Quail Run Assisted Living

Last inspection

September 11, 2024

Inspections

3, 1 deficiencies cited

Substantiated abuse

3

Substantiated licensing violations

4

Regulatory actions

0

Fines assessed

$1,125.00 (3 violations)

Current owner since

October 26, 2000

Inspections

• September 11, 2024: Re-Licensure, 1 deficiency cited report
  • C0372: Training within 30 days: Direct Care Staff severity level 2, scope L2 Isolated
• November 30, 2023: State Licensure, 0 deficiencies cited report
  • C0000: Comment severity level 0
• November 30, 2022: State Licensure, 0 deficiencies cited report
  • C0000: Comment severity level 0

Substantiated abuse or neglect

• August 14, 2024: Failed to properly plan care Abuse: Neglect; Level 3 - Moderate harm or potential for serious 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); 411-054-0036 (Service Plan – General)
  State’s findings

  According to the documentation, the facility failed to care plan appropriate fall interventions for the Alleged Victim’s (AV) known fall history. On or about June 21, 2024, and June 30, 2024, the AV experienced two falls sustaining head injuries. On or about July 21, 2024, facility documentation instructed staff to implement 2-person transfers for the AV and for toileting assistance. On or about July 22, 2024, AV suffered a witnessed fall in the hallway after they became dizzy and fell. A service plan update for the AV’s service plan instructed staff verbally to implement 2-hour safety checks and provide verbal reminders to the AV to use their call button for assistance. On or about August 14, 2024, the AV was found on the floor of their apartment and reported significant pain. The AV was sent to the ER and was found to have a vertebral fracture due to the fall, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• November 30, 2022: Failed to provide safe environment Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $375.00; 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); 411-054-0040 (Change of Condition and Monitoring)
  State’s findings

  Documentation, record review and facility staff interviews provided to ODHS indicate the following: Alleged Victim (AV) returned from the hospital on or about November 18, 2022, after a cardiac event that resulted in a fall. On or November 23, 2022, after an unwitnessed fall, AV’s legs were noted as being weak and shaky upon assistance from staff. From approximately November 23, 2022, to November 30, 2022, AV had about seven (7) documented falls. After each fall AV reported h/h knees have been feeling shaky and weak, causing h/h unsteady gait. On or about November 30, 2022, AV had an unwitnessed fall in h/h room that resulted in a thoracic spine fracture. The Facility failed to provide appropriate services by not implementing reasonable interventions for AV's change of condition, address AV's increasing and ongoing falls and provide a safe environment, which is a violation of resident rights, is neglect of care and constitutes abuse.

• November 30, 2022: Failed to provide safe environment Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $375.00; report
  Rules: 411-054-0025 (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

  Documentation, record review and facility staff interviews provided to ODHS indicate the following: Alleged Victim (AV) returned from the hospital on or about November 18, 2022, after a cardiac event that resulted in a fall. Staff were to assist AV with all ambulation and transfers, and AV was to call staff for assistance. Staff responded to AV’s call light on or about November 23, 2022, and found AV on the floor from a fall. AV’s legs were noted as being weak and shaky upon assistance from staff. AV was again, encouraged to use h/h call button for assistance with transfers and ambulation. On or about November 25, 2022, staff were doing rounds and found AV had fallen hitting h/h head and had bruising on the left side of h/h chin. The Facility failed to provide appropriate services by not implementing reasonable interventions to address AV’s falls and provide a safe environment, which is a violation of resident rights, is neglect of care and constitutes abuse.

Substantiated licensing violations

• June 8, 2026: Failed to staff as indicated by 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 implement and maintain an Acuity-Based Staffing Tool. The facility’s failure is a violation of Oregon Administrative Rules.

• May 6, 2026: Failed to staff as indicated by 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 implement and maintain an Acuity-Based Staffing Tool. The facility’s failure is a violation of Oregon Administrative Rules.

• April 27, 2026: Failed to staff as indicated by 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 implement and maintain an Acuity-Based Staffing Tool. The facility’s failure is a violation of Oregon Administrative Rules.

• September 18, 2025: Failed to staff as indicated by 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 develop, maintain, and implement an Acuity Based Staffing Tool. The facility’s failure 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 137 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.