Springs at Tanasbourne

Last inspection

July 15, 2024

Inspections

3, 14 deficiencies cited

Substantiated abuse

5

Substantiated licensing violations

6

Regulatory actions

0

Fines assessed

$3,188.00 (5 violations)

Current owner since

March 1, 2013

• Every deficiency from the July 15, 2024 inspection was corrected by January 18, 2025

Inspections

• July 15, 2024: Re-Licensure, 12 deficiencies cited report
  • C0000: Comment severity level 0
  • C0150: Facility Administration: Operation severity level 3, scope L3 Isolated, corrected September 16, 2024
  • C0155: Facility Administration: Records severity level 2, scope L2 Isolated, corrected September 16, 2024
  • C0260: Service Plan: General severity level 2, scope L2 Pattern, corrected January 18, 2025
  • C0270: Change of Condition and Monitoring severity level 3, scope L3 Isolated, corrected January 18, 2025
  Show all 15

  • C0280: Resident Health Services severity level 3, scope L3 Isolated, corrected September 16, 2024
  • C0290: Res Hlth Srvc: On- and Off-Site Health Srvc severity level 2, scope L2 Isolated, corrected January 18, 2025
  • C0305: Systems: Resident Right to Refuse severity level 2, scope L2 Isolated, corrected September 16, 2024
  • C0325: Systems: Self-Administration of Meds severity level 2, scope L2 Isolated, corrected September 16, 2024
  • C0360: Staffing Requirements and Training: Staffing severity level 2, scope L2 Widespread, corrected September 16, 2024
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Pattern, corrected September 16, 2024
  • C0363: Acuity Based Staffing Tool - Updates & Plan severity level 2, scope L2 Widespread, corrected January 18, 2025
  • C0422: Fire and Life Safety: Training For Residents severity level 2, scope L2 Widespread, corrected September 16, 2024
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Pattern, corrected January 18, 2025
  • C0613: General Building: Doors-Walls, Cleanable severity level 2, scope L2 Widespread, corrected September 16, 2024
• March 5, 2024: 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 4, 2024
• February 16, 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 April 3, 2023

Substantiated abuse or neglect

• September 15, 2024: Failed to provide safe environment 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)
  State’s findings

  According to the documentation, the facility failed to provide a safe environment in the Alleged Victim’s (AV) apartment by fixing a gap in the molding which created a trip hazard. On or about September 15, 2024, the AV experienced a fall and sustained lacerations to their face, head and fractured shoulder. The AV stated they tripped on the transition strip between the kitchenette and the living room. The transition strip was identified to be an issue, but was not fixed before or after the AV moved in. the failure to fix the transition strip which was identified to be an issue prior to the AV moving in, is a violation of resident rights, is considered neglect of care and constitutes abuse.

• October 7, 2023: Failed to provide a safe medication administration system Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $1,125.00; 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

  According to the documentation, the facility failed to provide adequate staffing levels to safely administer medication to the Alleged Victim (AV). On or about October 7, 2023, the Alleged Perpetrator 3 (AP3) did not administer the AV their short acting insulin due to not getting a proper reading on the glucometer. The AV fell and reported to staff the s/he felt dizzy and was transported to the hospital. The hospital admitted the AV for unstable blood sugars for approximately three days to ensure their blood sugars stabilized before discharging the AV back to the facility, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• October 6, 2023: 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); 411-054-0055 (Medications and Treatments)
  State’s findings

  According to the documentation, the facility failed to provide a safe medication administration for the Alleged Victim (AV). The Alleged Perpetrator 3 (AP3) prepared medications for a resident and allowed the Alleged Perpetrator 2 (AP2) to administer the medication. The AP2 thought the medications were for the AV and they administered the medication to them resulting in an adverse reaction which required the AV to be seen at the hospital, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• March 12, 2022: Failed to provide a safe medication administration system Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $1,125.00; 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

  On or about March 11, 2022 at 11 PM, the Alleged Victim (AV) was given 4 times the dosage of pain medication that he/she was supposed to receive, and again on March 12, 2022 at 3:00 AM, again, 4 times the dosage. AV complained of abnormal symptoms at 4 AM. Alleged Perpetrator #2 (AP2) realized his/her error at this time and contacted the facility Nurse and then called emergency services. AV was transported to the hospital for evaluation. AP2's failure is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failure to provide a safe medication administration system is a violation of resident rights, is considered neglect of care and constitutes abuse.

• January 4, 2022: Failed to follow care plan 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

  The facility failed to implement interventions and / or appropriately care plan regarding Alleged Victim’s (AV) known fall risk. AV had multiple documented falls between October 23, 2021, and January 4, 2022, some resulting in injury including but not limited to a head injury, skin tears, abrasions and bruising. The facility failed to implement interventions to mitigate AV’s increasing fall risk, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• May 1, 2026: Failed to provide oversight and monitoring of change of condition Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0040 (Change of Condition and Monitoring)
  State’s findings

  The facility failed to ensure to monitor each resident consistent with his or her evaluated needs and service plan in accordance with OAR 411-054-0040(2)(a). Per complainant, the resident was on hourly and or 90 minute safety checks. Resident was not checked on from 9:20pm to 11:40pm, which is a violation of Oregon Administrative Rules.

• January 25, 2024: Failed to communicate necessary information 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 follow the care plan update for the Alleged Victim (AV) new transfer instructions. On or about January 24, 2024, the facility implemented a temporary service plan update to change the transfer assistance to the AV from a 1-person assist to a 2-person assist. The AP2 called the Alleged Perpetrator 3 (AP3) to help with a transfer on or about January 25, 2024, and did not tell them the AV was now a 2-person assist. AP3 attempted to transfer the AV by themselves, causing a fall which resulted in bruising, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• January 24, 2024: Failed to protect resident from financial exploitation Licensing Violation; Level 3 - Moderate harm or potential for serious 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 protect the Alleged Victim (AV) from financial exploitation. On or about January 24, 2024, the AV noticed their bag of jewelry was missing and could not find it. After an investigation, the facility was unable to locate the jewelry but were able to determine no one from the facility had taken it. AP2’s failure to protect the AV from financial exploitation by stealing their jewelry is a violation of resident rights, is considered neglect of care and constitutes abuse. The Facility failed to provide a safe environment which is a violation of Oregon Administrative Rules.

• January 25, 2023: Failed to provide safe environment Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0050 (Infection Prevention and Control)
  State’s findings

  The facility failed to establish and maintain infection prevention and control protocols. An investigation determined a licensing violation occurred.

• November 14, 2022: Failed to protect resident from verbal 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, Alleged Perpetrator (AP2) failed to protect the Alleged Victim (AV) from verbal abuse while providing care. The failure resulted in AP2 using a harsh tone and language to direct the AV during cares resulting in emotional harm, which is a violation of resident rights is considered verbal abuse. The facility failed to provide a safe environment which is a violation of Oregon Administrative Rules.

• September 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 September 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 from August 1, 2022 to August 31, 2022, for a total of 30 days.

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 84 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.