Pine Rose

Last inspection

April 23, 2026

Inspections

6, 41 deficiencies cited

Substantiated abuse

3

Substantiated licensing violations

7

Regulatory actions

1

Fines assessed

$30,938.00 (7 violations)

Current owner since

November 1, 2025

License conditions and other regulatory actions

• April 11, 2022 to January 24, 2023: License Condition, Failed to provide safe environment RCFCD22-00712; 2 incidents: CALMS - 00027921, CALMS - 00026765
  On April 11, 2022, the Department issued a Notice & Order Imposing License Condition and mandated the facility restrict admission of residents, retain the services of a Registered Nurse and Administrative Consultant, maintain minimum Registered Nurse hours, along with staffing and reporting requirements. On May 9, 2022, the Department conducted a visit and determined the facility was not following the terms of the License Condition and continued to place residents at risk of serious harm.
  Rules: 411-054-0025 (Facility Administration); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0030 (Resident Services); 411-054-0034 (Resident Move-In and Evaluation); 411-054-0036 (Service Plan – General); 411-054-0040 (Change of Condition and Monitoring); 411-054-0045 (Resident Health Services); 411-054-0055 (Medications and Treatments); 411-054-0065 (Administrator Qualifications and Requirements); 411-054-0070 (Staffing Requirements and Training); 411-054-0090 (Fire and Life Safety); 411-054-0200 (Residential Care Facility Building Requirements)

Inspections

• April 23, 2026: Change of Owner, 4 deficiencies cited report
  • C0252: Resident Move-in & Evaluation: Res Evaluation severity level 2, scope L2 Isolated
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Pattern
  • C0355: Administrator: Administrator Requirements severity level 2, scope L2 Widespread
  • C0363: Acuity Based Staffing Tool - Updates & Staffing Plan severity level 2, scope L2 Widespread
• April 21, 2026: Kitchen, 1 deficiency cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
• June 12, 2025: Re-Licensure, 6 deficiencies cited report
  • C0242: Resident Services: Activities severity level 2, scope L2 Widespread
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Isolated
  • C0363: Acuity Based Staffing Tool - Updates & Staffing Plan severity level 2, scope L2 Pattern
  • C0370: Staffing Requirements and Training ? Pre-service severity level 2, scope L2 Pattern
  • C0372: Training Within 30 Days of Hire ? Direct Care Staff severity level 2, scope L2 Pattern
  • H1510: Individual Rights Settings: Privacy, Dignity severity level 2, scope L2 Pattern
• October 16, 2024: Kitchen, 3 deficiencies cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
  • C0545: Plumbing Systems severity level 2, scope L2 Widespread
  • C0555: Call Sys, Exit Dr Alarm, Phones, TV, or Cable severity level 2, scope L2 Widespread
• July 6, 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 September 4, 2023
• March 29, 2022: Validation, 26 deficiencies cited report
  • C0000: Comment severity level 0
  • C0150: Facility Administration: Operation severity level 4, scope L4 Widespread, corrected September 20, 2022
  • C0152: Facility Administration: Required Postings severity level 2, scope L2 Widespread, corrected September 20, 2022
  • C0156: Facility Administration: Quality Improvement severity level 2, scope L2 Widespread, corrected September 20, 2022
  • C0160: Reasonable Precautions severity level 2, scope L2 Widespread, corrected November 4, 2023
  Show all 29

  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Pattern, corrected September 20, 2022
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread, corrected September 20, 2022
  • C0242: Resident Services: Activities severity level 2, scope L2 Widespread, corrected September 20, 2022
  • C0252: Resident Move-In and Eval: Res Evaluation severity level 2, scope L2 Pattern, corrected September 20, 2022
  • C0260: Service Plan: General severity level 2, scope L2 Pattern, corrected September 20, 2022
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Pattern, corrected September 20, 2022
  • C0280: Resident Health Services severity level 2, scope L2 Pattern, corrected September 20, 2022
  • C0290: Res Hlth Srvc: On- and Off-Site Health Srvc severity level 2, scope L2 Isolated, corrected September 20, 2022
  • C0295: Infection Prevention & Control severity level 2, scope L2 Widespread, corrected November 4, 2023
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Pattern, corrected September 20, 2022
  • C0310: Systems: Medication Administration severity level 2, scope L2 Pattern, corrected September 20, 2022
  • C0350: Administrator Qualification and Requirements severity level 4, scope L4 Widespread, corrected September 20, 2022
  • C0360: Staffing Requirements and Training: Staffing severity level 4, scope L4 Widespread, corrected September 20, 2022
  • C0365: Staffing Rqmt and Training: Training Rqmts severity level 2, scope L2 Pattern, corrected November 4, 2023
  • C0370: Staffing Requirements and Training – Pre-Serv severity level 2, scope L2 Pattern, corrected November 4, 2023
  • C0372: Training Within 30 Days: Direct Care Staff severity level 2, scope L2 Pattern, corrected November 4, 2023
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread, corrected September 20, 2022
  • C0422: Fire and Life Safety: Training For Residents severity level 2, scope L2 Widespread, corrected September 20, 2022
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread, corrected November 4, 2023
  • C0510: General Building Exterior severity level 2, scope L2 Widespread, corrected September 20, 2022
  • C0513: Doors, Walls, Elevators, Odors severity level 2, scope L2 Widespread, corrected September 20, 2022
  • C0530: Housekeeping and Laundry severity level 2, scope L2 Widespread, corrected September 20, 2022
  • C0545: Plumbing Systems severity level 2, scope L2 Widespread, corrected September 20, 2022
  • C0555: Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable severity level 2, scope L2 Widespread, corrected September 20, 2022

Substantiated abuse or neglect

• January 24, 2026: Failed to follow care plan 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) relies on the facility for care and services. According to an investigation, facility staff heard a thump and found AV had suffered a fall. AV's care plan calls for AV to have a bed alarm, but the alarm did not sound because the batteries needed replaced. The facility failed to follow the care plan by ensuring the interventions were functioning properly, which is a violation of resident rights, is neglect of care which constitutes abuse.

• July 16, 2022: Failed to assure resident was safe 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)
  State’s findings

  The facility failed to provide appropriate supervision to the Alleged Victim (AV) according to his/her needs. The failure resulted in AV being located outside, for an undetermined period of time, wearing a jacket in approximately 90 degree weather without staff knowledge, placing him/her at risk of harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• June 16, 2022: Failed to provide a safe medication administration system 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); 411-054-0055 (Medications and Treatments)
  State’s findings

  The facility failed to provide a safe medication administration system to ensure the Alleged Victim’s (AV) medication was available to administer. AV went without essential medication from June 7, 2022 to June 15, 2022, placing AV at risk for serious harm. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• June 2, 2026: Failed to follow care plan 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) relies on the facility to provide safe environment and needed care. AV is care planned to have a pressure alarm for safety due to AV's lack of safety awareness and risk of falling. Alleged Perpetrator 2 (AP2) provided care to AV and when doing this, turned off AV's pressure alarm. AV later stood up and fell and staff were not aware due to the alarm being turned off. The facility failed to follow the care plan, which is a violation of Oregon Administrative Rule. AP2 failed to follow the care plan for AV, which is neglect and constitutes abuse.

• September 1, 2022: Failed to submit timely or adequate staffing documentation Licensing Violation; Level 2 - Minor harm or potential for moderate harm; fine $7,500.00; report
  Rules: 411-061-0010
  State’s findings

  On or about September 1, 2022, the Oregon Health Authority reported to the Department that Respondent failed to comply with weekly reporting requirements of vaccinated individuals, residents and staff, to the proper authority as required by law. This failure has been ongoing from August 1, 2022 to August 31, 2022, for a total of 30 days.

• August 1, 2022: Failed to submit timely or adequate staffing documentation Licensing Violation; Level 2 - Minor harm or potential for moderate harm; fine $7,500.00; report
  Rules: 411-061-0010
  State’s findings

  On or about August 1, 2022, the Oregon Health Authority reported to the Department that Respondent failed to comply with weekly reporting requirements of vaccinated individuals, residents and staff, to the proper authority as required by law. This failure has been ongoing from July 1, 2022 to July 31, 2022, for a total of 30 days.

• July 11, 2022: Failed to protect resident from physical 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

  Alleged Perpetrator 2 (AP2) caused unreasonable discomfort to Alleged Victim (AV) by non-accidental means. AP2 admitted to hitting AV and is responsible for physical abuse. The facility failed to protect AV from rough treatment which is a violation of Oregon Administrative Rules.

• May 9, 2022: 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 follow the care plan, which is a violation of Oregon administrative Rules.

• May 2, 2022: Failed to submit timely or adequate staffing documentation Licensing Violation; Level 2 - Minor harm or potential for moderate harm; fine $7,500.00; report
  Rules: 411-061-0010
  State’s findings

  On or about May 1, 2022, the Oregon Health Authority reported to the Department that Respondent failed to comply with weekly reporting requirements of vaccinated individuals, residents and staff, to the proper authority as required by law. This failure has been ongoing from April 1, 2022 to April 30, 2022, for a total of 30 days.

• April 1, 2022: Failed to submit timely or adequate staffing documentation Licensing Violation; Level 2 - Minor harm or potential for moderate harm; fine $7,500.00; report
  Rules: 411-061-0010
  State’s findings

  On or about April 1, 2022, the Oregon Health Authority reported to the Department that Respondent failed to comply with weekly reporting requirements of vaccinated individuals, residents and staff, to the proper authority as required by law. This failure has been ongoing from March 1, 2022 to March 31, 2022, for a total of 30 days.

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 15 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.