Mt. Bachelor Memory Care

Last inspection

January 27, 2026

Inspections

5, 38 deficiencies cited

Substantiated abuse

18

Substantiated licensing violations

15

Regulatory actions

1

Fines assessed

$8,720.00 (19 violations)

Current owner since

June 1, 2024

License conditions and other regulatory actions

• October 22, 2025 to June 16, 2026: License Condition, Failed to provide safe environment RCFCD25-01222; incident: CALMS - 00090530
  The facility failed to comply with Oregon Administrative Rules, posing a threat to the health, safety, and welfare of its residents.
  Rules: 411-054-0025 (Facility Administration); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0034 (Resident Move-In and Evaluation); 411-054-0036 (Service Plan – General); 411-054-0040 (Change of Condition and Monitoring); 411-054-0045 (Resident Health Services)

Inspections

• January 27, 2026: Kitchen, 2 deficiencies 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
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread
• October 10, 2025: Change of Owner, 27 deficiencies cited report
  • C0156: Facility Administration: Quality Improvement severity level 2, scope L2 Widespread
  • C0160: Reasonable Precautions severity level 4, scope L4 Isolated
  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Pattern
  • C0242: Resident Services: Activities severity level 2, scope L2 Widespread
  • C0252: Resident Move-in & Evaluation: Res Evaluation severity level 2, scope L2 Isolated
  Show all 30

  • 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 4, scope L4 Isolated
  • C0290: Res Hlth Srvc: On- and Off-Site Health Srvc severity level 2, scope L2 Isolated
  • C0295: Infection Prevention & Control severity level 2, scope L2 Pattern
  • C0302: Systems: Tracking Control Substances severity level 2, scope L2 Isolated
  • C0310: Systems: Medication Administration severity level 2, scope L2 Pattern
  • C0330: Systems: Psychotropic Medication severity level 2, scope L2 Pattern
  • C0360: Staffing Requirements and Training: Staffing severity level 2, scope L2 Widespread
  • C0361: Acuity Based Staffing Tool - Elements severity level 2, scope L2 Widespread
  • C0362: Acuity Based Staffing Tool - ABST Time severity level 2, scope L2 Widespread
  • 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
  • C0422: Fire and Life Safety: Training for Residents severity level 2, scope L2 Widespread
  • C0455: Inspections and Investigation: Insp Interval severity level 4, scope L4 Isolated
  • H1510: Individual Rights Settings: Privacy, Dignity severity level 2, scope L2 Pattern
  • H1517: Individual Privacy: Own Unit severity level 2, scope L2 Pattern
  • L0252: Resident Move-in & Evaluation: Res Evaluation severity level 2, scope L2 Isolated
  • Z0140: Administration Responsibilities severity level 4, scope L4 Isolated
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread
  • Z0155: Staff Training Requirements severity level 2, scope L2 Pattern
  • Z0162: Compliance with Rules Health Care severity level 4, scope L4 Isolated
  • Z0163: Nutrition and Hydration severity level 2, scope L2 Pattern
  • Z0164: Activities severity level 2, scope L2 Pattern
• July 17, 2024: Complaint Investig., 2 deficiencies cited report
  • C0260: Service Plan: General severity level 2, scope L2 Isolated
  • C0364: Acuity Based Staffing Tool - Documentation severity level 2, scope L2 Isolated
• February 26, 2024: 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 April 26, 2024
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected April 26, 2024
• May 8, 2023: Validation, 5 deficiencies cited report
  • C0000: Comment severity level 0
  • C0160: Reasonable Precautions severity level 2, scope L2 Pattern, corrected July 10, 2023
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread, corrected July 10, 2023
  • Z0142: Administration Compliance severity level 2, scope L2 Pattern, corrected July 10, 2023
  • Z0155: Staff Training Requirements severity level 2, scope L2 Isolated, corrected July 10, 2023
  • Z0164: Activities severity level 2, scope L2 Pattern, corrected July 10, 2023

Substantiated abuse or neglect

• November 3, 2025: Failed to provide inservice 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); 411-054-0070 (Staffing Requirements and Training)
  State’s findings

  The Alleged Victim (AV) relies on the facility for his/her care and to administer his/her medications. According to an investigation, on or about November 3, 2025, AV had not been receiving medicated cream correctly to treat a rash to the groin and coccyx that had been present for more than a year. Multiple staff had not received training on specific areas to apply the medication, resulting in AV experiencing continued pain and unreasonable discomfort. The facility failed to provide in-service training, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• October 20, 2025: Failed to properly plan care 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); 411-054-0036 (Service Plan – General)
  State’s findings

  The Alleged Victim (AV) suffered a large bruise on his/her back of unknown origin. The bruise was noted on a skin sheet on October 26, 2025, and again on October 30, 2025. On November 4, 2025, AV had a large bruise in the middle of his/her back. On November 17, 2025, the bruise was still noted to be on AV's back. At no time was AV placed on alert charting for the large bruise on his/her back. By the time the RN provided a skin check on November 26, 2025, the bruise had resolved. Respondent failed to ensure staff followed protocol to ensure the resident was placed on alert charting to monitor a large bruise of unknown origin, or to put interventions in place to ensure AV did not suffer more bruises. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

• September 28, 2025: Failed to properly plan care Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; 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); 411-054-0036 (Service Plan – General)
  State’s findings

  The Alleged Victim (AV) is dependent on the facility to meet his/her safety needs and has a history of falls. According to an investigation, between August 29, 2025, and September 28, 2025, AV had multiple falls with injury. AV's service plan, updated September 19, 2025, identifies AV as having a high fall risk with interventions for staff supervision and 2-person assist with transfers. AV had at least two additional falls after September 19, 2025, resulting in a fractured wrist. The facility did not develop, implement or communicate to staff any known changes to AV's care plan following the falls. The facility failed to develop fall interventions to address AV’s fall risk, resulting in injury. The facility failed to properly plan care for AV, which is a violation of resident rights.

• July 26, 2025: Failed to properly plan care 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); 411-054-0036 (Service Plan – General)
  State’s findings

  The Alleged Victim (AV) is dependent on the facility to meet his/her safety needs and has a history of falls. According to an investigation, between June 13, 2025, and August 14, 2025, AV had multiple falls with injury. AV's service plan, updated July 14, 2025, identifies AV as having a high fall risk with interventions for staff supervision, a fall mat and positioning with a pillow in bed. AV had at least two additional falls after July 14, 2025. The facility did not develop, implement or communicate to staff any known changes to AV's care plan following the falls. The facility failed to develop fall interventions to address AV’s fall risk, resulting in injury. The facility failed to properly plan care for AV, which is a violation of resident rights, is considered neglect of care which constitutes abuse.

• June 5, 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); 411-054-0070 (Staffing Requirements and Training)
  State’s findings

  Alleged Victim (AV) relies on facility staff to administer medications. According to an investigation, on or about, June 20, 2025, it was discovered that the AV had not received prescribed daily Lithium from 6/5/2025 through 6/22/2025. The Alleged Perpetrator 2 (AP2) did not administer the medication to AV, but had marked the medication administration record (MAR) as administered. AP2's actions exposed AV to risk of serious harm, are considered neglect and constitutes abuse. Based on the investigation, it was determined that the facility did not provide a safe medication administration system and did not provide required training to AP2, which is a violation of resident rights, is neglect of care which constitutes abuse. The allegation that the Alleged Perpetrator 3 (AP3) neglected AV was investigated and determined to be inconclusive.

Substantiated licensing violations

• September 7, 2025: 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)
  State’s findings

  The facility failed to provide a safe environment which resulted in the Alleged Victim (AV) eloping without injury. The failure is a violation of Oregon Administrative Rules.

• September 7, 2025: Failed to maintain a safe physical environment Licensing Violation; Level 3 - Moderate harm or potential for serious harm; report
  Rules: 411-057-0710
  State’s findings

  The facility failed to have outdoor furniture that is sufficient weight, stability, design to prevent resident elopement. The facility’s failure is a violation of Oregon Administrative Rules.

• December 18, 2024: 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) has severe cognitive deficits and relies on the facility to administer his/her medications. According to an investigation, on or about December 18, 2024, the Alleged Perpetrator 2 (AP2) marked AV had been "given" their thyroid medication on AV's electronic record when AP2 had not administered the medication. This exposed AV to potential risk of serious harm. AP2's actions are considered neglect and constitutes abuse. The facility failed to ensure medications were administered as ordered, which violates Oregon Administrative Rules.

• December 18, 2024: 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) has severe cognitive deficits and relies on the facility to administer his/her medications. According to an investigation, on or about December 18, 2024, the Alleged Perpetrator 2 (AP2) failed to administer medication as ordered when he/she marked AV's medication administration record (MAR) as Bupropion "drug not available" when the medication had been delivered and was in the cart on December 17, 2024. On December 19, 2024, AP2 did not mark AV's MAR whether the medication, Lisinopril, was administered or not administered. This exposed AV to potential risk of serious harm. AP2's actions are considered neglect and constitutes abuse. The facility failed to ensure medications were administered as ordered, which violates Oregon Administrative Rules.

• December 18, 2024: 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) has severe cognitive deficits and relies on the facility to administer his/her medications. According to an investigation, on or about December 18, 2024, and December 19, 2024, the Alleged Perpetrator 2 (AP2) failed to administer medication as ordered when he/she marked AV's medication administration record (MAR) as the medication "not available" on December 18 and 19, 2024. However, the medication was present at the facility. AP2 had signed that the medications were delivered to the facility prior to the ordered administration times. This exposed AV to potential risk of serious harm. AP2's actions are considered neglect and constitutes abuse. The facility failed to ensure medications were administered as ordered, which violates 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 56 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.