Oak Park Senior Living

Last inspection

March 30, 2026

Inspections

7, 8 deficiencies cited

Substantiated abuse

4

Substantiated licensing violations

8

Regulatory actions

0

Fines assessed

$1,250.00 (4 violations)

Current owner since

February 1, 2017

Inspections

• March 30, 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
• May 19, 2025: Kitchen, 1 deficiency cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
• July 22, 2024: Complaint Investig., 3 deficiencies cited report
  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Isolated
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Widespread
  • C0435: Emergency and Disaster Planning severity level 2, scope L2 Pattern
• June 4, 2024: State Licensure, 0 deficiencies cited report
  • C0000: Comment severity level 0
• September 26, 2023: Complaint Investig., 2 deficiencies cited report
  • C0010: Licensing Complaint Investigation severity level 2, scope L2 Isolated
  • C0153: Facility Administration: Notification severity level 2, scope L2 Isolated
  • C0200: Resident Rights and Protection - General severity level 2, scope L2 Isolated
• July 12, 2023: Validation, 0 deficiencies cited report
  • C0000: Comment severity level 0
• April 6, 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 May 7, 2023

Substantiated abuse or neglect

• September 28, 2025: Failed to properly plan care Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $250.00; 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) is a known fall risk and has suffered multiple falls over two months, and most recently suffered three falls in three days. AV's care plan states he/she has no impairment, although AV could not remember any falls, the care plan also states minimal assistance for mobility and independent in transfers, although AV suffered multiple falls in a short period of time. On or about October 2, 2025, AV suffered a fall in his/her room resulting in a skin tear to the forehead and upper extremities. AV was transferred to the hospital and discharged to a skilled nursing facility. Respondent failed to properly care plan to ensure AV was safe from suffering falls. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

• September 4, 2025: Failed to provide a safe medication administration system Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $250.00; report
  Rules: 411-054-0025 (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); 411-054-0070 (Staffing Requirements and Training)
  State’s findings

  On or about August 29, 2025 through September 1, 2025, the Alleged Victim (AV) received incorrect medication or late medication from Alleged Perpetrator #2 (AP2). Medication dispensed was not charted by AP2. AP2 was not properly trained by the facility to provide medication to residents accurately and was determined to provide medication administration prior to proper training and demonstrating competencies, due to short staffing at the facility. AV did not have any negative outcome to not receiving correct medication or timely medication, however, AV was placed at risk for harm. AP2's actions were found to be not substantiated for abuse. The facility's failure to properly train staff, provide appropriate staffing and to provide a safe medication administration system is a violation of resident rights, is considered neglect of care and constitutes abuse.

• December 16, 2023: Failed to properly plan care Abuse: Neglect; Level 3 - Moderate harm or potential for serious 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); 411-054-0036 (Service Plan – General)
  State’s findings

  The facility failed to implement interventions and appropriately care plan related to the Alleged Victim's (AV) fall history. The failure resulted in AV experiencing a fall on or about December 16, 2023, in which AV was transferred to the hospital and diagnosed with a hip fracture. Based on facility documentation and interviews, AV suffered falls on October 24, 2023, and December 15, 2023, in which facility failed to implement any safety interventions after these falls, even when AV was suffering from weakness and shortness of breath due to illness. The facility's failure to properly care plan for AV's fall risk is a violation of resident rights, is considered neglect of care and constitutes abuse.

• September 21, 2022: 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

  The facility failed to provide a safe medication administration system to ensure The Alleged Victim’s (AV) medications were administered as ordered. The failure resulted in unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• October 10, 2025: 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 maintain an Acuity Based Staffing Tool in accordance with OAR 411-054-0037(1-7), which is a violation of Oregon Administrative Rules.

• September 28, 2025: 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 maintain an Acuity Based Staffing Tool in accordance with OAR 411-054-0037(1-7).

• September 16, 2025: Failed to protect resident from mental or emotional 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); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare)
  State’s findings

  On or about September 16, 2025, the Alleged Perpetrator #2 (AP2) entered the Alleged Victim's (AV) room and advised AV he/she was there to administer AV's medication. AP2 had been previously advised by the facility to not provide medications to AV. AP2 made statements to AV about not taking his/her medication and that AV better take them. AV was made to feel uncomfortable and anxious, causing emotional distress. AP2's actions are a violation of resident rights, are considered neglect of care and constitute verbal and emotional abuse. The facility's failure to protect AV from verbal and emotional abuse is a violation of Oregon Administrative Rules.

• September 4, 2025: 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 develop, maintain, and implement an Acuity Based Staffing Tool in accordance with OAR 411-054-0037(1-7), which is a violation of Oregon Administrative Rules.

• August 7, 2025: 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 carry out medication and treatment orders as prescribed in accordance with OAR 411-054-0055(1)(f); Per a facility self report the resident received double the dose of morning insulin, 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.” This community is licensed for 76 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.