Waverly Place Assisted Living

Last inspection

March 20, 2025

Inspections

5, 27 deficiencies cited

Substantiated abuse

10

Substantiated licensing violations

26

Regulatory actions

3

Fines assessed

$5,626.00 (10 violations)

Current owner since

December 28, 2017

License conditions and other regulatory actions

• April 3, 2025 to October 6, 2025: License Condition, Failed to provide safe environment ALFCD25-00148; incident: CALMS - 00075676
  Rules: 411-054-0025 (Facility Administration); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0034 (Resident Move-In and Evaluation); 411-054-0036 (Service Plan – General); 411-054-0040 (Change of Condition and Monitoring); 411-054-0045 (Resident Health Services)
• August 4, 2023 to December 27, 2023: License Condition, Failed to meet the scheduled and unscheduled needs of residents ALFCD23-00470; 2 incidents: OR0004108601, OR0004108600
  The facility failed to fully implement an Acuity Based Staffing Tool (ABST) in accordance with OAR 411-054-0037 (1).
  Rules: 411-054-0037 (Acuity-Based Staffing Tool); 411-054-0070 (Staffing Requirements and Training)
• February 10, 2023 to March 28, 2023: License Condition, Failed to provide appropriate staffing ALFCD23-00100; 4 incidents: OR0003870110, OR0003870107, OR0003870101, OR0003870100
  The facility failed to have medical and other records kept confidential except as otherwise provided by law 411-054-0027(1)(i) per the complaint that the facility had 5 "new" service plans on a cork board near the med room for anyone to look at.
  Rules: 411-054-0027 (Resident Rights and Protections); 411-054-0037 (Acuity-Based Staffing Tool); 411-054-0070 (Staffing Requirements and Training); 411-054-0300 (Assisted Living Facility Building Requirements)

Inspections

• March 20, 2025: Re-Licensure, 19 deficiencies cited report
  • C0150: Facility Administration: Operation severity level 3, scope L3 Isolated
  • C0156: Facility Administration: Quality Improvement severity level 2, scope L2 Widespread
  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Pattern
  • C0252: Resident Move-in & Evaluation: Res Evaluation severity level 2, scope L2 Pattern
  • C0260: Service Plan: General severity level 2, scope L2 Pattern
  Show all 21

  • C0262: Service Plan: Service Planning Team severity level 2, scope L2 Pattern
  • C0265: Service Plan: Managed Risk severity level 2, scope L2 Isolated
  • C0270: Change of Condition and Monitoring severity level 3, scope L3 Isolated
  • C0280: Resident Health Services severity level 2, scope L2 Pattern
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Pattern
  • C0305: Systems: Resident Right to Refuse severity level 2, scope L2 Isolated
  • C0310: Systems: Medication Administration severity level 2, scope L2 Pattern
  • C0325: Systems: Self-Administration of Meds severity level 2, scope L2 Isolated
  • C0362: Acuity Based Staffing Tool - ABST Time severity level 2, scope L2 Pattern
  • C0363: Acuity Based Staffing Tool - Updates & Staffing Plan 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
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Pattern
  • C0545: Plumbing Systems severity level 2, scope L2 Widespread
• August 22, 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 21, 2023
• April 27, 2023: Complaint Investig., 2 deficiencies cited report
  • C0010: Licensing Complaint Investigation 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 Widespread
• December 1, 2022: Complaint Investig., 4 deficiencies cited report
  • C0010: Licensing Complaint Investigation severity level 2, scope L2 Isolated
  • C0200: Resident Rights and Protection - General 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 Widespread
  • C0613: General Building: Doors-Walls, Cleanable severity level 2, scope L2 Isolated
• November 28, 2022: 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 January 27, 2023

Substantiated abuse or neglect

• February 15, 2026: Failed to provide service Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $1,125.00; 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 their care. AV is care planned for assistance when ambulating in a wheelchair and for toileting, showering and transfers. AV has a history a history, including when needing to use the restroom. According to an investigation, on or about, February 15, 2026, AV fell while attempting to get out of bed to use the restroom, resulting in a fractured ankle. AV pressed their call light after the fall and according to the alert system, AV's call light went off for over 30 minutes. The facility failed to provide appropriate services, to include adequate care planning and/or the implementation of effective interventions and not answering the call light timely, which is a violation of resident rights, is neglect of care which constitutes abuse as defined in OAR 411-020-0002(1)(b)(A)(i).

• August 4, 2025: Failed to properly plan care Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $1,500.00; 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) relies on the facility for his/her care and has a history of falls related. According to an investigation, between July 21, 2025, and August 4, 2025, AV experienced multiple falls, resulting in multiple injuries and unreasonable discomfort. The facility failed to appropriately plan care and/or implement interventions to mitigate the risk of injury, which is a violation of resident rights, is neglect of care which constitutes abuse.

• April 1, 2025: Failed to properly plan care 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) relies on the facility for his/her care and has a history of falls. AV is known not to use AV’s call light and is care planned for standby assist with all ambulation. According to an investigation, on or about April 1, 2025, AV experienced a fall resulting in skin injury. The facility failed to implement interventions to mitigate the risk of injury due to AV's increase in falls. The facility failed to appropriately plan care and/or implement interventions to mitigate the risk of injury, which is a violation of resident rights, is neglect of care which constitutes abuse.

• March 29, 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

  According to the documentation, the facility failed to properly care plan appropriate interventions for the Alleged Victim (AV) who had orders from a provider to not walk on their injured leg for approximately 7 days. On or about March 24, 2025, the AV injured their knee. After a visit with a medical professional, it was determined the AV should not walk on their injured knee for about 7 days. The facility updated the service plan to provide all cares to the AV and to use their wheelchair for ambulation. On or about March 29, 2025, The AV attempted to ambulate without their wheelchair resulting in a fall. The AV suffered a fractured ankle due to the fall, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• March 23, 2025: Failed to properly plan care Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $188.00; 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

  According to the documentation, the facility failed to properly care plan appropriate interventions for the Alleged Victim’s (AV) repeated fall history. The AV experienced falls approximately three falls between February 23, 2025, through March 16, 2025. The implemented interventions appear to not be working as the AV continues to fall. There is no documented evidence the facility implemented new interventions to help mitigate future falls, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• July 6, 2026: Failed to cooperate with an investigation Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0105 (Inspections and Investigations)
  State’s findings

  The facility failed to provide records to the Department upon request. The facility’s failure is a violation of Oregon Administrative Rules.

• July 6, 2026: Failed to make facility or resident records accessible Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0105 (Inspections and Investigations)
  State’s findings

  The facility failed to provide records to the Department upon request. The facility’s failure is a violation of Oregon Administrative Rules.

• December 11, 2025: Failed to make facility or resident records accessible Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0105 (Inspections and Investigations)
  State’s findings

  The facility failed to provide records to the Department upon request. The facility’s failure is a violation of Oregon Administrative Rules.

• December 11, 2025: Failed to submit timely or adequate staffing documentation Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0105 (Inspections and Investigations)
  State’s findings

  The facility failed to provide records to the Department upon request. The facility’s failure is a violation of Oregon Administrative Rules.

• December 11, 2025: Failed to submit timely or adequate staffing documentation Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0105 (Inspections and Investigations)
  State’s findings

  The facility failed to provide records to the Department upon request. 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 71 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.