Mt. Bachelor Assisted Living

Last inspection

January 27, 2026

Inspections

7, 49 deficiencies cited

Substantiated abuse

8

Substantiated licensing violations

4

Regulatory actions

1

Fines assessed

$3,226.00 (8 violations)

Current owner since

June 1, 2024

License conditions and other regulatory actions

• May 9, 2024 to June 4, 2024: License Condition, Failed to provide safe environment ALFCD24-00186; incident: CALMS - 00056074
  The facility allegedly failed to operate is substantial compliance with Oregon Administrative Rules.
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0030 (Resident Services); 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); 411-054-0055 (Medications and Treatments); 411-054-0070 (Staffing Requirements and Training)

Inspections

• January 27, 2026: Kitchen, 1 deficiency cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread
• August 7, 2025: Change of Owner, 19 deficiencies cited report
  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Pattern
  • C0252: Resident Move-in & Evaluation: Res Evaluation severity level 2, scope L2 Pattern
  • C0260: Service Plan: General severity level 2, scope L2 Pattern
  • C0262: Service Plan: Service Planning Team severity level 2, scope L2 Pattern
  • C0270: Change of Condition and Monitoring severity level 3, scope L3 Isolated
  Show all 19

  • C0280: Resident Health Services severity level 3, scope L3 Isolated
  • C0295: Infection Prevention & Control severity level 2, scope L2 Isolated
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Pattern
  • C0310: Systems: Medication Administration severity level 2, scope L2 Pattern
  • C0340: Restraints and Supportive Devices severity level 2, scope L2 Pattern
  • C0362: Acuity Based Staffing Tool - ABST Time 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
  • 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
  • C0610: General Building Exterior severity level 2, scope L2 Widespread
  • L0252: Resident Move-in & Evaluation: Res Evaluation severity level 2, scope L2 Pattern
  • L0370: Staffing Requirements and Training ? Pre-service severity level 2, scope L2 Pattern
• June 11, 2024: Complaint Investig., 1 deficiency cited report
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Isolated
• April 29, 2024: Validation, 25 deficiencies cited report
  • C0000: Comment severity level 0
  • C0150: Facility Administration: Operation severity level 4, scope L4 Isolated
  • C0152: Facility Administration: Required Postings severity level 2, scope L2 Widespread
  • C0154: Facility Administration: Policy & Procedure severity level 2, scope L2 Widespread
  • C0156: Facility Administration: Quality Improvement severity level 2, scope L2 Widespread
  Show all 26

  • C0160: Reasonable Precautions severity level 4, scope L4 Isolated
  • C0200: Resident Rights and Protection - General severity level 2, scope L2 Widespread
  • C0242: Resident Services: Activities severity level 2, scope L2 Widespread
  • C0260: Service Plan: General severity level 2, scope L2 Pattern
  • C0270: Change of Condition and Monitoring severity level 4, scope L4 Isolated
  • C0280: Resident Health Services severity level 2, scope L2 Pattern
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Pattern
  • C0310: Systems: Medication Administration severity level 2, scope L2 Isolated
  • C0360: Staffing Requirements and Training: Staffing severity level 2, scope L2 Widespread
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Widespread
  • C0365: Staffing Rqmt and Training: Training Rqmts severity level 2, scope L2 Pattern
  • C0370: Staffing Requirements and Training – Pre-Serv severity level 2, scope L2 Pattern
  • C0372: Training Within 30 Days: Direct Care Staff severity level 2, scope L2 Pattern
  • C0374: Annual and Biennial Inservice For All Staff severity level 2, scope L2 Pattern
  • 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
  • C0613: General Building: Doors-Walls, Cleanable severity level 2, scope L2 Widespread
  • C0655: Call System severity level 2, scope L2 Widespread
  • H1510: Individual Rights Settings: Privacy, Dignity severity level 0
  • H1515: Physical Setting: Individual Accessible severity level 0
  • H1517: Individual Privacy: Own Unit severity level 0
• February 26, 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
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread
• May 17, 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 16, 2023
• July 20, 2022: 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 September 18, 2022

Substantiated abuse or neglect

• April 1, 2026: Failed to administer medication as ordered Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $675.00; 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 April 1, 2026, the Alleged Victim (AV) was taken to his/her physician due to abdominal pain. AV was prescribed medication to be given to AV upon receipt until AV had a bowel movement and then as needed. AV was not given the medication until the afternoon of April 2, 2026. AV experienced unreasonable discomfort due to not receiving the medication timely as ordered. Respondent failed to ensure staff provided medication as ordered by AV's physician. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

• April 1, 2026: Failed to assist with eating Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $675.00; 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)
  State’s findings

  The Alleged Victim (AV) was care planned to have his/her weight and meal consumption monitored. AV was noted to have a significant weight loss of 11 pounds between January 19, 2026, and February 1, 2026. Respondent failed to ensure AV's weight loss was noted and assessed to ensure AV was getting proper nutrition. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(ii).

• July 29, 2025: Failed to provide a safe medication administration system Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $250.00; report
  Rules: 411-054-0025 (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) relies on the facility to administer his/her medications. According to an investigation, on or about July 29, 2025, it was discovered AV did not have hypertension medication as ordered. Between July 28, 2025, and August 5, 2025, AV missed multiple doses of the prescribed medication when it had not been reordered, resulting in AV's legs becoming very swollen, discolored and causing AV discomfort. 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.

• June 30, 2025: Failed to administer ordered medication 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); 411-054-0055 (Medications and Treatments)
  State’s findings

  The Alleged Victim (AV) relies on the facility to administer his/her medications. According to an investigation, on or about July 9, 2025, AV did not receive multiple doses of anxiety medication as ordered. AV did not receive the medication as ordered on July 9, 2025, and July 10, 2025, as the medication was not available, resulting in the AV experiencing unreasonable discomfort with increased anxiety. The facility failed to have medications available, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• June 30, 2025: Failed to provide a safe medication administration system 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); 411-054-0055 (Medications and Treatments)
  State’s findings

  The Alleged Victim (AV) relies on the facility to administer his/her medications. According to an investigation, on or about July 6, 2025, AV did not receive anxiety medication as ordered. AV did not receive ordered medication on July 6, 2025, and July 12, 2025, resulting in AV experiencing increased anxiety. AP2 had marked the MAR as administered, but the narcotics log and medication count did not match. AP2's actions resulted in unreasonable discomfort for AV, are considered neglect and constitutes abuse. Medication audits had not been completed so the error was not identified. The facility failed to provide a safe medication system, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• October 7, 2024: Failed to assure resident rights Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0090 (Fire and Life Safety)
  State’s findings

  The facility failed to conduct fire drills. The facility’s failure is a violation of Oregon Administrative Rules.

• April 25, 2024: 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 1, 2023: Failed to report vaccination status Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-061-0010
  State’s findings

  On or about May 1, 2023, the Oregon Health Authority reported to the Department that Respondent failed to comply with weekly reporting requirements of vaccinated individuals, residents and staff, to the proper authority as required by law. This failure has been ongoing from April 1, 2023 to April 30, 2023, for a total of 30 days.

• February 1, 2023: Failed to report vaccination status Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-061-0010
  State’s findings

  On or about February 1, 2023, the Oregon Health Authority reported to the Department that Respondent failed to comply with weekly reporting requirements of vaccinated individuals, residents and staff, to the proper authority as required by law. This failure has been ongoing from January 1, 2023 to January 31, 2023, for a total of 30 days.

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 92 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.