Pheasant Pointe Memory Care Community

Last inspection

April 16, 2025

Inspections

4, 17 deficiencies cited

Substantiated abuse

6

Substantiated licensing violations

5

Regulatory actions

1

Fines assessed

$3,126.00 (7 violations)

Current owner since

March 1, 2021

License conditions and other regulatory actions

• September 16, 2026 to September 24, 2026: License Condition, Failed to provide safe environment RCFCD26-00773; incident: CALMS - 00129694
  Facility has failed to exercise reasonable precautions that could threaten the health, safety, or welfare of residents.
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0030 (Resident Services); 411-057-0110 (Definitions); 411-057-0170 (Physical Design, Environment, and Safety)

Inspections

• April 16, 2025: 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
• December 29, 2023: 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 February 27, 2024
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected February 27, 2024
• June 26, 2023: Validation, 11 deficiencies cited report
  • C0000: Comment severity level 0
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread, corrected August 27, 2023
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Isolated, corrected August 27, 2023
  • C0310: Systems: Medication Administration severity level 2, scope L2 Isolated, corrected August 27, 2023
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread, corrected August 27, 2023
  Show all 12

  • C0422: Fire and Life Safety: Training For Residents severity level 2, scope L2 Widespread, corrected August 27, 2023
  • C0510: General Building Exterior severity level 2, scope L2 Widespread, corrected August 27, 2023
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected August 27, 2023
  • Z0155: Staff Training Requirements severity level 2, scope L2 Widespread, corrected August 27, 2023
  • Z0162: Compliance With Rules Health Care severity level 2, scope L2 Isolated, corrected August 27, 2023
  • Z0164: Activities severity level 2, scope L2 Pattern, corrected August 27, 2023
  • Z0165: Behavior severity level 2, scope L2 Isolated, corrected August 27, 2023
• December 20, 2022: 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 April 14, 2023
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread, corrected April 14, 2023
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected April 14, 2023

Substantiated abuse or neglect

• July 27, 2024: Failed to provide safe environment 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); 411-054-0036 (Service Plan – General)
  State’s findings

  On or about July 27, 2024, the Alleged Victim (AV) wandered into Witness #1's (W1) room. AV has a history of wandering and W1 has a history of inappropriate sexual behaviors. W1 has a sensor on his/her door to alert staff when W1 leaves his/her room or if anyone enters his/her room. W1's sensor on his/her door was unplugged on this day. Staff went to W1's room to remind him/her that it was dinner time. Staff found W1 and AV in the room with their pants down, with W1 behind AV making thrusting motions, and AV was crying and trying to pull up his/her briefs and pants. AV had prior sexual trauma and stayed in bed the next day and did not want staff to assist him/her with brief changes and would urinate on the floor. The facility's failure to provide a safe environment for AV, causing him/her to suffer significant emotional harm is a violation of resident rights, is considered neglect of care and constitutes abuse.

• February 20, 2024: Failed to provide or assist with hygiene 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); 411-054-0030 (Resident Services)
  State’s findings

  The Alleged Victim (AV) needs assistance and cueing with oral care. The facility had no documentation regarding AV's refusal of care or interventions to ensure AV was getting appropriate oral care. AV went to the dentist in early February and it was found that AV's partial was stuck in AV's mouth and difficult to remove. AV was found to have significant tooth decay and will need to have fillings and extractions. The facility's failure to ensure proper dental care caused AV unreasonable discomfort and loss of teeth. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

• April 9, 2023: Failed to provide safe environment Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $750.00; 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

  Witness #1 (W1) is care planned for inappropriate behaviors. On or about April 9, 2023, W1 was found in the Alleged Victim's (AV) room, kissing AV. AV was emotionally upset after the interaction. The facility's failure to provide a safe environment is a violation of resident rights, is considered neglect of care and constitutes abuse.

• April 9, 2023: Failed to properly plan care Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $750.00; 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

  Witness #1 (W1) is care planned for inappropriate behaviors. W1 and the Alleged Victim (AV) had a previous incident of sexualized behaviors. On or about April 16, 2023, W1 and AV were found in AV's room, with clothes off and W1 rubbing AV's stomach. AV was emotionally upset after the interaction. The facility's failure to properly care plan is a violation of resident rights, is considered neglect of care and constitutes abuse.

• February 22, 2022: Failed to properly plan care 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); 411-054-0036 (Service Plan – General)
  State’s findings

  The Alleged Victim (AV) was a known fall risk. The facility had an interim service plan in place, however, AV continued to fall without other measures put into place to ensure AV's safety from falling. On or about February 22, 2022, AV suffered two separate falls, one in which AV was in pain. AV was found to not be using any assistive device during his/her second fall. The facility's failure to properly care plan is a violation of resident rights, is considered neglect of care and constitutes abuse.

• February 16, 2022: Failed to provide service 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); 411-054-0030 (Resident Services); 411-054-0070 (Staffing Requirements and Training)
  State’s findings

  The Alleged Victim (AV) was to receive assistance with cleaning his/her room, assistance with showers two times per week, and assistance with laundry. AV has been found multiple times in dirty clothing, smelling of urine / feces, face unshaven and hair unkempt. AV's room has been found to be dirty with ants on the floor and counters. These conditions have subjected AV to a loss of personal dignity and unreasonable discomfort. The facility's failure to provide enough staff and perform services for AV is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• May 7, 2024: Failed to protect resident from financial exploitation 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 May 8, 2024, the Alleged Victim (AV) was found to be missing money and a gold band from his/her apartment. Alleged Perpetrator #2 (AP2, unknown) took money and a gold band from AV’s apartment. AP2’s actions are a violation of resident rights, are considered neglect of care and constitute financial abuse. The facility’s failure is a violation of Oregon Administrative Rules.

• April 30, 2024: Failed to use restraint properly 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 April 30, 2024, the Alleged Victim (AV) was seated in the common area in his/her wheel chair. Alleged Perpetrator #2 (AP2) was sitting and looking at his/her cell phone, approximately 6 feet away from AV. AV got up out of his/her wheelchair. AV is capable of walking with the assistance from staff. When AV got up, AP2 used AV's gait belt to pull AV back into his/her wheelchair, preventing AV from standing. AP2 went back to sit down and continued to look on his/her cell phone. AP2's actions constitute wrongful restraint, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility's failure to ensure AV is not wrongfully restrained is a violation of Oregon Administrative Rules.

• February 22, 2022: Failed to protect resident from mental or emotional abuse Licensing Violation; 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)
  State’s findings

  The Alleged Victim (AV) was found on the floor in the hallway. Alleged Perpetrator #2 (AP2) repeatedly told AV they were not going to assist AV up and AV needed to get themselves up. AP2 continued to berate AV while AV was on the floor, and called AV an ass. AP2's actions are a violation of resident rights, are considered neglect of care and constitute verbal and emotional abuse. The facility's failure to protect AV is a violation of Oregon Administrative Rules.

• February 3, 2022: Failed to provide service Licensing Violation; Level 1 - No harm or potential for minor harm; report
  Rules: 411-054-0030 (Resident Services)
  State’s findings

  The facility failed to assist residents with bathing and dressing and undressing, which is a violation of Oregon Administrative Rules.

• December 13, 2021: Failed to follow care plan Licensing Violation; Level 1 - No harm or potential for minor harm; report
  Rules: 411-054-0036 (Service Plan – General)
  State’s findings

  The facility failed to ensure the implementation of services per resident service plan, 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 12 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.