Morningstar Memory Care at Laurelhurst

Last inspection

April 1, 2025

Inspections

2, 21 deficiencies cited

Substantiated abuse

5

Substantiated licensing violations

8

Regulatory actions

1

Fines assessed

$4,063.00 (5 violations)

Current owner since

August 4, 2023

License conditions and other regulatory actions

• April 24, 2025 to June 27, 2025: License Condition, Failed to provide safe environment RCFCD25-00426; incident: CALMS - 00077242
  The following statement of violations stem from evidence and interviews collected from ODHS re-licensure survey, Z7VC14, Revisit #3, completed on April 17, 2025.
  Rules: 411-054-0025 (Facility Administration); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0036 (Service Plan – General); 411-054-0040 (Change of Condition and Monitoring); 411-054-0055 (Medications and Treatments); 411-054-0105 (Inspections and Investigations)

Inspections

• April 1, 2025: 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 4, 2024: Initial Licensure, 19 deficiencies cited report
  • C0000: Comment severity level 0
  • C0150: Facility Administration: Operation severity level 3, scope L3 Isolated, corrected October 26, 2024
  • C0156: Facility Administration: Quality Improvement severity level 2, scope L2 Widespread, corrected May 17, 2025
  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Isolated, corrected May 17, 2025
  • C0252: Resident Move-In and Eval: Res Evaluation severity level 2, scope L2 Pattern, corrected May 5, 2024
  Show all 24

  • C0260: Service Plan: General severity level 2, scope L2 Isolated, corrected May 17, 2025
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Pattern, corrected May 17, 2025
  • C0280: Resident Health Services severity level 2, scope L2 Pattern, corrected October 26, 2024
  • C0290: Res Hlth Srvc: On- and Off-Site Health Srvc severity level 2, scope L2 Isolated, corrected October 26, 2024
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Pattern, corrected May 17, 2025
  • C0305: Systems: Resident Right to Refuse severity level 2, scope L2 Isolated, corrected May 5, 2024
  • C0310: Systems: Medication Administration severity level 2, scope L2 Pattern, corrected May 17, 2025
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Pattern, corrected May 5, 2024
  • C0372: Training Within 30 Days: Direct Care Staff severity level 2, scope L2 Pattern, corrected October 26, 2024
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread, corrected May 5, 2024
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Pattern, corrected May 17, 2025
  • C0540: Heating and Ventilation severity level 2, scope L2 Widespread, corrected May 5, 2024
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected May 17, 2025
  • Z0155: Staff Training Requirements severity level 2, scope L2 Pattern, corrected October 26, 2024
  • Z0162: Compliance With Rules Health Care severity level 2, scope L2 Pattern, corrected May 17, 2025
  • Z0163: Nutrition and Hydration severity level 2, scope L2 Pattern, corrected October 26, 2024
  • Z0164: Activities severity level 2, scope L2 Pattern, corrected May 5, 2024
  • Z0173: Secure Outdoor Recreation Area severity level 2, scope L2 Widespread, corrected May 5, 2024
  • Z0176: Resident Rooms severity level 2, scope L2 Widespread, corrected May 5, 2024

Substantiated abuse or neglect

• June 28, 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

  The Alleged Victim (AV) and Witness #1 (W1) rely on the facility for their care. On or about June 28, 2025, W1's personal belongings to include underwear were found in AV's room, and AV was found to not be wearing undergarments themselves, which is not typical for AV. According to an investigation, staff reported knowledge that W1 was targeting AV and attempting to be alone with them and some staff reported W1 as having a key to AV's apartment and using it to enter AV's apartment at night. Despite this being reported to management, there were no additional interventions added to ensure AV's safety. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• June 5, 2025: Failed to provide service 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); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General)
  State’s findings

  The Alleged Victim (AV) relies on the facility for care, supervision, and safety. On or about June 5, 2025, facility staff took AV to an activity in the unlocked portion of the facility. When the activity was over AV slipped away outside before staff members noticed, placing AV at risk of harm. The facility failed to provide appropriate services, regarding following care plans, resident monitoring and resident safety, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• April 5, 2025: 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); 411-054-0036 (Service Plan – General)
  State’s findings

  The Alleged Victim (AV) is a known fall risk and has suffered multiple falls with and without injury. From February 2025 to April 2025, AV suffered multiple falls, however, there is no temporary service plan for interventions from each fall to ensure AV's safety from falls. The facility's failure to properly care plan to keep AV safe from falls is a violation of resident rights, is considered neglect of care and constitutes abuse.

• March 22, 2024: Failed to provide oversight and monitoring of change of condition Abuse: Neglect; Level 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance; fine $1,500.00; 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); 411-054-0040 (Change of Condition and Monitoring)
  State’s findings

  The facility failed to provide appropriate services according to the Alleged Victim’s (AV) care needs after he/she had oral surgery to remove several teeth. The facility's failure caused AV to sustain significant weight loss in a short period of time resulting in loss of muscle mass. Based on facility documentation and interviews, AV returned the facility on or about February 26, 2024, following oral surgery. Facility care staff were to monitor AV's eating, offer soft foods, check for increased complaints of pain or discomfort in mouth, and report any concerns regarding AV's health as a result of AV's dental surgery. On March 22, 2024, an email was sent to the facility staff by Witness 1 (W1) outlining their concerns regarding AV's significant change of condition due AV's significant weight loss and the facility's failure to intervene. Prior to AV's dental surgery AV's weight was documented at 154lbs. A little over a month after AV's oral surgery, AV's weight was documented at 141lbs, which was a 6% weight loss in a short period of time. The facility staff failed to address AV's significant change in condition until April 25, 2024, when care staff contacted AV's physician to inform them of AV's weight loss. The facility failed to provide AV with oversight and monitoring when AV's condition changed, resulting in AV’s condition worsening causing further unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• December 17, 2023: Failed to provide a safe medication administration system Abuse: Neglect; Level 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance; 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); 411-054-0040 (Change of Condition and Monitoring); 411-054-0055 (Medications and Treatments)
  State’s findings

  On or about December 17, 2023, Alleged Victim (AV) went to the emergency room due to AV suffering from a medical event that affected his/her left side. AV suffered a stroke, and AV did not return to the facility until December 22, 2023, with hospice enrollment. Based on facility documentation and interviews, AV missed 7 doses of his/her blood thinner medication in October 2023, AV missed 19 doses of his/her blood thinner medication in November 2023, and AV missed 12 doses of his/her blood thinner medication in December 2023. AV is prescribed to take his/her blood thinner medication daily. AP2 is responsible to ensure that all medications prescribed are available by auditing the medication records and cart twice weekly. AP2 did not notice that AV had missed his/her blood thinner medications, contributing to AV missing multiple doses of his/her blood thinner medication. AP2's failure to provide basic care and services necessary to maintain AV's health and safety, resulted in serious physical harm. AP2's actions is considered neglect of care which constitutes abuse. The facility failed to ensure AV received the prescribed dosage of his/her blood thinner medication at the prescribed times. The facility's failure to provide a safe medication administration system, caused AV's health to significantly decline as a result of AV's stroke due to AV not getting his/her blood thinner medication as ordered. AV passed away in January 2024. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• October 18, 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

  Based on interview and record review, the facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident and complete or update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly as required and use the results of an ABST to develop and routinely update the facility's posted staffing plan. The facility’s failure is a violation of Oregon Administrative Rules.

• September 24, 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

  Based on interview and record review, the facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident and complete or update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly as required and use the results of an ABST to develop and routinely update the facility's posted staffing plan. The facility’s failure is a violation of Oregon Administrative Rules.

• September 2, 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

  Based on interview and record review, the facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident and complete or update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly as required and use the results of an ABST to develop and routinely update the facility's posted staffing plan. The facility’s failure is a violation of Oregon Administrative Rules.

• July 23, 2025: Failed to staff as indicated by ABST Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)
  State’s findings

  Based on interview and record review, the facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident and use the results of an ABST to develop and routinely update the facility's posted staffing plan. The facility’s failure is a violation of Oregon Administrative Rules.

• July 9, 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

  Based on interview and record review, the facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident and use the results of an ABST to develop and routinely update the facility's posted staffing plan. The facility’s failure 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 32 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.