Powell Valley Assisted Living Community

Last inspection

March 26, 2026

Inspections

7, 47 deficiencies cited

Substantiated abuse

9

Substantiated licensing violations

24

Regulatory actions

2

Fines assessed

$6,638.00 (9 violations)

Current owner since

March 1, 2020

License conditions and other regulatory actions

• July 8, 2026: License Condition, Failed to use an ABST ALFCD26-00258; incident: CALMS - 00114710
  The facility failed to have a sufficient number of direct care staff to meet the 24-hour scheduled and unscheduled needs of each resident in accordance OAR 411-054-0037(1-7).
  Rules: 411-054-0037 (Acuity-Based Staffing Tool); 411-054-0070 (Staffing Requirements and Training)
• August 8, 2025 to August 13, 2025: License Condition, Failed to use an ABST ALFCD25-00383; incident: OR0004780900
  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)

Inspections

• March 26, 2026: Re-Licensure, 12 deficiencies cited report
  • C0160: Reasonable Precautions severity level 4, scope L4 Pattern
  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Pattern
  • C0252: Resident Move-in & Evaluation: Res Evaluation severity level 2, scope L2 Pattern
  • C0260: Service Plan: General severity level 2, scope L2 Pattern
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Pattern
  Show all 17

  • C0280: Resident Health Services severity level 2, scope L2 Pattern
  • C0302: Systems: Tracking Control Substances severity level 2, scope L2 Pattern
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Pattern
  • C0305: Systems: Resident Right to Refuse severity level 2, scope L2 Pattern
  • C0310: Systems: Medication Administration severity level 2, scope L2 Pattern
  • C0330: Systems: Psychotropic Medication severity level 2, scope L2 Isolated
  • C0360: Staffing Requirements and Training: Staffing severity level 2, scope L2 Widespread
  • C0362: Acuity Based Staffing Tool - ABST Time severity level 2, scope L2 Pattern
  • C0363: Acuity Based Staffing Tool - Updates & Staffing Plan severity level 2, scope L2 Pattern
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Pattern
  • C0655: Call System severity level 2, scope L2 Widespread
• September 25, 2025: Kitchen, 1 deficiency cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
• April 24, 2025: Re-Licensure, 14 deficiencies cited report
  • C0155: Facility Administration: Records severity level 2, scope L2 Pattern
  • C0260: Service Plan: General severity level 2, scope L2 Pattern
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Pattern
  • C0280: Resident Health Services severity level 2, scope L2 Isolated
  • C0290: Res Hlth Srvc: On- and Off-Site Health Srvc severity level 2, scope L2 Pattern
  Show all 16

  • C0295: Infection Prevention & Control severity level 2, scope L2 Isolated
  • C0310: Systems: Medication Administration severity level 2, scope L2 Pattern
  • C0362: Acuity Based Staffing Tool - ABST Time severity level 2, scope L2 Pattern
  • C0363: Acuity Based Staffing Tool - Updates & Staffing Plan severity level 2, scope L2 Pattern
  • C0372: Training Within 30 Days of Hire ? Direct Care Staff severity level 2, scope L2 Pattern
  • C0374: Annual and Biennial Inservice for All Staff severity level 2, scope L2 Pattern
  • C0422: Fire and Life Safety: Training for Residents severity level 2, scope L2 Widespread
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread
  • C0610: General Building Exterior severity level 2, scope L2 Widespread
  • C0613: General Building: Doors-Walls, Cleanable severity level 2, scope L2 Widespread
  • C0640: Heating and Ventilation severity level 2, scope L2 Widespread
• October 29, 2024: Kitchen, 1 deficiency cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
• December 4, 2023: Complaint Investig., 5 deficiencies cited report
  • C0010: Licensing Complaint Investigation severity level 2, scope L2 Isolated
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Isolated
  • C0300: Systems: Medications and Treatments severity level 2, scope L2 Isolated
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Widespread
  • C0360: Staffing Requirements and Training: Staffing severity level 2, scope L2 Isolated
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Isolated
• August 2, 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 October 1, 2023
• April 4, 2022: Validation, 13 deficiencies cited report
  • C0000: Comment severity level 0
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread, corrected October 8, 2022
  • C0260: Service Plan: General severity level 2, scope L2 Pattern, corrected October 8, 2022
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Isolated, corrected October 8, 2022
  • C0282: Rn Delegation and Teaching severity level 2, scope L2 Isolated, corrected July 15, 2022
  Show all 15

  • C0303: Systems: Treatment Orders severity level 2, scope L2 Pattern, corrected October 8, 2022
  • C0305: Systems: Resident Right to Refuse severity level 2, scope L2 Isolated, corrected July 15, 2022
  • C0310: Systems: Medication Administration severity level 2, scope L2 Pattern, corrected July 15, 2022
  • C0340: Restraints and Supportive Devices severity level 2, scope L2 Pattern, corrected July 15, 2022
  • C0372: Training Within 30 Days: Direct Care Staff severity level 2, scope L2 Pattern, corrected October 8, 2022
  • C0374: Annual and Biennial Inservice For All Staff severity level 2, scope L2 Pattern, corrected July 15, 2022
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread, corrected October 8, 2022
  • C0422: Fire and Life Safety: Training For Residents severity level 2, scope L2 Widespread, corrected July 15, 2022
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread, corrected October 8, 2022
  • C0613: General Building: Doors-Walls, Cleanable severity level 2, scope L2 Pattern, corrected July 15, 2022

Substantiated abuse or neglect

• April 1, 2026: Failed to properly plan care Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $1,350.00; 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 April 23, 2026, Alleged Victim (AV), a resident of Respondent’s facility, suffered an unwitnessed fall in his/her room due to a delayed response to AV’s call light. Approximately 40 minutes after AV activated his/her call pendant seeking assistance with his/her care needs, facility staff arrived to AV's room and found AV on the floor, bleeding from his/her head with cuts on AV's head, right hand and knees. As a result of AV's fall, AV was transported to the hospital for treatment. Based on facility documentation and interviews, AV experienced several falls between January 28, 2026, and April 1, 2026. However, at the time of the investigation, AV’s service plan noted only one fall within the previous 90 days, occurring on December 13, 2025. The facility failed to adequately plan for AV’s safety despite a known fall risk that was not accurately documented in AV’s service plan. The facility's lack of appropriate oversight and care planning regarding AV's known fall risk, caused AV unreasonable discomfort and continued pain which constitutes abuse by neglect as outlined in OAR 411-020-0002(1)(b)(A)(i).

• April 1, 2026: Failed to answer call light in a timely manner Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $1,350.00; 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); 411-054-0070 (Staffing Requirements and Training)
  State’s findings

  Alleged Victim (AV) is a resident of the Respondent’s facility. The facility failed to provide adequate oversight to ensure AV’s care needs were met in a timely manner, resulting in unreasonable discomfort when AV remained on the floor for a prolonged period following a fall on April 1, 2026. According to facility documentation and interviews, AV is independent with ambulation, mobility, and transfers; however, care staff are expected to respond within a reasonable timeframe when AV activates the call light to request assistance. A review of AV’s call light data from March 14, 2026, through April 25, 2026, showed significant delays in staff response times, ranging from 12 minutes to 52 minutes across 14 separate days. The facility failed to ensure AV’s scheduled and unscheduled care needs were consistently met, demonstrating inadequate call system responsiveness. This lack of timely response caused AV unreasonable discomfort and constitutes abuse as outlined in 411-020-0002(1)(b)(A)(i).

• August 5, 2025: Failed to follow care plan 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); 411-054-0036 (Service Plan – General)
  State’s findings

  On or about August 5, 2025, the facility failed to provide services in accordance with the Alleged Victim’s (AV) assessed care needs related to AV’s diagnosed cognitive and hearing impairment. Facility documentation and staff interviews confirm that AV has bilateral sensorineural hearing loss and, due to cognitive impairment as stated in AV's care plan, requires assistance to ensure AV is wearing hearing aids consistently. The facility did not follow AV's care plan, resulting in AV having difficulty in participating in activities and conversations. The facility's failure to follow AV's care plan resulted in a loss of personal dignity. This constitutes abuse by neglect as defined by OAR 411-020-0002(1)(b)(A)(i).

• October 31, 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); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General)
  State’s findings

  The facility failed to implement appropriate interventions and monitoring measures in accordance with Witness 1’s (W1) known behavioral history and prior altercations. As a result, W1 engaged in repeated verbal aggression and intimidation toward the Alleged Victim (AV). Despite staff being aware of W1’s history of such behavior, the facility failed to develop and implement effective interventions to prevent further incidents. This ongoing exposure caused AV emotional harm, including fear and distress. Staff were unable to articulate or apply de-escalation techniques beyond contacting law enforcement, indicating a lack of adequate training and planning. The facility's failure to provide a safe and respectful environment for AV is a violation of resident rights, is considered neglect of care and constitutes abuse.

• June 14, 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); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General)
  State’s findings

  On July 2, 2024, ODHS Adult Protective Services (APS) initiated investigation #00340037 and issued a written investigation report, which is incorporated here by reference. The Alleged Victim (AV) resided at the Respondent’s facility and experienced a documented change of condition that resulted in increased confusion and agitation. In response, AV’s care plan was updated to reflect the elevated risk of wandering and potential harm due to disorientation in their living environment. On June 14, 2024, at approximately 4:25 PM, AV was observed wandering the facility halls in a confused state. Staff documented that AV was on alert and noted the need to monitor AV closely. However, by approximately 4:50 PM the same day, staff discovered that AV was missing from the facility. Staff began searching for AV off the facility grounds and was flagged down by staff from an adjacent building who informed that AV had entered that building and was confused, "completely winded" and could not state where AV lived. After being redirected back inside AV's facility, AV again left at about 6:00 PM and was found wandering in the parking lot. Based on facility documentation and interviews, the facility failed to develop sufficient interventions to mitigate risks to AV, which is a violation of resident rights, is considered neglect of care which constitutes abuse.

Substantiated licensing violations

• July 23, 2026: Failed to properly plan care Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0036 (Service Plan – General)
  State’s findings

  Based on interview and record review, conducted during a site visit on 07/23/26, the facility’s failure to ensure the implementation of services was substantiated for 1 of 1 sampled Resident (#1). Findings include, but are not limited to: Resident 1 stated the following: · S/he had limited mobility in his/her shoulder and required a one-person assist with bathing; · S/he received two showers a week on Mondays and Thursdays at 06:00 pm; · S/he had received only one weekly shower since the beginning of July 2026. Resident 1’s Service Plan, dated 07/04/26 indicated the following: · R1 required one-person assist with bathing; and · R1 received bathing assistance two times a week. Staff 2 (Caregiver) stated the following: · Shower schedules were posted in the medication room; · Caregivers were given a task sheet at the beginning of each shift indicating which residents they were assigned to and what services they were required to provide; and · Caregivers were required to complete shower sheets for each resident scheduled for a shower on their shift, whether the resident received a shower or not, and turn in the sheet to the residential care coordinator. PM Shower Schedule indicated Resident 1 was scheduled for bathing on Mondays and Thursdays and required one-person transfers. Resident 1’s Shower Sheets indicated the following: · R1 was assisted with showers on 07/02/26 and 07/13/26; · R1 did not receive showers on 07/06/26 and 07/09/26; and · R1 received a late shower on 07/10/26. There was no documented evidence that Resident 1 received showers on 07/16/26 and 07/20/26 as scheduled. The facility’s failure to ensure the implementation of services is a violation of Oregon Administrative Rules.

• July 14, 2026: Failed to meet the scheduled and unscheduled needs of residents Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0037 (Acuity-Based Staffing Tool); 411-054-0070 (Staffing Requirements and Training)
  State’s findings

  On or about July 14, 2026, the facility failed to have sufficient staff to meet the scheduled and unscheduled needs of the residents. It was determined the lack of staff is leading to needs not being met or taking extended periods of time to be met. Facility is not currently 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. Corrective Action taken on related allegation.

• May 21, 2026: 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

  Based on interviews and record review from the 05/21/26 investigation, it was determined the facility failed to obtain required background checks for all subject individuals (SI). Investigation Key findings: • On 05/19/26 at 03:15 a.m., the Background Check Unit closed Staff 4’s background check because fingerprints were not completed. The facility was instructed to immediately remove Staff 4 from work and submit a new application. • By 12:12 p.m. the same day, facility emails confirmed Staff 2, Staff 5, and Staff 1 all knew Staff 4 could no longer work. • Staff 2 reported that Staff 4 had been notified on 04/27/26 of the fingerprint deadline and was repeatedly reminded. Staff 2 also stated they informed Staff 1 and Staff 5 on 05/19/26 that Staff 4 must stop working but Staff 1 kept Staff 4 on the schedule anyway. • Scheduling and timesheet records show Staff 4 continued working on 05/19/26 and 05/20/26, after the application was closed. • Staff 1 stated they believed Staff 4 had submitted a new application, though no new application existed. • Before the investigation concluded, the facility terminated Staff 4 for failing to complete fingerprinting. The facility allowed Staff 4 to continue working after being instructed to remove them due to an incomplete background check. The facility’s failure to submit required background checks for all subject individuals (S1) is a violation of Oregon Administrative Rules.

• March 2, 2026: 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 March 2, 2026, an Unknown Alleged Perpetrator 2 (AP2) failed to provide appropriate services according to the Alleged Victim's (AV) care needs as outlined in AV's care plan which resulted in AV experiencing unreasonable discomfort and suffering bruising. AP2's actions caused AV harm which is considered neglect of care and constitutes abuse. The facility failed to provide a safe environment for AV which is considered a violation of Oregon Administrative Rules.

• January 2, 2026: 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, 2026, 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.

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 115 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.