Springs at Clackamas Woods ALF

Last inspection

October 16, 2024

Inspections

3, 12 deficiencies cited

Substantiated abuse

0

Substantiated licensing violations

6

Regulatory actions

0

Current owner since

October 15, 2012

Inspections

• October 16, 2024: Re-Licensure, 6 deficiencies cited report
  • C0252: Resident Move-in & Evaluation: Res Evaluation severity level 2, scope L2 Isolated
  • C0295: Infection Prevention & Control severity level 2, scope L2 Widespread
  • C0330: Systems: Psychotropic Medication severity level 2, scope L2 Isolated
  • C0362: Acuity Based Staffing Tool - ABST Time severity level 2, scope L2 Pattern
  • C0370: Staffing Requirements and Training ? Pre-service severity level 2, scope L2 Pattern
  • C0372: Training Within 30 Days of Hire ? Direct Care Staff severity level 2, scope L2 Pattern
• August 24, 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 September 10, 2023
• May 9, 2022: Validation, 5 deficiencies cited report
  • C0000: Comment severity level 0
  • C0160: Reasonable Precautions severity level 2, scope L2 Widespread, corrected August 31, 2022
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread, corrected August 31, 2022
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread, corrected August 31, 2022
  • C0422: Fire and Life Safety: Training For Residents severity level 2, scope L2 Widespread, corrected August 31, 2022
  • C0610: General Building Exterior severity level 2, scope L2 Widespread, corrected August 31, 2022

Substantiated licensing violations

• March 11, 2025: 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); 411-054-0027 (Resident Rights and Protections)
  State’s findings

  According to the documentation, the Alleged Perpetrator 2 (AP2) failed to provide a safe medication administration system for the Alleged Victim (AV). On or about March 11, 2025, AP2 did not follow protocol to ensure the AV received the correct medication and gave the AV their roommates medication. AP2 then administered the AV their correct medication in addition to their roommates medication without consulting AV’s primary care physician. The failure to provide a safe medication administration systems caused the AV to experience dizziness, abnormal blood pressure shakiness and other symptoms, placing them at risk of harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.

• December 19, 2023: Failed to follow care plan Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-020-0002 (Definitions)
  State’s findings

  According to the documentation, the Alleged Perpetrator (AP2) failed to follow the Alleged Victim’s (AV) care plan by using a gait belt when transferring. The failure resulted in the AV to fall and hit their head causing a bruise and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to ensure service plans were being followed which is a violation of Oregon Administrative Rules.

• June 23, 2023: 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)
  State’s findings

  According to the documentation, the Alleged Perpetrator (AP2) failed to follow the Alleged Victim’s (AV) care plan when s/he needed to get dressed. The failure resulted in the AV suffering a non-injury fall which is a violation of resident rights and is considered abuse. The facility failed to ensure the service plan was being followed which is a violation of Oregon Administrative Rules.

• January 20, 2023: Failed to provide safe environment 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 fully implement an Acuity Based Staffing Tool in accordance with OAR 411-054-0037.

• November 1, 2022: Failed to submit timely or adequate staffing documentation Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-061-0010
  State’s findings

  On or about November 1, 2022, the Oregon Health Authority reported to the Department that Respondent failed to comply with weekly reporting requirements of vaccinated individuals, residents and staff, to the proper authority as required by law. This failure has been ongoing for a total of 30 days.

• May 6, 2022: 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)
  State’s findings

  The Alleged Perpetrator 2 (AP2) failed to follow the Alleged Victim's (AV) care plan to ensure a fall mat was in place when AV was in bed. The failure resulted in AV falling from his/her bed onto the floor causing unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to ensure AV's care plan was followed, 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 58 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.