Liberty Pointe

Last inspection

December 4, 2025

Inspections

4, 11 deficiencies cited

Substantiated abuse

6

Substantiated licensing violations

4

Regulatory actions

1

Fines assessed

$1,813.00 (5 violations)

Current owner since

October 1, 2018

License conditions and other regulatory actions

• August 11, 2025 to October 6, 2025: License Condition, Failed to provide a safe medication administration system RCFCD25-00913; incident: CALMS - 00085374
  The following statement of violation(s) stem from preliminary evidence and interviews collected from Adult Protective Services (APS) Investigation #00418019 opened August 4, 2025, and Licensing Complaint Unit (LCU) Investigation #CC-59442 opened on August 6, 2025.
  Rules: 411-054-0025 (Facility Administration); 411-054-0055 (Medications and Treatments)

Inspections

• December 4, 2025: Re-Licensure, 2 deficiencies cited report
  • C0260: Service Plan: General severity level 2, scope L2 Pattern
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Isolated
• May 20, 2024: Complaint Investig., 1 deficiency cited report
  • C0010: Licensing Complaint Investigation severity level 2, scope L2 Isolated
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Isolated
• October 6, 2023: State Licensure, 2 deficiencies cited report
  • C0000: Comment severity level 0
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread, corrected February 5, 2024
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread, corrected February 5, 2024
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected February 5, 2024
• October 10, 2022: Validation, 6 deficiencies cited report
  • C0000: Comment severity level 0
  • C0154: Facility Administration: Policy & Procedure severity level 2, scope L2 Pattern, corrected December 5, 2022
  • C0260: Service Plan: General severity level 2, scope L2 Pattern, corrected December 5, 2022
  • C0295: Infection Prevention & Control severity level 2, scope L2 Widespread, corrected December 5, 2022
  • C0310: Systems: Medication Administration severity level 2, scope L2 Isolated, corrected December 5, 2022
  • Z0162: Compliance With Rules Health Care severity level 2, scope L2 Widespread, corrected December 5, 2022
  • Z0165: Behavior severity level 2, scope L2 Isolated, corrected December 5, 2022

Substantiated abuse or neglect

• February 1, 2025: Failed to provide safe environment Abuse: Neglect; Level 2 - Minor harm or potential for moderate 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)
  State’s findings

  Alleged Victim (AV) has a history of elopements. AV is known to attempt to open all doors. On or about February 1, 2025, video footage showed AV ambulating towards the back door of the memory care area. Minutes later, Witness 3 (W3) observed AV to be standing near the unsecured maintenance room, which was located outside of the memory care area. W3 redirected AV back into the memory care area. AV was assessed and did not have any injuries. AV did not appear to be in distress. The facility failed to provide a safe environment, resulting in AV eloping from the secure memory care unit, which is violation of resident’s rights, is considered neglect of care and constitutes abuse.

• May 3, 2024: 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); 411-054-0200 (Residential Care Facility Building Requirements)
  State’s findings

  The Alleged Victim (AV) has exit seeking behaviors and is an elopement risk. AV is known to push on locked doors with force, to open them. According to an investigation, on or about May 3, 2024, AV forcefully pushed on a door and was found outside in the non-secured courtyard, resulting in unreasonable discomfort. It was also discovered the door AV exited through was known to close slowly with the potential to not latch properly. The facility failed to provide a safe environment, which is a violation of resident’s rights, is neglect of care and constitutes abuse.

• January 20, 2024: Failed to follow care plan 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); 411-054-0036 (Service Plan – General)
  State’s findings

  The Alleged Victim (AV) is care planned to have a fall mat next to his/her bed. According to an investigation, on or about January 20, 2024, AV rolled out of bed, which resulted in a bump to his/her left eyebrow. It was discovered that the fall mat was not next to AV’s bed at the time of the fall. The facility failed to follow care plan, which is a violation of resident’s rights, is neglect of care and constitutes abuse.

• August 27, 2023: Failed to protect resident from inappropriate sexual contact 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

  Witness 1 (W1) had a known history of sexually inappropriate behaviors. According to an investigation, on or about August 27, 2023, W1 was found in the Alleged Victim’s (AV) room engaging in inappropriate sexual contact with the AV. The facility failed to provide a safe environment for AV by failing to protect AV from W1's sexualized behavior, which is a violation of resident rights, is neglect of care and constitutes abuse.

• July 25, 2023: Failed to provide safe environment Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0025 (Facility Administration)
  State’s findings

  The facility failed to provide a safe environment which resulted in the Alleged Victim (AV) eloping without injury. The failure is a violation of Oregon Administrative Rules.

• March 5, 2022: Failed to protect resident from financial exploitation Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $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 AV’s medication orders were documented, secured, and administered as ordered. On or about March 5, 2022, it was discovered some of AV’s medication was missing and s/he was not getting the appropriate doses, causing ongoing pain and financial exploitation, by way of theft. An unknown perpetrator 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.

Substantiated licensing violations

• August 3, 2025: Failed to administer medication as ordered Licensing Violation; Level 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0055 (Medications and Treatments)
  State’s findings

  The facility failed to carry out medication orders as prescribed. The facility's failure is a violation of Oregon Administrative Rules.

• January 13, 2023: 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.

• July 22, 2022: Failed to follow care plan Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0025 (Facility Administration)
  State’s findings

  The Alleged Victim (AV) has history of physical aggression, and resists to cares. AV has successful interventions in place for behaviors that include taking time with AV, building trust and AV doing well when given 1:1 attention. According to an investigation and camera review on or about July 22, 2022, Alleged Perpetrator 2 (AP2) and Alleged Perpetrator 3 (AP3) were attempting to assist AV with incontinence care and brief change. AV was uncooperative and refused care. AP2 and AP3 inappropriately responded to AV refusal of care by laughing at AV and treating AV in a negative manner, resulting in an increase of AV behaviors, which is considered verbal/emotional abuse. The facility failed to protect AV from verbal/emotional abuse which is a violation of Oregon Administrative Rules.

• February 1, 2022: Failed to provide safe environment Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0036 (Service Plan – General)
  State’s findings

  The facility failed to have the service plan readily available to staff. 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 55 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.