Rose Schnitzer Manor

Last inspection

August 19, 2026

Inspections

5, 41 deficiencies cited

Substantiated abuse

2

Substantiated licensing violations

3

Regulatory actions

1

Fines assessed

$825.00 (2 violations)

Current owner since

October 1, 2024

License conditions and other regulatory actions

• December 16, 2022 to April 5, 2023: License Condition, Failed to update staffing plan based on ABST ALFCD22-01135; incident: CALMS - 00035024
  The facility failed to implement an acuity-based staffing tool (ABST) that met the regulation.
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)

Inspections

• August 19, 2026: Re-Licensure, 9 deficiencies cited report
  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Pattern
  • C0280: Resident Health Services severity level 2, scope L2 Pattern
  • C0363: Acuity Based Staffing Tool - Updates & Staffing Plan severity level 2, scope L2 Widespread
  • C0370: Staffing Requirements and Training ? Pre-service severity level 2, scope L2 Pattern
  • C0372: Training Within 30 Days of Hire ? Direct Care Staff severity level 2, scope L2 Pattern
  Show all 9

  • 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
  • C0610: General Building Exterior severity level 2, scope L2 Widespread
  • C0630: House Keeping and Sanitation severity level 2, scope L2 Widespread
• June 11, 2026: Kitchen, 2 deficiencies cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
  • C0295: Infection Prevention & Control severity level 2, scope L2 Widespread
• November 20, 2025: Change of Owner, 9 deficiencies cited report
  • C0252: Resident Move-in & Evaluation: Res Evaluation severity level 2, scope L2 Isolated
  • 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 Pattern
  • C0305: Systems: Resident Right to Refuse severity level 2, scope L2 Isolated
  Show all 9

  • 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
  • C0422: Fire and Life Safety: Training for Residents severity level 2, scope L2 Widespread
  • C0613: General Building: Doors-Walls, Cleanable severity level 2, scope L2 Widespread
• October 24, 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 March 31, 2024
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread, corrected March 31, 2024
• October 24, 2022: Validation, 20 deficiencies cited report
  • C0000: Comment severity level 0
  • C0155: Facility Administration: Records severity level 2, scope L2 Pattern, corrected December 26, 2022
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread, corrected February 3, 2023
  • C0252: Resident Move-In and Eval: Res Evaluation severity level 2, scope L2 Pattern, corrected April 30, 2023
  • C0260: Service Plan: General severity level 2, scope L2 Pattern, corrected April 30, 2023
  Show all 22

  • C0262: Service Plan: Service Planning Team severity level 2, scope L2 Pattern, corrected December 26, 2022
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Pattern, corrected December 26, 2022
  • C0280: Resident Health Services severity level 2, scope L2 Pattern, corrected December 26, 2022
  • C0282: Rn Delegation and Teaching severity level 2, scope L2 Pattern, corrected December 26, 2022
  • C0300: Systems: Medications and Treatments severity level 2, scope L2 Pattern, corrected December 26, 2022
  • C0302: Systems: Tracking Control Substances severity level 2, scope L2 Isolated, corrected December 26, 2022
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Pattern, corrected December 26, 2022
  • C0310: Systems: Medication Administration severity level 2, scope L2 Pattern, corrected April 30, 2023
  • C0325: Systems: Self-Administration of Meds severity level 2, scope L2 Isolated, corrected December 26, 2022
  • C0330: Systems: Psychotropic Medication severity level 2, scope L2 Isolated, corrected December 26, 2022
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Widespread, corrected December 26, 2022
  • C0370: Staffing Requirements and Training – Pre-Serv severity level 2, scope L2 Pattern, corrected December 26, 2022
  • C0372: Training Within 30 Days: Direct Care Staff severity level 2, scope L2 Pattern, corrected December 26, 2022
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread, corrected December 26, 2022
  • C0422: Fire and Life Safety: Training For Residents severity level 2, scope L2 Widespread, corrected December 26, 2022
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Pattern, corrected April 30, 2023
  • C0610: General Building Exterior severity level 2, scope L2 Widespread, corrected December 26, 2022

Substantiated abuse or neglect

• February 5, 2024: Failed to properly plan care 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); 411-054-0040 (Change of Condition and Monitoring)
  State’s findings

  The Alleged Victim (AV) resides at the facility and has a history of falls. According to an investigation, on or about February 5, 2024, AV fell in their apartment. AV's service planned interventions were for AV to use a walker for ambulation and use of a call light when AV felt weak to receive assistance from staff. AV had falls on 9/22/23 and 1/12/24. The facility did not develop or implement any known changes to AV's care plan following the falls. The facility failed to develop fall interventions to address AV’s fall risk, resulting in a compression fracture, loss of mobility and required licensed professional intervention. The facility failed to properly care plan for AV, which is a violation of resident rights, is considered neglect of care which constitutes abuse.

• August 7, 2023: Failed to perform adequate screening or assessment Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $450.00; 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); 411-054-0045 (Resident Health Services)
  State’s findings

  According to the documentation, the Alleged Victim (AV) fell on or about August 7, 2023, and complained of back pain. The facility failed to assess the AV after s/he expressed back pain which affected their ability to ambulate and transfer at baseline. After family requested the AV be seen by a doctor, the facility sent the AV to the ER where they were diagnosed with a compression fracture in their back, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• October 27, 2025: Failed to make facility or resident records accessible Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0105 (Inspections and Investigations)
  State’s findings

  Based on interview and record review, conducted during an investigation on 12/30/25 the facility’s failure to provide records to the Department upon request was substantiated, which is a violation of Oregon Administrative Rules.

• November 26, 2024: Failed to provide appropriate staffing Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)
  State’s findings

  Based on interview and record review conducted during an investigation on 12/30/25 the facility’s failure to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident, and complete update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly as required was substantiated, this is a violation of Oregon Administrative Rules.

• March 22, 2023: 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 01, 2023, 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 for a total of 30 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 180 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.