Woodside Senior Living Community

Last inspection

October 17, 2024

Inspections

6, 13 deficiencies cited

Substantiated abuse

6

Substantiated licensing violations

17

Regulatory actions

0

Fines assessed

$17,188.00 (8 violations)

Current owner since

January 1, 2025

Inspections

• October 17, 2024: Re-Licensure, 8 deficiencies cited report
  • C0270: Change of Condition and Monitoring severity level 3, scope L3 Isolated
  • C0280: Resident Health Services severity level 3, scope L3 Isolated
  • C0310: Systems: Medication Administration severity level 2, scope L2 Pattern
  • C0325: Systems: Self-Administration of Meds severity level 2, scope L2 Pattern
  • C0363: Acuity Based Staffing Tool - Updates & Staffing Plan severity level 2, scope L2 Widespread
  Show all 8

  • 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
  • C0422: Fire and Life Safety: Training for Residents severity level 2, scope L2 Widespread
• July 22, 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 September 20, 2024
• June 25, 2024: Complaint Investig., 2 deficiencies cited report
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Isolated
  • C0365: Staffing Rqmt and Training: Training Rqmts severity level 2, scope L2 Isolated
• September 14, 2023: State Licensure, 0 deficiencies cited report
  • C0000: Comment severity level 0
• August 17, 2022: State Licensure, 0 deficiencies cited report
  • C0000: Comment severity level 0
• July 28, 2022: 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 Widespread
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Widespread

Substantiated abuse or neglect

• June 19, 2025: Failed to provide a safe medication administration system 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); 411-054-0040 (Change of Condition and Monitoring); 411-054-0055 (Medications and Treatments)
  State’s findings

  Based on witness statements, investigator observations, and documentary evidence collected during Adult Protective Services (APS) Investigation #00409708, the APS Investigator determined that on or about June 19, 2025, through June 22, 2025, the facility failed to provide a safe Medication Administration System for the Alleged Victim (AV). Despite receiving a faxed physician directive discontinuing an antipsychotic medication, the facility staff continued to administer to AV the discontinued antipsychotic medication in combination with a newly prescribed antipsychotic. The facility's failure resulted in the AV becoming excessively drowsy, difficult to awaken, experiencing bladder incontinence, and ultimately being transported to the emergency room due to sedation. Facility staff were aware of the discontinuation order via a faxed physician directive but failed to act accordingly. The facility failed to act on AV's physician's discontinuation order, ensure accurate medication administration, monitor AV's condition, and communicate critical changes in care, which caused unnecessary and unreasonable discomfort to AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• May 8, 2024: Failed to properly plan care Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $188.00; report
  Rules: 411-054-0036 (Service Plan – General); 411-054-0040 (Change of Condition and Monitoring)
  State’s findings

  The Alleged Victim (AV) is dependent on facility staff to assist with transfers, has a history of falls while in their room related to seizures and weakness. According to an investigation, on or about May 8, 2024, AV was found on the floor in the bathroom, was minimally responsive and was transported to the hospital. AV was then diagnosed with frontal sinus and orbital fractures. AV’s current service planned interventions included monitoring and assistance of AV during transfers. The facility failed to develop and implement interventions to reduce the risk of additional falls, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• January 13, 2022: Failed to provide service 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); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General)
  State’s findings

  The facility failed to provide appropriate services according to Alleged Victim (AV)'s needs. AV failed to receive assistance with his/her CPAP at night, interventions for fall prevention, meals and weight loss, and incontinence care. These failures are a violation of resident rights, is considered neglect of care and constitutes abuse.

• January 5, 2022: Failed to follow care plan Abuse: Neglect; Level 2 - Minor harm or potential for moderate 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); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General)
  State’s findings

  The facility failed to provide appropriate services according to resident needs, as it relates to care plan not being followed, and call light not being answered in a timely manner, which resulted in AV experiencing unreasonable discomfort and a loss of dignity. On or about, January 5, 2022, Alleged Perpetrator 2 (AP2) failed to follow proper procedure for responding to AV's call light for approximately three hours and AV was not given h/h shower. AP2's actions are considered neglect and constitutes abuse. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

• January 5, 2022: Failed to provide service 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); 411-054-0030 (Resident Services); 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 his/her care. AV was not provided assistance with ambulation according to his/her care plan, due to lack of staff and as a result AV has experienced unreasonable discomfort, risk of serious harm, and loss of personal dignity. AV's care plan has not been updated to reflect mobility changes. The facility failed to provide appropriate services for care, assessment, and ensuring daily needs are met, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• January 4, 2022: 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); 411-054-0055 (Medications and Treatments)
  State’s findings

  The facility failed to provide appropriate services according to the Alleged Victim's (AV) care plan and needs, relating to scheduled checks, missed meals, housekeeping and medical orders. During the investigation, a crushed bag of medication was found in the AV's room and the dryer was not in working order. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• April 15, 2025: Failed to provide safe environment 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)
  State’s findings

  On or about April 15, 2025, Alleged Victim (AV) fell in the bathroom when Alleged Perpetrator 2 (AP2) was transferring AV, causing AV to fall on his/her left knee. Based on facility documentation and interviews, AV is service planned as a two-person transfer. AP2 failed to follow AV's service plan when transferring AV caused AV to suffer a fall that fractured his/her knee due to a fall during a transfer. AP2's actions is considered neglect of care which constitutes abuse. The facility failed to provide a safe environment for AV which is a violation of Oregon Administrative Rules.

• December 3, 2024: Failed to answer call light in a timely manner Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0200 (Residential Care Facility Building Requirements)
  State’s findings

  On or about December 3, 2024, the Alleged Victim (AV) suffered a fall in his/her bathroom. AV is fully independent and is not care planned for checks. On this day, after the fall, AV tried to use the call system to call staff for assistance. AV pulled the cord in the bathroom, however, the call system was not working. AV was not injured in the fall and was able to get up on his/her own. The facility's failure to ensure the call system was working properly is a violation of Oregon Administrative Rules.

• June 5, 2024: Failed to make facility or resident records accessible Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0070 (Staffing Requirements and Training)
  State’s findings

  The facility failed to make facility or resident records accessible. An investigation determined this is a violation of Oregon Administrative Rules.

• May 15, 2024: 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 provide a safe medication administration system for the Alleged Victim (AV). According to an investigation, AV did not receive medication as ordered. The failure is a violation of Oregon Administrative Rules.

• May 15, 2024: 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 provide a safe medication administration system for the Alleged Victim (AV). According to an investigation, AV did not receive medication as ordered. The 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 62 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.