Pelican Pointe

Last inspection

June 4, 2024

Inspections

2, 21 deficiencies cited

Substantiated abuse

4

Substantiated licensing violations

0

Regulatory actions

1

Fines assessed

$2,000.00 (4 violations)

Current owner since

April 1, 2022

• Every deficiency from the June 4, 2024 inspection was corrected by August 4, 2024

License conditions and other regulatory actions

• January 14, 2021 to January 19, 2022: License Condition, Failed to provide safe environment RCFCD21-01617; incident: CALMS - 00009990
  Based on observations, interviews and record review it was determined Respondent failed to implement adequate infection control practices to prevent the spread of COVID-19 (Coronavirus).
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0093 (Emergency and Disaster Planning)

Inspections

• June 4, 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 August 4, 2024
• June 3, 2024: Validation, 20 deficiencies cited report
  • C0000: Comment severity level 0
  • C0152: Facility Administration: Required Postings severity level 2, scope L2 Widespread, corrected August 5, 2024
  • C0154: Facility Administration: Policy & Procedure severity level 2, scope L2 Widespread, corrected August 5, 2024
  • C0242: Resident Services: Activities severity level 2, scope L2 Widespread, corrected August 5, 2024
  • C0252: Resident Move-In and Eval: Res Evaluation severity level 2, scope L2 Isolated, corrected August 5, 2024
  Show all 23

  • C0260: Service Plan: General severity level 2, scope L2 Pattern, corrected August 5, 2024
  • C0282: Rn Delegation and Teaching severity level 2, scope L2 Isolated, corrected August 5, 2024
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Pattern
  • C0362: Acuity Based Staffing Tool - Abst Time severity level 2, scope L2 Widespread
  • C0370: Staffing Requirements and Training – Pre-Serv severity level 2, scope L2 Pattern, corrected August 5, 2024
  • C0372: Training Within 30 Days: Direct Care Staff severity level 2, scope L2 Pattern, corrected August 5, 2024
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread, corrected August 5, 2024
  • C0422: Fire and Life Safety: Training For Residents severity level 2, scope L2 Widespread, corrected August 5, 2024
  • C0455: Inspections and Investigation: Insp Interval 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, corrected August 5, 2024
  • C0515: Resident Units severity level 2, scope L2 Pattern, corrected August 5, 2024
  • C0540: Heating and Ventilation severity level 2, scope L2 Widespread, corrected August 5, 2024
  • C0555: Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable severity level 2, scope L2 Widespread, corrected August 5, 2024
  • H1501: Integrated Settings: Community Life severity level 0, corrected August 5, 2024
  • H1512: Optimize Settings: Independence, Activities severity level 0, corrected August 5, 2024
  • H1515: Physical Setting: Individual Accessible severity level 0, corrected August 5, 2024
  • H1517: Individual Privacy: Own Unit severity level 0, corrected August 5, 2024

Substantiated abuse or neglect

• December 27, 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); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General)
  State’s findings

  The Alleged Victim (AV) is a known fall risk and has suffered multiple falls over a few months. On or about December 27, 2025, AV suffered a fall out of his/her bed and sustained a skin tear and a bruise. AV was on two hour safety checks and was prescribed a wheelchair to assist with increased weakness and falls. AV's care plan stated that AV was independent with ambulation and transfers, and did not require assistance with safety checks or fall prevention measures. Hospital bed with rails were requested but have not been implemented. Respondent failed to ensure AV's care plan was updated with current information and ensure interventions were in place to reduce AV's risk of falls. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

• December 14, 2025: Failed to properly plan care Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $500.00; report
  Rules: 411-054-0025 (Facility Administration); 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 8 falls within 30 days, suffering bruises, skin tears, hitting his/her head and unreasonable discomfort. AV was not care planned as a fall risk. AV was prescribed a wheelchair by his/her physician, however, it doesn't appear, according to documentation, that it was being utilized. The facility had not implemented meaningful interventions to reduce AV's risk for falls. Respondent failed to ensure staff implemented interventions to reduce AV's risk of falling. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

• September 4, 2024: 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) was a known fall risk and suffered 8 falls within 30 days. AV's care plan stated he/she was an average fall risk and independent with transfers, despite having frequent falls during transfers. AV was found on the floor multiple times and no meaningful interventions were put into place to ensure AV's safety from falls. The facility's failure placed AV at risk for harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• September 4, 2024: Failed to provide safe environment 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); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General)
  State’s findings

  The Alleged Victim (AV) had wandering behaviors and episodic confusion. AV had multiple instances of wandering into other residents rooms and leaving the facility without supervision, and getting lost inside and outside the facility and not being able to find his/her way back. The only interventions in place were to have one or two hour checks on AV and to redirect when seen wandering and no other interventions to reduce AV's wandering behaviors. The facility's failure to provide a safe environment for AV is a violation of resident rights, is considered neglect of care and constitutes abuse.

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 48 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.