Oswego Grove

Last inspection

September 12, 2025

Inspections

4, 29 deficiencies cited

Substantiated abuse

2

Substantiated licensing violations

14

Regulatory actions

1

Fines assessed

$29,875.00 (6 violations)

Current owner since

October 1, 2026

License conditions and other regulatory actions

• October 7, 2025 to January 5, 2026: License Condition, Failed to provide safe environment RCFCD25-01111; incident: CALMS - 00088805
  The findings of the re-licensure survey, conducted 09/09/25 through 09/12/25, determined facility's non-compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 Home and Community Based Services Regulations.
  Rules: 411-004-0020; 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); 411-054-0037 (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); 411-054-0090 (Fire and Life Safety); 411-054-0200 (Residential Care Facility Building Requirements); 411-057-0140 (Responsibilities of Administration); 411-057-0155 (Staff Training Requirements); 411-057-0160 (Resident Services in a Memory Care Community); 411-057-0170 (Physical Design, Environment, and Safety)

Inspections

• September 12, 2025: Re-Licensure, 25 deficiencies cited report
  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Isolated
  • 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 Isolated
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Isolated
  Show all 25

  • C0290: Res Hlth Srvc: On- and Off-Site Health Srvc 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 Isolated
  • C0362: Acuity Based Staffing Tool - ABST Time severity level 2, scope L2 Isolated
  • C0363: Acuity Based Staffing Tool - Updates & Staffing Plan severity level 2, scope L2 Widespread
  • 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
  • C0510: General Building Exterior severity level 2, scope L2 Widespread
  • C0513: Doors, Walls, Elevators, Odors severity level 2, scope L2 Widespread
  • C0515: Resident Units severity level 2, scope L2 Widespread
  • C0545: Plumbing Systems severity level 2, scope L2 Pattern
  • H1517: Individual Privacy: Own Unit severity level 2, scope L2 Widespread
  • H1518: Individual Door Locks: Key Access severity level 2, scope L2 Widespread
  • L0370: Staffing Requirements and Training ? Pre-service severity level 2, scope L2 Pattern
  • 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 2, scope L2 Widespread
  • Z0164: Activities severity level 2, scope L2 Isolated
  • Z0173: Secure Outdoor Recreation Area severity level 2, scope L2 Widespread
• August 22, 2024: Complaint Investig., 3 deficiencies cited report
  • C0260: Service Plan: General severity level 2, scope L2 Widespread
  • C0360: Staffing Requirements and Training: Staffing severity level 2, scope L2 Widespread
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Widespread
• July 5, 2022: Validation, 0 deficiencies cited report
  • C0000: Comment severity level 0
• June 9, 2022: Complaint Investig., 1 deficiency cited report
  • C0555: Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable severity level 1, scope L1 Widespread

Substantiated abuse or neglect

• September 2, 2024: Failed to properly plan care Abuse: Neglect; Level 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance; fine $2,500.00; report
  Rules: 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0036 (Service Plan – General)
  State’s findings

  The facility failed to implement interventions and appropriately care plan related to the Alleged Victim's (AV) fall history. On or about September 2, 2024, AV suffered an unwitnessed fall. AV was found by staff sitting on the floor in his/her apartment by the bed. AV was gripping his/her left arm and verbalized he/she was in pain. AV was unable to move left arm. AV was transferred to the hospital and was diagnosed with a fractured left humerus. AV's injury was determined to be non-operable, and AV was discharged with a new narcotic pain medication prescription to wear a sling with instructions to follow-up with an Orthopedic doctor. Based on facility documentation and interviews, AV has a fall history which includes a history of falling out of bed. At time of incident, AV's room was dark due to a broken lamp and AV could not see. AV's locks on wheelchair were not working at time of incident and the only intervention for fall prevention was use of fall mat. An investigation determined the facility failed to implement sufficient fall interventions to mitigate AV's fall risk. The facility's failure to properly care plan for AV's fall risk caused unreasonable discomfort and severe pain lasting more than 24 hours which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• November 29, 2023: Failed to properly plan care Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $375.00; report
  Rules: 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0036 (Service Plan – General)
  State’s findings

  The facility failed to implement appropriate interventions and failed to appropriately care plan related to the Alleged Victim’s (AV) known history of falls. On or about November 29, 2023, AV suffered a fall and was diagnosed with a fractured left hip, causing unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• January 6, 2026: Failed to follow care plan 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 the implementation of services when a resident is care planned for two-person transfers. The facility is a violation of Oregon Administrative Rules.

• September 3, 2025: 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

  On or about September 3, 2025, the facility failed to have an Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population, their needs, and all required Activities of Daily Living (ADL). 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 3, 2025: 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

  On or about January 3, 2025, the facility failed to have an Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population, their needs, and all required Activities of Daily Living (ADL). Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. Facility was not staffing to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules.

• January 2, 2025: 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

  On or about January 2, 2025, the facility failed to have an Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population, their needs, and all required Activities of Daily Living (ADL). Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. Facility was not staffing to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules.

• September 1, 2024: Failed to provide safe environment Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0025 (Facility Administration)
  State’s findings

  On or about September 1, 2024, a visitor of the facility exited the memory care unit (MCU), which allowed Alleged Victim (AV) to leave the secured area and enter an unlocked portion of the facility. AV subsequently exited the building and was located in the facility parking lot. Based on facility documentation and interviews, AV has a history of wandering and displaying exit seeking behaviors. Although, AV did not experience injuries or exhibit any signs of distress as a result of the incident, AV was able to leave the secured facility, without staff knowledge 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 31 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.