Ocean Ridge Retirement And Assisted Living Community

Last inspection

July 23, 2026

Inspections

7, 7 deficiencies cited

Substantiated abuse

6

Substantiated licensing violations

5

Regulatory actions

1

Fines assessed

$2,750.00 (5 violations)

Current owner since

April 1, 2026

License conditions and other regulatory actions

• July 17, 2023 to February 15, 2024: License Condition, Failed to update staffing plan based on ABST ALFCD23-00447; incident: OR0004098500
  The facility failed to fully implement an Acuity Based Staffing Tool in accordance with OAR 411-054-0037.
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)

Inspections

• July 23, 2026: Kitchen, 1 deficiency cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
• June 5, 2025: Complaint Investig., 2 deficiencies cited report
  • C0362: Acuity Based Staffing Tool - Abst Time severity level 2, scope L2 Widespread
  • C0363: Acuity Based Staffing Tool - Updates & Plan severity level 2, scope L2 Widespread
• February 28, 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 April 28, 2024
• August 7, 2023: Validation, 0 deficiencies cited report
  • C0000: Comment severity level 0
• April 26, 2023: Complaint Investig., 1 deficiency cited report
  • C0010: Licensing Complaint Investigation severity level 2, scope L2 Isolated
  • C0360: Staffing Requirements and Training: Staffing severity level 2, scope L2 Isolated
• April 26, 2023: Complaint Investig., 1 deficiency cited report
  • C0010: Licensing Complaint Investigation severity level 2, scope L2 Isolated
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Widespread
• February 13, 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 March 30, 2023

Substantiated abuse or neglect

• April 15, 2026: 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) suffered three falls within 2 days. AV's physician noted concern on March 31, 2026, regarding AV's increased fall risks. No changes were made to AV's care plan to ensure AV's risk of falls, and the interventions put into place were not progressive to ensure AV's safety. On or about April 15, 2026, after AV's third fall in as many days, AV was found by family to have a large goose egg on his/her head, which was bruised. AV was sent to the hospital and it was determined that AV has had a recent cognitive decline, which could have occurred due to the three most recent falls that AV suffered. Respondent failed to ensure AV's care plan was updated after AV was determined to be a fall risk and ensure interventions in place were progressive and appropriate to ensure the safety of this resident, placing AV at risk for serious harm. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(ii).

• June 8, 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) had suffered recent falls during the month of June 2025. Incident report dated June 16, 2025, indicated that AV suffered 4 falls in 30 days. Interventions included bracelet pendant, non skid socks and frequent safety checks. AV suffered two more falls on June 18, 2025, which no new interventions were noted. On or about June 19, 2025, AV was found by the morning caregiver on the floor in his/her room. It appeared that AV was on the floor all night, as AV's bed was made, and AV does not have the ability to make his/her own bed. AV had bruising scattered across both knees, right hip, left arm and left shoulder. AV was sent to the hospital. AV's service plan indicated that AV was completely independent and does not need safety checks. Respondent failed to properly care plan for AV's needs, leading to AV suffering unreasonable discomfort and pain. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

• April 18, 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) has suffered falls on April 19, 2025, April 20, 2025 and April 29, 2025. AV suffered a skin tear on the latest fall on April 29, 2025. AV's care plan does not indicate that AV uses a walker, There were no interventions put into place after any of AV's falls, leaving AV at risk for continued falls. The facility's failure to properly care plan for AV's falls is a violation of resident rights, is considered neglect of care and constitutes abuse.

• March 31, 2025: Failed to provide safe environment Abuse: Neglect; 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); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General)
  State’s findings

  The Alleged Victim (AV) was found on the floor near his/her room after yelling for help. AV did not have a pendant to call for help as it was removed from his/her, and a baby monitor was installed. The monitor was to be monitored from the medication room, however, much of the time, no one was in the medication room to monitor it. AV suffered a skin tear from the fall. Later that day, AV was sent to the hospital for increasing pain to his/her knee and thigh. AV's service plan lacked guidance for safety checks or tracking when AV was last seen. Respondent failed to ensure staff were monitoring AV or completing safety checks to ensure the safety of AV. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

• August 14, 2024: 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); 411-054-0070 (Staffing Requirements and Training)
  State’s findings

  The Alleged Victim (AV) receives his/her medication from facility staff. On or about August 14, 2024, AV was given incorrect medication that belonged to another resident by Alleged Perpetrator #2 (AP2). AP2 realized his/her error and advised another staff. AV was sent out to the hospital for evaluation where he/she suffered drowsiness and ultimately passed out due to the medication error. AP2's actions are a violation of resident rights, are considered neglect of care and constitutes abuse as outlined in OAR 411-020-0002(1)(b)(A)(i). The facility's failure to ensure that AP2 was properly trained to dispense medication, which constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(ii).

• March 8, 2023: Failed to follow care plan 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) is care planned to have his/her brief changed two times per shift during waking hours, which requires two staff to assist AV with brief changes. Two facility staff were on light duty during night shift and could not lift more than 5 lbs, meaning they could not assist AV with brief changes. AV was to have his/her brief changed prior to dinner hour at 4:00 PM. It was determined to move this to after the dinner hour at 6:00 PM to make the last change at 10:00 PM, closer to NOC shift, so the staff wouldn't need to change AV, leaving AV unchanged until morning shift, which left AV at risk for harm. The facility's failure to follow the care plan is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• June 5, 2025: Failed to properly plan care Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0036 (Service Plan – General)
  State’s findings

  The facility failed to ensure resident service plans reflect the residents needs as identified in evaluation and resident preference; when a resident experiences a change of condition the service plan must be reviewed and updated as needed in accordance with OAR 411-054-0036(1-4), which is a violation of Oregon Administrative Rules.

• June 5, 2025: Failed to provide safe environment 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

  The facility failed to immediately notify the local Department office, or the local AAA, of any incident of abuse or suspected abuse, and promptly investigate all reports of abuse and suspected abuse in accordance with OAR 411-054-0028(1-3), which is a violation of Oregon Administrative Rules.

• June 5, 2025: Failed to provide safe environment 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

  The facility shall not interfered with good faith and the disclosure of information by an employee or volunteer of abuse or other action affecting a resident safety or welfare and take actions against or communicate to the the employees or volunteers may not disclose the information in accordance with OAR 411-054-0028 (4), which is a violation of Oregon Administrative Rules.

• April 5, 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 7, 2023: Failed to provide appropriate staffing Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0070 (Staffing Requirements and Training)
  State’s findings

  The facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident, 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 100 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.