Mcloughlin Place Senior Living

Last inspection

May 27, 2025

Inspections

8, 56 deficiencies cited

Substantiated abuse

21

Substantiated licensing violations

19

Regulatory actions

3

Fines assessed

$9,813.00 (19 violations)

Current owner since

May 1, 2023

License conditions and other regulatory actions

• April 25, 2025 to December 2, 2025: License Condition, Failed to provide safe environment ALFCD25-00177; incident: CALMS - 00077582
  The following statement of violation(s) stem from evidence and/or interviews collected from a Report of Serious Event (ROSE) which was received on or about April 23, 2025, a Licensing Complaint Unit (LCU) visit conducted on or about April 24, 2025, and the Community Base Care Survey Unit completed a re-licensure visit (survey #004472) which found the facility to not be in substantial compliance with Oregon Administrative Rules.
  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); 411-054-0034 (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)
• May 7, 2024 to October 29, 2024: License Condition, Failed to provide safe environment ALFCD24-00155; incident: CALMS - 00054958
  The facility failed to operate in substantial compliance with Oregon Administrative Rules.
  Rules: 411-054-0034 (Resident Move-In and Evaluation); 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); 411-054-0105 (Inspections and Investigations)
• October 25, 2022 to April 10, 2024: License Condition, Failed to use an ABST ALFCD22-00934; incident: OR0003704401
  Facility failure to adopt an acuity-based staffing tool (ABST) to determine appropriate staffing levels for the facility per OAR 411-054-0037(1).
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)

Inspections

• May 27, 2025: Re-Licensure, 27 deficiencies cited report
  • C0150: Facility Administration: Operation severity level 4, scope L4 Widespread
  • C0154: Facility Administration: Policy & Procedure severity level 2, scope L2 Pattern
  • C0156: Facility Administration: Quality Improvement severity level 2, scope L2 Widespread
  • C0160: Reasonable Precautions severity level 4, scope L4 Pattern
  • C0200: Resident Rights and Protection - General severity level 4, scope L4 Pattern
  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Pattern
  • C0252: Resident Move-in & Evaluation: Res Evaluation severity level 2, scope L2 Pattern
  • 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 4, scope L4 Isolated
  • C0300: Systems: Medications and Treatments severity level 4, scope L4 Pattern
  • C0301: Systems: Medication Administration severity level 2, scope L2 Pattern
  • C0302: Systems: Tracking Control Substances severity level 3, scope L3 Isolated
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Pattern
  • C0305: Systems: Resident Right to Refuse severity level 2, scope L2 Isolated
  • C0360: Staffing Requirements and Training: Staffing severity level 4, scope L4 Widespread
  • C0362: Acuity Based Staffing Tool - ABST Time severity level 2, scope L2 Pattern
  • C0363: Acuity Based Staffing Tool - Updates & Staffing Plan severity level 2, scope L2 Pattern
  • C0372: Training Within 30 Days of Hire ? 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 4, scope L4 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 Widespread
  • C0613: General Building: Doors-Walls, Cleanable severity level 2, scope L2 Widespread
  • C0655: Call System severity level 2, scope L2 Widespread
  • H1510: Individual Rights Settings: Privacy, Dignity severity level 2, scope L2 Pattern
  • H1522: Individual freedom & Support: Activities severity level 2, scope L2 Pattern
  • L0252: Resident Move-in & Evaluation: Res Evaluation severity level 2, scope L2 Pattern
• May 13, 2025: Kitchen, 1 deficiency cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
• October 9, 2023: Validation, 21 deficiencies cited report
  • C0000: Comment severity level 0
  • C0152: Facility Administration: Required Postings severity level 2, scope L2 Widespread, corrected December 11, 2023
  • C0200: Resident Rights and Protection - General severity level 2, scope L2 Pattern, corrected December 11, 2023
  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Isolated, corrected December 11, 2023
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread, corrected December 11, 2023
  • 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
  • C0262: Service Plan: Service Planning Team severity level 2, scope L2 Pattern, corrected May 5, 2024
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Pattern, corrected October 5, 2024
  • C0280: Resident Health Services severity level 2, scope L2 Isolated, corrected May 5, 2024
  • C0290: Res Hlth Srvc: On- and Off-Site Health Srvc severity level 2, scope L2 Pattern, corrected May 5, 2024
  • C0295: Infection Prevention & Control severity level 2, scope L2 Widespread, corrected December 11, 2023
  • C0302: Systems: Tracking Control Substances severity level 2, scope L2 Isolated, corrected December 11, 2023
  • C0310: Systems: Medication Administration severity level 2, scope L2 Isolated, corrected May 5, 2024
  • C0325: Systems: Self-Administration of Meds severity level 2, scope L2 Pattern, corrected December 11, 2023
  • C0350: Administrator Qualification and Requirements severity level 2, scope L2 Widespread, corrected December 11, 2023
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Widespread, corrected December 11, 2023
  • C0372: Training Within 30 Days: Direct Care Staff severity level 2, scope L2 Pattern, corrected December 11, 2023
  • C0374: Annual and Biennial Inservice For All Staff severity level 2, scope L2 Pattern, corrected December 11, 2023
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread, corrected December 11, 2023
  • C0422: Fire and Life Safety: Training For Residents severity level 2, scope L2 Widespread, corrected December 11, 2023
  • C0455: Inspections and Investigation: Insp Interval severity level 3, scope L3 Isolated, corrected October 5, 2024
  • C0610: General Building Exterior severity level 2, scope L2 Widespread, corrected December 11, 2023
  • C0613: General Building: Doors-Walls, Cleanable severity level 2, scope L2 Widespread, corrected May 5, 2024
  • C0630: House Keeping and Sanitation severity level 2, scope L2 Widespread, corrected December 11, 2023
  • C0655: Call System severity level 2, scope L2 Widespread, corrected December 11, 2023
• June 1, 2023: Complaint Investig., 2 deficiencies cited report
  • C0010: Licensing Complaint Investigation severity level 2, scope L2 Isolated
  • C0260: Service Plan: General severity level 2, scope L2 Isolated
  • C0360: Staffing Requirements and Training: Staffing severity level 2, scope L2 Widespread
• September 14, 2022: 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 September 19, 2022

Substantiated abuse or neglect

• October 27, 2025: Failed to provide a safe medication administration system Abuse: Neglect; Level 2 - Minor harm or potential for moderate 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); 411-054-0055 (Medications and Treatments)
  State’s findings

  Alleged Victim (AV) takes pain medication three (3) times a day, for chronic pain. AV’s scheduled pain medication is filled and deliver automatically every two (2) weeks. On or about October 23, 2025, at 12:00 PM, AV missed scheduled doses of pain medication. By using scheduled doses of pain medication to supplement AVs PRN, which resulted in AVs pain medication running out sooner than anticipated, causing AV to miss scheduled doses of AVs pain medication which created risk of serious harm as AV experiences increased pain when AV doesn't get AVs pain medication. Respondent failed to implement meaningful safe medication administration system, to ensure the safety of AV. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

• August 8, 2025: Failed to provide service 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)
  State’s findings

  Alleged Victim (AV) relies on the facility for his/her care needs. AV's assistance with bathing is extensive, AV requires hands on assistance with participation by the resident to complete task. AV was not getting extensive assistance with showers. AV’s right foot/toes had open wounds on them, the toes were swollen and draining liquid. As a result, AV was diagnosed with gangrene of the right foot, toes. Respondent failed to provide appropriate care to AV, and to ensure the safety of AV. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

• August 7, 2025: Failed to provide service 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)
  State’s findings

  Alleged Victim (AV) relies on the facility for his/her care. On or about August 7, 2025, AV went to ED for dislocation of left knee. Two (2) hours after AV's knee dislocated EMT's were called. AV's leg was turning blue, and AV was losing feeling in AV's left foot. AV waited for two (2) hours in severe pain. The facility failed to provide oversight necessary for AV when AV's left knee dislocates resulting in AV going to the hospital, which is a violation of resident rights, is neglect of care and constitutes abuse.

• May 21, 2025: 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); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General); 411-054-0045 (Resident Health Services)
  State’s findings

  The Alleged Victim (AV) has known behaviors of inappropriately touching other residents. AV had 9 reported incidents from December 24, 2025, through February 2, 2025. The facility had reoprted they were going to reach out to behavioral health for assistance; however, this action was never completed. The facility failed to implement effective interventions for AV's behaviors, AV has become secluded due to his/her behaviors, causing a loss of dignity. Respondent failed to ensure staff followed the service plan to redirect AV and ensure AV received additional services caused residents to be afraid of AV and AV to become secluded. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

• May 21, 2025: Failed to protect resident from inappropriate sexual contact 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

  On or about May 21, 2025, Witness #1 (W1) touched the Alleged Victim (AV) on his/her chest in an inappropriate manner. W1 is known to touch residents inappropriately and has interventions in place to prevent this action. Staff are to monitor and redirect W1 away from residents of the opposite sex. Respondent failed to implement effective interventions for the safety of AV, leaving AV frightened of W1, causing unreasonable discomfort. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

Substantiated licensing violations

• May 14, 2026: Failed to provide service Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0045 (Resident Health Services)
  State’s findings

  Based on interview and record review, conducted during an investigation on 06/30/26 and 07/01/26, the facility’s failure to have delegation and teaching provided and documented by a RN in accordance with the Oregon Administrative Rules adopted by the Oregon State Board of Nursing was substantiated, which is a violation of Oregon Administrative Rules.

• October 30, 2025: Failed to properly plan care 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 service plans reflective of the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence.

• October 24, 2025: Failed to provide a safe medication administration system Licensing Violation; 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

  Alleged Victim (AV) relies on the facility to administer his/her medications. On 10/24/2025, AV was administered Oxycodone 3. 5 hours early and Methadone 5.5 hours early. Alleged Perpetrator 2 (AP2) states AP2 was in the middle of being delegated to administer another medication when AV came up demanding medications. Instead of having AV wait, AP2 admits to pulling the medications out of the medication cart and popping Methadone and Oxycodone into a pill cup. AP2 let AV walk away with the pills. It was not until after AP2 gave AV the pills, AP2 saw the previous shift have given AV the medication. As a result, AV reported feeling ill and having increased pain as the day went on. AP2 failed to provide a safe medication administration system for AV, which is neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system for AV, which is a violation of Oregon Administrative Rules.

• June 16, 2025: Failed to properly plan care 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 develop a service plan by a Service Planning Team that consists of the resident, the resident's legal representative, if applicable, any person of the resident's choice. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

• April 24, 2025: Failed to provide safe environment Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0105 (Inspections and Investigations)
  State’s findings

  The facility failed to ensure records must be made available to the Department upon request in accordance with OAR 411-054-0105(1)(a), 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 74 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.