Morrow Heights Retirement and Assisted Living Community

Last inspection

December 3, 2024

Inspections

5, 8 deficiencies cited

Substantiated abuse

1

Substantiated licensing violations

9

Regulatory actions

0

Fines assessed

$188.00 (1 violation)

Current owner since

February 1, 2024

Inspections

• December 3, 2024: Kitchen, 1 deficiency cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
• February 6, 2023: Validation, 4 deficiencies cited report
  • C0000: Comment severity level 0
  • C0305: Systems: Resident Right to Refuse severity level 2, scope L2 Isolated, corrected March 1, 2023
  • C0310: Systems: Medication Administration severity level 2, scope L2 Pattern, corrected March 1, 2023
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread, corrected March 1, 2023
  • C0655: Call System severity level 2, scope L2 Widespread, corrected March 1, 2023
• September 6, 2022: Complaint Investig., 1 deficiency cited report
  • C0010: Licensing Complaint Investigation severity level 2, scope L2 Isolated
  • C0304: Systems: Medication and Treatment Review severity level 2, scope L2 Isolated
• August 31, 2022: Complaint Investig., 1 deficiency cited report
  • C0010: Licensing Complaint Investigation severity level 2, scope L2 Isolated
  • C0301: Systems: Medication Administration severity level 2, scope L2 Isolated
• July 25, 2022: Complaint Investig., 1 deficiency cited report
  • C0010: Licensing Complaint Investigation severity level 2, scope L2 Isolated
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Isolated

Substantiated abuse or neglect

• January 6, 2022: Failed to provide a safe medication administration system 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); 411-054-0055 (Medications and Treatments)
  State’s findings

  On or about January 24, 2022, it was discovered that the Alleged Victim (AV) was missing at least 16 pills from his/her prescription. The facility failed to provide a safe medication administration system, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• April 15, 2023: Failed to provide a safe medication administration system 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); 411-054-0055 (Medications and Treatments)
  State’s findings

  The Alleged Victim (AV) was taking blood pressure medication that was discontinued on April 15, 2023. Facility documentation shows Alleged Perpetrator #2 (AP2) did not follow proper medication administration checks, as AP2 is documented to have given AV medication from April 15 to April 20. Alleged Perpetrator #3 (AP3) found out about the med errors, however, didn't notify leadership to ensure an investigation was completed and and ensure proper monitoring of affected residents. AP2 and AP3's actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility's failure to provide a safe medication administration system is a violation of Oregon Administrative Rules.

• April 15, 2023: Failed to provide a safe medication administration system 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); 411-054-0055 (Medications and Treatments)
  State’s findings

  The Alleged Victim (AV) was taking two different blood pressure medications, one to be given in the morning and the other in the evening. Facility documentation shows Alleged Perpetrator #2 (AP2) did not follow proper medication administration checks, as AP2 is documented to have given AV the morning blood pressure mediation both morning and evening and not giving the other medication at all from April 15 to April 20. Alleged Perpetrator #3 (AP3) found out about the med errors, however, didn't notify leadership to ensure an investigation was completed and and ensure proper monitoring of affected residents. AP2 and AP3's actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility's failure to provide a safe medication administration system is a violation of Oregon Administrative Rules.

• August 22, 2022: Failed to protect resident from financial exploitation 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

  On or about August 21, 2022, the Alleged Victim (AV) reported to staff that his/her wallet was missing, which had cash in the wallet. Alleged Perpetrator 2 (AP2) was seen by staff with a "wad of cash" and AP2 later found AV's wallet in a room that another staff member had already searched. AP2’s actions are a violation of resident rights, are considered neglect of care and constitute financial abuse. The facility failed to protect AV from financial abuse, which is a violation of Oregon Administrative Rules.

• August 15, 2022: Failed to assure timely medical treatment Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0055 (Medications and Treatments)
  State’s findings

  Facility failure to carry out medication and treatment orders as prescribed, which is a violation of Oregon Administrative Rules.

• August 12, 2022: Failed to provide a safe medication administration system Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0055 (Medications and Treatments)
  State’s findings

  The facility failed to provide a safe medication administration system for the Alleged Victim. The 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 53 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.