The Bridge Assisted Living

Last inspection

May 1, 2025

Inspections

4, 28 deficiencies cited

Substantiated abuse

7

Substantiated licensing violations

20

Regulatory actions

1

Fines assessed

$31,688.00 (11 violations)

Current owner since

September 16, 2026

License conditions and other regulatory actions

• June 18, 2025 to October 6, 2025: License Condition, Failed to provide safe environment ALFCD25-00260; incident: CALMS - 00081066
  Violation : Resident Health Services (C-0280).STATEMENT OF FACTS:Based on interview and record review, it was determined the facility failed to ensure an RN assessment was completed in a timely manner and documented findings, resident status, and interventions made as a result of the assessment for 2 of 5 sampled residents (#s 1 and 4) who experienced significant changes of condition.
  Rules: 411-054-0045 (Resident Health Services)

Inspections

• May 1, 2025: Re-Licensure, 21 deficiencies cited report
  • C0154: Facility Administration: Policy & Procedure severity level 2, scope L2 Widespread
  • C0156: Facility Administration: Quality Improvement severity level 2, scope L2 Widespread
  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Pattern
  • C0260: Service Plan: General severity level 2, scope L2 Pattern
  • C0262: Service Plan: Service Planning Team severity level 2, scope L2 Pattern
  Show all 21

  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Pattern
  • C0280: Resident Health Services severity level 2, scope L2 Pattern
  • C0290: Res Hlth Srvc: On- and Off-Site Health Srvc severity level 2, scope L2 Isolated
  • C0295: Infection Prevention & Control severity level 2, scope L2 Pattern
  • C0300: Systems: Medications and Treatments severity level 2, scope L2 Pattern
  • C0302: Systems: Tracking Control Substances severity level 2, scope L2 Pattern
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Pattern
  • C0305: Systems: Resident Right to Refuse severity level 2, scope L2 Pattern
  • C0310: Systems: Medication Administration severity level 2, scope L2 Pattern
  • C0360: Staffing Requirements and Training: Staffing severity level 2, scope L2 Widespread
  • C0362: Acuity Based Staffing Tool - ABST Time severity level 2, scope L2 Pattern
  • C0363: Acuity Based Staffing Tool - Updates & Staffing Plan severity level 2, scope L2 Pattern
  • C0555: Call Sys, Exit Dr Alarm, Phones, TV, or Cable severity level 2, scope L2 Widespread
  • C0610: General Building Exterior severity level 2, scope L2 Widespread
  • C0613: General Building: Doors-Walls, Cleanable severity level 2, scope L2 Widespread
  • C0655: Call System severity level 2, scope L2 Widespread
• December 20, 2023: State Licensure, 0 deficiencies cited report
  • C0000: Comment severity level 0
• March 14, 2023: Licensure Complaint, 2 deficiencies cited report
  • C0010: Licensing Complaint Investigation severity level 2, scope L2 Isolated
  • C0300: Systems: Medications and Treatments severity level 2, scope L2 Isolated
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Widespread
• April 26, 2022: Validation, 5 deficiencies cited report
  • C0000: Comment severity level 0
  • C0282: Rn Delegation and Teaching severity level 2, scope L2 Isolated, corrected June 26, 2022
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Pattern, corrected June 26, 2022
  • C0340: Restraints and Supportive Devices severity level 2, scope L2 Pattern, corrected June 26, 2022
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread, corrected June 26, 2022
  • C0645: Plumbing Systems severity level 2, scope L2 Widespread, corrected June 26, 2022

Substantiated abuse or neglect

• December 29, 2025: Failed to provide a safe medication administration system 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); 411-054-0055 (Medications and Treatments)
  State’s findings

  Alleged Perpetrator 2 (AP2) failed to ensure that Alleged Victim's (AV) medications were administered as ordered, resulting in a significant medication administration error that caused physical harm to AV. On or about December 29, 2025, AV was given multiple medications that were not prescribed to AV, including antihypertensive medications and narcotics. As a result, AV experienced a critical drop in blood pressure, became lethargic, and was transported to the hospital for treatment. At the time of the incident, AP2 was training Witness 2 (W2) in medication administration. AP2 pre-popped medications intended for another resident, and those medications were subsequently administered to AV in error. Based on facility documentation and interviews, AP2 has a history of multiple documented medication errors. AP2's actions caused AV unnecessary physical harm and unreasonable discomfort, is considered neglect of care which constitutes abuse. The facility failed to provide adequate oversight of AP2, leading to AP2 improperly administering medication to AV, resulting in a hospital stay due to AV's blood pressure dropping and being lethargic. The facility's failure to provide a safe medication administration system for AV is a violation of resident rights, is considered neglect of care which constitutes abuse, as defined by 411-020-0002(1)(b)(A)(i).

• February 17, 2025: Failed to provide safe environment Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $375.00; 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 a safe environment for Alleged Victim (AV) by failing to respond to AV's call light in a timely manner. Based on facility documentation and interviews, AV was diagnosed and was being treated for a genital infection on December 31, 2024. AV suffers from skin breakdown and infections if left too long in soiled briefs. On or about, January 18, 2025, AV is noted to have several new, closed wounds in buttocks/thigh area. Facility records, show AV's longest call light response time between December 20, 2024, to February 20, 2025, was 2 hours, 14 minutes, and 45 seconds. During this time period, there are documented 39 response times to AV's room over 30 minutes and 2 response times to AV's room over 1 hour. The facility's failure to provide AV with timely response to pendant pushes to attend to AV's care needs and wound care, resulted in AV’s condition worsening causing further unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• January 12, 2025: Failed to provide service 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)
  State’s findings

  The facility failed to provide appropriate services according to the Alleged Victim’s (AV) toileting care needs resulting in AV being left in soiled briefs for periods of over and hour. AV is diagnosed with compromising skin, placing AV at risk if toileting care needs are met in a timely manner. Based on facility documentation and interviews, between November 15, 2024, and February 7, 2025, AV pressed AV's call light 952 times, 648 calls were cleared between 0-19 minutes, 218 calls were cleared between 20-39 minutes, 62 calls were cleared between 40- 59 minutes, and 24 calls were cleared 60+ minutes. The facility's failure to provide necessary care to maintain the health and safety of AV, caused AV unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• August 12, 2024: Failed to provide a safe medication administration system Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $500.00; report
  Rules: 411-054-0027 (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 facility failed to provide a safe medication administration system to ensure The Alleged Victim’s (AV) medications were administered as ordered. Based on facility documentation and interviews, AV missed 3 daily doses of his/her blood pressure medication from July 15, 2024, to July 17, 2024. As a result of missing AV's blood pressure medication, AV was hospitalized for two nights for treatment. The facility's failure to provide a safe medication administration system resulted in AV suffering from elevated blood pressure causing AV unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• July 6, 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

  On or about July 6, 2024, Alleged Perpetrator 2 (AP2) transferred Alleged Victim (AV) into AV's bed without using the Hoyer Lift or asking for other assistance. During the transfer, AV experienced pain and unreasonable discomfort. Based on facility documentation and interviews, AV is care planned to be transferred in and out of AV's bed with a Hoyer lift and is two caregivers assist. While at the time of the incident AV's care planned was not being followed, AP2 was following AV's wishes. AV admitted that AV asked AP2 to transfer AV from AV's wheelchair into AV's bed as quick as possible. AP2 was instructed to follow AV's wishes. The facility's failure to ensure services were properly implemented and followed caused AV unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse. Alleged Perpetrator 2 (AP2) allegedly physically abused AV. An investigation determined no abuse occurred by AP2.

• September 1, 2023: 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: 411-054-0027 (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 facility failed to provide a safe medication administration system to ensure The Alleged Victim’s (AV) medications were administered as ordered. Based on facility documentation and interviews, AV's narcotic medication patch was not given to AV for six days, which caused AV to experience full withdrawal symptoms. AV did not receive his/her medications for AV's muscular condition for eight days. The facility's failure resulted in unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• November 11, 2022: Failed to follow care plan Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $250.00; 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) toileting needs and behaviors which resulted in AV's care needs not being met in a timely manner, causing AV to sit in a soiled brief for a long period of time. The failure resulted in unreasonable discomfort which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• March 26, 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)
  State’s findings

  On or about March 26, 2026, Alleged Perpetrator 2 (AP2), an employee of the facility, directed inappropriate verbal comments, including profanity and derogatory statements, toward the Alleged Victim (AV), a resident of the facility, while in AV’s presence. As a result of AP2’s conduct, AV reported feeling humiliated, harassed, and uncomfortable. AP2’s actions constitute verbal and emotional abuse. The facility failed to protect AV from this verbal and emotional abuse, resulting in a violation of Oregon Administrative Rules. AP2 allegedly neglected AV. An investigation determined that AP2 did not neglect AV.

• July 7, 2025: 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 July 7, 2025, Alleged Victim (AV) had money and personal property go missing from his/her room. The property was taken by an unknown Alleged Perpetrator 2 (AP2) and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect AV’s property from theft, which is a violation of Oregon Administrative Rules.

• June 26, 2025: Failed to use an ABST Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0037 (Acuity-Based Staffing Tool)
  State’s findings

  Based on interview and record review conducted during a site visit on 07/24/25, the facility’s failure to have a fully implemented and updated Acuity-Based Staffing Tool (ABST) was substantiated. Findings include, but are not limited to: A review of the resident roster indicated that 45 residents had not been updated at least quarterly on the ABST. A review of Resident 1’s (R1) service plan dated 03/19/25 indicated R1 required assistance with transferring, bowel and bladder, vitals, one-person assist in all transfers, and safety checks every 2-3 hours. This was not reflected on ABST. In an interview on 07/24/25, Staff 1 stated the following: . The facility was staffing according to the condition and trying to overstaff when they could. . S/He was aware that not all residents were updated on the ABST. The facility failed to update the ABST for each resident no less than quarterly; and the facility failed to accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Findings were reviewed with and acknowledged by Staff 1 on 07/24/25. The facility's failure is a violation of Oregon Administrative Rules. Corrective Action has been taken.

• June 26, 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); 411-054-0055 (Medications and Treatments)
  State’s findings

  Based on interview and record review, conducted during a site visit on 07/24/25, the facility’s failure to carry out treatment orders as prescribed was substantiated for 1 of 1 sampled resident (#1). Findings include, but are not limited to: Compliance Specialist (CS) reviewed Resident’s 1’s (R1) service plans, progress notes, and Hospice RN charting orders, which indicated the following: · R1 service plan dated 03/19/25 indicated Fall prevention, 1-person assist for all transfers, and 2-3 safety checks. . Hospice Treatment Order/Interventions dated 06/24/25: indicated 15-minute checks, 0.5 morphine sulphate every 4 hrs. round the clock, vitals, please call with any questions or condition changes. 06/25/25: indicated discontinued all scheduled medication, the resident's breathing is labored, please call Hospice RN with any changes or concerns. . Progress notes 06/25/25 indicated resident was very tired, refused medication, but did receive .25 morphine. Next note 06/26/25 6:56 am Resident passed, notified Hospice. In an interview, Staff 4 stated the following: -S/He was the MT on 06/26/25 assisting R1. -S/He was not completing 15-minute or hourly safety checks on [R1]. -Stated s/he administered medication at 2 am and 4 am. [R1] was not responsive when administering medication. -S/He was not documenting any changes or vitals for [R1]. When asked why they didn’t, she/he stated, “I don’t know”. -S/He did not report to Hospice RN, ED, or call 911 with any changes in [R1's] condition or when she/he could not find a pulse. When asked why they didn’t, she/he stated, “I don’t know”. In an interview with Staff 2 and Staff 3, they stated the following: -The facility procedure was not to administer medication to a resident who was not alert and responsive. -When a resident’s condition changes, especially if you can’t find a pulse or the pulse is weak, staff are to immediately notify the RN, ED, or call 911. Findings were reviewed with and acknowledged by Staff 1 on 07/24/25. The facility’s failure to carry out medication and treatment orders as prescribed was substantiated which is a violation of Oregon Administrative Rules.

• June 26, 2025: Failed to provide safe environment Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0070 (Staffing Requirements and Training)
  State’s findings

  Based on an interview and record review conducted during a site visit on 07/24/25, the facility's failure to provide a training program that includes methods to determine the competency of direct care staff through evaluation, observation, or written testing was substantiated for 1 of 3 sampled staff (#5). Findings include, but are not limited to: Documents reviewed confirmed no documented completion of demonstrated competency to perform safe medication and treatment administration unsupervised for Staff 5. During an interview on 07/24/25, Staff 1 stated the LPN would complete competencies with Staff 5 by 07/25/25. Findings were reviewed and acknowledged by Staff 1 on 07/24/25. The facility's failure to provide a training program that includes methods to determine the competency of direct care staff through evaluation, observation, or written testing was substantiated 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 77 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.