Powell Valley Memory Care Community

Last inspection

August 19, 2026

Inspections

7, 42 deficiencies cited

Substantiated abuse

8

Substantiated licensing violations

5

Regulatory actions

1

Fines assessed

$4,001.00 (8 violations)

Current owner since

March 1, 2020

License conditions and other regulatory actions

• July 2, 2025 to October 6, 2025: License Condition, Failed to provide safe environment RCFCD25-00637; incident: CALMS - 00081627
  On or about May 21, 2025, through May 23, 2025, ODHS conducted survey re-licensure visit, #RL0004549. ODHS found facility out of compliance resulting in twenty-one violations, two of which were cited at harm. Due to facility being found out of compliance with Oregon Administrative Rules, ODHS issued Amended Order Imposing License Condition RCFCD25-00637, effective July 2, 2025.
  Rules: 411-004-0020; 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0034 (Resident Move-In and Evaluation); 411-054-0036 (Service Plan – General); 411-054-0037 (Acuity-Based Staffing Tool); 411-054-0040 (Change of Condition and Monitoring); 411-054-0045 (Resident Health Services); 411-054-0050 (Infection Prevention and Control); 411-054-0055 (Medications and Treatments); 411-054-0090 (Fire and Life Safety); 411-057-0140 (Responsibilities of Administration); 411-057-0155 (Staff Training Requirements); 411-057-0160 (Resident Services in a Memory Care Community)

Inspections

• August 19, 2026: Re-Licensure, 4 deficiencies cited report
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread
  • C0510: General Building Exterior severity level 2, scope L2 Widespread
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread
  • Z0173: Secure Outdoor Recreation Area severity level 2, scope L2 Widespread
• September 25, 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
• May 23, 2025: Re-Licensure, 21 deficiencies cited report
  • C0200: Resident Rights and Protection - General severity level 2, scope L2 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 21

  • C0280: Resident Health Services severity level 3, scope L3 Isolated
  • C0295: Infection Prevention & Control 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 Isolated
  • 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
  • C0422: Fire and Life Safety: Training for Residents severity level 2, scope L2 Widespread
  • H1510: Individual Rights Settings: Privacy, Dignity severity level 2, scope L2 Pattern
  • H1515: Physical Setting: Individual Accessible severity level 2, scope L2 Pattern
  • H1517: Individual Privacy: Own Unit severity level 2, scope L2 Pattern
  • H1518: Individual Door Locks: Key Access severity level 2, scope L2 Pattern
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread
  • Z0155: Staff Training Requirements severity level 2, scope L2 Pattern
  • Z0162: Compliance with Rules Health Care severity level 3, scope L3 Isolated
  • Z0163: Nutrition and Hydration severity level 2, scope L2 Pattern
  • Z0164: Activities severity level 2, scope L2 Pattern
• October 29, 2024: 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
• August 2, 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 October 1, 2023
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected October 1, 2023
• June 15, 2023: Complaint Investig., 1 deficiency cited report
  • C0010: Licensing Complaint Investigation severity level 2, scope L2 Isolated
  • C0380: Involuntary Move-Out Criteria severity level 2, scope L2 Isolated
• April 4, 2022: Validation, 10 deficiencies cited report
  • C0000: Comment severity level 0
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread, corrected July 15, 2022
  • C0270: Change of Condition and Monitoring severity level 3, scope L3 Isolated, corrected July 15, 2022
  • C0280: Resident Health Services severity level 2, scope L2 Isolated, corrected July 15, 2022
  • C0372: Training Within 30 Days: Direct Care Staff severity level 2, scope L2 Pattern, corrected July 15, 2022
  Show all 11

  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread, corrected October 5, 2022
  • C0422: Fire and Life Safety: Training For Residents severity level 2, scope L2 Widespread, corrected July 15, 2022
  • Z0142: Administration Compliance severity level 2, scope L2 Pattern, corrected October 5, 2022
  • Z0155: Staff Training Requirements severity level 2, scope L2 Pattern, corrected July 15, 2022
  • Z0162: Compliance With Rules Health Care severity level 3, scope L3 Isolated, corrected July 15, 2022
  • Z0164: Activities severity level 2, scope L2 Isolated, corrected July 15, 2022

Substantiated abuse or neglect

• September 27, 2024: Failed to properly plan care Abuse: Neglect; Level 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance; fine $1,500.00; report
  Rules: 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); 411-054-0040 (Change of Condition and Monitoring)
  State’s findings

  The facility failed to implement interventions and appropriately care plan related to the Alleged Victim's (AV) fall history. On or about September 27, 2024, AV suffered an unwitnessed fall, was transferred to the hospital, and was diagnosed with a right hip fracture which required surgery. Based on facility documentation and interviews, AV had previous falls on June 15, 2024, June 21, 2024, June 29, 2024, July 7, 2024, and July 28, 2024. An investigation determined the facility failed to implement sufficient fall interventions to mitigate AV's fall risk. The facility's failure to adequately safety plan and monitor AV for known fall history resulted in AV falling and breaking his/her right hip causing unreasonable discomfort and severe pain, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• March 11, 2024: Failed to provide safe environment 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); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General)
  State’s findings

  On or about March 11, 2024, the Alleged Victim (AV), a resident of the memory care unit, was able to elope by bypassing two secured doors and exiting the facility without staff knowledge. The facility failed to adequately monitor AV’s known exit-seeking behaviors, despite documented risk factors. This lapse in supervision resulted in the resident being placed at risk of harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• October 27, 2022: Failed to provide safe environment Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $188.00; report
  Rules: 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 facility failed to provide appropriate supervision to the Alleged Victim (AV) according to his/her needs. The failure resulted in AV eloping the secured building, 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.

• October 2, 2022: Failed to provide safe environment Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $500.00; report
  Rules: 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 interventions and appropriately care plan related to the Alleged Victim’s (AV) known behaviors and recent increase of altercations. From July 25, 2022 to September 30, 2022, AV physically assaulted five different residents. Repeated resident-to-resident altercations and unwanted interactions without sufficient interventions or supervision caused AV unreasonable discomfort which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• September 30, 2022: Failed to provide safe environment Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $375.00; report
  Rules: 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 failed to appropriately monitor Witness 1 (W1) according to his/her known behavior and prior resident-to-resident altercations. The failure resulted in a resident-to-resident altercation on or about September 30, 2022, causing unreasonable discomfort to the Alleged Victim (AV), which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• 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 updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules.

• January 3, 2024: Failed to provide a safe medication administration system Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0055 (Medications and Treatments)
  State’s findings

  On or about January 2, 2024, Witness 4 (W4) was starting his/her shift and while W4 counted the facility's supply of narcotic pain medication. W4 observed multiple cards of narcotic pain medication had been tampered with. A total of 14 pills of AV's narcotic pain medication appeared to have been diverted. The narcotic pain medication had been removed and replaced with other, unknown medication from an unknown source. Based on documentation, AV did not miss any medications and AV was not administered any medication that was contained in the tampered-with medication cards. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules. Alleged Perpetrator 2 (AP2) allegedly financially exploited AV. An investigation determined no abuse occurred by AP2. Alleged Perpetrator 4 (AP4) allegedly financially exploited AV. An investigation inconclusively determined no abuse occurred by AP4.

• January 3, 2024: Failed to provide a safe medication administration system Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0055 (Medications and Treatments)
  State’s findings

  On or about January 2, 2024, Witness 4 (W4) was starting his/her shift and while W4 counted the facility's supply of narcotic pain medication. W4 observed multiple cards of narcotic pain medication had been tampered with. A total of 8 pills of AV's narcotic pain medication appeared to have been diverted. The narcotic pain medication had been removed and replaced with other, unknown medication from an unknown source. Based on documentation, AV did not miss any medications and AV was not administered any medication that was contained in the tampered-with medication cards. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules. Alleged Perpetrator 2 (AP2) allegedly financially exploited AV. An investigation determined no abuse occurred by AP2. Alleged Perpetrator 4 (AP4) allegedly financially exploited AV. An investigation inconclusively determined no abuse occurred by AP4.

• September 30, 2022: Failed to provide safe environment Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0080 (Involuntary Move-out Criteria)
  State’s findings

  The facility failed to evaluate the resident's health, medical, behavioral or care needs within a reasonable time, but no later than 24 hours after the resident has been deemed ready for discharge in accordance with OAR 411-054-0080(11)(a)(C) per complainant that the hospital informed the facility that there was no reason to keep the resident and the facility refused to accept the resident back.

• October 17, 2021: 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 October 17, 2021, Alleged Perpetrator 2 (AP2) failed to follow Alleged Victim's (AV) care plan when AP2 attended to AV's care needs alone which caused AV to exhibit behaviors. An investigation determined that AV is care planned to have 2 staff assist with AV's care needs due to AV's behavior triggers. AP2's action is considered neglect of care which constitutes abuse. The facility failed to provide a safe environment for AV which is a violation of Oregon Administrative Rules. The allegation that AP2 physically abused AV was investigated and findings determined no wrongdoing by AP2.

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 42 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.