Santiam Gardens Residential Care

Last inspection

August 28, 2024

Inspections

7, 23 deficiencies cited

Substantiated abuse

9

Substantiated licensing violations

30

Regulatory actions

0

Fines assessed

$6,901.00 (10 violations)

Current owner since

November 1, 2026

Inspections

• August 28, 2024: Complaint Investig., 5 deficiencies cited report
  • C0154: Facility Administration: Policy & Procedure severity level 2, scope L2 Isolated
  • C0200: Resident Rights and Protection - General severity level 2, scope L2 Isolated
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Isolated
  • C0513: Doors, Walls, Elevators, Odors severity level 2, scope L2 Isolated
  • C0555: Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable severity level 2, scope L2 Widespread
• August 28, 2024: Licensure Complaint, 3 deficiencies cited report
  • C0154: Facility Administration: Policy & Procedure severity level 2, scope L2 Isolated
  • C0242: Resident Services: Activities severity level 2, scope L2 Isolated
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Isolated
• April 15, 2024: Validation, 10 deficiencies cited report
  • C0000: Comment severity level 0
  • C0154: Facility Administration: Policy & Procedure severity level 2, scope L2 Isolated, corrected June 16, 2024
  • C0260: Service Plan: General severity level 2, scope L2 Pattern, corrected June 16, 2024
  • C0290: Res Hlth Srvc: On- and Off-Site Health Srvc severity level 2, scope L2 Pattern, corrected June 16, 2024
  • C0310: Systems: Medication Administration severity level 2, scope L2 Pattern, corrected June 16, 2024
  Show all 11

  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Pattern, corrected June 16, 2024
  • C0510: General Building Exterior severity level 2, scope L2 Widespread, corrected June 16, 2024
  • C0530: Housekeeping and Laundry severity level 2, scope L2 Widespread, corrected June 16, 2024
  • H1518: Individual Door Locks: Key Access severity level 0, corrected June 16, 2024
  • H1521: Individual Visitors: Any Time severity level 0, corrected June 16, 2024
  • H1580: Limitations: Threats to Health and Safety severity level 0, corrected June 16, 2024
• March 19, 2024: Complaint Investig., 1 deficiency cited report
  • C0372: Training Within 30 Days: Direct Care Staff severity level 2, scope L2 Widespread
• February 6, 2024: Complaint Investig., 4 deficiencies cited report
  • C0200: Resident Rights and Protection - General severity level 2, scope L2 Isolated
  • C0301: Systems: Medication Administration severity level 2, scope L2 Isolated
  • C0360: Staffing Requirements and Training: Staffing severity level 2, scope L2 Isolated
  • C0555: Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable severity level 2, scope L2 Isolated
• December 7, 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 22, 2025: Failed to provide safe environment 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); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General)
  State’s findings

  On or about August 22, 2025, an Alleged Victim (AV) reported that Alleged Perpetrator 2 (AP2) entered AV’s room and engaged in non-consensual sexual contact, including kissing and forcing AV to perform oral sex. The incident reportedly occurred while AV was alone with AP2. Based on facility documentation and interviews, AV has a documented history of sexually inappropriate and threatening behavior toward both staff and residents. Upon AV's admission to the facility on August 21, 2025, facility completed a temporary care plan but did not include AV’s known behavioral history or need for two-person care requirement due to AV's known behavioral history. Staff interviewed during the investigation stated they were not informed of AV’s behavioral history and believed the two-person applied only to transfers, not all cares. The facility failed to document critical information regarding AV's prior behaviors in AV's temporary service plan. As a result, staff were not adequately informed of the need for enhanced supervision, increasing the risk of harm to AV. This failure resulted in staff being uninformed and unprepared to provide care for AV, thereby creating conditions that placed AV at risk of moderate harm, which is a violation of resident rights, is considered neglect of care, which constitutes abuse. AP2 allegedly sexually abused AV. An investigation inconclusively determined no abuse occurred.

• July 28, 2025: Failed to provide a safe medication administration system Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $1,013.00; 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

  Based on witness statements, investigator observations, and documentary evidence collected during Adult Protective Services (APS) Investigation #00416838, the APS Investigator determined that on or about July 28, 2025, the facility failed to provide a safe Medication Administration System for the Alleged Victim (AV). As a result of this failure, AV received a double dose of an antipsychotic medication, which caused AV to become lethargic and drowsy. AV was then transported to the Emergency Department for evaluation of antipsychotic medication toxicity. The facility's failure to provide a safe medication administration caused AV unnecessary and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care which constitutes abuse.

• June 26, 2025: Failed to provide a safe medication administration system Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $1,500.00; 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

  In July 2025, the facility experienced a breakdown in its medication management system, which directly affected an Alleged Victim (AV) under its care. Based on facility documentation and staff interviews, the facility failed to maintain a safe and accurate medication administration system. As a result, the Alleged Victim (AV) was administered a discontinued narcotic medication in addition to a newly prescribed narcotic medication which AV exhibited symptoms consistent with a drug overdose. AV experienced increased sedation that may have been a result of AV's medication not being administered as order. The facility’s failure to administer medications as ordered caused AV unreasonable discomfort, which is a violation of resident rights, is considered neglect of care, which constitutes abuse.

• October 1, 2024: Failed to provide a safe medication administration system Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $1,350.00; 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

  The Alleged Victim (AV) receives his/her medication administration from the facility. The facility is responsible to order AV's medication to ensure medications are received timely. On or about November 16, 2024, the facility faxed their contracted pharmacy to fill AV's medications. The pharmacy advised the facility they were faxing the incorrect pharmacy and to contact AV's pharmacy to fill his/her order. The facility failed to contact AV's pharmacy until November 27, 2024. AV ran out of his/her blood glucose medication on November 22, 2024. AV's medication arrived on November 28, 2024. AV missed 12 doses of his/her medication, leading to AV feeling dizzy, weak and lightheaded, due to his/her blood sugar being elevated. The facility's failure to provide a safe medication administration system is a violation of resident rights, is considered neglect of care and constitutes abuse.

• September 15, 2024: Failed to properly plan care Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $338.00; 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

  Witness #1 (W1) has a history of behaviors and altercations with residents. Staff are to keep W1 away from other residents and give him/her space if showing agitation. The Alleged Victim (AV) and W1 engaged in an altercation where W1 ran into AV's legs and argued and kicked AV in the legs. AV was not injured, however, AV was placed at risk for harm. The facility's failure to properly care plan for W1's behaviors is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• December 9, 2025: Failed to provide safe environment Licensing Violation; Level 3 - Moderate harm or potential for serious harm; report
  Rules: 411-054-0025 (Facility Administration)
  State’s findings

  On or about December 9, 2025, Alleged Perpetrator 2 (AP2), a facility employee, directed profanities and degrading remarks toward the Alleged Victim (AV) while assisting AV with his/her Activities of Daily Living (ADLs). According to facility records and witness statements, AP2 was observed yelling at AV to stop talking, calling AV derogatory names, and leaning over AV’s wheelchair while shouting in an aggressive and disrespectful manner. AV became visibly upset and cried as a result. AP2’s conduct caused significant emotional harm to AV and constitutes verbal abuse. The facility failed to protect AV from inappropriate verbal comments made by staff, resulting in a violation of Oregon Administrative Rules.

• December 3, 2025: Failed to provide safe environment 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 12/03/25, the facility’s failure to provide records to the Department upon request was substantiated. Findings include but are not limited to: A review of electronic communication, dated 10/16/25, indicated the Department requested documents related to the facility’s Acuity-Based Staffing Tool (ABST) alleged event timeframe from 09/21/25 through 09/27/25. The facility had not provided all requested documentation by the due date of 10/17/25. The facility's failure is a violation of Oregon Administrative Rules.

• August 25, 2025: Failed to use an 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 have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

• July 28, 2025: Failed to use an 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 have an Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population, their needs, and all required Activities of Daily Living (ADL). Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. Facility was not 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. Corrective Action taken on related allegation.

• July 16, 2025: Failed to use an 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 have an Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population, their needs, and all required Activities of Daily Living (ADL). Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. Facility was not 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. Corrective Action taken on related allegation.

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 55 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.