The Stafford Assisted Living Facility

Last inspection

April 29, 2026

Inspections

5, 5 deficiencies cited

Substantiated abuse

1

Substantiated licensing violations

3

Regulatory actions

0

Fines assessed

$375.00 (1 violation)

Current owner since

May 1, 2008

Inspections

• April 29, 2026: Kitchen, 1 deficiency 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
• June 9, 2025: Kitchen, 1 deficiency cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
• January 8, 2024: 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 April 28, 2024
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread, corrected April 28, 2024
• January 31, 2023: Validation, 1 deficiency cited report
  • C0000: Comment severity level 0
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread, corrected February 10, 2023
• January 17, 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

Substantiated abuse or neglect

• January 20, 2025: Failed to properly plan care 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); 411-054-0036 (Service Plan – General)
  State’s findings

  The facility failed to assess and implement appropriate interventions after the Alleged Victim (AV) experienced two balance-related incidents within three days. On or about January 17, 2025, AV lost balance during an activity, brushed against a fireplace, and reported pain. Despite AV’s known fall history, no new interventions were implemented. On or about January 20, 2025, AV fell again while putting on nonskid socks, resulting in fractured ribs. By failing to respond appropriately to the first incident, the facility allowed a preventable risk to escalate, culminating in the second fall and injury. Based on facility documentation and interviews, the facility failed to appropriately care plan by not implementing reasonable interventions to address AV's fall risk, which is a violation of resident rights, constitutes neglect of care, and is considered abuse.

Substantiated licensing violations

• May 9, 2024: Failed to follow care plan Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0025 (Facility Administration)
  State’s findings

  On or about May 9, 2024, Alleged Perpetrator 2 (AP2) failed to perform the Activities of Daily Living (ADL) as described in Alleged Victim's (AV) care plan for AV's nighttime cares. Based on facility documentation and interviews, AV was found to be neglected of nighttime care assistance. AV had not been given AV's oxygen as ordered, AV's call light pendant was not within AV's reach, AV was not offered toileting assistance, and AV was found left unattended in AV's recliner. On the evening of May 9, 2024, AP2 was tasked with providing AV with oxygen, his/her call light, and offering toileting assistance. AV's oxygen cord was found rolled up and on top of the oxygen machine. AV was found completed soaked through brief, pajamas, and onto AV's recliner. According to AP2's training record, AP2 was provided training on AV's nighttime cares. AP2's actions to provide basic care and services to maintain the health and safety of AV resulted in AV suffering unreasonable discomfort. AP2's actions is considered neglect of care which constitutes abuse. The facility is responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of his/her employment duties. The facility failed to provide a safe environment for AV which is a violation of Oregon Administrative Rules.

• April 1, 2022: Failed to submit timely or adequate staffing documentation Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-061-0010
  State’s findings

  On or about April 1, 2022, the Oregon Health Authority reported to the Department that Respondent failed to comply with weekly reporting requirements of vaccinated individuals, residents and staff, to the proper authority as required by law. This failure has been ongoing from March 1, 2022 to March 31, 2022, for a total of 30 days.

• November 24, 2021: 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 November 24, 2021, Alleged Victim (AV) noticed having $23 missing from his/her wallet. An investigation determined that an unknown Alleged Perpetrator 2 (AP2) wrongfully took funds belonging to AV. AP2's actions in considered financial exploitation which constitutes abuse. The facility's failure to provide a safe environment for AV 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 16 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.