Settler's Park Memory Care Community

Last inspection

July 9, 2026

Inspections

7, 32 deficiencies cited

Substantiated abuse

11

Substantiated licensing violations

7

Regulatory actions

1

Fines assessed

$6,001.00 (11 violations)

Current owner since

February 1, 2024

License conditions and other regulatory actions

• October 1, 2024 to May 30, 2025: License Condition, Failed to provide safe environment RCFCD24-00978; incident: CALMS - 00061013
  The Oregon Department of Human Services (ODHS) completed a change of owner re-licensure visit (50A226 - CHOW000053) on or about August 29, 2024, at Settler's Park Memory Care Community and determined the facility was not in substantial compliance with Oregon Administrative Rules and that the facilitys non-compliance constitutes a threat to the health, safety, and welfare of its residents.
  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)

Inspections

• July 9, 2026: Kitchen, 2 deficiencies cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread
• March 11, 2026: Re-Licensure, 4 deficiencies cited report
  • C0160: Reasonable Precautions severity level 2, scope L2 Isolated
  • C0513: Doors, Walls, Elevators, Odors 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
• December 16, 2025: Kitchen, 2 deficiencies cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread
• September 10, 2024: Complaint Investig., 0 deficiencies cited report
  • C0010: Licensing Complaint Investigation severity level 0
• August 29, 2024: Change of Owner, 22 deficiencies cited report
  • C0150: Facility Administration: Operation severity level 2, scope L2 Widespread
  • C0160: Reasonable Precautions severity level 2, scope L2 Isolated
  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Pattern
  • C0252: Resident Move-in and Eval: Res Evaluation severity level 2, scope L2 Isolated
  • C0260: Service Plan: General severity level 2, scope L2 Pattern
  Show all 22

  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Pattern
  • C0280: Resident Health Services severity level 2, scope L2 Isolated
  • C0310: Systems: Medication Administration severity level 2, scope L2 Isolated
  • C0330: Systems: Psychotropic Medication severity level 2, scope L2 Pattern
  • C0361: Acuity Based Staffing Tool: Development severity level 2, scope L2 Pattern
  • C0363: Acuity Based Staffing Tool: Frequency of Updates/Staffing Plan severity level 2, scope L2 Widespread
  • C0422: Fire and Life Safety: Training for Residents severity level 2, scope L2 Widespread
  • C0513: Doors, Walls, Elevators, Odors severity level 2, scope L2 Widespread
  • H1510: Individual Rights Settings: Privacy, Dignity severity level 2, scope L2 Pattern
  • H1515: Physical Setting: Individual Accessible severity level 2, scope L2 Pattern
  • H1518: Individual Door Locks: Key Access severity level 2, scope L2 Pattern
  • 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
  • Z0163: Nutrition and Hydration severity level 2, scope L2 Pattern
  • Z0164: Activities severity level 2, scope L2 Pattern
  • Z0176: Resident Rooms severity level 2, scope L2 Pattern
• August 28, 2023: State Licensure, 0 deficiencies cited report
  • C0000: Comment severity level 0
• July 12, 2022: State Licensure, 2 deficiencies cited report
  • C0000: Comment severity level 0
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread, corrected November 17, 2022
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread, corrected November 17, 2022
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected November 17, 2022

Substantiated abuse or neglect

• November 28, 2025: Failed to follow care plan Abuse: Neglect; Level 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance; fine $2,500.00; 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 their care. AV is a high fall risk with a history of falls and unsteady gait at times, especially at night as AV does not have the ability to use call pendant to call for assistance. AV is care planned for staff to encourage AV to wear proper footwear, and vision aids, to keep path well-lit and clear, keep walker nearby or be helped to sit safely, for staff to retrieve AV’s walker if AV has left it behind and to have motion detection light alarm to use at night to alert care partner or med tech that AV is getting up to use the bathroom. According to an investigation, on or about November 28, 2025, AV was found on the floor in their room. AV was missing a shoe, and facility staff were not using the motion alarm at night. AV was taken to the hospital and diagnosed with a fractured left arm and left leg and required surgery. The facility failed to follow the care plan, which is a violation is neglect of care and constitutes abuse as defined in OAR 411-020-0002(1)(b)(A)(i).

• September 5, 2025: Failed to provide service 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

  The Alleged Victim (AV) relies on the facility for his/her care. According to an investigation, on or about, September 5, 2025, AV was found with a golf ball sized bruise on right side of AV’s head. The facility failed to provide appropriate services, relating to appropriately care planning for safety and/or implement interventions for AV’s increased pattern of injuries, which is a violation of resident rights, is neglect of care which constitutes abuse.

• March 6, 2025: Failed to follow care plan 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) relies on the facility for their care and is a high fall risk. AV is care planned for full assist for dressing, including putting on non-slip socks or slippers. According to an investigation, on or about March 6, 2025, fell while being assisted with toileting and hit their head, resulting in a red mark and pain. AV was wearing regular socks at the time of the fall. The facility failed to follow the care plan, which is a violation of resident’s rights, is neglect of care and constitutes abuse.

• February 21, 2025: Failed to provide safe environment 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)
  State’s findings

  The Alleged Victim (AV) relies on the facility to provide a safe environment. On or about February 2, 2025, the AV was in the courtyard where snow and ice were present. When facility staff saw AV in the courtyard, they attempted to redirect AV back inside when AV fell and slipped on the snow and ice resulting in AV being injured. The door to the courtyard should have been locked to residents during inclement weather. The facility failed to ensure the door was locked, and did not provide AV with a safe environment. This is a violation of resident rights, is neglect of care and constitutes abuse.

• November 14, 2024: Failed to provide a safe medication administration system 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); 411-054-0055 (Medications and Treatments)
  State’s findings

  The Alleged Victim (AV) relies on the facility to manage their medications. According to an investigation, the facility failed to maintain a safe medication system and the AV was administered the incorrect dose of medication for approximately 14 days in October and November of 2024, placing the AV at risk for harm. The allegation that Alleged Perpetrator 2 (AP2) and Alleged Perpetrator 3 (AP3) neglected the AV was investigated and determined to be not substantiated. The facility failed to administer AV’s medication as ordered, which is a violation of resident’s rights, is neglect of care, and constitutes abuse.

Substantiated licensing violations

• September 8, 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 update the ABST quarterly as required. The facility’s failure is a violation of Oregon Administrative Rules.

• January 27, 2025: 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 medication as ordered for the Alleged Victim (AV). According to an investigation, AV experienced no negative outcome. The failure is a violation of Oregon Administrative Rules.

• December 12, 2024: Failed to assure resident rights 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

  The Alleged Victim (AV) relies on the facility for his/her care and utilizes a call pendant to request assistance. On or about December 11, 2024, the Alleged Perpetrator 2 (AP2) placed the AVs call pendant out of reach. The AV did not have access to the call pendant until the next morning, resulting in a loss of dignity. AP2's actions are considered neglect and constitute abuse. The facility failed to protect the AV’s dignity and rights, which is a violation of Oregon Administrative Rules.

• September 21, 2023: Failed to provide a safe medication administration system Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0055 (Medications and Treatments)
  State’s findings

  The Alleged Perpetrator 2 failed to provide a safe medication administration system to ensure the AV's medication was administered as ordered. The failure resulted in AV going to the hospital for monitoring, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to ensure AV's medication was safely administered, which is a violation of Oregon Administrative Rules.

• December 26, 2021: Failed to provide a safe medication administration system Licensing Violation; Level 2 - Minor harm or potential for moderate harm; 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 medication. On or about December 26, 2021, AV was given another resident’s medication. Alleged Perpetrator 2 (AP2) was passing med when an emergency came up and while distracted, he/she passed the medicine to the wrong resident. AP2 failed to provide a safe medication administration system, which is neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system, which is a violation of Oregon Administrative Rules.

• November 15, 2021: Failed to provide a safe medication administration system Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0027 (Resident Rights and Protections); 411-054-0055 (Medications and Treatments)
  State’s findings

  Alleged Victim (AV) relies on the facility to administer his/her medication. On or about November 14, 2021, while cleaning AV after finding medication ointment, staff found one of AV’s whole, uncrushed prescribed pain pills under his/her bed. The pill was given to the med tech, who did verify that it was one of AV’s. Alleged Perpetrator 2 (AP2) did not crush medication as mentioned in the Medication Administration Record (MAR). AP2 failed to provide to provide a safe medication administration system, which is neglect of care and constitutes abuse. The facility failed to assure AV was provided a safe medication administration system, which is a violation of Oregon Administrative Rules.

• November 5, 2021: Failed to provide a safe medication administration system Licensing Violation; Level 2 - Minor harm or potential for moderate harm; 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. On or about November 5, 2021, Alleged Perpetrator 2 (AP2) failed to give AV medication prescribed to him/her by medical doctor but verified in the system that he/she had given medication to AV. AP2’s failed to provide a safe medication administration system for AV, which is neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system, 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 30 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.