Trustwell Living at River Run Place

Last inspection

July 15, 2026

Inspections

3, 29 deficiencies cited

Substantiated abuse

4

Substantiated licensing violations

11

Regulatory actions

1

Fines assessed

$1,000.00 (3 violations)

Current owner since

September 30, 2024

License conditions and other regulatory actions

• January 20, 2026 to June 10, 2026: License Condition, Failed to provide safe environment ALFCD26-00039; incident: CALMS - 00097752
  Based preliminary information, evidence and interviews collected from the initial ODHS Change of Owner survey #CHOW008845 completed on January 16, 2026, ODHS concludes that Respondents acts or omissions create a situation that necessitates ODHS to issue a license condition. That is because the violations described above place residents at risk for serious harm. Facility failure to comply with Oregon Administrative Rules constitutes a threat to the health, safety, and welfare of its residents.
  Rules: 411-054-0025 (Facility Administration); 411-054-0037 (Acuity-Based Staffing Tool); 411-054-0055 (Medications and Treatments)

Inspections

• July 15, 2026: Kitchen, 1 deficiency cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
• January 16, 2026: Change of Owner, 27 deficiencies cited report
  • C0150: Facility Administration: Operation severity level 4, scope L4 Isolated
  • C0154: Facility Administration: Policy & Procedure severity level 2, scope L2 Widespread
  • C0156: Facility Administration: Quality Improvement severity level 2, scope L2 Widespread
  • C0160: Reasonable Precautions severity level 4, scope L4 Isolated
  • C0200: Resident Rights and Protection - General severity level 2, scope L2 Isolated
  Show all 27

  • C0260: Service Plan: General severity level 2, scope L2 Pattern
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Pattern
  • C0280: Resident Health Services severity level 2, scope L2 Pattern
  • 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 Isolated
  • 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 Pattern
  • C0340: Restraints and Supportive Devices severity level 2, scope L2 Pattern
  • C0360: Staffing Requirements and Training: Staffing severity level 2, scope L2 Widespread
  • C0363: Acuity Based Staffing Tool - Updates & Staffing Plan severity level 2, scope L2 Pattern
  • C0370: Staffing Requirements and Training ? Pre-service severity level 2, scope L2 Pattern
  • C0372: Training Within 30 Days of Hire ? Direct Care Staff severity level 2, scope L2 Pattern
  • C0374: Annual and Biennial Inservice for All Staff severity level 2, scope L2 Pattern
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread
  • C0422: Fire and Life Safety: Training for Residents severity level 2, scope L2 Widespread
  • C0613: General Building: Doors-Walls, Cleanable severity level 2, scope L2 Widespread
  • H1501: Integrated Settings: Community Life severity level 2, scope L2 Isolated
  • H1511: Individual Rights Settings Right to Freedom severity level 2, scope L2 Pattern
  • L0370: Staffing Requirements and Training ? Pre-service severity level 2, scope L2 Pattern
  • L0374: Annual and Biennial Inservice for All Staff severity level 2, scope L2 Pattern
• March 21, 2025: Kitchen, 1 deficiency cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread

Substantiated abuse or neglect

• March 10, 2024: Failed to follow care plan 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); 411-054-0036 (Service Plan – General)
  State’s findings

  The Alleged Victim (AV) relies on the facility for his/her care. On or about March 8, 2024, AV started experiencing behaviors and was care planned for thirty-minute checks. On or about March 10, 2024, AV left the facility and was found approximately five hours later at a nearby residence covered in mud and taken to the hospital for observation. The facility failed to follow the care plan, which is a violation of resident’s rights, is neglect of care and constitutes abuse.

• December 30, 2023: Failed to provide a safe medication administration system Abuse: Neglect; Level 2 - Minor harm or potential for moderate 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

  Alleged Victim (AV) relies on the facility to administer his/her medications. The facility has regularly failed to chart administration of AV’s gel drops in November and December 2023. Medication administration records were left blank for several days. Outside provider documentation shows that concerns were raised about AV’s eye drops on or about December 2, 2023, however, drops continued to be missed on or about December 8th, 11th, 15th through 18th and 27th through the 30th, 2023. No follow-up plan was created to address regular and ongoing missed doses of AV’s drops. 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 23, 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

  Alleged Victim (AV) is service planned to receive assistance with medication administration. On or about December 23, 2023, the facility did not administer AV’s narcotic medication as prescribed. The facility did not have any protocols or technology in place to ensure all medication are administered at the appropriate time. The facility failed to provide a safe medication administration system for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

• October 15, 2023: Failed to protect resident from financial exploitation 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)
  State’s findings

  Alleged Victim (AV) relies on the facility for his/her care needs. On or about October 1, 2023, AV gave notice of his/her intent to move out of the facility. AV paid for the room at the facility through the month of October 2023. AV and most of his/her possessions were moved out of the facility in early October. AV intended to return and get the rest of his/her possessions, but the facility sent out a notice that the facility was on lock-downed due to COVID-19 and for this reason, AV could not retrieve the rest of their belongings. Without notice to AV, the facility cleaned out AV’s apartment and disposed of AV’s remaining possessions prior to the end of AV’s paid rental period, resulting in a financial loss to AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Substantiated licensing violations

• May 7, 2026: 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 medications to the Alleged Victim (AV) as ordered. According to an investigation, AV experienced no negative outcome. The failure is a violation of Oregon Administrative Rules.

• May 7, 2026: 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 medications to the Alleged Victim (AV) as ordered. According to an investigation, AV experienced no negative outcome. The failure is a violation of Oregon Administrative Rules.

• May 4, 2026: 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

  Based on interview and record review, the facility failed to carry out medication and treatment orders as prescribed. The facility’s failure is a violation of Oregon Administrative Rules.

• January 16, 2026: Failed to administer ordered medication Licensing Violation; 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); 411-054-0055 (Medications and Treatments)
  State’s findings

  The Alleged Victim relies on the facility for medication management. According to an investigation, on or about January 16, 2026, Alleged Perpetrator 2 (AP2) was observed to place an envelope with twelve (12) narcotic pain medications belonging to the AV in their pocket. AP2 left the facility with the medications, did not return them, and was not truthful about taking them. The AV requested the pain medications to manage chronic moderate to severe to pain. The AV went without the medication and experienced pain and loss of sleep for approximately four (4) days. AP2's actions are a violation of resident rights, considered neglect of care, and constitutes abuse. The facility did not keep AV free from neglect which is a violation of Oregon Administrative rules.

• January 16, 2026: Failure to provide a system that prevents theft or misuse of medication 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); 411-054-0055 (Medications and Treatments)
  State’s findings

  The Alleged Victim relies on the facility for medication management. According to an investigation, on or about January 16, 2026, Alleged Perpetrator 2 (AP2) was observed to place an envelope with twelve (12) narcotic pain medications belonging to the AV in their pocket. AP2 left the facility with the medications, did not return them, and was not truthful about taking them. AP2's actions are a violation of resident rights, considered financial exploitation and constitutes abuse. The facility did not keep AV free from financial exploitation, 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.” 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.