Pricing ranges from
    $6,080 – 7,904/month

    Tanner Spring Assisted Living & Memory Care

    23000 Horizon Dr, West Linn, OR 97068
    • Independent Living
    • Assisted Living
    • Memory Care

    Caring staff, clean community, welcoming

    I placed my mom here and I'm very pleased overall. The staff are caring, knowledgeable and go above and beyond, keeping us informed and making her feel at home; the community is clean, safe, well-kept, with good food, plenty of activities and a welcoming atmosphere - great value and real peace of mind.

    Loved one of resident
    Jul 2026

    Pricing

    Prices shown are estimates and subject to change. Contact your senior living advisor for current pricing.

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    Tour Type

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    Amenities

    Healthcare services

    • Activities of daily living assistance
    • Assistance with bathing
    • Assistance with dressing
    • Assistance with transfers
    • Medication management
    • Mental wellness program

    Healthcare staffing

    • 12-16 hour nursing
    • 24-hour call system
    • 24-hour supervision

    Meals and dining

    • Diabetes diet
    • Meal preparation and service
    • Restaurant-style dining
    • Special dietary restrictions

    Room

    • Air-conditioning
    • Cable
    • Fully furnished
    • Housekeeping and linen services
    • Kitchenettes
    • Private bathrooms
    • Telephone
    • Wifi

    Memory care community services

    • Mild cognitive impairment
    • Specialized memory care programming

    Transportation

    • Community operated transportation
    • Transportation arrangement
    • Transportation arrangement (non-medical)

    Common areas

    • Beauty salon
    • Computer center
    • Dining room
    • Fitness room
    • Gaming room
    • Garden
    • Outdoor space
    • Small library
    • Wellness center

    Community services

    • Concierge services
    • Fitness programs
    • Move-in coordination

    Activities

    • Community-sponsored activities
    • Planned day trips
    • Resident-run activities
    • Scheduled daily activities

    Reviews

    3.94·(66)

    Overall rating

    1. 5
    2. 4
    3. 3
    4. 2
    5. 1
    • Care

      3.9
    • Staff

      3.9
    • Meals

      3.1
    • Amenities

      2.9
    • Value

      2.8

    Pros

    • Compassionate and attentive caregiving staff
    • Engaged, long-tenured activities program
    • Varied social events and family activities
    • Clean and recently remodeled common areas
    • Positive dining options with varied menus
    • Private bathrooms and in-room refrigerator/microwave
    • Pleasant residential setting with ample parking
    • Knowledgeable and helpful admissions/marketing team
    • Staff continuity and personal familiarity with residents
    • Medicaid spend-down acceptance and financial accessibility options
    • Private and semi-private assisted living and memory-care options
    • Responsive front-desk and welcoming lobby atmosphere

    Cons

    • Inconsistent management communication and responsiveness
    • Unclear contract terms and ancillary-fee transparency
    • Gaps in guardianship and legal-mail handling procedures
    • Variable memory-care staffing experience and staffing ratios
    • Unreliable meal-service timing and food-quality consistency
    • Medication-management and call-response process weaknesses
    • Housekeeping and laundry process inconsistencies
    • Facility maintenance and infrastructure shortcomings (HVAC, outdoor connections)
    • Small resident room sizes and inconsistent in-room furnishings
    • Variable activity engagement and programming in memory-care unit
    • Admission and move-in process coordination gaps
    • Potential staff compensation and retention challenges

    Summary of reviews

    Tanner Spring Assisted Living & Memory Care elicits a wide range of family experiences. Strengths commonly cited include a caregiving staff described as compassionate and attentive, an active and well-established activities program, and a generally clean, recently updated appearance in many common areas. The community's location, parking availability, and in-room amenities such as private bathrooms and small refrigerators/microwaves are clear positives. Admissions and marketing personnel receive frequent praise for welcoming tours and smooth move-ins, and the facility accepts Medicaid spend-downs and offers private and semi-private options.

    Care quality perceptions vary by unit. Assisted living residents are more often described as well cared-for: staff continuity, personal familiarity with residents, and compassionate bedside care are mentioned frequently. Memory care feedback is mixed to negative in several reviews, with concerns about staff experience level, staffing ratios, and activity engagement within that unit. There are also accounts of improvement in memory care after targeted changes (new furniture, odor remediation, increased family communication), indicating that conditions can change with management attention.

    Dining and activities are both points of strength and inconsistency. Many families appreciate varied menus, special social events, and an active calendar led by a long-tenured activities director. At the same time, reviewers describe long meal waits, occasional forgotten meals, and uneven food quality, suggesting variability in kitchen operations and meal-service continuity. Activities are generally well organized in assisted living but are described as limited or inconsistently executed in parts of the memory-care unit.

    Operational and management themes are notable. Multiple reviewers raise concerns about contract clarity, ancillary charges, and promises not memorialized in writing; prospective residents should seek detailed, written service agreements. Communication and responsiveness from management are uneven in several accounts, including slow responses to family inquiries and inconsistent explanations from staff. Several reviews raise serious procedural issues around guardianship, handling of legal mail/documents, and verification of guardian authority; these point to the need for clearer policies and documentation practices.

    Quality-safety and housekeeping issues appear intermittently. Concerns include inconsistent medication administration and missed orders, slow responses to call buttons, variable housekeeping and laundry performance, and facility maintenance gaps such as HVAC/comfort issues and incomplete outdoor pathway connections. These represent operational weaknesses that could affect resident comfort and safety if not monitored.

    Overall pattern: many families report highly positive personal interactions with caregivers and value the community's social programming and location, while recurring operational weaknesses—especially around management communication, memory-care staffing consistency, contract transparency, and certain housekeeping/clinical processes—produce mixed satisfaction. For prospective residents and family decision-makers, recommended due diligence includes asking about memory-care staffing ratios and training, written guarantees for agreed services (shuttle, walking assistance, furnishings), medication-administration protocols and response-time standards, guardianship/document-handling policies, and recent corrective actions or survey outcomes. A focused visit during different times of day and direct conversations with current family members or the activities director can help clarify whether the community's strengths align with a specific resident's needs.

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    Location

    Map showing location of Tanner Spring Assisted Living & Memory Care

    Tanner Spring Assisted Living & Memory Care is located at 23000 Horizon Dr, West Linn, OR, 97068.

    About Tanner Spring Assisted Living & Memory Care

    Tanner Spring Assisted Living offers a warm and welcoming environment where residents truly thrive by embracing life each day. The tranquil atmosphere of the community is thoughtfully designed to promote holistic well-being, supporting not just physical health, but also emotional fulfillment and social engagement. Residents at Tanner Spring are encouraged to participate actively in day-to-day activities, surrounded by a team of compassionate caregivers who take pride in fostering a loving and supportive environment.

    One of the distinguishing features of Tanner Spring Assisted Living is its innovative use of advanced technology to personalize each resident’s care plan. Cutting-edge AI supports the team in anticipating health concerns, providing proactive interventions, and helping residents maintain their healthiest and fullest lives. With a focus on safety and responsiveness, the community employs smart connected devices to monitor vital health indicators such as sleep patterns, heart rates, posture changes, and more. This system enables instant detection of falls, prompt alerting of the care team for quick response, and analysis to better understand risk trends, including potential urinary tract infections, bone density declines, and increasing frailty. By identifying possible health issues before they become problems, the community ensures a safer and more responsive environment for all who live there.

    Families are kept closely connected and reassured through proactive notifications about their loved one's health and well-being. This high level of communication not only fosters stronger family bonds but also provides valuable peace of mind. Residents benefit from these innovations through personalized care, early interventions, and an overall sense of security, allowing them to enjoy life confidently and comfortably.

    Tanner Spring Assisted Living also offers a variety of thoughtfully designed floor plans to meet the diverse needs and preferences of its residents—options range from cozy, intimate spaces ideal for private relaxation to layouts that foster opportunities for connection and socialization with friends and family. Emergency assistance is available around the clock, ensuring peace of mind at all times. The vibrant activity calendar is robust with engaging social, physical, and creative programs to keep residents active and fulfilled. Dining at Tanner Spring is not only about quality nutrition but also about the pleasure of sharing delicious meals in comfortable, welcoming spaces.

    Personalized care is at the heart of the Tanner Spring experience, with every resident receiving support uniquely tailored to their daily living requirements and individual personalities. The community is committed to setting the standard of excellence in senior living by combining top-tier amenities, attentive service, and innovative health technologies. Whether for assisted living or memory care, Tanner Spring provides an opportunity to craft an ideal living experience shaped by comfort, dignity, and a strong sense of belonging. Here, seniors find far more than a place to live—they discover a thriving, supportive community that feels like home.

    People often ask...

    Tanner Spring Assisted Living & Memory Care offers competitive pricing, with rates starting at a cost of $6,080 per month.

    Tanner Spring Assisted Living & Memory Care offers independent living, assisted living, and memory care.

    There are 20 photos of Tanner Spring Assisted Living & Memory Care on Mirador.

    Yes, Tanner Spring Assisted Living & Memory Care allows residents to age in place and adjust their level of care as needed.

    The full address for this community is 23000 Horizon Dr, West Linn, OR 97068.

    No, Tanner Spring Assisted Living & Memory Care does not offer respite care. Respite care in assisted living communities provides temporary, short-term relief for primary caregivers by offering professional care for their loved ones. It allows individuals to stay in an assisted living community for a limited time, giving caregivers a break while ensuring residents receive necessary support and assistance with daily activities.

    Safety & Compliance

    In Oregon, the Department of Human Services' Aging & People with Disabilities program licenses assisted living and residential care facilities, conducting inspections, complaint investigations, and renewals.

    License number50R366
    StatusActive
    Facility typeResidential Care Facility
    Capacity52 residents
    LicenseeDC West Linn Owner, LLC
    EffectiveJanuary 21st, 2010
    Special certificationMemory Care
    View the official license record

    Inspection Reports

    188

    Reports

    0

    Type A Citations

    0

    Type B Citations

    5

    Complaints

    16

    Years

    04 Feb 2026Kitchen
    Identified multiple kitchen sanitation and food storage deficiencies, resulting in rule violations. A subsequent visit documented a repeat deficiency.
    • DeficiencyResident Services Meals, Food Sanitation Rule
    • DeficiencyInspections and Investigation: Insp Interval
    04 Feb 2026Kitchen
    Identified deficiencies in kitchen sanitation and food storage, and in administration compliance.
    • DeficiencyResident Services Meals, Food Sanitation Rule
    • DeficiencyInspections and Investigation: Insp Interval
    • DeficiencyAdministration Compliance
    12 Dec 2025License Condition
    Found failure to develop, maintain, and implement an acuity-based staffing tool.
    • Regulatory ActionFailed to staff as indicated by ABST
    21 Oct 2025Complaint
    Investigated a licensing complaint and reviewed compliance with state regulations for residential care and assisted living. The investigation covered staffing requirements and service planning.
    • DeficiencyLicensing Complaint Investigation
    • DeficiencyService Plan: General
    • DeficiencyStaffing Requirements and Training: Staffing
    22 Jun 2025Inspection
    Determined that a caregiver failed to follow the resident's toileting care plan, causing an unwitnessed fall and injury, and found that a safe environment was not provided.
    • LicensingFailed to provide safe environment
    22 Jan 2025Kitchen
    Found multiple deficiencies in kitchen sanitation and food handling, and administration compliance related to licensing rules.
    • DeficiencyResident Services Meals, Food Sanitation Rule
    • DeficiencyAdministration Compliance
    22 Jan 2025Kitchen
    Identified sanitation deficiencies in kitchen practices, including dirty equipment and unlabeled foods, with improper beard restraints observed.
    • DeficiencyResident Services Meals, Food Sanitation Rule
    30 Dec 2024Inspection
    Investigated staffing and identified deficiencies in meeting ABST-indicated levels, with inconsistencies between the staffing schedule and ABST data that left resident needs unmet.
    • LicensingFailed to staff as indicated by ABST
    16 Dec 2024Inspection
    Investigated and found that an employee stole two checks from the alleged victim and cashed them for personal gain totaling $600, and that there was a failure to provide a safe environment.
    • LicensingFailed to provide safe environment
    23 Nov 2024Inspection
    Found staffing levels inconsistent with the ABST and not sufficient to meet resident needs. The ABST data did not align with the staffing schedule, indicating a rule violation.
    • LicensingFailed to staff as indicated by ABST
    25 Oct 2024Inspection
    Investigated the staffing allegation and found inconsistent staffing levels compared to the ABST guidance, indicating insufficient staffing to meet resident needs.
    • LicensingFailed to staff as indicated by ABST
    18 Oct 2024Inspection
    Investigated a financial exploitation allegation; found that an employee stole and cashed two checks totaling $1,500 and did not provide a safe environment for the resident.
    • LicensingFailed to provide safe environment
    09 Oct 2024Inspection
    Found that two checks totaling $700 were cashed without authorization by an employee, constituting financial exploitation and a failure to provide a safe environment.
    • LicensingFailed to provide safe environment
    29 Sept 2024Inspection
    Investigated a violation alleging failure to protect a resident's property, resulting in theft and financial exploitation.
    • LicensingFailed to provide safe environment
    23 Sept 2024License Condition
    Identified deficiencies in estimating ADL time and using an acuity-based staffing tool to plan for 24-hour resident needs.
    • Regulatory ActionFailed to meet the scheduled and unscheduled needs of residents
    22 Jul 2024Licensure
    The review found multiple deficiencies across clinical care, medication management, staffing, fire safety, and facility operations, with substantial compliance achieved after follow-up. Key issues included failure to monitor changes in condition, gaps in medication orders and self-administration, staffing planning inaccuracies, incomplete staff training, and fire safety documentation shortcomings.
    • DeficiencyComment
    • DeficiencyChange of Condition and Monitoring
    • DeficiencySystems: Treatment Orders
    • DeficiencySystems: Self-Administration of Meds
    • DeficiencyAcuity-Based Staffing Tool
    • DeficiencyStaffing Requirements and Training – Pre-Serv
    • DeficiencyTraining Within 30 Days: Direct Care Staff
    • DeficiencyAnnual and Biennial Inservice For All Staff
    • DeficiencyFire and Life Safety: Safety
    • DeficiencyFire and Life Safety: Training For Residents
    • DeficiencyInspections and Investigation: Insp Interval
    • DeficiencyGeneral Building Exterior
    • DeficiencyHouse Keeping and Sanitation
    • DeficiencyIntegrated Settings: Community Life
    • DeficiencyIntegrated Settings: Services
    22 Jul 2024Licensure
    Identified multiple deficiencies across resident rights, care planning, condition monitoring, staffing, health services, and safety, later resulting in substantial compliance after follow-up.
    • DeficiencyComment
    • DeficiencyResident Rights and Protection - General
    • DeficiencyService Plan: General
    • DeficiencyChange of Condition and Monitoring
    • DeficiencyResident Health Services
    • DeficiencyAcuity-Based Staffing Tool
    • DeficiencyFire and Life Safety: Safety
    • DeficiencyFire and Life Safety: Training For Residents
    • DeficiencyInspections and Investigation: Insp Interval
    • DeficiencyIndividual Rights Settings: Privacy, Dignity
    • DeficiencyIndividual Privacy: Own Unit
    • DeficiencyAdministration Compliance
    • DeficiencyStaff Training Requirements
    • DeficiencyCompliance With Rules Health Care
    • DeficiencyNutrition and Hydration
    • DeficiencyActivities
    12 Jul 2024Abuse: Neglect
    Investigated an elopement incident and found inadequate supervision that allowed a resident to leave the secured area, placing them at risk of harm.
    • AbuseFailed to provide safe environment
    18 Jun 2024Abuse: Neglect
    Investigated the allegation and found a failure to provide a safe environment by not monitoring a new roommate, which led to a physical altercation and unreasonable discomfort; a fine was assessed.
    • AbuseFailed to provide safe environment
    20 Mar 2024Inspection
    Identified a deficiency in supervision that allowed an individual to elope from the secured area and be at risk of harm; the person was later found safe nearby with no injuries.
    • LicensingFailed to provide safe environment
    15 Feb 2024Abuse: Neglect
    Investigated and found staff forcibly transferred a resident, leading to a physical altercation and emotional harm; resident rights were violated and safety concerns identified.
    • AbuseFailed to provide safe environment
    15 Feb 2024Abuse: Neglect
    Investigated a complaint and found failures to plan care and provide appropriate supervision for falls, resulting in multiple unwitnessed falls and resident discomfort. This constitutes neglect and abuse.
    • AbuseFailed to properly plan care
    11 Feb 2024Abuse: Neglect
    Found neglect and abuse due to failure to supervise a resident who eloped twice, resulting in a fine.
    • AbuseFailed to provide safe environment
    28 Jan 2024Inspection
    Investigated the allegation of an unsafe environment leading to elopement; the unit's magnetized locks were inoperable due to fire-system issues after a pipe burst, with no injuries reported.
    • LicensingFailed to provide safe environment
    26 Jan 2024Abuse: Neglect
    Found failures to supervise a resident and secure exits, resulting in the resident being found outside the secured area unsupervised.
    • AbuseFailed to provide safe environment
    16 Jan 2024Abuse: Neglect
    Concluded that inadequate supervision allowed an elopement and exposure to freezing temperatures; a fine was assessed.
    • AbuseFailed to provide safe environment
    12 Dec 2023Licensure
    Identified deficiencies in kitchen sanitation practices, including grease buildup on hoods, dust on vents and ceilings, and improper hair/beard restraints. A follow-up visit determined substantial compliance with applicable rules.
    • DeficiencyComment
    • DeficiencyResident Services Meals, Food Sanitation Rule
    12 Dec 2023Licensure
    Identified deficiencies in kitchen sanitation practices, including grease and dust buildup and inadequate hair restraints; a follow-up found substantial compliance.
    • DeficiencyComment
    • DeficiencyResident Services Meals, Food Sanitation Rule
    • DeficiencyAdministration Compliance
    26 Nov 2023Abuse: Neglect
    Found deficiencies in care planning and interventions that led to multiple falls and injuries, with a fine assessed.
    • AbuseFailed to properly plan care
    13 Nov 2023Complaint
    Identified privacy rights violations, emergency-response policy gaps, and staffing shortages based on the investigation.
    • DeficiencyLicensing Complaint Investigation
    • DeficiencyResident Rights and Protection - General
    • DeficiencyResident Health Services
    • DeficiencyAcuity-Based Staffing Tool
    11 Aug 2023Abuse: Neglect
    Investigated an allegation of unsafe environment. Found insufficient supervision that allowed a resident to elope, risking harm.
    • AbuseFailed to provide safe environment
    24 Mar 2023License Condition
    Investigated an allegation that licensing was not obtained. Found a failure to obtain a facility license and to maintain licensure as a separate and distinct operation.
    • Regulatory ActionFailed to obtain a facility license
    24 Mar 2023License Condition
    Identified failure to fully implement and update the Acuity Based Staffing Tool as required by the rule.
    • Regulatory ActionFailed to staff as indicated by ABST
    24 Mar 2023License Condition
    Found that direct care staff were not sufficient to meet residents' scheduled and unscheduled needs.
    • Regulatory ActionFailed to meet the scheduled and unscheduled needs of residents
    24 Mar 2023License Condition
    Determined that direct care staffing was not sufficient to meet residents' scheduled and unscheduled needs.
    • Regulatory ActionFailed to meet the scheduled and unscheduled needs of residents
    24 Mar 2023License Condition
    Investigated and identified a failure to provide service.
    • Regulatory ActionFailed to provide service
    24 Mar 2023License Condition
    Investigated the complaint that medications were administered 2-3 hours late and found that medication and treatment orders were not carried out as prescribed.
    • Regulatory ActionFailed to administer medication as ordered
    24 Mar 2023License Condition
    Found that an ABST was not used as required by the rule.
    • Regulatory ActionFailed to use an ABST
    21 Mar 2023Inspection
    Identified a violation of residents' privacy and dignity protections.
    • LicensingFailed to provide safe environment
    26 Feb 2023Abuse: Neglect
    Investigated an abuse allegation and found a failure to provide appropriate supervision, which allowed a resident to elope from a secured area and risk harm.
    • AbuseFailed to provide safe environment
    10 Feb 2023Abuse: Neglect
    Found violations of safety and resident rights, including physical abuse and financial exploitation, and assessed a $250 fine.
    • AbuseFailed to provide safe environment
    08 Feb 2023Inspection
    Found failure to fully implement an acuity-based staffing tool, constituting a licensing violation.
    • LicensingFailed to staff as indicated by ABST
    01 Feb 2023Abuse: Neglect
    Found neglect due to failure to follow the care plan, causing a resident to sit in feces and urine for several hours and endure significant discomfort and loss of dignity.
    • AbuseFailed to follow care plan
    30 Jan 2023Complaint
    Identified deficiencies in providing daily living assistance, service planning, medication administration, and staffing to meet resident needs.
    • DeficiencyLicensing Complaint Investigation
    • DeficiencyResident Services: Adls
    • DeficiencyService Plan: General
    • DeficiencySystems: Treatment Orders
    • DeficiencyStaffing Requirements and Training: Staffing
    • DeficiencyAcuity-Based Staffing Tool
    30 Jan 2023Complaint
    Investigated and found multiple deficiencies. The operation did not maintain separate facilities, lacked a full-time licensed administrator on-site, and had staffing and acuity-based planning problems.
    • DeficiencyLicensing Complaint Investigation
    • DeficiencyLicensing Standard
    • DeficiencyInfection Prevention & Control
    • DeficiencyAdministrator Qualification and Requirements
    • DeficiencyStaffing Requirements and Training: Staffing
    • DeficiencyAcuity-Based Staffing Tool
    23 Jan 2023Inspection
    Found that a full-time on-site administrator was not scheduled to be present for at least 40 hours per week.
    • LicensingFailed to provide appropriate staffing
    17 Jan 2023Inspection
    Found insufficient awake direct care staff to meet residents' 24-hour needs, creating a safety hazard.
    • LicensingFailed to provide safe environment
    17 Jan 2023Inspection
    Investigated a complaint and found failure to provide personal hygiene assistance. This violated Oregon Administrative Rules.
    • LicensingFailed to provide service
    12 Jan 2023Inspection
    Identified insufficient qualified awake direct care staff to meet 24-hour scheduled and unscheduled resident needs, creating a safety risk.
    • LicensingFailed to provide appropriate staffing
    12 Jan 2023Inspection
    Investigated the allegation that daily living assistance was not provided; found failure to assist with bathing, washing hair, toileting, and bowel/bladder management.
    • LicensingFailed to provide service
    09 Jan 2023Inspection
    Investigated a licensing allegation and found a failure to implement written policies and procedures on medical emergency response for all shifts.
    • LicensingFailed to provide safe environment
    08 Dec 2022Complaint
    Investigated a complaint and found multiple deficiencies related to grievances, records, room cleanliness and safety, service plans, medication administration, and ABST updates.
    • DeficiencyLicensing Complaint Investigation
    • DeficiencyFacility Administration: Policy & Procedure
    • DeficiencyFacility Administration: Records
    • DeficiencyReasonable Precautions
    • DeficiencyResident Rights and Protection - General
    • DeficiencyResident Services: Adls
    • DeficiencyService Plan: General
    • DeficiencySystems: Treatment Orders
    • DeficiencyAcuity-Based Staffing Tool
    13 Nov 2022Abuse: Neglect
    Investigated the allegation of neglect and found staff were not properly trained by a medical professional for a two-person transfer using a hoyer lift, leading to a resident injury.
    • AbuseFailed to provide safe environment
    09 Nov 2022Licensure
    Determined substantial compliance with meals and food sanitation requirements. No deficiencies cited.
    • DeficiencyComment
    09 Nov 2022Licensure
    Determined substantial compliance with the applicable meal service and food sanitation rules. Found no deficiencies.
    • DeficiencyComment
    03 Sept 2022Inspection
    Identified failure to provide a safe environment and essential household services, resulting in a licensing violation.
    • LicensingFailed to provide safe environment
    03 Sept 2022Abuse: Neglect
    Identified failures to implement interventions and care planning for a resident's fall history, leading to a fall and injury requiring hospital care.
    • AbuseFailed to properly plan care
    03 Sept 2022Abuse: Neglect
    Investigated the complaint and found failure to provide or assist with hygiene, causing discomfort and loss of dignity for the resident. A fine of 3500 dollars was assessed.
    • AbuseFailed to provide or assist with hygiene
    03 Sept 2022Abuse: Neglect
    Investigated a complaint and found failure to assist with eating, resulting in risk of harm to a resident.
    • AbuseFailed to assist with eating
    03 Sept 2022Abuse: Neglect
    Concluded neglect and abuse occurred due to failure to plan care and provide supervision for a resident with a history of falls, leading to several falls with injuries.
    • AbuseFailed to properly plan care
    03 Sept 2022Inspection
    Found failure to update ABST quarterly, creating a potential safety risk.
    • LicensingFailed to update staffing plan based on ABST
    30 Aug 2022Abuse: Neglect
    Found a failure to implement interventions and monitor a resident, leading to a physical altercation and neglect/abuse; a fine was assessed.
    • AbuseFailed to provide safe environment
    02 Aug 2022Abuse: Neglect
    Identified neglect of care due to failing to administer medication as ordered and unsafe medication storage that left discontinued medications in the cart.
    • AbuseFailed to provide a safe medication administration system
    06 Jun 2022Abuse: Neglect
    Investigated abuse and neglect where failure to monitor a resident led to a physical altercation and unreasonable discomfort.
    • AbuseFailed to provide safe environment
    05 Jun 2022Abuse: Neglect
    Found that the licensee failed to implement interventions and monitor residents according to known behaviors, resulting in a physical altercation and harm to a resident.
    • AbuseFailed to provide safe environment
    24 May 2022Abuse: Neglect
    Found neglect due to insufficient supervision that allowed a person to elope from a secured building, risking harm.
    • AbuseFailed to provide safe environment
    18 May 2022Inspection
    Identified a failure to establish and maintain infection prevention and control protocols, resulting in an unsafe environment.
    • LicensingFailed to provide infection control
    22 Apr 2022Inspection
    Investigated the allegation of failing to properly plan care and found that quarterly service plans were not performed.
    • LicensingFailed to properly plan care
    22 Apr 2022Inspection
    Found resident records were not prepared, complete, accurate, or preserved. The finding involved a licensing violation.
    • LicensingFailed to make facility or resident records accessible
    20 Apr 2022Inspection
    Investigated an allegation of a safe medication administration system and found that medication orders were not carried out as prescribed, indicating a deficient system.
    • LicensingFailed to provide a safe medication administration system
    10 Apr 2022Abuse: Neglect
    Investigated an allegation of unsafe medication administration and found a deficient system that caused unnecessary discomfort, indicating neglect and abuse.
    • AbuseFailed to provide a safe medication administration system
    01 Apr 2022Abuse: Neglect
    Investigated and found that care planning and supervision for a resident with known fall risk were inadequate, leading to an unwitnessed fall and injuries.
    • AbuseFailed to properly plan care
    01 Apr 2022Abuse: Neglect
    Found violations related to care planning that led to an unwitnessed fall and hospice care; a $3,000 fine was assessed.
    • AbuseFailed to properly plan care
    24 Mar 2022Abuse: Neglect
    Found neglect of care due to failure to provide timely peri-care, leaving incontinence briefs unchanged and causing discomfort; a fine was assessed.
    • AbuseFailed to provide peri care
    23 Mar 2022Inspection
    Found failure to develop and implement a written policy prohibiting falsification of records.
    • LicensingFalsified records
    23 Mar 2022Inspection
    Investigated the allegation of an unsafe environment and found deficiencies in how resident complaints were addressed and resolved.
    • LicensingFailed to provide safe environment
    23 Mar 2022Inspection
    Found that a resident was not treated with respect and dignity and that a homelike environment was not provided.
    • LicensingFailed to provide a homelike environment
    23 Mar 2022Inspection
    Found failure to provide a safe environment that could threaten residents' health, safety, or welfare.
    • LicensingFailed to provide safe environment
    17 Mar 2022Abuse: Neglect
    Identified a failure to provide a safe medication administration system that caused resident discomfort; a $500 fine was assessed.
    • AbuseFailed to provide a safe medication administration system
    15 Mar 2022Abuse: Neglect
    Determined that care planning and fall-risk interventions were not adequately addressed, resulting in a fall and a broken femur. A fine was assessed.
    • AbuseFailed to properly plan care
    03 Mar 2022Abuse: Neglect
    Found a deficient medication administration system due to inadequate staff training, resulting in the wrong medication being given to a resident.
    • AbuseFailed to provide a safe medication administration system
    06 Jan 2022Inspection
    Found a deficiency for failing to protect a resident's property from theft, allowing jewelry to go missing. The finding involved an unknown individual and financial exploitation.
    • LicensingFailed to provide safe environment
    25 Dec 2021Abuse: Neglect
    Investigated a neglect allegation and found failure to provide a safe environment resulting in risk of serious injury; a $375 fine was assessed.
    • AbuseFailed to provide safe environment
    15 Nov 2021Abuse: Neglect
    Determined that supervision was inadequate, leaving a resident unsafely without assistance and at risk of harm.
    • AbuseFailed to provide safe environment
    12 Nov 2021Abuse: Neglect
    Investigated and found substantiated neglect and abuse due to failure to implement interventions and care planning for a resident's fall history, resulting in an unwitnessed fall with pain.
    • AbuseFailed to provide safe environment
    12 Nov 2021Abuse: Neglect
    Concluded that fall-risk care planning was inadequate, leading to an unwitnessed fall and three prior falls. A fine of $375 was assessed.
    • AbuseFailed to properly plan care
    02 Nov 2021Abuse: Neglect
    Found neglect and abuse due to failure to assess cognitive status and wandering risk, with a fine assessed. The care-planning failure left a resident at risk of harm.
    • AbuseFailed to properly plan care
    11 Oct 2021Abuse: Neglect
    Investigated the alleged failure to oversee and monitor a resident's change in condition; found neglect and abuse due to insufficient supervision, resulting in an unwitnessed fall and injuries.
    • AbuseFailed to provide oversight and monitoring of change of condition
    27 Sept 2021Abuse: Neglect
    Found a failure to provide a safe environment, resulting in neglect and abuse.
    • AbuseFailed to provide safe environment
    26 Sept 2021Abuse: Neglect
    Determined neglect and abuse occurred due to failure to implement care planning and interventions for aggressive behavior toward a resident; a fine was assessed.
    • AbuseFailed to properly plan care
    23 Sept 2021Abuse: Neglect
    Identified a failure to provide a safe environment that harmed a resident, constituting abuse and neglect. A $500 fine was assessed.
    • AbuseFailed to provide safe environment
    23 Sept 2021Abuse: Neglect
    Found a violation for failing to provide a safe environment, resulting in a $500 fine.
    • AbuseFailed to provide safe environment
    23 Sept 2021Abuse: Neglect
    Found a failure to provide a safe environment that resulted in a resident bruise; a $500 fine was assessed.
    • AbuseFailed to provide safe environment
    19 Sept 2021Abuse: Neglect
    Found neglect of care due to failure to plan for fall history, leading to an unwitnessed fall and hospital transfer; a $500 fine assessed.
    • AbuseFailed to properly plan care
    18 Sept 2021Abuse: Neglect
    Investigated and concluded there was neglect due to failure to assess and monitor a change in condition, leading to increased refusals of care and discomfort. A timely urine sample was not obtained and a urinary tract infection was diagnosed later; a $500 fine was assessed.
    • AbuseFailed to provide oversight and monitoring of change of condition
    08 Sept 2021Abuse: Neglect
    Investigated an allegation of neglect and abuse. Found that the resident was left in soiled briefs for about sixteen hours and care planning did not address toileting needs, causing unreasonable discomfort.
    • AbuseFailed to properly plan care
    24 Aug 2021Abuse: Neglect
    Identified a resident safety violation due to failure to prevent elopement by a wandering resident; a fine was assessed.
    • AbuseFailed to provide safe environment
    15 Aug 2021Abuse: Neglect
    Investigated and found failures to implement interventions and an appropriate care plan for aggressive behaviors, resulting in a resident-to-resident altercation and constituting neglect and abuse.
    • AbuseFailed to provide safe environment
    10 Aug 2021Abuse: Neglect
    Determined that the care plan for close monitoring was not followed, resulting in abuse and neglect.
    • AbuseFailed to follow care plan
    25 Jul 2021Abuse: Neglect
    Investigated the complaint and found abuse and neglect; a $500 fine was assessed.
    • AbuseFailed to provide safe environment
    25 Jul 2021Abuse: Neglect
    Found neglect of a resident by staff due to long nails causing a skin tear, constituting abuse; a $500 fine was assessed.
    • AbuseFailed to provide safe environment
    24 Jul 2021Abuse: Neglect
    Investigated and determined that the care plan was not followed, leading to an unwitnessed fall with minor harm or potential for moderate harm; a $500 fine was assessed.
    • AbuseFailed to follow care plan
    15 Jul 2021Abuse: Neglect
    Investigated an incident involving a resident found in another resident's room with yogurt on themselves, the other resident, and the walls, and determined the care provided was not adequate to address the resident's behavior; a separate abuse allegation against a staff member was investigated and found not to involve abuse.
    • AbuseFailed to properly plan care
    12 Jul 2021Abuse: Neglect
    Identified a failure to protect a resident from a resident-to-resident altercation that resulted in neglect and abuse.
    • AbuseFailed to provide safe environment
    12 Jul 2021Abuse: Neglect
    Investigated a complaint and found a failure to provide a safe environment, resulting in a bruise of unknown origin. Violations cited and a $250 fine assessed.
    • AbuseFailed to provide safe environment
    06 Jul 2021Abuse: Neglect
    Investigated found neglect and abuse due to failure to properly plan care and address fall interventions after an unwitnessed fall, resulting in hospitalization.
    • AbuseFailed to properly plan care
    26 Jun 2021Abuse: Neglect
    Found neglect and abuse due to failure to plan care and provide fall interventions and supervision, resulting in multiple falls and a head injury.
    • AbuseFailed to properly plan care
    25 Jun 2021Abuse: Neglect
    Investigated allegations of abuse and neglect and found an unsafe environment due to a door not being closed, leading to a $250 fine.
    • AbuseFailed to provide safe environment
    24 Jun 2021Abuse: Neglect
    Investigated the allegation of neglect and found failure to toilet the resident per the care plan during a shift, causing discomfort from a skin injury. A $375 fine was assessed.
    • AbuseFailed to follow care plan
    22 Jun 2021License Condition
    Found that needed/necessary services were not provided.
    • Regulatory ActionFailed to provide service
    19 Jun 2021Abuse: Neglect
    Investigated allegations of abuse and neglect; found failure to implement interventions and monitor a resident according to known behavior, leading to a physical altercation and unreasonable discomfort.
    • AbuseFailed to provide safe environment
    19 Jun 2021Abuse: Neglect
    Investigated a complaint and found neglect related to failure to plan and implement interventions for a resident's falls.
    • AbuseFailed to properly plan care
    16 Jun 2021Abuse: Neglect
    Investigated and found an unwitnessed fall occurred and a safe environment was not provided, resulting in injury requiring hospital care.
    • AbuseFailed to provide safe environment
    08 Jun 2021Abuse: Neglect
    Found neglect and abuse due to failure to follow the care plan, leaving a resident in soiled briefs and unclean.
    • AbuseFailed to follow care plan
    04 Jun 2021Abuse: Neglect
    Identified a failure to provide a safe environment that caused discomfort, constituting abuse and neglect.
    • AbuseFailed to provide safe environment
    02 Jun 2021Abuse: Neglect
    Found neglect due to failure to provide a safe environment, resulting in pain and markings during a resident-to-resident altercation.
    • AbuseFailed to provide safe environment
    28 May 2021Inspection
    Investigated a complaint about infection control and identified a failure to provide a safe environment.
    • LicensingFailed to provide infection control
    19 May 2021Inspection
    Found a deficiency in the medication administration system that placed a resident at risk. This involved neglect and abuse.
    • LicensingFailed to provide a safe medication administration system
    09 May 2021Abuse: Neglect
    Found that a safe environment was not provided, resulting in abuse and neglect.
    • AbuseFailed to provide safe environment
    27 Apr 2021Inspection
    Identified insufficient qualified awake direct care staff to meet 24-hour scheduled and unscheduled needs. The finding reflects staffing requirements under Oregon rules.
    • LicensingFailed to provide appropriate staffing
    16 Mar 2021Inspection
    Determined that a resident’s personal property went missing due to failure to protect it from theft, resulting in financial exploitation.
    • LicensingFailed to protect resident from financial exploitation
    15 Mar 2021Abuse: Neglect
    Found violations for failing to plan care around a resident's history of aggression, contributing to abuse and neglect.
    • AbuseFailed to properly plan care
    04 Mar 2021Abuse: Neglect
    Found neglect related to medication management and oxygen supply, with a fine assessed.
    • AbuseFailed to administer medication as ordered
    01 Feb 2021Abuse: Neglect
    Investigated allegations found failure to plan care and implement fall-prevention interventions, leading to an unwitnessed fall and rib fractures.
    • AbuseFailed to properly plan care
    07 Dec 2020Inspection
    Investigated the staffing allegation and found a deficiency in verifying direct care staff performance in assigned duties.
    • LicensingFailed to provide appropriate staffing
    07 Dec 2020Inspection
    Determined that 24-hour assistance with daily living activities was not provided to a resident.
    • LicensingFailed to provide service
    23 Nov 2020Inspection
    Investigated and determined a failure to verify direct care staff performance occurred, constituting a violation.
    • LicensingFailed to provide appropriate staffing
    23 Nov 2020Inspection
    Investigated a licensing allegation and identified a deficiency for failing to provide resident services to assist with activities of daily living.
    • LicensingFailed to provide service
    23 Nov 2020Inspection
    Identified deficiencies in infection control practices risking COVID-19 spread, based on multiple visits; a $1500 fine was assessed.
    • LicensingFailed to provide infection control
    21 Nov 2020Abuse: Neglect
    Found a failure to provide a safe environment resulting in abuse and neglect; a $500 fine assessed.
    • AbuseFailed to provide safe environment
    16 Nov 2020Inspection
    Investigated an allegation that services to assist residents were not provided. Found a failure to implement services in violation of state rules.
    • LicensingFailed to provide service
    16 Nov 2020Inspection
    Found insufficient staff to meet residents' scheduled and unscheduled needs.
    • LicensingFailed to provide appropriate staffing
    04 Nov 2020Inspection
    Identified a staffing deficiency due to insufficient qualified awake direct care staff to meet 24-hour scheduled and unscheduled needs.
    • LicensingFailed to provide appropriate staffing
    02 Nov 2020Inspection
    Found a failure to maintain required direct care staffing levels, with two direct care staff not scheduled and available at all times when two staff were needed.
    • LicensingFailed to provide appropriate staffing
    02 Nov 2020Inspection
    Found that residents were not assisted with all activities of daily living on a 24-hour basis, including toileting and bowel and bladder management.
    • LicensingFailed to provide service
    02 Nov 2020Inspection
    Found insufficient qualified awake direct care staff to meet 24-hour needs of residents.
    • LicensingFailed to provide appropriate staffing
    27 Oct 2020Inspection
    Investigated a staffing allegation and found insufficient direct care staff to meet residents' scheduled and unscheduled needs.
    • LicensingFailed to provide appropriate staffing
    27 Oct 2020Inspection
    Found that the service planning team was not involved in developing a resident's service plan.
    • LicensingFailed to properly plan care
    27 Oct 2020Inspection
    Found failure to provide services to assist with activities of daily living.
    • LicensingFailed to provide service
    24 Oct 2020Inspection
    Found insufficient direct care staffing to meet residents' needs, violating staffing requirements.
    • LicensingFailed to provide appropriate staffing
    16 Oct 2020Inspection
    Found a failure to provide toileting assistance by staff. The finding reflected a violation of Oregon rules.
    • LicensingFailed to assist with toileting
    16 Oct 2020Inspection
    Determined that staffing levels were insufficient to meet scheduled and unscheduled resident needs.
    • LicensingFailed to provide appropriate staffing
    15 Oct 2020Abuse: Neglect
    Investigated a resident-to-resident altercation and found a failure to provide a safe environment. This resulted in a neglect and abuse finding with an assessed fine.
    • AbuseFailed to provide safe environment
    08 Oct 2020Inspection
    Investigated a care plan violation where a caregiver did not use a gait belt during transfers, causing a resident to fall and suffer hip and wrist fractures; the care plan was not followed.
    • LicensingFailed to follow care plan
    28 Sept 2020Abuse: Neglect
    Investigated and found failures to follow the resident's care plan and monitor known behaviors, resulting in a physical altercation causing injury and constituting abuse and neglect.
    • AbuseFailed to provide safe environment
    29 Jul 2020Abuse: Neglect
    Identified violations for failing to monitor residents according to their history, resulting in a physical altercation and neglect/abuse; a fine was assessed.
    • AbuseFailed to provide safe environment
    14 Apr 2020Abuse: Neglect
    Investigated a neglect allegation and found a safe-environment deficiency that allowed a resident to leave a secured unit without staff knowledge, risking harm.
    • AbuseFailed to provide safe environment
    14 Apr 2020Abuse: Neglect
    Found that a safe environment wasn't provided when a resident could leave the secured unit without staff knowledge, risking harm.
    • AbuseFailed to provide safe environment
    02 Dec 2019Abuse: Neglect
    Found a safety violation when a resident gained access to a cleaning closet and was injured. A $188 fine was assessed.
    • AbuseFailed to provide safe environment
    16 Aug 2019Abuse: Neglect
    Found neglect by failing to prevent falls, which led to physical injury. The findings were substantiated.
    • AbuseFailed to adequately care plan related to falls
    20 Jun 2019Abuse: Financial abuse
    Concluded that there was a failure to protect a resident from financial exploitation and neglect related to preventing theft of medication, creating risk of serious harm.
    • AbuseFailed to protect resident from financial exploitation
    20 Jun 2019Abuse: Financial abuse
    Investigated a financial exploitation allegation and found failures to protect residents from exploitation and to prevent theft of medication, creating risk of serious harm.
    • AbuseFailed to protect resident from financial exploitation
    29 Apr 2019Abuse: Neglect
    Found a failure to follow the care plan that harmed health and safety. A fine was assessed.
    • AbuseFailed to follow care plan
    19 Apr 2019Abuse: Neglect
    Found a failure to provide a safe environment that resulted in physical harm to an adult.
    • AbuseFailed to provide safe environment
    31 Mar 2019Abuse: Neglect
    Determined a neglect violation that failed to keep a person safe from wandering, resulting in injury. A fine was assessed.
    • AbuseFailed to provide safe environment
    07 Mar 2019Abuse: Neglect
    Investigated a complaint and found neglect by failing to keep a resident safe in their room after a known aggressor slept in a spare bed, creating risk of serious harm. A fine was assessed.
    • AbuseFailed to provide safe environment
    07 Mar 2019Abuse: Neglect
    Found neglect for failing to provide a safe environment, which led to physical harm; a $375 fine was assessed.
    • AbuseFailed to provide safe environment
    16 Jan 2019Inspection
    Found a staffing deficiency due to failure to provide adequate staff.
    • LicensingFailed to provide appropriate staffing
    16 Jan 2019Inspection
    Investigated an allegation of failing to provide service and substantiated it.
    • LicensingFailed to provide service
    16 Jan 2019Inspection
    Investigated the allegation of failing to provide a safe environment and concluded that the allegation was supported.
    • LicensingFailed to provide safe environment
    12 Jan 2019Abuse: Neglect
    Found that an Alleged Victim sustained bruises and skin injury due to improper transfers, indicating neglect and abuse; a fine was assessed.
    • AbuseFailed to investigate injury of unknown origin to rule out abuse
    06 Dec 2018Abuse: Neglect
    Investigated a neglect allegation and found that a documented intervention was not implemented, resulting in physical harm to a resident.
    • AbuseFailed to assure resident was safe
    04 Sept 2018Abuse: Neglect
    Identified a failure to provide a safe environment, resulting in a resident-to-resident altercation.
    • AbuseFailed to provide safe environment
    31 Aug 2018Abuse: Neglect
    Found deficiencies for failing to provide basic care, creating risk of serious harm; a fine was assessed.
    • AbuseFailed to properly plan care
    30 May 2018Inspection
    Investigated a staffing allegation and found inadequate staffing to meet residents' scheduled and unscheduled needs, with family members assisting due to shortages.
    • LicensingFailed to provide appropriate staffing
    13 Mar 2018Inspection
    Investigated the allegation and found a deficiency for not providing a homelike environment due to a staff member speaking harshly to a resident while rushing them.
    • LicensingFailed to provide a homelike environment
    26 Feb 2018Inspection
    Investigated a complaint and substantiated a licensing violation involving failure to follow the care plan, which led to a resident-to-resident altercation. A $375 fine was assessed.
    • LicensingFailed to provide safe environment
    30 Jan 2018Abuse: Neglect
    Found failure to assess and intervene when a resident's condition changed, resulting in harm. A fine was assessed.
    • AbuseFailed to intervene when resident's condition changed
    24 Sept 2017Abuse: Neglect
    Found deficiencies in patient care tracking that led to missed medical appointments and hospitalization. A $250 fine was assessed.
    • AbuseFailed to provide medical treatment as ordered
    22 Sept 2017Inspection
    Found a violation for failing to protect a resident from rough treatment.
    • LicensingFailed to follow care plan
    22 Sept 2017Inspection
    Investigated an allegation that care planning after a fall was inadequate. Found a failure to assess and intervene after a fall resulting in harm.
    • LicensingFailed to adequately care plan related to falls
    22 Sept 2017Inspection
    Found failure to follow the care plan that increased the risk of a fall.
    • LicensingFailed to follow care plan
    22 Sept 2017Abuse: Verbal/Mental abuse
    Determined that residents were not protected from verbal abuse, resulting in loss of dignity.
    • AbuseFailed to protect resident from verbal abuse
    01 Sept 2017Abuse: Financial abuse
    Determined that a secure environment was not provided, resulting in theft of residents' property.
    • AbuseFailed to provide safe environment
    07 Aug 2017Inspection
    Investigated the allegation that a resident was not shaved or dressed and identified a failure to provide dressing and grooming assistance.
    • LicensingFailed to assist with dressing or grooming
    29 Apr 2017Abuse: Neglect
    Investigated an allegation of neglect and found that residents did not receive appropriate care or hygiene supplies, resulting in injury.
    • AbuseFailed to provide safe environment
    29 Mar 2017Inspection
    Found a failure to provide a secure environment, including an elopement from the Memory Care Unit.
    • LicensingFailed to provide safe environment
    29 Mar 2017Inspection
    Concluded there was a failure to provide a secure environment, resulting in an elopement.
    • LicensingFailed to provide safe environment
    08 Sept 2016Inspection
    Investigated the allegation and found that residents were not given the required 60-day written notice before a nonemergent remodel that would displace them, including where they would be moved, remodel length, and the assurance of returning.
    • LicensingFailed to comply with move-out, transfer or discharge requirements
    29 Jun 2016Inspection
    Found a failure to provide a safe environment.
    • LicensingFailed to provide safe environment
    26 Feb 2016Abuse: Physical Abuse
    Found a violation of safety standards due to failing to protect a resident from rough treatment.
    • AbuseFailed to protect resident from rough treatment
    10 Jan 2016Abuse: Neglect
    Found safety-related deficiencies in medication administration and in providing a safe environment.
    • AbuseFailed to provide a safe medication administration system
    24 Jul 2015Abuse: Neglect
    Found a failure to provide a secure environment.
    • AbuseFailed to provide safe environment
    26 Sept 2013Abuse: Physical Abuse
    Found substantiated abuse and an unsafe environment.
    • AbuseFailed to protect resident from rough treatment
    23 Sept 2013Abuse: Neglect
    Found a failure to provide a safe medication system, resulting in a medication error. Violations were cited.
    • AbuseFailed to administer medication as ordered
    30 Jul 2013Abuse: Neglect
    Found that a safe environment was not provided and the falls-related neglect allegation was substantiated.
    • AbuseFailed to adequately care plan related to falls
    09 Mar 2013Inspection
    Found that a safe medication administration system was not in place.
    • LicensingFailed to have medication available
    29 Nov 2010Inspection
    Found a licensing violation for not complying with move-out, transfer or discharge requirements and not providing appropriate care to the resident.
    • LicensingFailed to comply with move-out, transfer or discharge requirements

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