Mcloughlin Memory Care of Oregon

Last inspection

June 11, 2025

Inspections

5, 56 deficiencies cited

Substantiated abuse

14

Substantiated licensing violations

10

Regulatory actions

3

Fines assessed

$6,502.00 (14 violations)

Current owner since

May 1, 2023

License conditions and other regulatory actions

• June 9, 2025 to December 22, 2025: License Condition, Failed to meet the scheduled and unscheduled needs of residents RCFCD25-00592; 2 incidents: CALMS - 00082278, CALMS - 00080159
  The following statement of violation(s) stem from evidence and interviews collected from ODHS Survey Unit investigation #50R357 - RL004882 completed on June 11, 2025.
  Rules: 411-004-0020; 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); 411-054-0034 (Resident Move-In and Evaluation); 411-054-0036 (Service Plan – General); 411-054-0037 (Acuity-Based Staffing Tool); 411-054-0040 (Change of Condition and Monitoring); 411-054-0055 (Medications and Treatments); 411-054-0070 (Staffing Requirements and Training); 411-054-0090 (Fire and Life Safety); 411-054-0200 (Residential Care Facility Building Requirements); 411-057-0155 (Staff Training Requirements); 411-057-0160 (Resident Services in a Memory Care Community); 411-057-0170 (Physical Design, Environment, and Safety)
• May 7, 2024 to November 4, 2024: License Condition, Failed to provide safe environment RCFCD24-00426; 2 incidents: CALMS - 00055223, CALMS - 00049008
  The facility failed to operate in substantial compliance with Oregon Administrative Rules.
  Rules: 411-054-0025 (Facility Administration); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0034 (Resident Move-In and Evaluation); 411-054-0036 (Service Plan – General); 411-054-0040 (Change of Condition and Monitoring); 411-054-0055 (Medications and Treatments); 411-054-0070 (Staffing Requirements and Training); 411-054-0090 (Fire and Life Safety); 411-057-0155 (Staff Training Requirements)
• November 6, 2023 to April 10, 2024: License Condition, Failed to use an ABST RCFCD23-01336; incident: CALMS - 00048376
  The facility failed to implement an acuity-based staffing tool (ABST) that addressed all the following activities of daily living (ADLs) for each resident and the amount of staff time needed to provide care.
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)

Inspections

• June 11, 2025: Re-Licensure, 27 deficiencies cited report
  • C0152: Facility Administration: Required Postings severity level 2, scope L2 Widespread
  • C0160: Reasonable Precautions severity level 2, scope L2 Pattern
  • C0200: Resident Rights and Protection - General severity level 2, scope L2 Isolated
  • 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
  Show all 28

  • 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 Pattern
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Pattern
  • C0310: Systems: Medication Administration severity level 2, scope L2 Pattern
  • C0360: Staffing Requirements and Training: Staffing severity level 2, scope L2 Widespread
  • C0362: Acuity Based Staffing Tool - ABST Time severity level 2, scope L2 Isolated
  • C0363: Acuity Based Staffing Tool - Updates & Staffing Plan severity level 2, scope L2 Isolated
  • C0372: Training Within 30 Days of Hire ? Direct Care 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
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Pattern
  • C0510: General Building Exterior severity level 2, scope L2 Widespread
  • C0513: Doors, Walls, Elevators, Odors severity level 2, scope L2 Widespread
  • H1510: Individual Rights Settings: Privacy, Dignity severity level 2, scope L2 Isolated
  • H1518: Individual Door Locks: Key Access severity level 2, scope L2 Pattern
  • L0152: Facility Administration: Required Postings severity level 2, scope L2 Widespread
  • L0252: Resident Move-in & Evaluation: Res Evaluation severity level 2, scope L2 Pattern
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread
  • Z0155: Staff Training Requirements severity level 2, scope L2 Pattern
  • Z0162: Compliance with Rules Health Care severity level 2, scope L2 Pattern
  • Z0163: Nutrition and Hydration severity level 2, scope L2 Isolated
  • Z0176: Resident Rooms severity level 2, scope L2 Pattern
• June 4, 2025: Complaint Investig., 1 deficiency cited report
  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Isolated
• May 13, 2025: Kitchen, 2 deficiencies cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread
• October 9, 2023: Validation, 24 deficiencies cited report
  • C0000: Comment severity level 0
  • C0152: Facility Administration: Required Postings severity level 2, scope L2 Widespread, corrected December 10, 2023
  • C0155: Facility Administration: Records severity level 2, scope L2 Widespread, corrected December 10, 2023
  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Isolated, corrected September 27, 2024
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread, corrected December 10, 2023
  Show all 27

  • C0252: Resident Move-In and Eval: Res Evaluation severity level 2, scope L2 Isolated, corrected May 5, 2024
  • C0260: Service Plan: General severity level 2, scope L2 Pattern, corrected May 5, 2024
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Pattern, corrected September 27, 2024
  • C0280: Resident Health Services severity level 2, scope L2 Isolated, corrected December 10, 2023
  • C0295: Infection Prevention & Control severity level 2, scope L2 Widespread, corrected December 10, 2023
  • C0300: Systems: Medications and Treatments severity level 2, scope L2 Widespread, corrected December 10, 2023
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Pattern, corrected December 10, 2023
  • C0310: Systems: Medication Administration severity level 2, scope L2 Pattern, corrected May 5, 2024
  • C0330: Systems: Psychotropic Medication severity level 2, scope L2 Isolated, corrected December 10, 2023
  • C0350: Administrator Qualification and Requirements severity level 2, scope L2 Widespread, corrected December 10, 2023
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Widespread, corrected December 10, 2023
  • C0372: Training Within 30 Days: Direct Care Staff severity level 2, scope L2 Pattern, corrected May 5, 2024
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread, corrected September 27, 2024
  • C0422: Fire and Life Safety: Training For Residents severity level 2, scope L2 Widespread, corrected December 10, 2023
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread, corrected September 27, 2024
  • C0513: Doors, Walls, Elevators, Odors severity level 2, scope L2 Widespread, corrected May 5, 2024
  • C0530: Housekeeping and Laundry severity level 2, scope L2 Widespread, corrected December 10, 2023
  • C0545: Plumbing Systems severity level 2, scope L2 Widespread, corrected May 5, 2024
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected September 27, 2024
  • Z0155: Staff Training Requirements severity level 2, scope L2 Pattern, corrected May 5, 2024
  • Z0162: Compliance With Rules Health Care severity level 2, scope L2 Widespread, corrected September 27, 2024
  • Z0164: Activities severity level 2, scope L2 Pattern, corrected May 5, 2024
• September 14, 2022: 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 September 19, 2022
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected September 19, 2022

Substantiated abuse or neglect

• October 4, 2025: Failed to administer medication as ordered 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); 411-054-0055 (Medications and Treatments)
  State’s findings

  Alleged Victim (AV) requires medication assistance, including medication administration, per AV’s service plan. AV was prescribed antibiotics on or about October 4, 2025, with a start date of October 5, 2025, which was to be taken four (4) times a day for seven (7) days. On or about October 11, 2025, six (6) antibiotic pills were remaining despite being the last day of the prescription. Respondent failed to administer prescribed medication, and to ensure the safety of AV. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

• August 17, 2025: Failed to properly plan care 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); 411-054-0036 (Service Plan – General)
  State’s findings

  Alleged Victim (AV) relies on the facility for his/her care. On or about August 17, 2025, at around 7:20 PM, AV fell while walking laps. AV had three (3) prior falls in the past 90 days. On or about August 5, 2025, physical therapy identified AV as a high fall risk and AV was to have supervision at all times. AV was not being supervised when walking laps and was found on the ground. Respondent failed to update AV's service plan noting AV is at a high risk for falls and should have supervision at all times, and to ensure the safety of AV. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

• June 11, 2025: Failed to provide a safe medication administration system Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $1,500.00; 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) suffered a fractured ankle on June 7, 2025, which was causing AV increased pain. On or about June 9, 2025, due to increased pain, hospice increased AV's pain medication. Staff thought that hospice canceled AV's current medication and did not have the new order for AV's pain medication. When staff checked for the new order, later it was discovered that the fax machine had been unplugged, therefore, hospices new order could not get through. Hospice did not cancel the current order and staff could have given AV pain medication through the old medication order. AV went without pain medication for at least 5 hours, leaving AV in pain and unreasonable discomfort. Respondent failed to provide a safe medication administration system. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(ii).

• January 18, 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)
  State’s findings

  The Alleged Victim (AV) was a new admission; however, AV was identified as an elopement risk upon admission. On or about January 17, 2025, AV eloped from the facility. The door to the facility does not latch closed for approximately 5-8 seconds after being closed. At the time of the incident, the door to the unit was not being monitored to ensure it was securely latched. It is unknown how long AV was outside of the facility. Respondent failed to ensure a safe environment and ensure that staff were aware that AV was an elopement risk, placing AV at risk for harm. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(ii).

• October 7, 2024: Failed to properly plan care 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

  The Alleged Victim (AV) has a history of wandering into Witness #1's (W1) and other residents rooms. On or about October 7, 2024, AV wandered into W1's room and sat on his/her bed. W1 yelled at AV to leave and AV did not respond. W1 became upset and grabbed AV by the hair and was pulling AV's hair when staff arrived. Neither resident was harmed, however, both were placed at risk for harm. Respondent failed to ensure AV's service plan was updated to ensure the safety of AV and other residents. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

Substantiated licensing violations

• July 26, 2026: 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

  Based on interview and record review conducted during a site visit on 09/01/26 the facility’s failure to ensure a written description is available of who shall provide the services and what, when, how, and how often the services shall be provided for 2 of 2 sampled residents was substantiated, which is a violation of Oregon Administrative Rules.

• March 21, 2025: Failed to assure resident rights 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) relies on facility staff to ensure resident’s rights. According to an investigation, on or about March 21, 2025, The AV was wrongfully restrained by Alleged Perpetrator 2 (AP2). The AV was seated as a table in a wheelchair. AP2 wedged the back of a dining room chair a under the wheelchair handles, restraining the AV. Alleged Perpetrator 3 (AP3) and Alleged Perpetrator 4 (AP4) were working the same shift an aware of the restraint of the AV and failed to take action. AP2, AP3 and AP4’s actions are considered neglect and constitutes abuse. The facility did not keep AV free from wrongful restraint, which is a violation of Oregon Administrative rules.

• November 18, 2024: 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 failed to obtain background checks on all subject individuals in accordance with OAR 411-054-0025(1)(d) per complaint staff working without a background check, which is a violation of Oregon Administrative Rules.

• September 17, 2024: Failed to make facility or resident records accessible Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0105 (Inspections and Investigations)
  State’s findings

  Based on interview and record review, conducted during an investigation on 06/09/26, the facility’s failure to provide records to the Department upon request was substantiated, which is a violation of Oregon Administrative Rules.

• September 14, 2024: Failed to make facility or resident records accessible Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0105 (Inspections and Investigations)
  State’s findings

  Based on interview and record review, conducted during an investigation on 06/09/26, the facility's failure to provide records to the Department upon request was substantiated, which is a violation of Oregon Administration 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 28 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.