Mt Angel Towers

Last inspection

May 14, 2026

Inspections

5, 15 deficiencies cited

Substantiated abuse

6

Substantiated licensing violations

11

Regulatory actions

0

Fines assessed

$2,388.00 (6 violations)

Current owner since

April 6, 2002

Inspections

• May 14, 2026: Re-Licensure, 1 deficiency cited report
  • C0555: Call Sys, Exit Dr Alarm, Phones, TV, or Cable severity level 2, scope L2 Widespread
• June 18, 2025: Re-Licensure, 7 deficiencies cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
  • C0260: Service Plan: General severity level 2, scope L2 Pattern
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Pattern
  • C0310: Systems: Medication Administration severity level 2, scope L2 Pattern
  • C0363: Acuity Based Staffing Tool - Updates & Staffing Plan severity level 2, scope L2 Pattern
  • C0370: Staffing Requirements and Training ? Pre-service severity level 2, scope L2 Pattern
  • C0372: Training Within 30 Days of Hire ? Direct Care Staff severity level 2, scope L2 Pattern
• June 11, 2024: 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 July 5, 2024
• June 1, 2023: 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 July 20, 2023
• March 7, 2022: Validation, 5 deficiencies cited report
  • C0000: Comment severity level 0
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread, corrected May 13, 2022
  • C0242: Resident Services: Activities severity level 2, scope L2 Widespread, corrected May 13, 2022
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Pattern, corrected May 13, 2022
  • C0510: General Building Exterior severity level 2, scope L2 Widespread, corrected May 13, 2022
  • C0513: Doors, Walls, Elevators, Odors severity level 2, scope L2 Widespread, corrected May 13, 2022

Substantiated abuse or neglect

• April 17, 2026: Failed to properly plan care Abuse: Neglect; Level 3 - Moderate harm or potential for serious 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); 411-054-0036 (Service Plan – General)
  State’s findings

  On or about April 17, 2026, the Alleged Victim (AV) experienced an unwitnessed fall after attempting to transfer without assistance. Based on facility documentation and interviews, AV activated his/her pendant alarm at approximately 3:25 PM and was found on the floor with a head injury and a forearm skin tear. AV is a known fall risk with a history of forgetting to use their call pendant, had multiple prior falls, including a head injury on February 26, 2026. Additional falls occurred after the April 17, 2026, incident with one fall on April 18, 2026, and another fall on April 19, 2026, with the April 19 incident involving another head injury. Despite repeated falls and documented risks, the facility did not implement additional or enhanced fall-prevention measures to mitigate AV's fall risk. The lack of adequate oversight and care planning resulted in continued falls and unreasonable discomfort to AV, constituting abuse by neglect as defined in OAR 411-020-0002(1)(b)(A)(i).

• December 8, 2025: Failed to provide a safe medication administration system Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $338.00; 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 December 8, 2025, Alleged Perpetrator 2 (AP2) submitted a refill request for the Alleged Victim’s (AV) Proton Pump Inhibitor medication via fax. On December 11, 2025, it was discovered that AP2 had faxed the refill request to the incorrect pharmacy. Based on facility documentation and staff interviews, AV’s Medication Administration Record (MAR) listed three different pharmacies for AV’s medication refills, which contributed to the error. The investigation determined that AP2’s error resulted from the facility’s failure to provide adequate oversight and maintain an accurate and consistent MAR for AV, rather than any lack of ability on AP2’s part to perform assigned job duties. The facility’s failure to maintain a safe and reliable medication administration system caused AV unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse. AP2 was initially alleged to have neglected AV; however, the investigation determined that no abuse occurred by AP2.

• October 14, 2025: Failed to provide a safe medication administration system Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $450.00; 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 January 21, 2026, ODHS Adult Protective Services (APS) completed investigation #00433403 and issued a written investigation report, which is incorporated here by reference. Alleged Victim (AV) lived at Respondent’s facility. Based on facility documentation and interviews, on or about October 14, 2025, AV ran out of his/her restless leg syndrome medication and was without this medication until October 17, 2025. The facility is responsible for managing AV’s medications, including monitoring supply levels and ensuring timely reordering. Based on facility documentation and staff interviews, the facility did not order AV’s medication for restless leg syndrome in a timely manner, resulting in missed doses, causing AV unnecessary pain and discomfort which is a violation of resident's rights, is considered neglect of care, which constitutes abuse.

• August 21, 2025: Failed to properly plan care Abuse: Neglect; Level 3 - Moderate harm or potential for serious 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); 411-054-0036 (Service Plan – General); 411-054-0040 (Change of Condition and Monitoring)
  State’s findings

  In August 2025, a significant failure in care occurred involving an Alleged Victim (AV) who was under the facility's care at time of incident. On August 11, 2025, AV reported a pressure sore on his/her coccyx area and described experiencing sharp pain at the site. Facility documentation and staff interviews confirmed the presence of a wound measuring approximately 1.5 cm by 0.4 cm, with no visible drainage. Despite this discovery, the facility did not initiate wound care or document AV’s change in condition. AV was seen by his/her physician on or about August 21, 2025, who confirmed the wound on AV coccyx area. By then, the condition had worsened, resulting in unnecessary discomfort and physical harm to AV. The facility’s failure to provide timely and appropriate care is a violation of resident rights, is considered neglect of care which constitutes abuse.

• August 12, 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: 411-054-0025 (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 August 20, 2025, ODHS Adult Protective Services (APS) initiated investigation #00421228 and issued a written investigation report, which is incorporated here by reference. Alleged Victim (AV) lived at Respondent’s facility. The facility failed to ensure a safe medication administration system to ensure that the Alleged Victim (AV) received his/her prescribed diuretic medications as ordered. The facility's failure to provide a safe medication system caused AV unreasonable discomfort and increased shortness of breath, is a violation of resident rights, is considered neglect of care and constitutes abuse.

• August 25, 2024: Failure to provide a system that prevents theft or misuse of medication Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $225.00; 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) relies on the facility to administer his/her medications. On or about August 25, 2024, while doing the narcotic count, staff discovered that 2.5mL of AV’s pain medication was missing. All the staff’s drug test came back negative for narcotics. The facility failed to provide a system that prevents theft of medication, which is a violation of resident rights, is neglect of care and constitutes abuse.

Substantiated licensing violations

• April 17, 2026: 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 updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules.

• April 3, 2026: 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 updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules.

• January 5, 2026: 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); 411-054-0055 (Medications and Treatments)
  State’s findings

  On January 23, 2026, ODHS Adult Protective Services (APS) completed investigation #00449853 and issued a written report which is incorporated by reference. The Alleged Victim (AV) resided at the Respondent’s facility. On or about January 5, 2026, AV left the facility on a scheduled departure. The facility failed to provide AV with prescribed medication upon departure, as required by facility protocol and Oregon Administrative Rules. Although AV did not experience any negative health outcome, this failure constitutes non-compliance with safe medication administration standards, which is a violation of Oregon Administrative Rules.

• December 16, 2025: 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); 411-054-0055 (Medications and Treatments)
  State’s findings

  On December 11, 2025, medications were found in the Alleged Victim’s (AV) room. The facility conducted a thorough cleaning and search of the room that same day. Despite this, additional medications, equivalent to two days’ worth, were discovered again in AV’s room on December 16, 2025. Based on facility documentation and interviews, AV's room had been fully searched on December 11, it was determined the medications found on December 16 came from doses that were to be administered to AV between December 12 and December 16, 2025. Medication administration records show that Alleged Perpetrator 2 (AP2) was responsible for administering AV’s medications on December 11, 12, and 15, 2025. AP2 did not watch AV swallow his/her medications. Between December 11, 2025, to December 16, 2025, AV experienced pain and discomfort as a result of not taking his/her medications as prescribed. AP2 failed to follow proper medication administration procedures by not watching AV swallow his/her medication, resulting in AV experiencing unreasonable discomfort. AP2's actions is considered neglect of care which constitutes abuse. The facility failed to provide a safe medication administration system for AV which is a violation of Oregon Administrative Rules.

• December 16, 2025: 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); 411-054-0055 (Medications and Treatments)
  State’s findings

  On December 11, 2025, medications were found in the Alleged Victim’s (AV) room. The facility conducted a thorough cleaning and search of the room that same day. Despite this, additional medications, equivalent to two days’ worth, were discovered again in AV’s room on December 16, 2025. Based on facility documentation and interviews, AV's room had been fully searched on December 11, it was determined the medications found on December 16 came from doses that were to be administered to AV between December 12 and December 16, 2025. Medication administration records show that Alleged Perpetrator 3 (AP3) was responsible for administering AV’s medications on December 13, and 14, 2025. AP3 did not watch AV swallow his/her medications. Between December 13, 2025, to December 14, 2025, AV experienced pain and discomfort as a result of not taking his/her medications as prescribed. AP3 failed to follow proper medication administration procedures by not watching AV swallow his/her medication, resulting in AV experiencing unreasonable discomfort. AP3's actions is considered neglect of care which constitutes abuse. The facility failed to provide a safe medication administration system for AV 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 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.