Reflections Memory Care

Last inspection

August 20, 2026

Inspections

6, 18 deficiencies cited

Substantiated abuse

4

Substantiated licensing violations

1

Regulatory actions

0

Fines assessed

$1,125.00 (4 violations)

Current owner since

October 1, 2008

Inspections

• August 20, 2026: Re-Licensure, 1 deficiency cited report
  • Z0155: Staff Training Requirements severity level 2, scope L2 Pattern
• September 11, 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
• April 10, 2025: Re-Licensure, 3 deficiencies cited report
  • C0362: Acuity Based Staffing Tool - ABST Time severity level 2, scope L2 Pattern
  • Z0155: Staff Training Requirements severity level 2, scope L2 Pattern
  • Z0162: Compliance with Rules Health Care severity level 2, scope L2 Pattern
• December 19, 2023: State Licensure, 0 deficiencies cited report
  • C0000: Comment severity level 0
• December 13, 2022: State Licensure, 0 deficiencies cited report
  • C0000: Comment severity level 0
• January 11, 2022: Validation, 12 deficiencies cited report
  • C0000: Comment severity level 0
  • C0150: Facility Administration: Operation severity level 2, scope L2 Widespread, corrected March 15, 2022
  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Pattern, corrected March 15, 2022
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread, corrected September 15, 2022
  • C0260: Service Plan: General severity level 2, scope L2 Pattern, corrected March 15, 2022
  Show all 14

  • C0270: Change of Condition and Monitoring severity level 3, scope L3 Isolated, corrected March 15, 2022
  • C0340: Restraints and Supportive Devices severity level 2, scope L2 Pattern, corrected March 15, 2022
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread, corrected March 15, 2022
  • C0510: General Building Exterior severity level 2, scope L2 Widespread, corrected March 15, 2022
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected September 15, 2022
  • Z0162: Compliance With Rules Health Care severity level 3, scope L3 Isolated, corrected March 15, 2022
  • Z0163: Nutrition and Hydration severity level 2, scope L2 Pattern, corrected March 15, 2022
  • Z0164: Activities severity level 2, scope L2 Pattern, corrected March 15, 2022
  • Z0173: Secure Outdoor Recreation Area severity level 2, scope L2 Widespread, corrected March 15, 2022

Substantiated abuse or neglect

• August 13, 2022: Failed to provide appropriate skin 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

  The facility failed to provide appropriate services according to the Alleged Victim’s (AV) needs and wound care. The failure resulted in AV’s condition worsening causing further unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• November 27, 2021: 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); 411-054-0027 (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); 411-054-0045 (Resident Health Services)
  State’s findings

  Alleged Victim's (AV's) Home Health Physical Therapy note dated August 23, 2021, indicates AV has a cognitive deficit, and has a strong tendency to lean back when sitting unsupported, standing, and walking, making AV a high risk for falls. Temporary Service Plan (TSP) dated on or about October 5, 2021, recommend, walk with AV to dining room using walker with 1-person contact guard assist. On or about October 23, 2021, it is noted that AV has a history of impulsive behavior and falling. Service plan dated on or about November 13, 2021, indicates AV requires 1-person hands-on assist to shower; 1-person assist with transfers using gait belt; can use a walker and ambulates with 1-person assist; can self-propel with a wheelchair; needs 1-person assist to toileting; staff to toilet AV at least 6 times per shift and as needed, and is a high fall risk. AV will wear tab/pad alarm at all times, staff to ensure it is turned on; will use a scoop mattress in hospital bed; staff to check AV 6 times per shift to ensure all needs are met; AV will wear velcro posey belt at all times when sitting in h/h recliner; and is a full assist with night needs. Staff to do a visual check on AV 6 times per shift or as needed to change h/h Depends and ensure needs are met. On or about November 27, 2021, staff in AV's room helping AV back to bed when AV leaned back hitting the wall and slid to the ground resulting in an abrasion to h/h right elbow. The physical therapy notes indicate AV has strong tendency to lean back when sitting unsupported, the TSP with PT instructions and AV service plan makes no mention of AV’s strong tendency to lean back and does not provide guidance on how to prevent falls related to this tendency. The facility failed to appropriately care plan and implement person centered interventions to address AV’ tendency to lean back, resulting in AV falling and sustaining an abrasion, which is violation of resident rights, is considered neglect of care and constitutes abuse.

• November 27, 2021: Failed to provide safe environment 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); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General)
  State’s findings

  Alleged Victim's (AV's) Home Health Physical Therapy note dated August 23, 2021, indicates AV has a cognitive deficit, and has a strong tendency to lean back when sitting unsupported, standing, and walking, making AV a high risk for falls. Temporary Service Plan (TSP) dated on or about October 5, 2021, recommend, walk with AV to dining room using walker with 1-person contact guard assist. On or about October 23, 2021, it is noted that AV has a history of impulsive behavior and falling. Staff entered AV's room, observed AV getting out of bed unassisted and falling. Interventions put into place, to continue frequent checks to ensure safety. Service plan dated on or about November 13, 2021, indicates AV requires 1-person hands-on assist to shower; 1-person assist with transfers using gait belt; can use a walker and ambulates with 1-person assist; can self-propel with a wheelchair; needs 1-person assist to toileting; staff to toilet AV at least 6 times per shift and as needed, and is a high fall risk. AV will wear tab/pad alarm at all times, staff to ensure it is turned on; will use a scoop mattress in hospital bed; staff to check AV 6 times per shift to ensure all needs are met; AV will wear velcro posey belt at all times when sitting in h/h recliner; and is a full assist with night needs. Staff to do a visual check on AV 6 times per shift or as needed to change h/h Depends and ensure needs are met. On or about November 27, 2021, AV leaned back hitting the wall and slid to the ground resulting in an abrasion to h/h right elbow. On or about December 16, 2021, staff assisting AV to toilet, left AV alone in the bathroom in order to step out and grab a brief from the bed. While AV was left unattended, AV stood up and fell, sustaining bruises on left shoulder, upper back, right thigh and hip. AV's physical therapy notes indicate AV has strong tendency to lean back when sitting unsupported, the TSP with PT instructions and AV service plan makes no mention of AV’s strong tendency to lean back and does not provide guidance on how to prevent falls related to this tendency. The service plan indicates 1-person assist with transfers using gait belt; needs 1-person assist to toileting; AV is a high fall risk; Staff to ensure needs are met. The facility failed to provide a safe environment and failed to follow AV's care plan resulting in AV falling and sustaining multiple abrasions, which is violation of resident rights, is considered neglect of care and constitutes abuse.

• October 24, 2021: 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); 411-054-0027 (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 August 13, 2021, AV was documented to be a high fall risk, with one-person assist needed for gait belt transfers, toileting, and ambulation. It was noted that AV may not use h/h call light to request assistance, and that staff were to check on AV 6 times per shift. AV was to have a scoop mattress and a tab alarm when AV is in bed. Staff were to ensure the alarm is on. On October 23, 2021, staff was coming into AV’s room when they saw AV fall while trying to get out of bed by h/h self. AV sustained bruises on h/h left hand and leg. Service plan written for AV on November 13, 2021, after the fall on October 23, 2021, lists the same fall prevention interventions as noted before AV’s October 23, 2021, fall. No new interventions were implemented after the fall on October 23, 2021. On or about November 27, 2021, AV fell after leaning back and sliding down the wall, sustaining an abrasion to h/h right elbow. The only intervention noted was for staff to use a gait belt with AV. This intervention had already been put in place on the August 13, 2021, Service Plan, which was also in place on the November 13, 2021, service plan. AV fell in the bathroom on December 16, 2021, when left alone while staff stepped out for a brief. Intervention noted was for staff to bring supplies to the restroom when toileting AV. No interventions were implemented that would prevent a fall under any other circumstances even though AV had fallen twice under different circumstances on October 23, 2021, and November 27, 2021. Progress Notes from December 27, 2021, indicate AV had fallen and hit h/h head. AV is unable to tell anyone if s/he is in pain, and there is no indication that the facility used a pain assessment to determine if AV was in pain after hitting h/h head. No alert charting or follow up regarding AV hitting h/h head on December 27, 2021, was found in documentation. There is no indication that the facility monitored AV for pain or injury. AV hitting h/h head on December 27, 2021, was found in documentation, no incident report was completed, there was no indication the facility monitored AV for pain or injury as AV is unable to tell anyone if s/he is in pain. There were no new added interventions to address AV’s falls after prior falls. The facility failed to appropriately care plan and implement new reasonable interventions to address AV’s falls, which is violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

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

  On or about March 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 February 1, 2022 to February 28, 2022, for a total of 27 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 16 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.