Assisted Living
Lone Oak Assisted Living Facility
2615 Lone Oak Way, Eugene, OR 97404 · Map
Licensed for 85 residents
Lone Oak Assisted Living Facility is a state-licensed assisted living community in Eugene, Oregon. It is licensed for 85 residents. Lilisity publishes no score or ranking for this community; the details below come from the state licensing record.
Prices
This community does not publish its prices.
Area costs
Lilisity’s independent report
What the public record shows
Gathered by Lilisity from state and federal sources. Communities can’t edit this part of the page.
State inspections
Last inspection: Aug 16, 2024. See the record
License
Active, 85 residents
Assisted Living Facility 70M242.
Nearest emergency room
5.0 miles
Sacred Heart Medical Center - Riverbend, rated 4 of 5 stars by CMS.
Side by side with nearby communities
The 4 nearest communities that offer assisted living, by straight-line distance. Prices are starting prices each community publishes; we never show estimates.
| Community | Distance | Licensed capacity | Published starting price | License | Inspection citations |
|---|---|---|---|---|---|
| Lone Oak Assisted Living Facility this community | 85 | Not published | Active | 33 deficiencies, 35 violations | |
| Mckenzie Living Eugene | 0.0 mi | 58 | Not published | Active | 17 deficiencies, 18 violations |
| Quail Crest Memory Care | 0.1 mi | 80 | Not published | Active | 29 deficiencies, 12 violations |
| River Grove Memory Care | 0.2 mi | 60 | $6,564/mo | Active | 14 deficiencies, 30 violations |
| Trustwell Living at River Run Place | 1.4 mi | Not listed | Not published | Active | 29 deficiencies, 15 violations |
State inspection record33 deficiencies, 35 violations
- Last inspection
- August 16, 2024
- Inspections
- 8, 33 deficiencies cited
- Substantiated abuse
- 10
- Substantiated licensing violations
- 25
- Regulatory actions
- 2
- Fines assessed
- $2,169.00 (7 violations)
- Current owner since
- February 1, 2024
- Every deficiency from the August 16, 2024 inspection was corrected by January 17, 2025
License conditions and other regulatory actions
- July 25, 2025 to October 14, 2025: License Condition, Failed to use an ABST ALFCD25-00354; 4 incidents: CALMS - 00086069, CALMS - 00086067, CALMS - 00086056, CALMS - 00084224
The facility failed to carry out medication and treatment orders as prescribed in accordance with OAR 411-054-0055(1)(f) per a complaint that the facility did not follow the orders from the primary care provider to monitor the resident's weight and blood pressure.
Rules: 411-054-0036 (Service Plan – General); 411-054-0037 (Acuity-Based Staffing Tool); 411-054-0055 (Medications and Treatments) - July 17, 2023 to January 4, 2024: License Condition, Failed to use an ABST ALFCD23-00425; incident: OR0003960300
The facility failed to fully implement an Acuity Based Staffing Tool in accordance with OAR 411-054-0037(1).
Rules: 411-054-0037 (Acuity-Based Staffing Tool)
Inspections
- August 16, 2024: 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 January 17, 2025
- C0370: Staffing Requirements and Training – Pre-Serv severity level 2, scope L2 Pattern, corrected October 15, 2024
- C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread, corrected January 17, 2025
- June 18, 2024: Complaint Investig., 4 deficiencies cited report
- C0200: Resident Rights and Protection - General severity level 2, scope L2 Pattern
- C0260: Service Plan: General severity level 2, scope L2 Isolated
- C0303: Systems: Treatment Orders severity level 2, scope L2 Isolated
- C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Widespread
- November 2, 2023: Complaint Investig., 3 deficiencies cited report
- C0010: Licensing Complaint Investigation severity level 2, scope L2 Isolated
- C0302: Systems: Tracking Control Substances severity level 2, scope L2 Isolated
- C0303: Systems: Treatment Orders severity level 2, scope L2 Isolated
- C0613: General Building: Doors-Walls, Cleanable severity level 2, scope L2 Isolated
- October 2, 2023: Validation, 19 deficiencies cited report
- C0000: Comment severity level 0
- C0150: Facility Administration: Operation severity level 2, scope L2 Widespread
- C0252: Resident Move-In and Eval: Res Evaluation severity level 2, scope L2 Isolated
- C0260: Service Plan: General severity level 2, scope L2 Pattern
- C0262: Service Plan: Service Planning Team severity level 2, scope L2 Pattern
- C0270: Change of Condition and Monitoring severity level 2, scope L2 Isolated
- C0280: Resident Health Services severity level 2, scope L2 Isolated
- C0295: Infection Prevention & Control severity level 2, scope L2 Widespread
- C0303: Systems: Treatment Orders severity level 2, scope L2 Pattern
- C0305: Systems: Resident Right to Refuse severity level 2, scope L2 Pattern
- C0310: Systems: Medication Administration severity level 2, scope L2 Pattern
- C0325: Systems: Self-Administration of Meds severity level 2, scope L2 Isolated
- C0340: Restraints and Supportive Devices severity level 2, scope L2 Isolated
- C0372: Training Within 30 Days: Direct Care Staff severity level 2, scope L2 Pattern
- C0374: Annual and Biennial Inservice For All Staff severity level 2, scope L2 Pattern
- C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread
- C0422: Fire and Life Safety: Training For Residents severity level 2, scope L2 Widespread
- C0610: General Building Exterior severity level 2, scope L2 Widespread
- C0613: General Building: Doors-Walls, Cleanable severity level 2, scope L2 Widespread
- C0655: Call System severity level 2, scope L2 Widespread
- April 14, 2023: Complaint Investig., 1 deficiency cited report
- C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Widespread
Show all 8
- November 16, 2022: State Licensure, 0 deficiencies cited report
- C0000: Comment severity level 0
- September 27, 2022: Complaint Investig., 3 deficiencies cited report
- C0010: Licensing Complaint Investigation severity level 2, scope L2 Isolated
- C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Isolated
- C0360: Staffing Requirements and Training: Staffing severity level 2, scope L2 Isolated
- C0370: Staffing Requirements and Training – Pre-Serv severity level 2, scope L2 Isolated
- August 10, 2022: Complaint Investig., 1 deficiency cited report
- C0010: Licensing Complaint Investigation severity level 2, scope L2 Isolated
- C0303: Systems: Treatment Orders severity level 2, scope L2 Isolated
Substantiated abuse or neglect
- May 18, 2024: Failed to provide service 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); 411-054-0070 (Staffing Requirements and Training)State’s findings
The Alleged Victim (AV) relies on the facility for his/her care. AV was care planned for assistance when transferring to and from bed in the morning and evening. According to an investigation, on or about May 18, 2024, AV pressed his/her call light for assistance to get out of bed, which went unanswered due to lack of staffing, resulting in AV transferring AV’s self to go to breakfast independently. It was also discovered that AV was not receive walks when requested due to lack of staffing. The facility failed to provide appropriate services, posing a serious risk of harm to AV, which is a violation of resident rights, is neglect of care which constitutes abuse.
- April 29, 2024: Failed to provide service Abuse: Neglect; Level 3 - Moderate harm or potential for serious 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); 411-054-0036 (Service Plan – General)State’s findings
The facility failed to provide appropriate services according to Alleged Victim’s needs, relating to care planning and lack of appropriate interventions. The Alleged Victim (AV) was care planned as a fall risk and known to forget to use his/her walker. On or about April 29, 2024, AV had an unwitnessed fall in his/her room and was sent to the hospital for evaluation. On or about May 10, 2024, AV was sent back to the hospital due to persistent pain, where it was determined that AV had sustained three fractured ribs. On or about May 13, 2024, AV was not using his/her walker and told staff that he/she fell, and his/her back was hurting. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.
- September 6, 2023: Failed to provide inservice Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; 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
The facility failed to conduct an internal investigation into allegations of sexual abuse of the Alleged Victim (AV) by a staff member, placing AV at risk for harm. The facility failure is a violation of resident rights, is considered neglect of care and constitutes abuse.
- September 6, 2023: Failed to protect resident from financial exploitation Abuse: Financial Exploitation; Level 2 - Minor harm or potential for moderate harm; 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
The Alleged Victim (AV) gave pens to Alleged Perpetrator #2 (AP2) to give to his/her child for their birthday. AP2 accepted the pens from AV, which is a violation of facility policy. AP2's actions are a violation of resident rights, are considered neglect of care and constitute financial abuse. The facility failed to have a specific definition in policy about accepting gifts from residents, leaving some staff confused. The facility failure is a violation of resident rights, is considered neglect of care and constitutes abuse.
- August 31, 2023: Failed to administer medication as ordered Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; 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 Alleged Victim (AV) relies on the facility to manage his/her medications. The facility failed to provide a safe medication administration system to ensure Alleged Victim (AV)’s pain medication was administered as ordered, resulting in AV experiencing unreasonable discomfort. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.
Show all 10
- November 4, 2022: Failed to properly plan care 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); 411-054-0036 (Service Plan – General)State’s findings
The Alleged Victim (AV) had a known history of falls and was care planned for frequent checks. On or about November 4, 2022, AV was found on the ground in his/her room with a skin tear, his/her wrist hurt and he/she was confused. AV was sent to the hospital and was diagnosed with a broken wrist. After this fall, the facility put into place a change of condition and updated his/her care plan, however, did not put into place person specific interventions to anticipate AV's needs to reduce the risk of falls. AV suffered two additional falls, one with injury and one without. The facility's failure to properly care plan is a violation of resident rights, is considered neglect of care and constitutes abuse.
- October 29, 2022: 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
On or about October 29, 2022, the Alleged Victim (AV) suffered a fall resulting in a laceration that required staples. The facility failed to implement interventions after AV's October 29, 2022 fall, leading to additional falls with injury. AV experienced a significant change of condition, including an unsteady gait, increased weakness and confusion, and complaints of pain. AV was later diagnosed with a hairline fracture to the right hip. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.
- September 7, 2022: Failed to answer call light in a timely manner 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); 411-054-0030 (Resident Services); 411-054-0070 (Staffing Requirements and Training)State’s findings
The facility failed to respond timely to the Alleged Victim's (AV) call for assistance. Multiple times, AV had to wait in excess of 20 minutes for assistance, causing AV unreasonable discomfort. The facility failure to timely answer call lights is a violation of resident rights, is considered neglect of care and constitutes abuse.
- August 20, 2022: Failed to provide safe environment 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)State’s findings
On or about June 23, 2022, the Alleged Victim (AV) received a package at the facility, which was signed for by facility staff, but was not delivered to AV. AV's package went missing. AV's package was taken by an unknown individual, Alleged Perpetrator #2 (AP2). AP2's actions are a violation of resident rights, are considered neglect of care and constitute financial abuse. The facility failed to have policies and procedures in place to ensure the safety of resident belongings, which is a violation of resident rights, is considered neglect of care and constitute abuse.
- April 27, 2022: Failed to provide a safe medication administration system Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $169.00; 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) receives pain medication daily for pain management. On or about April 27, 2022, Alleged Perpetrator #3 (AP3) was passing medication and AV did not have any pain medication available to give. Alleged Perpetrator #2 (AP2) had given AV the last of the pain medication and failed to re-order, leaving AV without any pain medication, leaving AV in unnecessary pain. AP2's actions are a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
Substantiated licensing violations
- July 7, 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 develop, maintain, and implement an Acuity Based Staffing Tool. The facility’s failure is a violation of Oregon Administrative Rules.
- May 11, 2025: Failed to use an ABST Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
State’s findings
The facility allegedly failed to develop, maintain, and implement an Acuity Based Staffing Tool. The facility’s failure is a violation of Oregon Administrative Rules.
- May 21, 2024: Failed to provide medical treatment 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 and treatment orders as prescribed. An investigation determined this is a violation of Oregon Administrative Rules.
- May 21, 2024: Failed to assure resident rights Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
Rules: 411-054-0027 (Resident Rights and Protections)State’s findings
The facility failed to have medical and other records kept confidential except as otherwise provided by law. An investigation determined this is a violation of Oregon Administrative Rules.
- May 17, 2024: 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 fully implement and update an acuity-based staffing tool. An investigation determined this is a violation of Oregon Administrative Rules.
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- December 16, 2023: 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
The facility failed to provide a safe medication administration system for the Alleged Victim (AV). According to documentation, AV experienced no negative outcome. The failure is a violation of Oregon Administrative Rules.
- November 8, 2023: Failed to provide service 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 ensure the implementation of services. An investigation determined this is a violation of Oregon Administrative Rules.
- October 26, 2023: 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
The facility failed to ensure a system for tracking controlled substances and for disposal of all unused, outdated, or discontinued medications administered by the facility. An investigation determined this is a violation of Oregon Administrative Rules.
- October 13, 2023: Failed to maintain a safe physical environment Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
Rules: 411-054-0300 (Assisted Living Facility Building Requirements)State’s findings
The facility failed to keep all interior and exterior materials and surfaces (e.g. floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident must be kept clean and in good repair. An investigation determined this is a violation of Oregon Administrative Rules.
- October 7, 2023: 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
The facility failed to carry out medication orders as prescribed, per complaint that the resident received the wrong dose of their medication, which is a violation of Oregon Administrative Rules.
- September 6, 2023: 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); 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) requires a two person assist for transfers. Alleged Perpetrator #2 (AP2) attempted a single person transfer with AV, in which AP2 fell next to or on top of AV, causing a risk of harm. AP2's actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility's failure is a violation of Oregon Administrative Rules.
- September 6, 2023: 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
On or about September 6, 2023, the Alleged Victim (AV) gave Alleged Perpetrator #2 (AP2) approximately $60.00 to purchase alcohol for him/herself and AV. AV had gifted AP2 $40.00 the day before also. AP2's actions are a violation of resident rights, are considered neglect of care and constitute financial abuse. The facility's failure is a violation of Oregon Administrative Rules.
- December 6, 2022: 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
On or about December 2, 2022, it was discovered that the Alleged Victim's (AV) credit card had been being used without authorization. Alleged Perpetrator #2 (AP2) admitted to other staff that he/she took AV's credit card and used it to buy gas and snacks. AP2's actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility's failure to protect AV from financial abuse is a violation of Oregon Administrative Rules.
- November 1, 2022: Failed to submit timely or adequate staffing documentation Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
Rules: 411-061-0010State’s findings
On or about November 1, 2022, the Oregon Health Authority reported to the Department that Respondent failed to comply with weekly reporting requirements of vaccinated individuals, residents and staff, to the proper authority as required by law. This failure has been ongoing from October 1, 2022 to October 31, 2022, for a total of 30 days.
- September 16, 2022: Failed to follow care plan 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); 411-054-0036 (Service Plan – General)State’s findings
On or about September 16, 2022, the Alleged Victim (AV) was being assisted to the bathroom by Alleged Perpetrator #2 (AP2). AV is care planned to be assisted with a gait belt. AP2 did not have a gait belt, AV advised AP2 that he/she did have a gait belt for AP2 to use. AP2 declined to use the gait belt and assisted AV without one. During the course of assisting AV, AP2 and AV both fell, causing hip, leg and foot pain to AV. AP2's actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility's failure is a violation of Oregon Administrative Rules.
- September 13, 2022: Failed to provide appropriate staffing Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
Rules: 411-054-0070 (Staffing Requirements and Training)State’s findings
The facility failed to provide direct care staff sufficient in number to meet the scheduled and unscheduled needs of the residents, which is a violation of Oregon Administrative Rules.
- September 13, 2022: Failed to provide proper food/nutrition Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
Rules: 411-054-0030 (Resident Services)State’s findings
The facility failed to provide three daily nutritious, palatable meals. Residents are served fish that is still frozen, meatballs that were burnt and inedible, or steak that is so tough it is not edible. Residents are hungry and not being fed appropriate amounts of food, which is a violation of Oregon Administrative Rules.
- September 13, 2022: Failed to assure a qualified caregiver was present Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
Rules: 411-054-0070 (Staffing Requirements and Training)State’s findings
The facility failed to directly supervise staff until they have successfully demonstrated satisfactory performance in any task assigned, which is a violation of Oregon Administrative Rules.
- July 27, 2022: Failed to have medication available 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 Rules.
- June 10, 2022: Failed to provide service Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
Rules: 411-054-0030 (Resident Services)State’s findings
The facility failed to assist the resident in performing activities of daily living, which is a violation of Oregon Administrative Rules.
- May 19, 2022: Failed to provide a safe medication administration system Licensing Violation; Level 1 - No harm or potential for minor harm; report
Rules: 411-054-0055 (Medications and Treatments)State’s findings
The facility failed to carry out medication orders as prescribed
- April 27, 2022: Failed to provide a safe medication administration system Licensing Violation; Level 1 - No harm or potential for minor harm; report
Rules: 411-054-0055 (Medications and Treatments)State’s findings
The facility failed to carry out medication and treatment orders as prescribed
- April 1, 2022: Failed to protect resident from financial exploitation Licensing Violation; Level 3 - Moderate harm or potential for serious 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); 411-054-0055 (Medications and Treatments)State’s findings
On or about April 1, 2022, it was discovered that the Alleged Victim (AV) was missing pain pills from his/her prescription. Alleged Perpetrator #2 (AP2) counted AV's medication and reported that 15 pills were missing. AP2 is seen on camera counting the medication, then leaving the camera view with the medication, and can be heard opening the bottle and pills moving. AV self-administers his/her medication and it is not facility policy to count self-administer medications. AP2 later tested positive for the pain medication. AP2's actions are a violation of resident rights, are considered neglect of care and constitutes financial abuse. The facilities failure to protect AV from financial abuse is a violation of Oregon Administrative Rules.
- February 10, 2022: 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); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare)State’s findings
The facility and Alleged Perpetrator #2 (AP2) failed to provide a safe environment. On or about February 10, 2022, AP2 entered the community lounge where the Alleged Victim (AV) was. In an attempt to be playful, AP2 shot a nerf gun at AV, hitting him/her in the eye, causing injury to AV. AP2's actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facilities failure to provide a safe environment is a violation of Oregon Administrative Rules.
- November 1, 2021: Failed to provide a safe medication administration system Licensing Violation; Level 1 - No harm or potential for minor harm; report
Rules: 411-054-0055 (Medications and Treatments)State’s findings
The facility failed to carry out medication orders as prescribed
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 85 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.
License and ownershipActive license
- License type
- Assisted Living Facility
- License number
- 70M242
- License status
- Active
- Licensed capacity
- 85
- County
- Lane County
- Administrator
- Ivy Marchbanks
Source: Oregon state licensing records (agency listing), retrieved 2026-09-09. Licensing status is a matter of public record; it is not a quality rating.
Administrator name from public records we reviewed, as of Oct 12, 2026.
Paying with Medicaid and other programsOn the Oregon list of Medicaid providers (2026)
On the Oregon list of Medicaid providers. Listed as Lone Oak Assisted Living Facility under Accepts Medicaid (ODHS licensing record). (state list, as of Sep 9, 2026)
Being on the list means the community has taken part in the program. Ask whether it has a Medicaid opening now, and how many residents it serves on Medicaid.
Staff pay and workplace safety2 OSHA inspections, 3 violations cited
Federal records about how the employer here treats its staff.
OSHA workplace safety inspections
OSHA inspects workplaces for staff safety, such as lifting, needles, chemicals and workplace violence. It does not inspect resident care.
- Oct 23, 2024: programmed (planned) inspection, complete (safety). Case closed Aug 15, 2026. 1 violation cited (1 other). Penalties: $0 proposed, $0 now. OSHA record. OSHA recorded the employer as 317738254 - Lone Oak Al LLC.
Details
- Other than serious: Cited rule OAR. Penalty $0 proposed, $0 now. To be fixed by Jan 10, 2025.
- Sep 12, 2019: programmed (planned) inspection, complete (safety). Case closed Feb 26, 2020. 2 violations cited (2 other). Penalties: $0 proposed, $0 now. OSHA record. OSHA recorded the employer as 317725495 - Lone Oak Al LLC.
Details
- Other than serious: Electrical wiring methods and equipment (1910.305(g)(1)(iv)(a)). Penalty $0 proposed, $0 now. To be fixed by Nov 25, 2019.
- Other than serious: Cited rule OAR. Penalty $0 proposed, $0 now. To be fixed by Nov 25, 2019.
Source: U.S. Department of Labor OSHA enforcement data, as of Oct 15, 2026, inspections since 2016. Penalties can change while a case is open or contested.
Location and nearby careNearest hospital 5.0 mi, nursing home 1.7 mi, pharmacy 0.2 mi
- Nearest hospital with an emergency room
- Sacred Heart Medical Center - Riverbend, Springfield. 5.0 miles away, straight line. CMS overall hospital rating: 4 of 5 stars.
- Nearest Medicare nursing home
- Avamere Riverpark of Eugene, Eugene. 1.7 miles away, straight line.
- Nearest home health agency office
- Signature Healthcare At Home, Eugene. 0.5 miles away, straight line. Agencies travel to clients, so ask which ones serve this address.
- Nearest pharmacy
- Fred Meyer Pharmacy. 0.2 miles away, straight line. From OpenStreetMap, which does not list every pharmacy, so one may be closer.
- Area
- USDA classes ZIP code 97404 as metropolitan (metropolitan core).
- Dialysis within 15 miles
- Fmc Eugene, Eugene, 0.3 miles away, straight line (CMS rating 3 of 5 stars)
Fresenius Kidney Care West Eugene, Eugene, 3.9 miles away, straight line (CMS rating 2 of 5 stars)
Qualicenters - Eugene-Springfield Ltd, Springfield, 5.8 miles away, straight line (CMS rating 4 of 5 stars) - Hospice
- 6 Medicare hospices tell CMS they serve ZIP code 97404.
Serenity Hospice, office in Eugene, 1.5 miles away, straight line
Brighton Hospice, office in Eugene, 2.2 miles away, straight line (CMS family survey rating 4 of 5 stars)
Cascade Health, office in Eugene, 3.1 miles away, straight line (CMS family survey rating 4 of 5 stars) - Nearest geriatric medicine practice
- Peacehealth Medical Group, Eugene. 2.2 miles away, straight line. 2 geriatric medicine doctors listed there.
Distances are straight lines from the community, not driving distance. Hospitals, home health, dialysis, hospice and doctors come from CMS provider data (CMS, hospital list updated Jul 22, 2026). Star ratings are CMS’s own.
Emergency and natural hazard riskFEMA overall risk relatively moderate; outside FEMA's high-risk flood areas
Public hazard maps for this location. Ask the community about its emergency plan, its generator and where residents would go in an evacuation.
- Flood zone
- Outside the high and moderate risk flood areas on FEMA's flood map (Zone X, minimal flood hazard, or not studied). (FEMA flood map)
- FEMA National Risk Index
- Overall: relatively moderate. By hazard: inland flooding relatively high, wildfire very low, tornado very low, heat wave relatively moderate, earthquake relatively moderate. These are FEMA’s ratings for the census tract, compared with tracts nationwide. (FEMA, December 2025)
A flood zone describes the map at this point, not the building's elevation. In an emergency, follow the local emergency management agency.
Questions to ask on a tour10 questions picked for this community from its record
Picked for this community from its record. Ask them in person and write down the answers.
- The state recorded a finding in July 2025. What was it, and how was it fixed?
- What does the base rate include, and when did rates last go up?
- How many caregivers are on duty during the day and at night?
- What happens if care needs increase? When would someone need to move?
- What fees are charged at move-in?
- How do you tell families about falls, illness or changes?
- How long have the executive director and the head of care been here?
- Who gives medications, and what training do they have?
- For what reasons can a resident be asked to leave?
- Is the apartment held during a hospital stay, and at what cost?
What we checked12 public sources we searched, with dates
Every public source we searched for this community. “Nothing on record” means we found no record that matched it. A record can be missed when a name or address differs.
| Source | Data as of | What we found |
|---|---|---|
| Oregon Department of Human Services, Long-Term Care Licensing inspection records | Oct 15, 2026 | See above |
| Oregon Medicaid provider list | Sep 9, 2026 | See above |
| U.S. Department of Labor wage and hour cases | Oct 15, 2026 | Nothing on record |
| OSHA workplace safety inspections since 2016 | Oct 15, 2026 | See above |
| FEMA flood map | See above | |
| USDA wildfire risk | Apr 15, 2026 | Not shown: FEMA rates wildfire risk here very low |
| FEMA National Risk Index | See above | |
| CMS hospitals, home health, dialysis, hospice and doctors; OpenStreetMap pharmacies | See above | |
| HUD Multifamily Properties - Assisted | Jul 6, 2026 | Nothing on record |
| State Veterans Homes (NASVH directory) | Sep 20, 2026 | Nothing on record |
| CMS Hospice - General Information | Aug 19, 2026 | Nothing on record |
| CMS Home Health Care Agencies | May 27, 2026 | Nothing on record |
Common questionsAnswers to 4 questions families ask
What type of care does Lone Oak Assisted Living Facility provide?
Lone Oak Assisted Living Facility is licensed by the state of Oregon for assisted living in Eugene, Oregon. Its licensed capacity is 85 residents.
Does Lilisity rate Lone Oak Assisted Living Facility?
No. We publish state licensing details for Lone Oak Assisted Living Facility but no score, rating, or ranking. Only communities on the Top Communities list or with a Senior Living Alliance Excellence Award, both based on phone-verified resident and family interviews, are ranked.
How much does Lone Oak Assisted Living Facility cost?
Assisted Living in Oregon typically starts at $4,600 to $5,800 a month. Based on 108 communities that publish prices. These are area figures, not this community's price. Lone Oak Assisted Living Facility does not publish its prices.
How do I contact Lone Oak Assisted Living Facility?
Visit Lone Oak Assisted Living Facility at 2615 Lone Oak Way, Eugene, OR 97404.
How Lilisity works. The only scores or rankings Lilisity publishes are the Top Communities list and the Excellence Awards, both built from phone-verified resident and family interviews. Communities can pay Lilisity a flat monthly fee to manage their own listing: photos, prices, contact details, and receiving the inquiries families choose to send them. The fee is the same no matter how many families contact them or move in. Senior Living Alliance, which runs Lilisity, offers the same listing to its member communities as part of their membership; members pay SLA for its resident and family interview program. No community pays Lilisity per inquiry, per referral or per move-in. Payment never changes a testimonial, a rating, or the order of search results. The "Nearby Senior Living Alliance communities" box shows member communities only. How we verify testimonials · How we are paid