Oak Lane Residential Care Facility

Last inspection

July 28, 2026

Inspections

6, 23 deficiencies cited

Substantiated abuse

9

Substantiated licensing violations

21

Regulatory actions

2

Fines assessed

$9,188.00 (9 violations)

Current owner since

May 1, 2023

License conditions and other regulatory actions

• August 20, 2026 to September 21, 2026: License Condition, Failed to provide safe environment RCFCD26-00727; incident: CALMS - 00121107
  Facility failed to provide a safe environment for Alleged Victim (AV) based on preliminary findings for APS #00497074, along with the relevant preliminary evidence identified in the notice, meet the criteria for Immediate Jeopardy.
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0036 (Service Plan – General)
• January 30, 2023 to June 7, 2023: License Condition, Failed to meet the scheduled and unscheduled needs of residents RCFCD23-00068; 4 incidents: OR0003765103, OR0003765102, OR0003765101, OR0003765100
  The facility failed to carry out medication and treatment orders as prescribed in accordance with OAR 411-054-0055(1)(f) per Complainant that medication adminsitration is being done outside the two hour window.
  Rules: 411-054-0030 (Resident Services); 411-054-0037 (Acuity-Based Staffing Tool); 411-054-0055 (Medications and Treatments); 411-054-0070 (Staffing Requirements and Training)

Inspections

• July 28, 2026: Kitchen, 2 deficiencies cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread
• February 27, 2025: Re-Licensure, 12 deficiencies cited report
  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Isolated
  • C0260: Service Plan: General severity level 2, scope L2 Pattern
  • C0295: Infection Prevention & Control severity level 2, scope L2 Widespread
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Isolated
  • C0363: Acuity Based Staffing Tool - Updates & Staffing Plan severity level 2, scope L2 Widespread
  Show all 12

  • C0510: General Building Exterior severity level 2, scope L2 Widespread
  • C0513: Doors, Walls, Elevators, Odors severity level 2, scope L2 Widespread
  • C0555: Call Sys, Exit Dr Alarm, Phones, TV, or Cable severity level 2, scope L2 Widespread
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread
  • Z0162: Compliance with Rules Health Care severity level 2, scope L2 Widespread
  • Z0163: Nutrition and Hydration severity level 2, scope L2 Pattern
  • Z0165: Behavior severity level 2, scope L2 Pattern
• June 3, 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 August 2, 2024
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected August 2, 2024
• January 19, 2023: State Licensure, 0 deficiencies cited report
  • C0000: Comment severity level 0
• November 2, 2022: Complaint Investig., 2 deficiencies cited report
  • C0010: Licensing Complaint Investigation severity level 2, scope L2 Isolated
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Isolated
  • C0421: Fire and Life Safety: Safety severity level 2, scope L2 Isolated
• October 6, 2022: Complaint Investig., 5 deficiencies cited report
  • C0010: Licensing Complaint Investigation severity level 2, scope L2 Isolated
  • C0200: Resident Rights and Protection - General severity level 2, scope L2 Isolated
  • C0242: Resident Services: Activities severity level 2, scope L2 Isolated
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Isolated
  • C0360: Staffing Requirements and Training: Staffing severity level 2, scope L2 Isolated
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Isolated

Substantiated abuse or neglect

• February 3, 2026: Failed to provide a safe medication administration system 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); 411-054-0055 (Medications and Treatments)
  State’s findings

  The facility failed to ensure that Alleged Victim (AV) received AV’s prescribed pain medication during two separate periods, resulting in AV experiencing significant and preventable pain, discomfort, and withdrawal symptoms. As a resident, AV relies on facility staff to appropriately order, manage, and administer all prescribed medications. During the facility-initiated pharmacy transition, the facility proceeded with the pharmacy change without a plan in place to ensure continued access to AV’s prescribed pain medication. Facility documentation and staff interviews indicate that AV did not receive his/her pain medication from approximately October 25, 2025, to October 31, 2025, and again from November 15, 2025, to November 18, 2025. The facility's failure to provide a safe medication administration system for AV caused AV continued pain and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care which constitutes abuse, as defined by 411-020-0002(1)(b)(A)(i).

• November 8, 2025: Failed to provide a safe medication administration system 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); 411-054-0055 (Medications and Treatments)
  State’s findings

  On or about November 8, 2025, the facility failed to provide adequate oversight of its Medication Administration System, resulting in harm to the Alleged Victim (AV). AV, a full-assist resident for medication management, did not receive his/her prescribed PRN pain medication for approximately 12 days. Based on facility documentation and interviews, AV’s last documented administered dose was given on November 7, 2025, at around 3:45 AM. On or about, November 8, 2025, the facility faxed refill orders to AV's health care provider; however, the order was returned unsigned and had to be resent. Additional delays occurred when the provider indicated AV had a new PCP and the facility in the process of transitioning to a new in-house pharmacy. From November 8, 2025, to November 13, 2025, AV was without any supply of the PRN pain medication resulting in continued pain. The facility did not receive the refill until November 19, 2025, when administration finally resumed. The facility's failure to provide a safe medication system for AV, resulted in continued pain and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• November 8, 2025: Failed to provide a safe medication administration system 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); 411-054-0055 (Medications and Treatments)
  State’s findings

  Based on witness statements, investigator observations, and documentary evidence, the investigator determined by a preponderance of the evidence that the facility failed to maintain an adequate supply of the Alleged Victim’s (AV’s) prescribed pain medication. As a result, AV did not receive the ordered medication from November 4, 2025, through November 10, 2025, because the medication was not available in the facility. On November 5, 2025, staff placed AV on alert charting due to the missing medication. Staff were instructed to monitor AV for increased pain, withdrawal symptoms, anxiety, agitation, sweating, chills, nausea, vomiting, diarrhea, muscle aches, back pain, joint pain, insomnia, and flu-like symptoms. Despite this, the facility did not obtain the required medication in a timely manner, and AV continued without the prescribed treatment. On November 8, 2025, AV was transferred to the hospital for evaluation. The investigation determined that the facility failed to maintain a safe and reliable medication administration system to ensure AV received medications as ordered. This failure resulted in unreasonable discomfort to AV, which is a violation of resident rights, is considered neglect of care, which constitutes abuse.

• November 5, 2025: Failed to provide a safe medication administration system Abuse: Neglect; Level 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance; fine $2,500.00; 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

  On or about November 17, 2025, the Alleged Victim (AV) was hospitalized and diagnosed with an acute kidney injury (AKI) requiring dialysis. According to the medication list received from the facility at time of admission, AV was receiving a diuretic (20 mg daily), an ACE inhibitor (40 mg daily), and a weight-management injection (0.25 mg). Based on facility documentation and interviews, AV had a prior November 2025 hospitalization and at time of discharge on November 2, 2025, the hospital discontinued AV’s ACE inhibitor, diuretic, and weight-management medication. At time of AV's November 17, 2025, hospitalization, it was determined facility staff continued administering all three discontinued medications. The administration of discontinued medications negatively affected AV, resulting in AV being admitted to the hospital with concerns for AV’s kidneys. The facility’s failure to reconcile discharge medication orders, verify discontinuations, and ensure safe medication administration directly contributed to AV developing AKI requiring hospitalization and dialysis which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• October 25, 2025: Failed to provide a safe medication administration system 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); 411-054-0055 (Medications and Treatments)
  State’s findings

  The facility failed to ensure a safe and reliable medication administration system for the Alleged Victim (AV). Specifically, the facility did not maintain an adequate supply of AV’s prescribed narcotic pain medication, resulting in AV not receiving medications as ordered. Facility documentation and interviews indicate that during a five-day period, AV missed approximately twelve doses of AV’s prescribed narcotic pain medication, which was ordered every four hours. During this time, AV only received AV’s nightly dose of prescribed narcotic pain medication and five doses of PRN non-narcotic pain medication. This failure caused AV unreasonable discomfort and resulted in AV being sent to the emergency room for pain management. The facility’s failure to provide AV’s medication as prescribed is a violation of resident rights, is considered neglect of care which constitutes abuse.

Substantiated licensing violations

• July 13, 2026: Failed to provide safe environment Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0036 (Service Plan – General)
  State’s findings

  On or about July 13, 2026, the facility failed to provide appropriate supervision to the Alleged Victim (AV) according to his/her care needs. The failure resulted in AV eloping the secured building, placing him/her at risk of harm, which is a violation of Oregon Administrative Rules.

• July 12, 2026: Failed to report potential or suspected abuse Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare)
  State’s findings

  On or about July 12, 2026, the facility failed to immediately report abuse or suspected abuse to the Department and promptly investigate all reports of abuse and suspected abuse which is a violation of Oregon Administrative Rules.

• February 3, 2026: Failed to administer medication as ordered 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 ensure medication and treatment orders must be carried out as prescribed in accordance with OAR 411-054-0055(1)(f). Per complainant, resident was not getting medications for two months. Facility swapped pharmacy's but residents did not get medications for months. The resident's health declined very badly because h/she did not get their medication, which is a violation of Oregon Administrative Rules.

• February 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 update and review an Acuity Based Staffing Tool in accordance with OAR 411-054-0037(4).

• November 17, 2025: Failed to keep medication record current or accurate 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 carry out medication and treatment orders as prescribed in accordance with OAR 411-054-0055(1)(f); per complainant that a resident was hospitalized for acute kidney injury due to the facility administering medications that were discontinued, 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 80 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.