Stephanie Gardens Residential Care

Last inspection

July 9, 2025

Inspections

4, 22 deficiencies cited

Substantiated abuse

14

Substantiated licensing violations

18

Regulatory actions

0

Fines assessed

$9,852.00 (14 violations)

Current owner since

June 1, 2023

Inspections

• July 9, 2025: Complaint Investig., 1 deficiency cited report
  • C0260: Service Plan: General severity level 2, scope L2 Isolated
• August 5, 2024: Change of Owner, 10 deficiencies cited report
  • C0000: Comment severity level 0
  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Isolated, corrected October 7, 2024
  • C0260: Service Plan: General severity level 2, scope L2 Pattern, corrected October 7, 2024
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Pattern, corrected October 7, 2024
  • C0280: Resident Health Services severity level 3, scope L3 Isolated, corrected October 7, 2024
  Show all 11

  • C0303: Systems: Treatment Orders severity level 2, scope L2 Pattern, corrected October 7, 2024
  • C0325: Systems: Self-Administration of Meds severity level 2, scope L2 Isolated, corrected October 7, 2024
  • C0330: Systems: Psychotropic Medication severity level 2, scope L2 Isolated, corrected October 7, 2024
  • C0513: Doors, Walls, Elevators, Odors severity level 2, scope L2 Widespread, corrected October 7, 2024
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected October 7, 2024
  • Z0162: Compliance With Rules Health Care severity level 3, scope L3 Isolated, corrected October 7, 2024
• December 5, 2023: 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 5, 2024
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread, corrected March 5, 2024
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected March 5, 2024
• June 27, 2022: Initial Licensure, 9 deficiencies cited report
  • C0000: Comment severity level 0
  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Isolated, corrected August 28, 2022
  • C0252: Resident Move-In and Eval: Res Evaluation severity level 2, scope L2 Isolated, corrected August 28, 2022
  • C0270: Change of Condition and Monitoring severity level 3, scope L3 Isolated, corrected August 28, 2022
  • C0513: Doors, Walls, Elevators, Odors severity level 2, scope L2 Pattern, corrected August 28, 2022
  Show all 10

  • C0555: Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable severity level 2, scope L2 Widespread, corrected August 28, 2022
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected August 28, 2022
  • Z0162: Compliance With Rules Health Care severity level 3, scope L3 Isolated, corrected August 28, 2022
  • Z0163: Nutrition and Hydration severity level 2, scope L2 Isolated, corrected August 28, 2022
  • Z0164: Activities severity level 2, scope L2 Pattern, corrected August 28, 2022

Substantiated abuse or neglect

• April 17, 2026: Failed to provide a safe medication administration system 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); 411-054-0055 (Medications and Treatments)
  State’s findings

  On or about April 21, 2026, the facility failed to administer the Alleged Victim’s (AV) prescribed medications as ordered. Based on facility documentation and interviews, when AV moved into the facility on April 17, 2026, staff obtained two medication lists, one of which was outdated. Although staff attempted to confirm the correct orders with AV’s medical provider, updated orders faxed on April 17 were not reviewed by staff until April 21. At time of incident, AV informed staff that some medications being administered were no longer prescribed. On April 21, 2026, AV lost consciousness, resulting in a fall and injury to AV’s leg. Following the fall, AV was confused and unable to recall baseline information. The facility failed to ensure a safe medication administration system for AV, resulting in unreasonable discomfort which constitutes abuse by neglect as outlined in OAR 411 020 0002(1)(b)(A)(i).

• January 15, 2026: Failed to provide safe environment Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $1,125.00; 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 January 20, 2026, ODHS Adult Protective Services (APS) completed investigation #00451172 and issued a written investigation report, which is incorporated here by reference. The Alleged Victim (AV) resided at the Respondent’s facility and had a documented history of leaving prior care settings, placing AV’s safety at significant risk. AV’s service plan identified AV as being at risk for elopement; however, the facility failed to implement adequate interventions to mitigate this risk. Based on facility documentation and staff interviews, AV eloped on two separate occasions: On or about January 14, 2026: AV exited the facility unnoticed before the automatic door lock re-engaged. After leaving the secure area, AV entered the exterior courtyard and was able to leave the courtyard due to the gate either being left unsecured or in disrepair. AV then exited the courtyard and was observed by staff running across a major street, creating a significant safety hazard. AV did not sustain physical injuries but was tearful and verbalized distress upon returning to the facility. Following this incident, staff were instructed to ensure all doors were locked prior to leaving them unattended. There was no policy in place prior to this event requiring staff to do so. On or about January 16, 2026, AV was standing near the memory care front door when a visitor entered. AV quickly pushed past the visitor and the secure door, then ran to a second set of automatically locking doors and was able to pull them open. AV exited the facility through the front door unnoticed by staff. During both elopements, AV was observed walking and/or running along a heavily traveled four-lane street. Both incidents demonstrate that the facility failed to implement effective interventions to address AV’s identified elopement risk, resulting in potential for serious harm. The facility's failure to properly care plan for AV's known elopement risk is a violation of resident rights, is considered neglect of care, which constitutes abuse.

• October 24, 2025: 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); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General)
  State’s findings

  On October 24, 2025, ODHS Adult Protective Services (APS) initiated Investigation #00434848 and issued a written report, which is incorporated here by reference. The Alleged Victim (AV), a resident of a secured memory care unit, has a documented cognitive impairment and a known history of exit-seeking behavior. Despite these risk factors, AV was able to exit the facility without staff awareness. At the time of the incident, AV was not being monitored in accordance with their care plan, resulting in AV eloping the secured building, without staff knowledge, placing him/her at risk of harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• September 21, 2025: Failed to properly plan care 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); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General)
  State’s findings

  Both Witness 1 (W1) and the Alleged Victim (AV) reside at the Respondent’s facility. On or about September 19, 2025, W1 entered AV’s bedroom and groped AV. On or about September 21, 2025, W1 was again observed engaging in physical contact with AV by kissing AV in the dining room. After the initial incident, the facility failed to implement an effective safety plan to protect AV, who could not and/or did not consent, resulting in a second incident. Facility documentation and interviews show that W1 had a known history of inappropriate sexual behaviors, yet the facility failed to develop and implement an adequate care plan or sufficient interventions to protect other residents. This failure constitutes abuse by neglect as defined by OAR 411-020-0002(1)(b)(A)(i).

• February 28, 2025: Failed to provide safe environment Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $1,125.00; report
  Rules: 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General); 411-054-0040 (Change of Condition and Monitoring); 411-057-0170 (Physical Design, Environment, and Safety)
  State’s findings

  The facility failed to provide appropriate supervision to the Alleged Victim (AV) according to his/her needs. Based on facility documentation and interviews, AV was admitted to the facility as a new resident on February 25, 2025. Shortly after admissions to the secured memory care facility, AV began showing signs of exit seeking behavior. On February 27, 2025, AV was able to elope from facility by lunging and breaking through the magna-locked emergency door. After AV eloped on February 27, 2025, the facility put in a "maintenance order" to have the door out of which AV eloped checked to ensure it was safe and secure, and facility staff increased safety checks for AV. On February 28, 2025, AV eloped from the facility a second time by the same way. A member of the community alerted facility staff to AV's presence outside of the facility and staff then found AV walking down a high-traffic street and AV appeared confused due to AV's diagnosed cognitive disease and AV was newly admitted resident needing full time care. The facility's failure to provide a safe and secure environment as a memory care endorsed facility resulted in AV eloping from the secured building, without staff knowledge, placing him/her at risk of serious harm due to AV being found walking on a busy street appearing confused, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• June 25, 2026: Failed to provide safe environment Licensing Violation; Level 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance; report
  Rules: 411-054-0025 (Facility Administration)
  State’s findings

  Based on observation, interview, and record review conducted during a site visit on 06/25/26 the facility’s failure to exercise reasonable precautions against any condition that may threaten the health, safety, or welfare of Residents was substantiated for 1 of 1 sampled Resident (#2). Resident 2 was smoking in his/her room. This posed an immediate jeopardy situation that could threaten the health safety and welfare of Residents. Findings include but are not limited to: On 06/25/26 at approximately 11:30 am, the following was observed inside Resident 2’s room: · A strong odor of cigarette smoke; · Two packs of cigarettes in his/her bedside nightstand; and · A lighter, two cigarette butts and ash residue on his/her tray table. Resident 2’s smoking agreement dated 10/09/25 stated Residents may not smoke in their apartment in any manner or inside the community. Resident 2’s service plan dated 04/06/26 stated the following: · Resident 2 had been provided the smoking policy and had signed the agreement; · Resident 2 had a history of forgetting not to smoke in his/her room; · Staff were to remind the Resident to smoke outside; and · If staff happened to see or smell Resident 2 smoking, they were to ensure the cigarette was put out and re-direct Resident 2 outside; and · Ensure all findings are documented in the progress notes. Progress note dated 05/24/26 at 02:11pm indicated Resident 2’s room smelled like smoke. Progress note dated 05/25/26 at 10:27 pm indicated Resident 2’s room had strong cigarette odor. Progress note 05/26/26 at 09:51 pm indicated the following: · Resident 2’s room had extremely strong smell of cigarette smoke; · The entire hallway smelled of cigarette smoke; and · Resident was not observed going outside to smoke. Progress note dated 05/27/26 at 06:15 am indicated Resident 2’s room smelled like smoke. Staff 2, Staff 3, Staff 4, and Staff 5 were interviewed and all stated Resident 2 smoked in his/her room every day and nothing had been done about it since the resident had moved in. There was no documented evidence that staff had re-directed Resident 2 to smoke outside or documented all Resident’s occurrences of smoking as specified in the Service Plan. Prior to completing the investigation, the facility had implemented a risk management agreement with Resident 1. On 06/25/26 at 01:47 pm the LCU team requested an immediate plan of correction. An acceptable plan of correction was received from the facility on 06/25/26 at 03:34 pm. The immediate risk was addressed; however, the facility will need to evaluate the overall system failures associated with the licensing violations. The facility’s failure to ensure reasonable precautions that threaten the health, safety, or welfare of residents is a violation of Oregon Administrative Rules.

• June 11, 2026: Failed to provide safe environment Licensing Violation; Level 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0036 (Service Plan – General)
  State’s findings

  Based on observations, interviews, and record reviews conducted during the 6/6/2026, site visit, the facility failed to implement required services for Resident 1, the sole sampled resident. Resident 1 was injured when staff did not follow the Service Plan and failed to intervene when Resident 1’s smoking created an immediate safety risk. Findings include: Service Plan dated 06/10/26: • Resident 1 admitted on 06/11/26. • Staff were required to intervene when smoking or vaping posed an immediate safety risk. • Staff were required to assist Resident 1 in preparing smoking materials. Incident Report – 06/11/26: • At approximately 12:15 p.m., a caregiver escorted Resident 1 to the smoking area. • Resident 1 did not have a lighter and grabbed one from another resident. • Resident 1 lit a cigarette while still wearing oxygen, resulting in Resident 1 catching on fire. • Staff extinguished the fire and provided care. Staff 10 Interview: • Resident 1 had moved in only 15 minutes earlier and wanted to smoke. • Staff 11 left to retrieve Resident 1’s cigarettes, leaving Staff 10 with Resident 1. • Staff 10 had not yet been oriented to Resident 1 or the Service Plan and was unaware of Resident 1’s impulsive behaviors. • Resident 1 quickly took another resident’s lighter and cigarette and ignited it before staff could intervene. • Resident 1’s oxygen was still on, causing the fire. • Staff 10 assisted and extinguished the fire. Staff 1 Interview: • Reported that all direct care staff received orientation on Resident 1’s Service Plan and smoking the day before move-in. Staff Interviews: • All reported they were not oriented to Resident 1’s Service Plan and were unaware of Resident 1’s smoking needs prior to move-in. Documentation Review: • No evidence was found that Staff 10 was oriented to Resident 1 or the Service Plan before providing care. Observation – 06/25/26 at 1:05 p.m.: • Multiple staff were observed yelling “stop” and running to the smoking area. • Resident 1 held an unlit cigarette. • Staff intervened before it was lit. • Staff 1 was seen walking inside with Resident 1’s oxygen tubing. Incident Report – 06/25/26 at 1:05 p.m.: • Resident 1 asked another resident for a cigarette in the smoking area. • No staff were present at the time. • Staff intervened and found Resident 1 with a cigarette and lighter. • Resident 1 had a cannula around the neck but no oxygen tank in place. • A caregiver arrived, provided supervision, and Resident 1 was allowed to smoke. Staff 1 Interview – 06/25/26: • Resident 1 went to the smoking area without staff knowledge or escort. • Resident 1 should have been escorted and supervised. • Resident 1 obtained a lighter and cigarette from another resident. • Staff intervened before the cigarette was lit. • Resident 1 had a cannula on but no oxygen connected, and Staff 1 stated Resident 1 was not in danger. • Staff 1 returned the oxygen tubing to Resident 1’s apartment. Service Plan dated 06/12/26: • Staff must assist Resident 1 in getting to the smoking area. • Staff must monitor Resident 1 at all times during smoking due to impulsive behaviors that pose safety risks. • Resident 1 has a history of lighting their face on fire while smoking with oxygen. • Staff must ensure oxygen is off and tubing removed before Resident 1 lights a cigarette. At 1:47 p.m. on 06/25/26, the LCU team requested an immediate plan of correction. The facility submitted an acceptable plan at 3:34 p.m. The immediate risk was addressed; however, the facility must evaluate broader systemic failures related to these licensing violations. The investigation determined staff failed to follow Resident 1’s Service Plan regarding smoking safety. On 06/11/26, staff did not intervene when smoking posed an immediate risk, resulting in Resident 1 catching fire. On 06/25/26, Resident 1 accessed the smoking area unsupervised, obtained smoking materials from another resident, and attempted to smoke with oxygen tubing around the neck. Documentation confirmed no staff were present, despite the requirement for staff escort and monitoring. The facility's failuire to ensure the implementation of services for Resident 1, caused serious harm to Resident 1 which is a violation of Oregon Administrative Rules.

• May 21, 2026: Failed to provide safe environment 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); 411-057-0140 (Responsibilities of Administration)
  State’s findings

  On or about May 21, 2026, the facility failed to adequately oversee its daily operations, resulting in insufficient safeguards to ensure resident safety which allowed Alleged Victim (AV) to elope from the secured memory care community. Based on facility documentation and staff interviews, a secured exit door was malfunctioning and did not operate as intended. As a result of this failure, the AV eloped from the secured memory care unit when the door failed to lock and close properly after use by Witness 5 (W5). The facility's failure to maintain a secure facility environment, ensuring that all exit door function properly and lock securely is a violation of Oregon Administrative Rules.

• May 21, 2026: 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

  Based on observation, interview, and record review, conducted during an investigation on 06/08/26, the facility’s failure to have service plans available to staff and provide clear direction regarding delivery of services was substantiated. Findings include, but are not limited to: During the investigation, the Temporary Service Plan (TSP) binder was observed not to have contained Resident 1’s service plan dated 05/22/26 or a TSP following Resident 1’s elopement on 05/21/26. In an interview, Staff 3 and Staff 4 stated they were not present during Resident 1’s elopement on 05/21/26 and did not recall seeing a TSP regarding Resident 1’s elopement in the TSP binder. And they did not know about the elopement on 05/21/26 until the Department investigation on 06/08/26. In an interview, Staff 1 and Staff 5 stated they suspected Resident 1’s service plan, and the TSP was in the locked office of a staff member who was not at the facility during the investigation. On 06/09/26 an electronic communication from Staff 1 was received by the Department. Staff 1 confirmed Resident 1’s Service Plan had been locked in the staff member’s office and provided Resident 1’s Service Plan dated 05/22/26 and Resident 1’s TSP dated 05/21/26 regarding the elopement. The TSP had not been signed by Staff 3 or Staff 4. And the Service Plan had not been signed by Staff 4. The facility's failure to have service plans available to staff and provide clear direction regarding delivery of services is a violation of Oregon Administrative Rules.

• April 22, 2026: Failed to provide safe environment Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0025 (Facility Administration)
  State’s findings

  On or about April 22, 2026, Alleged Victim (AV) exited the secured building, placing AV at risk of harm. Facility documentation and interviews confirmed that Alleged Perpetrator 2 (AP2) was recorded on facility video footage assisting AV through a locked door. AP2 stated at time of incident, AP2 believed AV was a visitor not a resident. Law enforcement later located AV at a bus stop approximately five miles from the facility. AV refused to return and was transported to the hospital on a hold for evaluation. AV returned to the facility later the same day. The APS investigator determined AP2 did not follow established facility procedures as outlined in AP2's completed trainings. AP2 had completed online elopement-prevention training and received instruction on proper entry and exit from the secured area. AP2 also acknowledged understanding that residents must not be allowed to leave the secure area without verifying their identity and assessing their risk of elopement. By enabling AV to exit the secure facility, AP2 placed AV at risk of harm. AP2’s actions constitutes neglect, which constitutes abuse. Additionally, the facility failed to maintain a safe environment for AV, resulting in 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 52 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.