Bear Creek Memory Care

Last inspection

December 19, 2025

Inspections

8, 35 deficiencies cited

Substantiated abuse

12

Substantiated licensing violations

15

Regulatory actions

3

Fines assessed

$5,439.00 (12 violations)

Current owner since

April 29, 2021

License conditions and other regulatory actions

• January 26, 2026 to April 8, 2026: License Condition, Failed to provide safe environment RCFCD26-00068; incident: CALMS - 00097867
  The following statement of violations stem from evidence and interviews collected from Re-licensure Survey #RL008395 completed December 19, 2025.
  Rules: 411-004-0020; 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General); 411-054-0037 (Acuity-Based Staffing Tool); 411-054-0040 (Change of Condition and Monitoring); 411-054-0070 (Staffing Requirements and Training); 411-054-0090 (Fire and Life Safety)
• June 14, 2024 to August 28, 2024: License Condition, Failed to meet the scheduled and unscheduled needs of residents RCFCD24-00530; 2 incidents: OR0004270901, OR0004270900
  The facility failed to fully implement and update an Acuity Based Staffing Tool (ABST) in accordance with OAR 411-054-0037.
  Rules: 411-054-0037 (Acuity-Based Staffing Tool); 411-054-0070 (Staffing Requirements and Training)
• July 25, 2023 to August 23, 2023: License Condition, Failed to use an ABST RCFCD23-00833; incident: OR0003849204
  The facility failed to fully implement an Acuity Based Staffing Tool in accordance with OAR 411-054-0037.
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)

Inspections

• December 19, 2025: Re-Licensure, 15 deficiencies cited report
  • C0200: Resident Rights and Protection - General severity level 2, scope L2 Pattern
  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Pattern
  • C0242: Resident Services: Activities severity level 2, scope L2 Widespread
  • C0260: Service Plan: General severity level 2, scope L2 Pattern
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Pattern
  • C0295: Infection Prevention & Control severity level 2, scope L2 Pattern
  • C0360: Staffing Requirements and Training: Staffing severity level 2, scope L2 Widespread
  • 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
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread
  • H1517: Individual Privacy: Own Unit severity level 2, scope L2 Widespread
  • H1518: Individual Door Locks: Key Access severity level 2, scope L2 Widespread
  • 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
• February 13, 2024: Complaint Investig., 6 deficiencies cited report
  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Isolated
  • C0260: Service Plan: General severity level 2, scope L2 Isolated
  • C0295: Infection Prevention & Control severity level 2, scope L2 Widespread
  • C0360: Staffing Requirements and Training: Staffing severity level 2, scope L2 Widespread
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Widespread
  • C0513: Doors, Walls, Elevators, Odors severity level 2, scope L2 Isolated
• October 17, 2023: State Licensure, 0 deficiencies cited report
  • C0000: Comment severity level 0
• April 25, 2023: Complaint Investig., 2 deficiencies cited report
  • C0010: Licensing Complaint Investigation severity level 2, scope L2 Isolated
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Widespread
  • C0370: Staffing Requirements and Training – Pre-Serv severity level 2, scope L2 Isolated
• September 7, 2022: Initial Licensure, 7 deficiencies cited report
  • C0000: Comment severity level 0
  • C0160: Reasonable Precautions severity level 2, scope L2 Isolated, corrected October 31, 2022
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread, corrected October 31, 2022
  • C0260: Service Plan: General severity level 2, scope L2 Pattern, corrected October 31, 2022
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected October 31, 2022
  • Z0155: Staff Training Requirements severity level 2, scope L2 Pattern, corrected October 31, 2022
  • Z0162: Compliance With Rules Health Care severity level 2, scope L2 Pattern, corrected October 31, 2022
  • Z0164: Activities severity level 2, scope L2 Pattern, corrected October 31, 2022

Substantiated abuse or neglect

• May 6, 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); 411-054-0036 (Service Plan – General)
  State’s findings

  According to the documentation, the facility failed to properly care plan appropriate interventions for Witness 1’s (W1) known aggressive behaviors towards the Alleged Victim (AV). on or about May 06, 2025, W1 and the AV were heard yelling at each other in the dining area. W1 then struck AV with a chair on their leg, causing bruising. The facility failed to update W1’s service plan with appropriate interventions to prevent altercations between W1 and the AV causing the AV pain and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• December 27, 2024: 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’s (AV) known fall risk resulting in multiple falls. On or about December 27, 2024, the AV experienced a fall and sustained a fractured hip. There was no documented evidence the care plan was updated after this fall for fall interventions. On or about January 06, 2025, the AV suffered a second fall and sustained a scratch on their back. The failure to update the care plan for the known fall risk is a violation of resident rights, is considered neglect of care and constitutes abuse.

• June 1, 2024: Failed to follow care plan 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 follow the care plan for Witness 1 (W1) who has a history of resident-to-resident altercations. On or about March 22, 2024, the facility placed 1:1 care for W1 due to repeated altercations with other residents. On or about June 01, 2024, W1 blocked the entrance to AV’s room. W1 then rammed their wheelchair into the AV’s knee causing them to fall to the ground and suffering minor injuries. The failure to follow the resident’s care plan caused injury to the AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• July 28, 2023: Failed to provide safe environment Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $375.00; report
  Rules: 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0036 (Service Plan – General)
  State’s findings

  Alleged Victim (AV) has a history of wandering the facility. Witness 1 (W1) has history of behavioral physical outburst, and cornering residents so they cannot get around W1. On or about August 29, 2023, staff heard screaming coming from W1 room. Staff unlocked W1 door and found AV against the wall in W1 bathroom and W1 in h/h wheelchair rolling towards AV. Staff intervened, AV reported W1 kicked h/h resulting in pain to both legs and abrasion to left shin. Facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

• April 19, 2023: Failed to follow care plan Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $750.00; 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

  Alleged Victim (AV) has a history of resident altercations because of wandering the facility, wandering into other residents’ rooms, grabbing other resident items, wheelchairs, walkers, food, and drinks. AV’s care plan includes staff to have constant supervision, always have AV in the field of view and redirect constantly, involving AV in activities. W2 has known behaviors of becoming upset when other residents wander, and is care planed for safety checks throughout the day. On or about April 14, 2023, AV walked behind W2 wheelchair and began moving it. W2 yelled at AV to stop. When AV did not stop, W2 threw h/h hand up, hitting AV in the face resulting in a bloody nose. The facility failed to follow AV care plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• March 18, 2026: Failed to follow care plan 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); 411-054-0036 (Service Plan – General)
  State’s findings

  Alleged Victim (AV) resides in the Respondent’s facility and depends on facility staff to meet safety and care needs. AV’s service plan requires a two-person assist for transfers into a wheelchair. AV prefers to sit in the common area in an armchair with legs elevated and is able to self-direct when needing to stand, reposition, or use the bathroom. Staff are responsible for ensuring that wheelchair brakes are engaged during all transfers. It is standard safety practice that wheelchairs must be locked prior to any task involving movement or repositioning. On March 18, 2026, Alleged Perpetrator 2 (AP2) and Alleged Perpetrator 3 (AP3) attempted to elevate AV’s legs while AV was seated in a wheelchair. The wheelchair was not locked during this procedure, causing it to tilt backward. As a result, AV fell backward and struck their head against the wall. AP2 and AP3 had been trained on the requirement to lock a wheelchair before elevating a resident’s feet. Their failure to lock the wheelchair and to follow AV’s service plan constitutes a violation of resident rights, is considered neglect of care, and meets the definition of abuse. The facility failed to provide adequate oversight and monitoring to ensure AP2 and AP3 followed AV’s service plan and facility safety standards while providing care. This failure represents a violation of Oregon Administrative Rules.

• January 1, 2026: Failed to use an 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 implement and maintain an Acuity-Based Staffing Tool in accordance with OAR 411-054-0037(1-7), which is a violation of Oregon Administrative Rules.

• May 30, 2024: Failed to protect resident from physical abuse 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)
  State’s findings

  According to the documentation, the Alleged Perpetrator 2 (AP2) was not following the care plan for the Alleged Victim (AV) during their bathing routine resulting in physical and verbal abuse. On or about May 30, 2024, AP2 was witnessed to physically abuse the AV when AV was exhibiting signs of aggressive behavior. AP2 was seen spraying the AV with cold water and shoving a washcloth in their mouth. AP2 was also heard yelling “Fuck you!” to the AV during the incident causing emotional distress. The AP2 did not follow the care plan of the AV when they showed signs of behaviors, resulting in physical and verbal abuse of the AV which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to protect the AV from physical and verbal abuse which is a violation of the Oregon Administrative Rules.

• October 29, 2023: Failed to address resident's behavior Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0036 (Service Plan – General)
  State’s findings

  Staff 1stated Resident 3 had exhibited sexually aggressive behaviors with another resident, but that resident had since moved out of the facility. S/he also stated that Resident 3 had been physically and verbally combative with staff and attempted to grab a female staff member by the neck. S/he stated the interventions the facility attempted for Resident 3's behaviors were to monitor and provide frequent checks. An incident report, dated October 29, 2023, indicated Resident 3 was found in a female resident's room near the female resident's bed. Resident 3's Temporary Service Plans indicated February 11, 2024 : "No female staff alone in residents’ room"; November 4, 2023 : "Make sure to be completing 15-minute checklist on resident. Getting more aggressive with staff. Keep away from female resident"; and October 31, 2023 : "Resident is to have 100% eyes on, and to be frequently checked on." Resident 3's service plan, dated January 18, 2024, did not include information regarding h/h aggressive behaviors with staff or residents, or interventions for staff to implement in the event Resident 3 became aggressive. A review of facility documentation for Resident 3's "15-minute safety checks" were incomplete and frequently un-dated. A site visit on February 13, 2024, and February 14, 2024, confirmed the facility failed to develop and implement a service plan that was reflective of resident needs for resident (# 3).

• September 27, 2023: Failed to provide infection control Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0050 (Infection Prevention and Control)
  State’s findings

  On or about February 13, 2024, dirty laundry, including what appeared to be soiled incontinence products, was observed on the floor outside of the facility soiled utility room, with a rack of clean laundry hanging above it. The soiled utility room was disorganized, with clean and folded laundry sitting on the counter directly across from the hopper (a facility used for removing feces from clothing and linens). Washing machines were in the room adjacent to the soiled utility room and there was a door on each side of the laundry room, though the door to the washing machine side was blocked by the rack of clean clothing outside. Staff 5 stated that s/he arrives before laundry staff and will try to help with laundry if s/he is able. S/he further stated they kept clean laundry folded on the counter across from the hopper. S/he acknowledged there are separate entrances/exits, but s/he stated the facility did not use a clean/dirty side. Staff 9 stated s/he was working on a plan to separate clean from dirty but didn't have one yet because there was no counter on the clean side to fold laundry. It was confirmed the facility failed to establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment.

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 68 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.