Still Waters

Last inspection

April 24, 2026

Inspections

6, 17 deficiencies cited

Substantiated abuse

3

Substantiated licensing violations

6

Regulatory actions

1

Fines assessed

$2,375.00 (3 violations)

Current owner since

April 8, 2021

License conditions and other regulatory actions

• October 19, 2022 to November 17, 2022: License Condition, Failed to use an ABST RCFCD22-01512; incident: OR0003735104
  The facility failed to fully implement and update an Acuity Based Staffing Tool (ABST) in accordance with OAR 411-054-0037.
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)

Inspections

• April 24, 2026: Kitchen, 1 deficiency cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread
• June 30, 2025: Kitchen, 1 deficiency cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
• May 6, 2025: Complaint Investig., 2 deficiencies cited report
  • C0010: Licensing Complaint Investigation severity level 0
  • 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
• July 2, 2024: 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 August 31, 2024
• March 21, 2023: Initial Licensure, 11 deficiencies cited report
  • C0000: Comment severity level 0
  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Isolated, corrected May 23, 2023
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread, corrected May 23, 2023
  • C0260: Service Plan: General severity level 2, scope L2 Isolated, corrected May 23, 2023
  • C0270: Change of Condition and Monitoring severity level 3, scope L3 Isolated, corrected May 23, 2023
  Show all 12

  • C0280: Resident Health Services severity level 3, scope L3 Isolated, corrected May 23, 2023
  • C0290: Res Hlth Srvc: On- and Off-Site Health Srvc severity level 2, scope L2 Isolated, corrected May 23, 2023
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Isolated, corrected May 23, 2023
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread, corrected May 23, 2023
  • C0422: Fire and Life Safety: Training For Residents severity level 2, scope L2 Widespread, corrected May 23, 2023
  • C0510: General Building Exterior severity level 2, scope L2 Widespread, corrected May 23, 2023
  • C0513: Doors, Walls, Elevators, Odors severity level 2, scope L2 Widespread, corrected May 23, 2023
• September 1, 2022: Complaint Investig., 1 deficiency cited report
  • C0010: Licensing Complaint Investigation severity level 2, scope L2 Isolated
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Widespread

Substantiated abuse or neglect

• March 22, 2026: Failed to provide a safe medication administration system 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); 411-054-0055 (Medications and Treatments)
  State’s findings

  On or about March 22, 2026, the facility failed to administer the Alleged Victim’s (AV) newly prescribed medication. AV is a resident of the facility, and the facility is responsible for administering all of AV’s prescribed medications. Based on facility documentation and staff interviews, AV returned from the hospital on March 21, 2026, with medication changes that included discontinued medications and new medication orders. On March 23, 2026, the facility discovered that these new medication orders had not been properly entered into AV’s Medication Administration Record (MAR). As a result of this error, AV’s medications were not administered as ordered, causing unnecessary discomfort, including a weight gain of more than four pounds in a short period of time. According to the Risk of Harm Letter collected during the investigation, missing these medications could pose a Serious Risk of Harm or Decompensation due to the potential for an abrupt and serious worsening of health requiring urgent medical attention. 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.

• October 28, 2025: Failed to provide safe environment 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); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General); 411-054-0040 (Change of Condition and Monitoring); 411-054-0055 (Medications and Treatments)
  State’s findings

  On or about October 28, 2025, a physical altercation occurred between Witness 1 (W1) and the Alleged Victim (AV), both residents of the facility. During this incident, W1 initiated physical aggression toward AV, resulting in unreasonable discomfort and a loss of personal dignity for AV. Documentation and interviews revealed that the facility failed to appropriately monitor W1 in accordance with his/her known behavioral history and mental health needs. W1 was admitted to the facility on or about September 3, 2025, from a mental health placement where he/she had been assessed as stable and capable of thriving in a long-term care setting. Although W1 was generally described as pleasant and happy by facility care staff, the staff noted a marked change in the week leading up to the incident. W1 began exhibiting significant emotional and behavioral changes, including fear, paranoia, delusional thinking, and sadness. The investigation determined that the facility did not adequately address or mitigate a lapse in W1’s mental health medications. This failure contributed to W1’s sudden destabilization and the behavioral escalation that led to the physical altercation with AV. According to the Risk of Harm Letter collected during the APS investigation, W1 was noted as being a high risk for abrupt regression of mental health symptoms related to his/her diagnosis, including hallucinations, manic or depressive episodes, and general destabilization, without proper medication management and monitoring by the facility. The facility’s failure to ensure a safe environment by adequately monitoring and supporting W1’s mental health needs allowed W1 to suffer a sudden behavioral change which led directly to the resident-to-resident altercation between W1 and AV, that caused AV unnecessary and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• October 3, 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); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General); 411-054-0040 (Change of Condition and Monitoring); 411-054-0055 (Medications and Treatments)
  State’s findings

  In the month of October 2025, the facility failed to provide a safe medication administration system for the Alleged Victim (AV) which resulted in several lapses of AV's psychotropic medications. AV was admitted to the facility on or about September 3, 2025, with a long-standing history of significant mental health conditions. According to facility documentation and interviews, AV's mental health was stable at time of being admitted to the facility. In early October 2025, AV began exhibiting acute psychiatric deterioration, including hearing voices and experiencing fear, sadness, and agitation. According to facility documentation, AV experienced multiple lapses in prescribed psychotropic medications due to the medications being unavailable and/or lacking timely refill requests: • Medication #1: 10-day lapse (10/6–10/15); Medication #1 was requested for refill on 10/15. The same date the prescriber signed the order. • Medication #2: 14-day lapse (10/3–10/16); Medication #2 was requested for refill on 10/17. The same date the prescriber signed the order. • Medication #3: 14-day lapse (10/3–10/16); Medication #3 was requested for refill on 10/15. The same date the prescriber signed the order. • Medication #4: 4-day lapse (10/3–10/6); Medication #4 was requested for refill on 10/6. The same date the prescriber signed the order. • Medication #5: 5-day lapse (10/2–10/6); Medication #5 was unavailable and/or needing a new script. According to facility documentation, there was no documentation showing staff attempted to request AV's refills one week prior to medications running out, as required and late refill requests were not initiated timely. Staff were unable to explain why AV went without these medications for extended periods. AV showed signs of significant behavioral changes that would negatively impact AV's safety and the safety of other residents at the facility. On October 26, 2025, AV vocalized suicidal ideation with a plan of action to light AV's self on fire and on October 31, 2025, AV made the following statement to his/her medical provider, " I am not in my right mind. I feel like I'm going to hurt someone". AV presented as mentally and emotionally stable upon admission to the facility on September 3, 2025. Within less than 45 days of admission, AV experienced a significant decline in mental health functioning, evidenced by symptoms consistent with his/her diagnosed mental health conditions, including but not limited to hallucinations, suicidal ideation, agitation, and expressed intent to harm others. The facility's failure to mitigate a lapse of medications prescribed to stabilize AV's mental health resulted in unnecessary and unreasonable discomfort and a serious loss of personal dignity which is a violation of resident rights, is considered neglect of care which constitutes abuse.

Substantiated licensing violations

• June 16, 2026: 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 was not staffed 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.

• June 16, 2026: 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); 411-054-0070 (Staffing Requirements and Training)
  State’s findings

  The facility failed to have sufficient staff to meet the scheduled and unscheduled needs of the residents. 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.

• June 16, 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

  The facility failed to ensure resident service plans reflect the residents needs as identified in evaluation and resident preference; when a resident experiences a significant change of condition the service plan must be reviewed and updated as needed. The failure is a violation of Oregon Administrative Rules.

• June 18, 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.

• May 30, 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.

• March 14, 2024: 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

  Based on interview and record review, conducted during a desk review on 05/06/25, the facility's failure to fully implement and update an Acuity-Based Staffing Tool (ABST) was substantiated. Findings include, but are not limited to: 1) A review of the facility's ABST and resident roster indicated 15 residents were included in the tool and three of the 15 ABST evaluations were not updated in the tool. 2) A review of facility ODHS tool and Specific Needs Contract (SNC) indicated the SNC hours were higher, and facility should have been staffing the following: - Day Shift: three direct care staff and Night Shift: three direct care staff required. 3) A review of the posted staffing plan and staff schedule dated 04/30/25 through 05/06/25 indicated the facility was not staffing to the SNC for 2 out of the 14 shifts. - The facility was not consistently staffed per the posted staffing plan and SNC. 4) In an interview on 05/07/25, Staff 1 stated the following: - They were aware the facility was not fully staffed for day and night shifts on 05/03/25. - The facility was not able to cover shifts when staff called-out. 5) In an interview on 05/06/25, Staff 2 stated the following: - They were unaware of how to update residents that had no changes to service plans. - The facility direct care staff worked 12-hour shifts. 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.

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 19 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.