The Creston Senior Living

Last inspection

December 12, 2025

Inspections

6, 36 deficiencies cited

Substantiated abuse

6

Substantiated licensing violations

9

Regulatory actions

1

Fines assessed

$2,125.00 (4 violations)

Current owner since

April 1, 2026

License conditions and other regulatory actions

• October 10, 2022 to February 21, 2023: License Condition, Failed to update staffing plan based on ABST RCFCD22-01475; incident: CALMS - 00032462
  The facility failed to fully implement the Acuity-Based Staffing Tool as required by Oregon Administrative Rules.
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)

Inspections

• December 12, 2025: Re-Licensure, 4 deficiencies cited report
  • C0280: Resident Health Services severity level 2, scope L2 Isolated
  • C0310: Systems: Medication Administration severity level 2, scope L2 Isolated
  • 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
• August 25, 2025: Kitchen, 1 deficiency cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
• September 26, 2024: Kitchen, 1 deficiency cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
• February 26, 2024: Complaint Investig., 5 deficiencies cited report
  • C0010: Licensing Complaint Investigation severity level 2, scope L2 Isolated
  • C0301: Systems: Medication Administration severity level 2, scope L2 Isolated
  • C0302: Systems: Tracking Control Substances severity level 2, scope L2 Isolated
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Isolated
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Isolated
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Isolated
• October 5, 2023: State Licensure, 0 deficiencies cited report
  • C0000: Comment severity level 0
• September 12, 2022: Validation, 25 deficiencies cited report
  • C0000: Comment severity level 0
  • C0156: Facility Administration: Quality Improvement severity level 2, scope L2 Widespread, corrected February 1, 2023
  • C0160: Reasonable Precautions severity level 2, scope L2 Isolated, corrected February 1, 2023
  • C0200: Resident Rights and Protection - General severity level 2, scope L2 Pattern, corrected February 1, 2023
  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Isolated, corrected February 1, 2023
  Show all 27

  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread, corrected February 1, 2023
  • C0252: Resident Move-In and Eval: Res Evaluation severity level 2, scope L2 Isolated, corrected February 1, 2023
  • C0260: Service Plan: General severity level 2, scope L2 Pattern, corrected February 1, 2023
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Pattern, corrected May 30, 2023
  • C0280: Resident Health Services severity level 2, scope L2 Pattern, corrected May 30, 2023
  • C0290: Res Hlth Srvc: On- and Off-Site Health Srvc severity level 2, scope L2 Pattern, corrected February 1, 2023
  • C0295: Infection Prevention & Control severity level 2, scope L2 Pattern, corrected February 1, 2023
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Pattern, corrected May 30, 2023
  • C0305: Systems: Resident Right to Refuse severity level 2, scope L2 Pattern, corrected February 1, 2023
  • C0310: Systems: Medication Administration severity level 2, scope L2 Pattern, corrected February 1, 2023
  • C0325: Systems: Self-Administration of Meds severity level 2, scope L2 Isolated, corrected May 30, 2023
  • C0360: Staffing Requirements and Training: Staffing severity level 2, scope L2 Widespread, corrected February 1, 2023
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Pattern, corrected February 1, 2023
  • C0370: Staffing Requirements and Training – Pre-Serv severity level 2, scope L2 Pattern, corrected February 1, 2023
  • C0372: Training Within 30 Days: Direct Care Staff severity level 2, scope L2 Pattern, corrected February 1, 2023
  • C0374: Annual and Biennial Inservice For All Staff severity level 2, scope L2 Isolated, corrected February 1, 2023
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread, corrected May 30, 2023
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread, corrected May 30, 2023
  • C0510: General Building Exterior severity level 2, scope L2 Widespread, corrected February 1, 2023
  • C0513: Doors, Walls, Elevators, Odors severity level 2, scope L2 Widespread, corrected February 1, 2023
  • C0555: Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable severity level 2, scope L2 Widespread, corrected February 1, 2023
  • H1522: Individual Freedom & Support: Activities severity level 2, scope L2 Pattern, corrected February 1, 2023

Substantiated abuse or neglect

• February 26, 2026: Failed to provide safe environment Abuse: Neglect; 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

  On or about February 26, 2026, Alleged Victim (AV) experienced significant emotional harm as a direct result of the facility’s directive instructing facility management not to communicate with AV unless AV was accompanied by an attorney. This directive prevented AV from accessing support from facility leadership and led Witness 3 (W3) to deny AV’s repeated request for an in-person meeting. AV reported that the continued refusal of facility management to meet created a profound sense of isolation and dismissal. AV stated these actions made AV feel as though staff “don’t care if I live or die,” and described experiencing feelings of hopelessness, depression, distress, and lack of motivation. The APS investigation determined that the facility’s communication restriction created a substantial barrier to AV’s ability to obtain needed support and engagement from facility management. The resulting emotional impact on AV constitutes demonstrable emotional harm and meets the criteria for neglect as defined in OAR 411-020-0002(1)(b)(A)(i). The facility's failure is a violation of resident rights, is considered neglect of care which constitutes abuse. As the new owner of this facility, you are responsible for correcting any deficiencies which pre-date your ownership. You must correct violations which occurred under previous ownership, as directed by the Department. You will not be responsible for paying civil penalties incurred by previous owner(s). However, if you fail to correct identified deficiencies within the specified time you may be subject to aggravated civil penalties.

• October 6, 2025: Failed to properly plan care Abuse: Neglect; Level 3 - Moderate harm or potential for serious 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); 411-054-0036 (Service Plan – General)
  State’s findings

  The Alleged Victim (AV) is dependent on facility staff to meet some of his/her care needs and has a history of falls. According to an investigation, on or about October 3, 2025, AV returned from a hospital stay. Between October 3, 2025, and October 6, 2025, AV had three falls and was found on the floor. On October 6, 2025, AV was experiencing pain and was transported to the hospital and found to have fractures in both feet. AV's care plan did not identify effective interventions to address the falls. The facility failed to properly plan care, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• July 27, 2023: Failed to follow care plan 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); 411-054-0036 (Service Plan – General); 411-054-0070 (Staffing Requirements and Training)
  State’s findings

  The Alleged Victim (AV) relies on the facility for assistance with transfers, which includes use of a gait belt. According to an investigation, on or about July 27, 2023, the AV was being transferred without the use of a gait belt, which resulted in AV sliding to the floor and his/her prosthetic leg getting caught under the wheelchair. AV was transported to the hospital where he/she was diagnosed with a fractured femur. The facility failed to follow the Alleged Victim’s (AV) care plan and ensure that staff were properly trained in the use of a gait belt, which is a violation of resident rights, is neglect of care which constitutes abuse. The allegation that Alleged Perpetrator 2 (AP2) failed to provide services was investigated and determined to be not substantiated.

• May 13, 2023: Failed to properly plan care 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 Alleged Victim (AV) relies on the facility for assistance with his/her oxygen. According to an investigation, on or about May 13, 2023, during a change of AV’s oxygen tank, the tank was dropped on AV’s knee, resulting in swelling to AV’s shin and pain in his/her right knee. The facility failed to appropriately care plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The allegation that the Alleged Perpetrator 2 (AP2) failed to provide appropriate services was investigated and determined to be Not Substantiated.

• April 10, 2023: Failed to provide a safe medication administration system 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); 411-054-0055 (Medications and Treatments)
  State’s findings

  The facility failed to provide a safe medication administration system to ensure the Alleged Victim’s (AV) medication was available to be administered as ordered. According to an investigation, the medication was ordered and delivered, but could not be located, resulting in AV not receiving his/her scheduled narcotic pain medication from approximately April 7, 2023, to April 10, 2023, causing AV to feel ill and weak. The facility failed to provide a safe medication administration system, which is a violation of resident rights, is neglect of care and constitutes abuse.

• December 2, 2021: Failed to follow care plan 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); 411-054-0036 (Service Plan – General)
  State’s findings

  The facility failed to provide assistance with bathing to the Alleged Victim (AV), who was not put on the shower schedule. Resulting in AV going without a shower for over a month and experiencing unreasonable discomfort and a serious loss of dignity. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• July 1, 2024: Failed to administer medication as ordered Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0055 (Medications and Treatments)
  State’s findings

  The facility failed to administer medication as ordered for the Alleged Victim (AV). According to an investigation, AV experienced no negative outcome. The failure is a violation of Oregon Administrative Rules

• June 13, 2024: 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

  On or about June 13, 2024 Alleged Victim (AV) took the h/h electric scooter down the stairwell from the 3rd floor to 2nd floor when the elevator was in service and AV got stuck in the stairwell. Staff called Alleged Perpetrator 2 (AP2) and other staff to come and assist AV. AV was yelling at staff and AP2. AP2 responded verbally aggressive and used inappropriate language toward AV. AP2 turned around and was going toward AV and stated “curse at me again, curse at me again and I will show you”. Witness 2 (W2) held AV back from going toward AV and redirected AP2 to leave the area. AV felt like AP2 was scolding AV like a young child and it was demeaning to AV. AP2 has history of having verbal altercations with other residents. AP2 received corrective actions and multiple trainings to work with residents with difficult behaviors to address AP2 behaviors. AP2's action is considered verbal/emotional abuse. The facility failed to protect AV from verbal/emotional abuse which is a violation of Oregon Administrative Rules.

• November 3, 2023: Failed to provide a safe medication administration system Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0055 (Medications and Treatments)
  State’s findings

  The facility failed to have a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility. An investigation determined this is a violation of Oregon Administrative Rules.

• November 3, 2023: Failed to provide safe environment Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0090 (Fire and Life Safety)
  State’s findings

  The facility allegedly failed to conduct and record unannounced fire drills every other month at different times of the day, evening, and night shifts. An investigation determined this is a violation of Oregon Administrative Rules.

• May 28, 2023: Failed to provide a safe medication administration system Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0055 (Medications and Treatments)
  State’s findings

  The Facility failed to comply with safe medication administration or treatment practices and to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident. 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 115 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.