The Meadow at Mt Bachelor Memory Care

Last inspection

February 12, 2026

Inspections

7, 54 deficiencies cited

Substantiated abuse

3

Substantiated licensing violations

10

Regulatory actions

2

Fines assessed

$1,000.00 (3 violations)

Current owner since

June 1, 2024

License conditions and other regulatory actions

• August 15, 2025 to May 26, 2026: License Condition, Failed to provide safe environment RCFCD25-00942; incident: CALMS - 00085700
  On August 13, 2025, the Department opened an APS investigation, and based on preliminary information ODHS concludes that Respondents acts or omissions create a situation where the residents of the facility and future residents are at risk of immediate jeopardy.
  Rules: 411-054-0025 (Facility Administration); 411-057-0100 (Statement of Purpose); 411-057-0170 (Physical Design, Environment, and Safety)
• August 28, 2023 to March 31, 2025: License Condition, Failed to use an ABST RCFCD23-01032; incident: OR0004216000
  The facility failed to fully implement and update an acuity-based staffing tool in accordance with OAR 411-054-0037(1).
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)

Inspections

• February 12, 2026: Change of Owner, 17 deficiencies cited report
  • C0154: Facility Administration: Policy & Procedure severity level 2, scope L2 Widespread
  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Isolated
  • C0242: Resident Services: Activities severity level 2, scope L2 Widespread
  • C0260: Service Plan: General severity level 2, scope L2 Isolated
  • C0262: Service Plan: Service Planning Team severity level 2, scope L2 Pattern
  Show all 17

  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Isolated
  • C0280: Resident Health Services severity level 2, scope L2 Isolated
  • C0290: Res Hlth Srvc: On- and Off-Site Health Srvc severity level 2, scope L2 Isolated
  • C0310: Systems: Medication Administration severity level 2, scope L2 Isolated
  • C0372: Training Within 30 Days of Hire ? Direct Care Staff severity level 2, scope L2 Pattern
  • H1518: Individual Door Locks: Key Access severity level 2, scope L2 Widespread
  • L0370: Staffing Requirements and Training ? Pre-service severity level 2, scope L2 Pattern
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread
  • Z0155: Staff Training Requirements severity level 2, scope L2 Pattern
  • Z0162: Compliance with Rules Health Care severity level 2, scope L2 Pattern
  • Z0163: Nutrition and Hydration severity level 2, scope L2 Pattern
  • Z0164: Activities severity level 2, scope L2 Pattern
• January 27, 2026: Kitchen, 2 deficiencies 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
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread
• April 29, 2024: Validation, 28 deficiencies cited report
  • C0000: Comment severity level 0
  • C0156: Facility Administration: Quality Improvement severity level 2, scope L2 Widespread
  • C0200: Resident Rights and Protection - General severity level 2, scope L2 Widespread
  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Pattern
  • C0252: Resident Move-In and Eval: Res Evaluation severity level 2, scope L2 Isolated
  Show all 29

  • C0260: Service Plan: General severity level 2, scope L2 Pattern
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Isolated
  • C0280: Resident Health Services severity level 2, scope L2 Isolated
  • C0282: Rn Delegation and Teaching severity level 2, scope L2 Isolated
  • C0295: Infection Prevention & Control severity level 2, scope L2 Widespread
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Pattern
  • C0310: Systems: Medication Administration severity level 2, scope L2 Pattern
  • C0330: Systems: Psychotropic Medication severity level 2, scope L2 Isolated
  • C0340: Restraints and Supportive Devices severity level 2, scope L2 Isolated
  • C0360: Staffing Requirements and Training: Staffing severity level 2, scope L2 Isolated
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Pattern
  • C0365: Staffing Rqmt and Training: Training Rqmts severity level 2, scope L2 Pattern
  • C0372: Training Within 30 Days: Direct Care Staff severity level 2, scope L2 Pattern
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread
  • C0510: General Building Exterior severity level 2, scope L2 Widespread
  • C0513: Doors, Walls, Elevators, Odors severity level 2, scope L2 Widespread
  • C0555: Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable severity level 2, scope L2 Widespread
  • H1510: Individual Rights Settings: Privacy, Dignity severity level 0
  • H1511: Individual Rights Settings Right to Freedom severity level 0
  • H1518: Individual Door Locks: Key Access severity level 0
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread
  • Z0155: Staff Training Requirements severity level 2, scope L2 Pattern
  • Z0162: Compliance With Rules Health Care severity level 2, scope L2 Pattern
  • Z0164: Activities severity level 2, scope L2 Pattern
• February 26, 2024: State Licensure, 2 deficiencies cited report
  • C0000: Comment severity level 0
  • 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
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread
• July 14, 2023: 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
• May 17, 2023: State Licensure, 2 deficiencies cited report
  • C0000: Comment severity level 0
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread, corrected July 16, 2023
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected July 16, 2023
• July 20, 2022: State Licensure, 2 deficiencies cited report
  • C0000: Comment severity level 0
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread, corrected September 18, 2022
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected September 18, 2022

Substantiated abuse or neglect

• August 9, 2025: Failed to provide safe environment 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

  The Alleged Victim (AV) is dependent on the facility to meet his/her safety needs and has a history of exit seeking and elopement from the secured unit. According to an investigation, on or about August 9, 2025, AV was noticed to be missing and was found on or about an hour and a half later at a grocery store. AV's service plan identified signs of the exit seeking behavior and directed staff to offer to go walking with AV around the community and courtyards, invite AV to assist with tasks and to perform hourly checks. Staff were aware AV would often try to leave the secured unit when visitors entered or exited. The facility failed to develop interventions to ensure AV's service planned need for supervision. The facilities failure to properly plan care resulted in potential risk of serious harm for AV, which is a violation of resident rights, is considered neglect of care which constitutes abuse.

• August 2, 2025: Failed to provide or assist with hygiene 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); 411-054-0030 (Resident Services)
  State’s findings

  The Alleged Victim (AV) relies on the facility for his/her daily care. According to an investigation, on or about August 2, 2025, AV appeared covered in urine, unshaven, and without having had a recent shower. Facility staff reported they had been behind on providing showers. Over a period of at least two months, AV's mattress and clothing had to be replaced due to AV not receiving timely incontinence care, resulting in AV experiencing unreasonable discomfort. The facility failed to provide appropriate or timely incontinence care and failed to provide proper hygiene, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• June 17, 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) has cognitive deficits, fragile skin and relies on the facility for his/her care. AV's service planned interventions for falls were for two staff to assist with transfers and to remind AV to use the call cord when needing assistance. According to an investigation, on or about June 17, 2025, AV was observed to have two lacerations on their buttocks. The lacerations were determined to be caused when AV scooted down in their recliner and rubbed against metal parts in the footrests. AV has a history of attempting to self-transfer. AV's service plan did not have effective interventions to address the use of the recliner and reduce the risk of injury. The facility failed to properly care plan, which is a violation of resident’s rights, is neglect of care and constitutes abuse.

Substantiated licensing violations

• August 25, 2025: Failed to update staffing plan based on 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 update and review the ABST evaluation for each resident no less than quarterly. The facility’s failure is a violation of Oregon Administrative Rules.

• August 25, 2025: Failed to assure resident rights Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare)
  State’s findings

  The facility failed to promptly investigate all reports of abuse and suspected abuse. The facility’s failure is a violation of Oregon Administrative Rules.

• August 25, 2025: Failed to provide appropriate activities Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0030 (Resident Services)
  State’s findings

  The facility failed to provide a daily program of activities for residents. The facility’s failure is a violation of Oregon Administrative Rules.

• August 25, 2025: Failed to assure resident rights Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  State’s findings

  The facility failed to provide meaningful activities and evaluate any residents for activities. The facility’s failure is a violation of Oregon Administrative Rules.

• August 25, 2025: 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 document what action or intervention was needed for a resident. The facility’s 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 24 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.