W1. W1 requires moderate care from staff for mental health and behavior management, which includes redirection, monitoring, cueing and reminders to prevent incidents. W1 has had an issue with Alleged Victim (AV) since AV walked into several individuals’ rooms at night without clothing on the lower half of AV’s body. On or about June 29, 2025, AV was standing outside of AV’s apartment waiting for a staff to assist AV. While AV was waiting, W1 walked up to AV and started yelling at AV and directing derogatory language at AV. W1 threaten AV with bodily harm. The facility failed to follow W1 behavioral plan by the facility not monitoring W1 for behaviors as indicated in the behavior plan resulting in AV being scared, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• June 14, 2025: Failed to administer medication as ordered Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $1,500.00; 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 a resident at AP1, and AP1 is responsible for AV's care and responsible for ordering and administering AV’s medications. Medication refills are requested 7-days before the last pill. The first request for AV’s medication refill was made on Thursday June 12, 2025, the first day AV was out of the medication. AV went three days without being administered AV’s prescribed medication. AV was taken to the Emergency Room on or about June 14, 2025, for an elevated pulse, where medical intervention was needed to reduce, resume AV’s heart rate. AP1 failed to provide a safe medication system, failed to request a timely refill of AV’s prescribed heart medication and did not have the medication available in the facility to administer to AV resulting in AV being sent to the hospital for medication intervention, which is a violation of resident’s rights is neglect of care and constitutes abuse.

Substantiated licensing violations

• April 24, 2026: Failed to provide oversight and monitoring of change of condition Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0040 (Change of Condition and Monitoring)
  State’s findings

  Based on interview, and record review, the facility failed to evaluate, monitor, and document significant change of condition requirements. The facility’s failure is a violation of Oregon Administrative Rules.

• March 30, 2026: Failed to protect resident from financial exploitation 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)
  State’s findings

  Alleged Victim (AV) lives at Respondent’s facility. Respondent provides a lockable drawer with a key in AV's room. AV reported a bag containing approximately $20.00-$30.00 in nickels missing 2-3 weeks prior to April 1, 2026. AV's lock on the drawer is inoperable, and AV has not reported that the lock on the drawer is inoperable to facility staff. An Unknown Alleged Perpetrator 3 (AP3) is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The Respondent failed to protect AV from financial exploitation which is a violation of Oregon Administrative Rules.

• March 30, 2026: Failed to protect resident from verbal abuse 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)
  State’s findings

  The Alleged Victim (AV) resides in the Respondent’s facility and depends on facility staff to provide the care and services necessary to maintain AV’s health and safety. According to AV’s service plan, AV uses a cane to assist with repositioning in bed and requires staff assistance with toileting and brief changes. Alleged Perpetrator 2 (AP2) completed training in approximately December 2025. The facility has received multiple complaints regarding AP2’s behavior. Witness 2 (W2) observed AP2 yell “spread your legs” approximately three times while providing care to AV. This conduct caused AV embarrassment and emotional distress. AP2’s behavior constitutes verbal/emotional abuse. The facility failed to protect AV from verbal/emotional abuse and did not provide a safe environment, which is a violation of Oregon Administrative Rules.

• December 30, 2025: 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

  Based on interview and record review, conducted during a site visit on 04/22/26-04/24/26, the facility failed to provide a safe medication administration system for Resident 1. Findings include but are not limited to: Resident 1 was admitted to the assisted living facility 05/2021. A review of the facility’s incident report dated 12/18/25, indicated Resident 1 reported s/he felt constipated and was unable to urinate. Resident 1 requested to be seen in the emergency room. The following documents were reviewed for Resident 1: - Service plan dated 10/30/25, indicated staff assistance for extensive and complex medication management. Staff were to administer both prescribed and PRN medications; - Hospital discharge instructions dated 12/18/25, Resident 1 was given a new laxative “Senna” prescription; - Medication administration record (MAR) for the month of 12/2025 indicated staff administered Resident 1’s Senna medication twice daily 12/18/25-12/31/25; and Physician order dated 12/18/25. In an interview on 04/22/26, Witness 1 stated: - On 12/30/25, Resident 1 showed Witness 1 where s/he had been stockpiling their Senna medications because Resident 1 didn’t feel s/he needed them; - S/He saw approximately 15 medication cups in Resident 1’s room and each cup contained Senna medication; and - S/He was concerned because Resident 1 had been to the emergency room on 12/18/25 for symptoms of constipation and was prescribed the Senna to alleviate potential issues; and - Witness 1 reported the incident to Staff 1. In an interview on 04/24/26, Staff 1 stated: - S/He acknowledged Witness 1 reported Resident 1 was stockpiling medications and Staff 1 saw the medications in Resident 1’s room; and - On 01/09/2026, med techs were re-trained on medication administration policy and procedures and were reminded they needed to watch residents ingest their medications prior to leaving the room. The facility failure to ensure medication and treatment orders must be carried out as prescribed for Resident 1 is a violation of Oregon Administrative Rules.

• December 15, 2025: Failed to provide safe environment Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0025 (Facility Administration)
  State’s findings

  The facility allegedly failed to exercise reasonable precautions against any condition that may threaten the health, safety, or welfare of residents. An investigation determined this 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 70 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.