Mill View Memory Care

Last inspection

July 22, 2026

Inspections

6, 10 deficiencies cited

Substantiated abuse

7

Substantiated licensing violations

1

Regulatory actions

1

Fines assessed

$2,188.00 (7 violations)

Current owner since

September 1, 2022

License conditions and other regulatory actions

• August 3, 2026 to September 16, 2026: License Condition, Failed to use an ABST RCFCD26-00697; 2 incidents: CALMS - 00119387, CALMS - 00119386
  The facility failed to ensure the implementation of services in accordance with OAR 411-054-0036(2)(g); per Report of a Serious Event.
  Rules: 411-054-0036 (Service Plan – General); 411-054-0037 (Acuity-Based Staffing Tool)

Inspections

• July 22, 2026: Re-Licensure, 2 deficiencies cited report
  • 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
• February 12, 2026: Kitchen, 2 deficiencies cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread
• March 1, 2024: State Licensure, 0 deficiencies cited report
  • C0000: Comment severity level 0
• October 30, 2023: Validation, 6 deficiencies cited report
  • C0000: Comment severity level 0
  • C0374: Annual and Biennial Inservice For All Staff severity level 2, scope L2 Pattern, corrected February 28, 2024
  • C0513: Doors, Walls, Elevators, Odors severity level 2, scope L2 Widespread, corrected April 1, 2024
  • C0530: Housekeeping and Laundry severity level 2, scope L2 Widespread, corrected February 28, 2024
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected February 28, 2024
  • Z0155: Staff Training Requirements severity level 2, scope L2 Pattern, corrected February 28, 2024
  • Z0173: Secure Outdoor Recreation Area severity level 2, scope L2 Widespread, corrected February 28, 2024
• June 14, 2023: State Licensure, 0 deficiencies cited report
  • C0000: Comment severity level 0
• July 20, 2022: State Licensure, 0 deficiencies cited report
  • C0000: Comment severity level 0

Substantiated abuse or neglect

• July 12, 2025: Failed to address resident's behavior Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $375.00; 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

  The Alleged Victim (AV) relies on the facility for their care and has a history of aggressive behaviors and multiple altercations requiring daily interventions for disruptive, aggressive, or socially inappropriately behaviors. Staff were directed to keep the AV and Witness 1 (W1) apart during mealtimes. According to an investigation, on or about July 12, 2024, the AV and W1 were left together unattended and involved in an altercation, resulting in significant emotional distress to AV. The facility failed to provide appropriate services and supervision to ensure a safe environment, which is a violation of resident rights, is neglect of care, and constitutes abuse.

• July 12, 2025: Failed to address resident's behavior Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $375.00; 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

  The Alleged Victim (AV) relies on the facility for their care. Witness 1 (W1) has a history of aggressive behaviors and multiple altercations requiring daily interventions for disruptive, aggressive, or socially inappropriately behaviors. Staff were directed to keep the AV and W1 apart during mealtimes. According to an investigation, on or about July 12, 2024, the AV and W1 were left together unattended and involved in an altercation, resulting in injury to the AVs face and shin. The facility failed to provide appropriate services and supervision to ensure a safe environment, which is a violation of resident rights, is neglect of care, and constitutes abuse.

• October 25, 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

  Per a temporary care plan dated October 17, 2024, staff are to know Alleged Victim (AV) and Witness 1 (W1) whereabouts and to keep a watchful eye on them. On or about October 25, 2024, at 9:15 a.m., AV and W1 were both walking around the facility when they crossed paths. W1 grabbed AV by the arm with force, resulting in AV losing his/her balance and falling. A few hours later at 11:45 a.m., W1 and AV had another altercation. This time W1 aggressively and violently committed an unprovoked attack on AV, resulting in a fall with injury to AV. AV sustained an abrasion on his/her head that measured about 5-6 cm and resulted in AV being visibly scared. Neither incident was witnessed by staff. The facility failed to assure that the temporary care plan was being followed, which is a violation of resident rights, is neglect of care and constitutes abuse.

• March 24, 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); 411-054-0036 (Service Plan – General)
  State’s findings

  The facility failed to provide appropriate supervision to the Alleged Victim (AV) according to his/her care needs and known elopement risk. On or about March 24, 2024, AV eloped from the secured building, without staff knowledge, fell and fractured his/her wrist. AV also suffered bruising and abrasions to his/her face. AV was found by a community member who notified the Law Enforcement Agency. Based on facility documentation and interviews, the facility door was not properly locked due to a magnet malfunction. The facility's failure to provide a safe environment by failing to ensure the door properly locked resulted in AV eloping from the facility which resulted in AV sustaining a fractured wrist from falling in the community, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• September 20, 2023: Failed to properly plan care 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); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General)
  State’s findings

  The facility failed to implement interventions and appropriately care plan related to the Alleged Victim’s (AV) fall history. On or about September 20, 2023, AV suffered an unwitnessed fall in h/h room, resulting in an injury to h/h hip. The failure resulted in AV experiencing pain and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• February 25, 2023: Failed to provide a safe medication administration system Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $250.00; report
  Rules: 411-054-0027 (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) medication was administered as ordered. On or about February 25, 2023, medication was given to AV that was for another resident, AV was transported to the hospital for treatment. The failure resulted in AV experiencing unreasonable discomfort, which is violation of resident rights, is considered neglect of care and constitutes abuse.

• March 14, 2022: Failed to properly plan care 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); 411-054-0036 (Service Plan – General)
  State’s findings

  The facility failed to implement interventions and provide appropriate supervision related to the Alleged Victim’s (AV) known history of falls. On or about March 14, 2022, AV had four falls in one day prior to AV getting admitted to the hospital with a diagnosis of a broken knee cap. Based on interviews and facility documentation, it was determined that facility failed to train staff members how to appropriately respond to incidents, and implement additional safety precautions, in order to mitigate the risk to AV, which led to the AV's multiple injuries and complaints of pain on March 14, 2022. The facility failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• June 22, 2023: Failed to protect resident from physical abuse 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); 411-054-0036 (Service Plan – General)
  State’s findings

  Alleged Perpetrator 2 (AP2) caused unreasonable discomfort to the Alleged Victim (AV) by non-accidental means. On or about June 22, 2023, AP2 wrapped h/h hands around AV’S wrists, in result AV sustained a skin tear. The facility failed to protect AV from physical abuse 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.” 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.