The Butte

Last inspection

November 4, 2024

Inspections

4, 13 deficiencies cited

Substantiated abuse

2

Substantiated licensing violations

5

Regulatory actions

0

Fines assessed

$419.00 (2 violations)

Current owner since

December 1, 2022

Inspections

• November 4, 2024: Kitchen, 1 deficiency cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
• March 25, 2024: Complaint Investig., 2 deficiencies cited report
  • C0260: Service Plan: General severity level 2, scope L2 Isolated
  • C0410: Medicaid Personal Incidental Funds severity level 2, scope L2 Isolated
• June 27, 2023: Validation, 9 deficiencies cited report
  • C0000: Comment severity level 0
  • C0160: Reasonable Precautions severity level 2, scope L2 Widespread, corrected October 14, 2023
  • C0260: Service Plan: General severity level 2, scope L2 Pattern, corrected October 14, 2023
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Pattern, corrected October 14, 2023
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Pattern, corrected October 14, 2023
  Show all 10

  • C0513: Doors, Walls, Elevators, Odors severity level 2, scope L2 Widespread, corrected October 14, 2023
  • C0515: Resident Units severity level 2, scope L2 Pattern, corrected October 14, 2023
  • C0530: Housekeeping and Laundry severity level 2, scope L2 Widespread, corrected October 14, 2023
  • C0550: Wiring Systems severity level 2, scope L2 Pattern, corrected October 14, 2023
  • H1518: Individual Door Locks: Key Access severity level 2, scope L2 Pattern, corrected October 14, 2023
• April 27, 2023: 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 October 14, 2023
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread, corrected October 14, 2023

Substantiated abuse or neglect

• January 5, 2025: Failed to properly plan care 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 Alleged Victim (AV) relies on the facility to provide care and services. AV has experienced over ten falls from December 22, 2024, to January 5, 2025, and some of the falls resulted in injury to AV. The facility failed to implement progressive interventions into the care plan to help prevent AV from continuing to fall, which is considered neglect of care and constitutes abuse.

• August 23, 2024: Failed to properly plan care Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $169.00; 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) relies on the facility for care and services. According to an investigation, the AV suffered multiple falls from July 2024 to September 2024. The facility failed to implement progressive measures to address AV's falls and AV suffered a fall on August 23, 2024, and substantiated broken bones. The facility's failure to implement progressive measures in AV's care plan to address the multiple falls is a violation of resident rights, is considered neglect which constitutes abuse.

Substantiated licensing violations

• November 27, 2025: Failed to protect resident from verbal abuse 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); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare)
  State’s findings

  The Alleged Victim (AV) relies on the facility to provide a safe environment, free from verbal and emotional abuse. According to an investigation, Alleged Perpetrator 2 (AP2) used profanity, derogatory and inappropriate names towards AV when AV was exhibiting behaviors. The facility failed to provide a safe environment, which is a violation of Oregon Administrative Rules. The allegation that AP2 verbally abused AV is a violation of resident rights, considered verbal and emotional abuse which constitutes abuse.

• March 25, 2024: Failed to assure resident rights Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0085 (Refunds and Financial Management)
  State’s findings

  The facility allegedly failed to show in detail with supporting documentation all monies received on behalf of the resident and the disposition of all funds received, and providing a list showing description and price of items purchased along with payment receipts for items. An investigation determined this is a violation of Oregon Administrative Rules.

• January 13, 2024: Failed to provide safe environment 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 implementation of resident services. An investigation determined this is a violation of Oregon Administrative Rules.

• December 2, 2022: Failed to protect resident from physical abuse 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

  According to an investigation, it was determined that Alleged Perpetrator 2 (AP2) pushed the Alleged Victim (AV) in the back , which caused AV emotional distress. AP2’s actions are a violation of resident rights, are considered neglect of care and constitutes physical abuse. The facility failed to provide a safe environment which violates Oregon Administrative Rules.

• December 2, 2022: Failed to protect resident from verbal abuse 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

  According to an investigation, on or about December 2, 2022, Alleged Perpetrator 2 (AP2) made an inappropriate verbal comment toward the Alleged Victim (AV) in his/her presence, which resulted in the Alleged Victim (AV) experiencing emotional distress and loss of personal dignity. AP2’s actions are a violation of resident rights, are considered neglect of care and constitutes verbal abuse. The facility failed to protect AV from inappropriate verbal comments made by staff and the failure 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 32 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.