Rackleff Place

Last inspection

July 30, 2025

Inspections

8, 32 deficiencies cited

Substantiated abuse

4

Substantiated licensing violations

14

Regulatory actions

2

Fines assessed

$1,450.00 (4 violations)

Current owner since

April 14, 2011

License conditions and other regulatory actions

• August 19, 2025 to November 5, 2025: License Condition, Failed to provide safe environment ALFCD25-00397; incident: CALMS - 00085555
  ODHS completed a Survey 70M075 - RL005815 - Visit on or about June 30, 2025, and determined the facility was not in substantial compliance with Oregon Administrative Rules and that the facilitys non-compliance constitutes a threat to the health, safety, and welfare of its residents.
  Rules: 411-054-0034 (Resident Move-In and Evaluation); 411-054-0045 (Resident Health Services); 411-054-0055 (Medications and Treatments)
• February 8, 2023 to May 15, 2024: License Condition, Failed to meet the scheduled and unscheduled needs of residents ALFCD23-00094; 4 incidents: OR0003816903, OR0003816902, OR0003816901, OR0003816900
  The facility failed to provide personal and other laundry services in accordance with OAR 411-054-0030(1)(b) per complainant that a resident's friend does their laundry, and staff does not.
  Rules: 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General); 411-054-0037 (Acuity-Based Staffing Tool); 411-054-0070 (Staffing Requirements and Training)

Inspections

• July 30, 2025: Re-Licensure, 9 deficiencies cited report
  • C0252: Resident Move-in & Evaluation: Res Evaluation severity level 2, scope L2 Isolated
  • C0280: Resident Health Services severity level 2, scope L2 Widespread
  • C0302: Systems: Tracking Control Substances severity level 2, scope L2 Isolated
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Pattern
  • C0310: Systems: Medication Administration severity level 2, scope L2 Pattern
  • C0325: Systems: Self-Administration of Meds severity level 2, scope L2 Isolated
  • C0340: Restraints and Supportive Devices severity level 2, scope L2 Pattern
  • C0613: General Building: Doors-Walls, Cleanable severity level 2, scope L2 Widespread
  • C0655: Call System severity level 2, scope L2 Widespread
• July 1, 2024: Complaint Investig., 4 deficiencies cited report
  • C0242: Resident Services: Activities severity level 2, scope L2 Widespread
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Isolated
  • C0370: Staffing Requirements and Training – Pre-Serv severity level 2, scope L2 Widespread
  • C0513: Doors, Walls, Elevators, Odors severity level 2, scope L2 Isolated
• March 21, 2024: State Licensure, 0 deficiencies cited report
  • C0000: Comment severity level 0
• May 18, 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 May 25, 2023
• November 17, 2022: Complaint Investig., 2 deficiencies cited report
  • C0010: Licensing Complaint Investigation severity level 2, scope L2 Isolated
  • C0360: Staffing Requirements and Training: Staffing severity level 2, scope L2 Isolated
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Isolated

Substantiated abuse or neglect

• October 24, 2025: Failed to provide service 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

  The Alleged Victim (AV) relies on the facility for their care. According to an investigation, on or about October 20, 2025, AV fell in the dining room. AV was sent to the hospital, returning with a sling on their arm. On or about October 24, 2025, AV was taken to breakfast in a wheelchair due to being weak and in pain. AV was given pain medication, known for causing drowsiness. Later AV was feeling drowsy, so they went to their room and while in their room, experienced a fall. AV was taken to the hospital and diagnosed with a broken hip. The facility failed to provide appropriate services, to include adequate monitoring, care planning and/or the implementation of effective interventions, which is a violation of resident rights, is neglect of care which constitutes abuse as defined in OAR 411-020-0002(1)(b)(A)(i).

• June 23, 2024: Failed to properly plan care Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $250.00; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0036 (Service Plan – General)
  State’s findings

  The Alleged Victim (AV) resides at the facility and has a history of frequent falls. AV had seven falls in the last six months. Fall interventions documented in AV's care plan included to remind AV to use assistive device when walking and have AV's call pendant within reach. According to an investigation, on or about June 23, 2024, AV fell in their apartment while walking without their assistive device, resulting in multiple skin tears. The fall interventions had not been updated following the previous falls to reflect AV's need for more support. The facility failed to properly care plan, which is a violation of resident’s rights, is neglect of care and constitutes abuse.

• October 28, 2023: Failed to provide safe environment Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $450.00; report
  Rules: 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare)
  State’s findings

  Alleged Victim (AV) has a known history of falls. AV has had seven (7) falls between April 2023 through October 2023. On or about October 28, 2023, staff found AV lying on the floor in front of their recliner. Prior to the incident, AV was sitting in their recliner with the footrest in the upward position. Staff know that AV was prone to get up and out of bed and their recliner, which would lead to potential falls. As a result of the fall, AV was diagnosed with a fracture to his/her left hip. The facility failed to provide a safe environment for AV, which resulted in a fracture to AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

• December 1, 2022: Failed to provide a safe medication administration system Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $250.00; report
  Rules: 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0055 (Medications and Treatments)
  State’s findings

  The facility failed to provide a safe medication administration system to ensure the Alleged Victims (AV) medication orders were administered as prescribed. On multiple occasions, it was discovered that AV did not receive h/h eye drop medication as scheduled, causing AV an increase in anxiety, disruption of treatment, and risk of losing eyesight. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• September 22, 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 implement and maintain an Acuity-Based Staffing Tool. The facility’s failure is a violation of Oregon Administrative Rules.

• July 2, 2025: 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

  The facility failed to provide a safe medication administration system for the Alleged Victim (AV). According to an investigation, AV experienced no negative outcome. The failure is a violation of Oregon Administrative Rules. The allegation that Alleged Perpetrator 2 (AP2) neglected AV was investigated and determined to be substantiated.

• October 9, 2024: Failed to provide inservice 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); 411-054-0055 (Medications and Treatments)
  State’s findings

  The Alleged Victim (AV) relies on the facility to administer his/her medications. According to an investigation, on or about October 9, 2024, the Alleged Perpetrator 2 (AP2) failed to administer medication as ordered when he/she administered another resident's Gabapentin to AV in error. AV is allergic to Gabapentin. This exposed AV to potential risk of serious harm. AP2's actions are considered neglect and constitutes abuse. The facility failed to ensure medications were administered as ordered, which violates Oregon Administrative Rules.

• October 5, 2024: Failed to provide service 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); 411-054-0036 (Service Plan – General)
  State’s findings

  The Alleged Victim (AV) relies on the facility to meet his/her daily needs. According to an investigation, on or about October 5, 2024, the Alleged Perpetrator 2 (AP2) and the Alleged Perpetrator 3 (AP3) failed to provide service when AP2 and AP3 did not provide incontinence care for AV, resulting in AV having reddened skin and unreasonable discomfort. AP2 and AP3's actions are considered neglect and constitutes abuse. The facility failed to assure resident rights, which violates Oregon Administrative Rules.

• June 6, 2024: Failed to administer medication as ordered Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0055 (Medications and Treatments)
  State’s findings

  The facility failed to carry out medication and treatment orders as prescribed. 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 29 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.