Royalton Place Memory Care

Last inspection

May 27, 2026

Inspections

8, 29 deficiencies cited

Substantiated abuse

6

Substantiated licensing violations

9

Regulatory actions

2

Fines assessed

$2,188.00 (6 violations)

Current owner since

October 1, 2026

License conditions and other regulatory actions

• August 8, 2025 to December 2, 2025: License Condition, Failed to staff as indicated by ABST RCFCD25-00767; incident: CALMS - 00082811
  The facility failed to fully implement and update an acuity-based staffing tool in accordance with OAR 411-054-0037.
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)
• December 4, 2024 to March 21, 2025: License Condition, Failed to provide safe environment RCFCD24-01202; incident: CALMS - 00066887
  The following statement of violations stem from evidence and interviews collected from ODHS Survey Team, Survey number 000975.
  Rules: 411-054-0027 (Resident Rights and Protections); 411-054-0036 (Service Plan – General); 411-054-0050 (Infection Prevention and Control); 411-054-0090 (Fire and Life Safety); 411-054-0200 (Residential Care Facility Building Requirements)

Inspections

• May 27, 2026: 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
• June 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
• April 1, 2025: Complaint Investig., 2 deficiencies cited report
  • C0360: Staffing Requirements and Training: Staffing severity level 2, scope L2 Widespread
  • C0363: Acuity Based Staffing Tool - Updates & Plan severity level 2, scope L2 Widespread
• October 31, 2024: Re-Licensure, 16 deficiencies cited report
  • C0200: Resident Rights and Protection - General severity level 2, scope L2 Isolated
  • C0260: Service Plan: General severity level 2, scope L2 Pattern
  • C0270: Change of Condition and Monitoring severity level 3, scope L3 Isolated
  • C0295: Infection Prevention & Control severity level 2, scope L2 Widespread
  • 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
  • C0510: General Building Exterior severity level 2, scope L2 Widespread
  • C0513: Doors, Walls, Elevators, Odors severity level 2, scope L2 Widespread
  • C0530: Housekeeping and Laundry severity level 2, scope L2 Widespread
  • H1510: Individual Rights Settings: Privacy, Dignity severity level 2, scope L2 Isolated
  • 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
  • Z0162: Compliance with Rules Health Care severity level 3, scope L3 Isolated
  • Z0164: Activities severity level 2, scope L2 Isolated
  • Z0176: Resident Rooms severity level 2, scope L2 Pattern
• January 3, 2024: 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 March 3, 2024
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected March 3, 2024

Substantiated abuse or neglect

• November 18, 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)
  State’s findings

  Witness #1 (W1) has a history of altercations and is care planned for interventions when he/she becomes agitated or anxious. Staff are to redirect him/her to a puzzle, folding towels or scheduled activity. On or about November 18, 2024, W1 was seen being agitated and running W1's walker into objects in the hallway. Staff did not provide interventions as outlined in the care plan. Later than same day, W1 ran into the Alleged Victim (AV) with his/her walker, causing pain to AV's knee. The facility's failure to provide a safe environment and provide interventions as directed for W1 is a violation of resident rights, is considered neglect of care and constitutes abuse.

• May 14, 2023: 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

  Witness #1 (W1) has a history of aggression and Alleged Victim (AV) does not like being touched by other residents and is easily annoyed. W1 and AV have had a prior resident-to-resident altercation were W1 hit AV. On or about May 14, 2023, AV entered the med room and reported W1 was in a utility closet. AV said for W1 to get out; W1 grabbed AV's hand and AV pulled away. W1 hit AV in the mouth causing AV’s bottom lip to bleed. The facility failed to provide a safe environment and appropriately adjust care plans and implement reasonable interventions to address W1s behavior and prior resident altercation with AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• August 3, 2022: 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); 411-054-0036 (Service Plan – General)
  State’s findings

  The facility failed to provide a safe environment and implement appropriate interventions resulting in AV receiving rug burns and bruising to arms and legs related to AV being placed on the floor. The facility failure is a violation of resident rights, is neglect of care and constitutes abuse.

• July 22, 2022: Failed to follow care plan 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)
  State’s findings

  Alleged Victim (AV) is a high fall risk and is care planned for a one person assist for all transfers. On or about July 22, 2022, Staff woke AV and did not provide cares as required by the care plan. Shortly after AV was found on the floor, resulting in a head and back injury, and transported to the emergency room. The facility failed to follow AV care plan, which is a violation of resident’s rights is neglect of care and constitutes abuse.

• March 2, 2022: Failed to provide a safe medication administration system Abuse: Neglect; Level 2 - Minor harm or potential for moderate 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); 411-054-0055 (Medications and Treatments)
  State’s findings

  Alleged Victim (AV) is prescribed Morphine for pain and Lorazepam for anxiety and agitation. On or about March 02, 2022, the facility discovered AV medication was tampered with. The consistency of the medication and taste was different than other bottles of the same medication and identified as water. The amount of liquid in the bottle was correct, but a math error was found in the narcotic book. The Unknown Alleged Perpetrator (AP2’s) actions are a violation of resident rights, are considered neglect of care and constitute financial abuse. The facility failed to provide a safe medication administration system, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• March 2, 2022: Failed to provide a safe medication administration system Abuse: Neglect; Level 2 - Minor harm or potential for moderate 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); 411-054-0055 (Medications and Treatments)
  State’s findings

  Alleged Victim (AV) is administered liquid Lorazepam for agitation. In the month of February 2022 AV was administered Lorazepam eighteen times, and nine of those times the medication was documented as not effective. On or about March 02, 2022, the facility discovered the Lorazepam was tampered with. The consistency of the medication and taste was different than other bottles of the same medication and identified as water. The amount of liquid in the bottle matched the narcotic sheet. The Unknown Alleged Perpetrator (AP2’s) actions are a violation of resident rights, are considered neglect of care and constitute financial abuse. The facility failed to provide a safe medication administration system, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• December 23, 2025: Failed to provide a safe medication administration system 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) receives his/her medication from facility staff. On or about December 23, 2025, Alleged Perpetrator #2 (AP2) was passing medications and gave AV narcotic medication which belonged to another resident. AV was allergic to the other resident's medication. AV suffered discomfort and dizziness from receiving the incorrect medication. AP2's actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility's failure to provide a safe medication administration system is a violation of Oregon Administrative Rules.

• December 14, 2024: Failed to protect resident from physical abuse 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)
  State’s findings

  The Alleged Victim (AV) is independent with care needs. On or about December 14, 2024, AV exited his/her room without a shirt on. Alleged Perpetrator #2 (AP2) told AV to put a shirt on. AV refused and AP2 then attempted to forcefully place a shirt on AV. AV tried to hit AP2, and AP2 grabbed AV by the arms and pushed AV against the door. Another staff member picked AV up off the floor and it was noted that AV sustained a bruise on his/her back. AP2's actions are a violation of resident rights, are considered neglect of care and constitute physical abuse. The facility's failure to protect AV from physical abuse is a violation of Oregon Administrative Rules.

• May 26, 2023: 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 consistently staff to the levels, intensity and qualifications indicated by the Acuity-Based Staffing Tool (ABST). Inconsistencies were identified between the staffing schedule and the data produced by the ABST. Facility is not currently staffing to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules.

• April 25, 2023: Failed to provide a safe medication administration system 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

  Alleged Perpetrator 2 (AP2) failed to provide a safe medication administration system to ensure the Alleged Victim's (AV) medications were administered as ordered. On or about April 25, 2023, AV medications were found in the trash, but AP2 marked administered on AV MAR, AP2's actions are considered neglect of care and constitutes abuse. The facility failed to make sure AV medications were administer as ordered which is a violation of Oregon Administrative Rules.

• August 2, 2022: Failed to properly plan care Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0036 (Service Plan – General)
  State’s findings

  The facility failed to have resident's service plan be reflective of resident's needs. The service plan states that resident is a 1-person assist, when the resident is really a 2-person assist placing the resident at risk of potential harm, which 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 28 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.