Suzanne Elise Assisted Living

Last inspection

December 4, 2024

Inspections

3, 7 deficiencies cited

Substantiated abuse

11

Substantiated licensing violations

15

Regulatory actions

0

Fines assessed

$3,814.00 (11 violations)

Current owner since

November 1, 2007

Inspections

• December 4, 2024: Re-Licensure, 5 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
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Isolated
  • C0305: Systems: Resident Right to Refuse severity level 2, scope L2 Pattern
• October 5, 2023: State Licensure, 1 deficiency cited report
  • C0000: Comment severity level 0
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Pattern, corrected December 4, 2023
• August 1, 2022: Complaint Investig., 1 deficiency cited report
  • C0010: Licensing Complaint Investigation severity level 2, scope L2 Isolated
  • C0360: Staffing Requirements and Training: Staffing severity level 2, scope L2 Isolated

Substantiated abuse or neglect

• October 13, 2025: Failed to follow care plan 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); 411-054-0036 (Service Plan – General)
  State’s findings

  On or about October 13, 2025, the facility failed to adhere to the Alleged Victim’s (AV) individualized care plan and care needs. Based on facility documentation and staff interviews, AV was observed wearing a pad containing dried fecal matter, with fecal matter adhered to their body, indicating inadequate hygiene care. Furthermore, staff applied topical cream by pulling AV’s shirt downward without ensuring privacy. The facility’s failure to provide appropriate hygiene care and maintain privacy resulted in unreasonable discomfort and a loss of dignity for AV which is a violation of resident rights and is considered neglect of care which constitutes abuse.

• May 29, 2025: Failed to follow care plan 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 basic care and services necessary to maintain Alleged Victim's (AV) health and safety. This included not assisting with hygiene, bathing, and foot care, and failing to follow the individualized care plan, which placed AV at risk for skin breakdown and other health complications. Additionally, the facility failed to ensure a safe and effective medication administration system, resulting in AV not receiving prescribed anxiety and pain medications. This failure caused AV to experience increased pain and anxiety, further compromising AV’s well-being. The facility’s overall failure to provide services in accordance with AV’s assessed care needs caused AV unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• November 14, 2024: Failed to properly plan care 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); 411-054-0036 (Service Plan – General)
  State’s findings

  The Alleged Victim (AV) is care planned as a fall risk and has some interventions in place to reduce falls, such as proper footwear, calling for assistance with transfers and increased safety checks. Between November 8, 2024 and November 16, 2024, AV suffered 11 falls, with and without injury. On some falls, AV was not wearing proper footwear and on other falls, AV's pendant was not on when he/she fell. Interventions placed after these falls were not effective and often recycled. The facility's failure to properly care plan to reduce the risk of falls is a violation of resident rights, is considered neglect of care and constitutes abuse.

• August 22, 2022: Failed to follow care plan Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $500.00; report
  Rules: 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0036 (Service Plan – General)
  State’s findings

  The facility failed to provide appropriate services according to the Alleged Victim’s (AV) Insulin resistant medical need and toenail care. The facility's failure to follow AV's care plan resulted in unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• June 4, 2022: Failed to follow care plan 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); 411-054-0036 (Service Plan – General)
  State’s findings

  According to the documentation, the facility failed to follow the care plan of the Alleged Victim’s (AV) by placing their fall mat next to their bed when the AV was in bed. On or about June 04, 2022, the AV fell out of their bed and landed on the floor. When the AV was found, the fall mat was not placed next to their bed and the AV was on the ground. The AV was sent to the hospital for evaluation for serious injury. They returned later that day with a diagnosis of a hematoma on their head. The facility failed to follow the care plan by placing the fall mat next to AV’s bed placing the AV at risk of harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• April 17, 2024: Failed to provide safe environment Licensing Violation; Level 3 - Moderate harm or potential for serious harm; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections)
  State’s findings

  On or about April 17, 2024, Alleged Victim (AV) gave Alleged Perpetrator 2 (AP2) his/her debit card so AP2 could mail personal packages for AV to AV's family members. AV trusted AP2 to only use his/her debit card to mail personal packages for AV. AP2, an employee of the facility, financially exploited AV by taking AV's debit card and using AV’s debit card to pay for AP2's personal expenses, causing AV financial and emotional harm. Based on facility documentation and interviews, AP2 used AV's debit card to charge $100 at a gas station and another charge, totaling $1,084.17 at a dance studio. AV did not authorize AP2 to use his/her debit card at the gas station and/or at the dance studio. AV only authorized AP2 to use his/her debit card to mail AV’s packages. AP2's action is considered financial exploitation which is considered abuse. The facility failed to protect AV from financial exploitation, which is a violation of Oregon Administrative Rules.

• June 30, 2023: 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

  Alleged Perpetrator 2 (AP2) physically abused Alleged Victim (AV) by using physical force while assisting AV with his/her Activities of Daily Living resulting in physical harm to AV. Based on facility documentation and interviews, AP2 pulled off AV's compression sock roughly, causing AV unreasonable pain and discomfort. AP2's actions is considered physical abuse. The facility failed to provide a safe environment for AV which is a violation of Oregon Administrative Rules.

• July 6, 2022: Failed to provide safe environment Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0070 (Staffing Requirements and Training)
  State’s findings

  The facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. The facility's failure to provide a safe environment is a violation of Oregon Administrative Rules.

• May 23, 2022: Failed to administer medication as ordered Licensing Violation; Level 1 - No harm or potential for minor harm; report
  Rules: 411-054-0055 (Medications and Treatments)
  State’s findings

  The allegation that the facility failed to have a safe medication system in place in accordance with OAR 411-054-0055(1). Per complaint that the facility loses the residents medications on a regular basis was substantiated.

• May 10, 2022: Failed to assure physician services Licensing Violation; Level 1 - No harm or potential for minor harm; report
  Rules: 411-054-0045 (Resident Health Services)
  State’s findings

  The allegation that the facility failed to have a protocol to facilitate the receipt of information from the provider in accordance with OAR 411-054-0045(2)(b)(D) was substantiated.

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 90 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.