Laurelhurst Senior Living

Last inspection

March 5, 2026

Inspections

4, 16 deficiencies cited

Substantiated abuse

4

Substantiated licensing violations

5

Regulatory actions

2

Fines assessed

$2,625.00 (4 violations)

Current owner since

August 1, 2025

License conditions and other regulatory actions

• April 25, 2025 to August 5, 2025: License Condition, Failed to provide safe environment ALFCD25-00176; 4 incidents: CALMS - 00078832, CALMS - 00077570, CALMS - 00077568, CALMS - 00077567
  The facility failed to exercise reasonable precautions against any condition that may threaten the health, safety, or welfare of resident in accordance with OAR 411-054-0025 (4) per onsite observation of a resident smoking inside his/her apartment.
  Rules: 411-054-0025 (Facility Administration); 411-054-0036 (Service Plan – General); 411-054-0040 (Change of Condition and Monitoring)
• October 25, 2024 to December 3, 2024: License Condition, Failed to provide safe environment ALFCD24-00822; incident: CALMS - 00064620
  The facilitys failure to comply with Oregon Administrative Rules constitutes a threat to the health, safety, and welfare of its residents. In addition, ODHS finds that the residents of the facility are at risk of immediate jeopardy. That is because the facilitys failure to comply with ODHS rules has caused or is likely to cause serious injury, serious harm, serious impairment, or death to a resident or residents. ODHS further concludes that this finding of immediate jeopardy is likely to present an immediate jeopardy to future residents upon admission. As a result, ODHS is authorized to impose a condition restricting admissions to the facility.
  Rules: 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)

Inspections

• March 5, 2026: Change of Owner, 5 deficiencies cited report
  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Isolated
  • C0252: Resident Move-in & Evaluation: Res Evaluation severity level 2, scope L2 Pattern
  • C0260: Service Plan: General severity level 2, scope L2 Pattern
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Isolated
  • C0363: Acuity Based Staffing Tool - Updates & Staffing Plan severity level 2, scope L2 Pattern
• August 7, 2024: Complaint Investig., 2 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
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Isolated
• November 20, 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 January 19, 2024
• October 24, 2022: Validation, 8 deficiencies cited report
  • C0000: Comment severity level 0
  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Isolated, corrected December 20, 2022
  • C0252: Resident Move-In and Eval: Res Evaluation severity level 2, scope L2 Isolated, corrected December 20, 2022
  • C0260: Service Plan: General severity level 2, scope L2 Pattern, corrected December 20, 2022
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Pattern, corrected December 20, 2022
  Show all 9

  • C0303: Systems: Treatment Orders severity level 2, scope L2 Pattern, corrected December 20, 2022
  • C0325: Systems: Self-Administration of Meds severity level 2, scope L2 Isolated, corrected December 20, 2022
  • C0370: Staffing Requirements and Training – Pre-Serv severity level 2, scope L2 Pattern, corrected December 20, 2022
  • C0372: Training Within 30 Days: Direct Care Staff severity level 2, scope L2 Pattern, corrected December 20, 2022

Substantiated abuse or neglect

• October 21, 2025: 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

  On November 1, 2025, ODHS Adult Protective Services (APS) conducted investigation #00433952 and issued a written investigation report, which is incorporated here by reference. The Alleged Victim (AV) is a resident of the facility and under its care. The facility is responsible for managing and administering all of AV's prescribed medications, including pain medication scheduled at 8:00 AM, 12:00 PM, and 4:00 PM daily. Based on interviews and record review, it was determined that the facility failed to administer pain medication as ordered: - 09/24/2025: Missed 4:00 PM dose. - 09/25/2025 – 09/28/2025: No doses administered. - 09/29/2025: Missed 8:00 AM dose. The facility failed to provide a safe medication administration system to ensure AV's pain medications were administered as ordered which resulted in AV experiencing continued pain and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse

• April 8, 2025: Failed to provide a safe medication administration system Abuse: Neglect; Level 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance; 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

  The facility failed to provide a safe medication administration system to ensure The Alleged Victim’s (AV) medications were administered as ordered. On or about August 7, 2025, AV told facility staff that he/she was feeling increased pain and discomfort. AV's medical provider was contacted due to AV's complaint which resulted in AV's medical provider sending a nurse to the facility to assess AV. The nurse reviewed AV's medications, and it was determined that AV's diuretic medication was not being administered as ordered. After consultation with the AV's medical provider, AV was administered a double dose of his/her diuretic medication. AV continued to experience pain, discomfort, and difficulty breathing. In the early morning hours of April 8, 2025, AV requested to be sent out to the hospital. AV was admitted to the hospital for worsening renal function, swelling, and discomfort. Based on facility documentation and interviews, AV was prescribed his/her diuretic medication on March 25, 2025. The order was not properly processed by facility staff and did not get added to AV's MAR. The delay in administering AV's diuretic medication resulted in unreasonable discomfort and continued pain lasting longer than 24 hours due to fluid retention symptoms. The facility's failure to provide a safe medication administration system for AV is a violation of resident rights, is considered neglect of care and constitutes abuse.

• August 2, 2024: Failed to provide safe environment Abuse: Neglect; Level 3 - Moderate harm or potential for serious 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)
  State’s findings

  AV is a resident of the facility and is under the care of the facility. On or about August 2, 2024, Alleged Victim (AV) experienced a fall in their room. Based on facility documentation and interviews, AV used their pendant to call for assistance and staff did not arrive to AV's room to assist AV for over 40 minutes. It was reported that staff only responded when a nurse from AV's medical provider called the facility's front desk to request assistance for AV. AV experienced pain, frustration, and discomfort throughout the period AV was on the ground unattended. The facility was short staffed during the time of AV's fall. Staff responsible for providing care reported not having access to equipment to monitor resident calls in the period that AV was waiting for assistance. The facility's failure to respond to AV's call for assistance following a fall in a timely manner, resulted in unreasonable discomfort which is a violation of resident rights, is considered neglect of care which constitutes abuse.

• May 30, 2022: Failed to provide a safe medication administration system Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $250.00; report
  Rules: 411-054-0025 (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 pain medication stolen by an unknown individual and this person is responsible for theft of medications, which is considered financial exploitation and constitutes abuse. The facility failed to provide a safe medication administration system resulting in AV's loss of medication which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• January 9, 2026: 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); 411-054-0055 (Medications and Treatments)
  State’s findings

  On January 9, 2026, Alleged Perpetrator 2 (AP2) made a medication administration error involving the Alleged Victim’s (AV) prescribed narcotic pain medication. Facility documentation and interviews show that AP2 administered 2.5 mg instead of the prescribed 5 mg after inadvertently selecting medication from the incorrect bubble pack. As a result of receiving the incorrect dosage, AV complained of pain and experienced disturbed sleep due to breakthrough discomfort. During the interview, AP2 stated that the error occurred because he/she was fatigued after working a 15-hour shift on the day of the incident and was distracted while simultaneously investigating another facility matter. AP2 did not report any concerns related to training, competency, or unfamiliarity with the medication that contributed to the error. The facility was short-staffed that day due to another employee calling out, and AP2 had volunteered to stay and assist with medication administration. AP2’s failure to administer the correct dosage of AV’s prescribed narcotic pain medication resulted in unreasonable discomfort to AV. AP2's actions is considered neglect of care which constitutes abuse. The facility failed to provide a safe medication administration for AV which is a violation of Oregon Administrative Rules.

• July 8, 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); 411-054-0055 (Medications and Treatments)
  State’s findings

  Alleged Victim (AV) had two medication errors that occurred by facility staff in less than a three-week time period. First Medication Error: On or about June 20, 2024, Alleged Perpetrator 2 (AP2) failed to ensure Alleged Victim (AV) received his/her medication(s) as ordered. Based on facility documentation and interviews, AP2 administered multiple medications in error that caused AV to experience adverse side effects resulting in unreasonable discomfort. During the investigation, AP2 stated that he/she was properly trained to administer medication by the facility and admitted that he/she was distracted at time of incident. AP2's actions is considered neglect of care which constitutes abuse. Second Medication Error: On or about July 8, 2024, Alleged Perpetrator 3 (AP3) failed to ensure the same AV received his/her medication(s) as ordered. Based on facility documentation and interviews, AP3 administered incorrect narcotic medication to AV which resulted in risk of harm to AV because the medication could have negatively interacted with the medication administered to AV in the prior 24 hours before incident. During the investigation, AP3 stated that he/she was properly trained to administer medication by the facility and admitted that he/she was distracted at time of incident. AP3's actions is considered neglect of care which constitutes abuse. The facility failed to ensure AV's medication were properly administered on both June 20, 2024, and July 8, 2024. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.

• February 16, 2024: Failed to provide a safe medication administration system Licensing Violation; Level 3 - Moderate harm or potential for serious harm; report
  Rules: 411-054-0025 (Facility Administration)
  State’s findings

  On or about February 16, 2024, Alleged Perpetrator 2 (AP2) administered another resident's medication to Alleged Victim (AV) in error. Based on facility documentation and interviews, AP2 did not follow the protocol for placing medication cups into resident-specific dividers on the medication cart and did not verify if the medication cup was for the correct resident before administering it to AV. As a result of AP2's error, AV became ill, appeared pale, and complained of dry heaves. AV was sent out to the hospital and was diagnosed with accidental medicine ingestion. AV experienced sedation and dizziness due to the accidental medication ingestion. AP2's actions caused AV unreasonable discomfort which is considered neglect of care and constitutes abuse. The facility failed to ensure a safe medication administration system which is a violation of Oregon Administrative Rules.

• December 14, 2023: 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

  Alleged Perpetrator 2 (AP2) financially exploited Alleged Victim (AV) by taking funds belonging to AV. Based on facility documentation and interviews, AP2 endorsed and deposited a check issued to AV in the amount $200.00 into a bank account that was not AV's on December 14, 2023. AP2 is responsible for financial exploitation. The facility failed to protect AV from financial exploitation which is a violation of Oregon Administrative Rules.

• July 8, 2022: Failed to provide a safe medication administration system Licensing Violation; Level 3 - Moderate harm or potential for serious harm; report
  Rules: 411-054-0025 (Facility Administration)
  State’s findings

  On or about July 7, 2022, Alleged Perpetrator 2 (AP2) failed to administer the Alleged Victim's (AV) medication as ordered, causing AV to be sent to the hospital for treatment. AP2 is responsible for neglect of care which constitutes abuse. The facility failed to provide a safe medication administration system 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 89 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.