Pheasant Pointe Assisted Living Community

Last inspection

April 16, 2025

Inspections

9, 26 deficiencies cited

Substantiated abuse

1

Substantiated licensing violations

19

Regulatory actions

2

Fines assessed

$188.00 (1 violation)

Current owner since

March 1, 2021

License conditions and other regulatory actions

• August 6, 2025 to October 17, 2025: License Condition, Failed to use an ABST ALFCD25-00326; incident: OR0004392501
  The facility failed to fully implement and update an acuity-based staffing tool in accordance with OAR 411-054-0037(1).
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)
• February 22, 2023 to July 27, 2023: License Condition, Failed to meet the scheduled and unscheduled needs of residents ALFCD23-00143; 2 incidents: OR0003717401, OR0003717400
  The facility failed to fully implement and update an Acuity Based Staffing Tool (ABST) in accordance with OAR 411-054-0037.
  Rules: 411-054-0037 (Acuity-Based Staffing Tool); 411-054-0070 (Staffing Requirements and Training)

Inspections

• April 16, 2025: Kitchen, 1 deficiency cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
• December 29, 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 February 27, 2024
• June 26, 2023: Validation, 12 deficiencies cited report
  • C0000: Comment severity level 0
  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Isolated, corrected August 28, 2023
  • C0252: Resident Move-In and Eval: Res Evaluation severity level 2, scope L2 Isolated, corrected August 28, 2023
  • C0260: Service Plan: General severity level 3, scope L3 Isolated, corrected August 28, 2023
  • C0280: Resident Health Services severity level 2, scope L2 Isolated, corrected August 28, 2023
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Isolated, corrected August 28, 2023
  • C0310: Systems: Medication Administration severity level 2, scope L2 Isolated, corrected August 28, 2023
  • C0330: Systems: Psychotropic Medication severity level 2, scope L2 Isolated, corrected August 28, 2023
  • C0370: Staffing Requirements and Training – Pre-Serv severity level 2, scope L2 Widespread, corrected August 28, 2023
  • C0372: Training Within 30 Days: Direct Care Staff severity level 2, scope L2 Widespread, corrected August 28, 2023
  • C0374: Annual and Biennial Inservice For All Staff severity level 2, scope L2 Widespread, corrected August 28, 2023
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread, corrected August 28, 2023
  • C0422: Fire and Life Safety: Training For Residents severity level 2, scope L2 Widespread, corrected August 28, 2023
• April 27, 2023: Complaint Investig., 2 deficiencies cited report
  • C0010: Licensing Complaint Investigation severity level 2, scope L2 Isolated
  • C0260: Service Plan: General severity level 2, scope L2 Isolated
  • C0295: Infection Prevention & Control severity level 2, scope L2 Isolated
• December 20, 2022: Complaint Investig., 2 deficiencies cited report
  • C0010: Licensing Complaint Investigation severity level 2, scope L2 Isolated
  • C0360: Staffing Requirements and Training: Staffing severity level 2, scope L2 Widespread
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Widespread

Substantiated abuse or neglect

• July 26, 2022: Failed to provide a safe medication administration system Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $188.00; 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 Alleged Victim (AV) is known to refuse medications regularly. The facility has not care planned AV for medication refusal. AV not getting his/her prescribed narcotic medication leaves AV at risk for unreasonable discomfort. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• January 17, 2026: Failed to protect resident from mental or emotional abuse 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)
  State’s findings

  On or about January 17, 2026, the Alleged Victim (AV) reported to staff that Alleged Perpetrator #2 (AP2) yelled at AV regarding using his/her pendant too much and told AV that if he/she would be evicted if AV didn't cooperate with staff. AV was terrified, crying and shaking after the interaction with AP2. AP2's actions are a violation of resident rights, are considered neglect of care and constitute verbal and emotional abuse, as outlined in OAR 411-020-0002(1)(d)(A)(ii) and (B)(ii). Respondent failed to protect AV from verbal and emotional abuse, which is a violation of Oregon Administrative Rules.

• December 24, 2025: Failed to protect resident from mental or emotional abuse 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)
  State’s findings

  The Alleged Victim (AV) returned from the hospital after an injury and was a two person transfer. Alleged Perpetrator #2 (AP2) told AV that due to his/her condition, AV needed to use the restroom in his/her bed, rather than having staff transfer him/her, for his/her safety. There were no orders to keep AV in bed after his/her return. AP2 moved AV's wheelchair to the bathroom so AV could not leave his/her bed. AV was embarrassed to be told he/she had to urinate or have a bowel movement in his/her bed, and have staff clean him/her up. AP2's actions caused AV unreasonable emotional distress, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility's failure to ensure AV was not emotionally abused is a violation of Oregon Administrative Rules.

• January 9, 2025: Failed to update staffing plan based on 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 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.

• October 23, 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 fully implement and update an Acuity Based Staffing Tool (ABST) in accordance with OAR 411-054-0037, which is a violation of Oregon Administrative Rules.

• February 7, 2023: Failed to provide service Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0036 (Service Plan – General)
  State’s findings

  The facility's service plan failed to provide to staff clear direction regarding the delivery of services and failed to provide a written description of how and how often the services shall be provided, 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 61 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.