Morningstar Memory Care of Beaverton

Last inspection

November 5, 2024

Inspections

5, 28 deficiencies cited

Substantiated abuse

5

Substantiated licensing violations

8

Regulatory actions

2

Fines assessed

$3,125.00 (5 violations)

Current owner since

January 2, 2020

License conditions and other regulatory actions

• July 15, 2025 to October 17, 2025: License Condition, Failed to provide safe environment RCFCD25-00744; incident: CALMS - 00083306
  Information is based on evidence and interviews collected from Licensing Complaint Unit on July 14, 2025, and evidence and interview collected from preliminary Adult Protective Services Report number 412280, on July 8, 2025.
  Rules: 411-054-0037 (Acuity-Based Staffing Tool); 411-057-0170 (Physical Design, Environment, and Safety)
• May 21, 2024 to February 7, 2025: License Condition, Failed to provide safe environment RCFCD24-00471; incident: CALMS - 00056450
  Information is based on evidence and interviews collected from Re-Licensure Survey (#3CCF11) on May 1, 2024, and evidence and interview collected from first re-visit to the Re-Licensure Survey, (#3CCF12), on October 4, 2024.
  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); 411-054-0037 (Acuity-Based Staffing Tool); 411-054-0040 (Change of Condition and Monitoring); 411-054-0045 (Resident Health Services); 411-054-0050 (Infection Prevention and Control); 411-054-0055 (Medications and Treatments); 411-054-0090 (Fire and Life Safety); 411-057-0140 (Responsibilities of Administration); 411-057-0155 (Staff Training Requirements); 411-057-0160 (Resident Services in a Memory Care Community)

Inspections

• November 5, 2024: Complaint Investig., 1 deficiency cited report
  • C0360: Staffing Requirements and Training: Staffing severity level 2, scope L2 Widespread
• April 29, 2024: Validation, 24 deficiencies cited report
  • C0000: Comment severity level 0
  • C0150: Facility Administration: Operation severity level 4, scope L4 Isolated, corrected November 15, 2024
  • C0152: Facility Administration: Required Postings severity level 2, scope L2 Widespread, corrected June 30, 2024
  • C0155: Facility Administration: Records severity level 2, scope L2 Pattern, corrected June 30, 2024
  • C0156: Facility Administration: Quality Improvement severity level 2, scope L2 Widespread, corrected November 15, 2024
  Show all 29

  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Pattern, corrected November 15, 2024
  • C0260: Service Plan: General severity level 2, scope L2 Pattern, corrected November 15, 2024
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Pattern, corrected November 15, 2024
  • C0280: Resident Health Services severity level 2, scope L2 Pattern, corrected November 15, 2024
  • C0282: Rn Delegation and Teaching severity level 2, scope L2 Isolated, corrected June 30, 2024
  • C0295: Infection Prevention & Control severity level 2, scope L2 Pattern, corrected November 15, 2024
  • C0300: Systems: Medications and Treatments severity level 2, scope L2 Widespread, corrected June 30, 2024
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Isolated, corrected November 15, 2024
  • C0305: Systems: Resident Right to Refuse severity level 2, scope L2 Isolated, corrected June 30, 2024
  • C0310: Systems: Medication Administration severity level 2, scope L2 Pattern, corrected June 30, 2024
  • C0330: Systems: Psychotropic Medication severity level 2, scope L2 Pattern, corrected June 30, 2024
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Pattern, corrected November 15, 2024
  • C0372: Training Within 30 Days: Direct Care Staff severity level 2, scope L2 Isolated, corrected November 15, 2024
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread, corrected November 15, 2024
  • C0455: Inspections and Investigation: Insp Interval severity level 4, scope L4 Isolated, corrected November 15, 2024
  • H1517: Individual Privacy: Own Unit severity level 0, corrected June 30, 2024
  • H1518: Individual Door Locks: Key Access severity level 0, corrected June 30, 2024
  • H1580: Limitations: Threats to Health and Safety severity level 0, corrected June 30, 2024
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected November 15, 2024
  • Z0155: Staff Training Requirements severity level 2, scope L2 Pattern, corrected November 15, 2024
  • Z0162: Compliance With Rules Health Care severity level 2, scope L2 Widespread, corrected November 15, 2024
  • Z0163: Nutrition and Hydration severity level 2, scope L2 Pattern, corrected June 30, 2024
  • Z0164: Activities severity level 2, scope L2 Pattern, corrected November 15, 2024
  • Z0173: Secure Outdoor Recreation Area severity level 2, scope L2 Widespread, corrected June 30, 2024
• September 14, 2023: 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 November 13, 2023
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected November 13, 2023
• July 27, 2022: State Licensure, 0 deficiencies cited report
  • C0000: Comment severity level 0
• June 28, 2022: Complaint Investig., 1 deficiency cited report
  • C0555: Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable severity level 1, scope L1 Widespread

Substantiated abuse or neglect

• August 27, 2025: 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); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General)
  State’s findings

  The Alleged Victim (AV) relied on the facility for safety and had known exit seeking behaviors. On or about August 9, 2025, AV was found outside the locked facility alone, unbeknownst to facility staff inside the secured area where AV resides. The facility failed to provide a safe environment, which is a violation of resident’s rights, is considered neglect of care and constitutes abuse defined in OAR 411-020-0002(1)(b)(A)(i).

• August 27, 2025: 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); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General)
  State’s findings

  The Alleged Victim (AV) relied on the facility for safety and had known exit seeking behaviors. On or about August 27, 2025, AV was found outside the locked facility alone, unbeknownst to facility staff inside the secured area where AV resides. The facility failed to provide a safe environment, which is a violation of resident’s rights, is considered neglect of care and constitutes abuse as defined in OAR 411-020-0002(1)(b)(A)(i).

• August 16, 2023: Failed to properly plan care Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $1,125.00; 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. The failure resulted in AV suffering a fall on or about August 17, 2023, in which AV was diagnosed with a fractured hip. Based on review of facility documentation and interviews, AV suffered falls on June 4, 2023, June 22, 2023, June 30, 2023, July 10, 2023, July 16, 2023, and July 23, 2023. Despite multiple falls, the facility failed to place preventative measures in order to reduce risk for the AV. The facility's failure caused unreasonable discomfort to AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• March 1, 2022: Failed to properly plan care Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $1,125.00; 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 March 1, 2022, Alleged Victim (AV) reported pain to the morning staff. Based on facility documentation and interviews, AV fell in the night on his/her right hip. AV was sent to the hospital for evaluation and was diagnosed with a fractured hip. AV sustained an injury from a fall and was in pain for an undetermined amount of time between NOC shift and day shift without interventions. It was determined that Alleged Perpetrator 2 (AP2) failed to assess and render first aide to AV which resulted in unreasonable discomfort. AP2 neglected to follow facility policy and procedure regarding a fall or when finding a resident on the floor including proper notifications, documentation, and rendering first aid. AP2's action is considered neglect of care which constitutes abuse. The facility failed to implement interventions and provide appropriate supervision related to the Alleged Victim’s (AV) known history of falls. The failure resulted in AV experiencing several falls with injury including the March 1, 2022 incident that caused AV to be sent to the hospital for treatment. The facility's failure to properly care plan for AV's fall risk caused unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• November 30, 2021: Failed to properly plan care Abuse: Neglect; Level 3 - Moderate harm or potential for serious 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); 411-054-0036 (Service Plan – General)
  State’s findings

  The facility failed to implement interventions and appropriately care plan regarding Alleged Victim’s (AV) known fall risk. AV had multiple falls between November 1, 2021, and November 30, 2021, some resulting in injury including but not limited to a head injury, skin tears, abrasions and bruising, and causing AV repeated unreasonable discomfort. The facility failed to implement interventions to mitigate AV’s increasing fall risk, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• August 27, 2025: 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 allegedly failed to ensure reasonable precautions must be exercised against any condition that may threaten the health, safety, or welfare of residents. An investigation determined this is a violation of Oregon Administrative Rules.

• July 17, 2025: Failed to cooperate with an investigation 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 provide records to the Department upon request. An investigation determined this is a violation of Oregon Administrative Rules.

• July 6, 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 have an Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population, their needs, and all required Activities of Daily Living (ADL). Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. Facility was not staffing to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

• July 6, 2025: Failed to provide safe environment Licensing Violation; Level 3 - Moderate harm or potential for serious harm; report
  Rules: 411-054-0025 (Facility Administration)
  State’s findings

  The facility failed to exercise reasonable precautions against any condition that may threaten the health, safety, or welfare of residents. An investigation determined this is a violation of Oregon Administrative Rules.

• May 27, 2024: Failed to provide safe environment Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0027 (Resident Rights and Protections); 411-054-0036 (Service Plan – General)
  State’s findings

  On or about May 27, 2024, Alleged Victim (AV) eloped from the secured facility and was found in the parking lot by facility staff. Based on facility documentation and interviews, AV unsafely left the facility without assistance and was exposed to potential harm but did not suffer any injury while out of the facility. 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 44 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.