Tanner Spring Memory Care

Last inspection

February 4, 2026

Inspections

8, 30 deficiencies cited

Substantiated abuse

20

Substantiated licensing violations

14

Regulatory actions

3

Fines assessed

$12,938.00 (20 violations)

Current owner since

August 1, 2020

License conditions and other regulatory actions

• December 12, 2025 to February 18, 2026: License Condition, Failed to staff as indicated by ABST RCFCD25-01417; incident: CALMS - 00094784
  The facility failed to develop, maintain, and implement an Acuity Based Staffing Tool in accordance with OAR 411-054-0037(1-7).
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)
• March 24, 2023 to December 27, 2023: License Condition, Failed to meet the scheduled and unscheduled needs of residents RCFCD23-00369; 3 incidents: OR0003897203, OR0003897201, OR0003897200
  The facility failed to ensure that each residential care and assisted living facility is licensed, maintained, and operated as a separate and distinct facility in accordance with OAR 411-054-0010 (3).
  Rules: 411-054-0010 (Licensing Standard); 411-054-0037 (Acuity-Based Staffing Tool); 411-054-0070 (Staffing Requirements and Training)
• June 22, 2021 to February 14, 2022: License Condition, Failed to provide service RCFCD21-02590; incident: CALMS - 00014782
  Per re-licensure survey (1D1711) the facility failed to provide effective administrative oversight to ensure quality care and services were rendered in the facility.
  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)

Inspections

• February 4, 2026: Kitchen, 2 deficiencies cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread
• October 21, 2025: Complaint Investig., 2 deficiencies cited report
  • C0010: Licensing Complaint Investigation severity level 2, scope L2 Isolated
  • C0260: Service Plan: General severity level 2, scope L2 Isolated
  • C0360: Staffing Requirements and Training: Staffing severity level 2, scope L2 Isolated
• January 22, 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
• July 22, 2024: Re-Licensure, 14 deficiencies cited report
  • C0000: Comment severity level 0
  • C0200: Resident Rights and Protection - General severity level 2, scope L2 Widespread, corrected September 23, 2024
  • C0260: Service Plan: General severity level 2, scope L2 Pattern, corrected September 23, 2024
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Pattern, corrected December 28, 2024
  • C0280: Resident Health Services severity level 2, scope L2 Pattern, corrected September 23, 2024
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Pattern, corrected September 23, 2024
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread, corrected September 23, 2024
  • C0422: Fire and Life Safety: Training For Residents severity level 2, scope L2 Widespread, corrected September 23, 2024
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread, corrected December 28, 2024
  • H1510: Individual Rights Settings: Privacy, Dignity severity level 2, scope L2 Widespread, corrected September 23, 2024
  • H1517: Individual Privacy: Own Unit severity level 2, scope L2 Widespread, corrected September 23, 2024
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected September 23, 2024
  • Z0155: Staff Training Requirements severity level 2, scope L2 Pattern, corrected September 23, 2024
  • Z0162: Compliance With Rules Health Care severity level 2, scope L2 Pattern, corrected December 28, 2024
  • Z0163: Nutrition and Hydration severity level 2, scope L2 Pattern, corrected September 23, 2024
  • Z0164: Activities severity level 2, scope L2 Pattern, corrected September 23, 2024
• December 12, 2023: 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 December 14, 2023
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected December 14, 2023

Substantiated abuse or neglect

• July 12, 2024: Failed to provide safe environment Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $375.00; report
  Rules: 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0036 (Service Plan – General)
  State’s findings

  The facility failed to provide appropriate supervision to the Alleged Victim (AV) according to his/her known risk for elopement. On or about July 12, 2024, AV eloped from the locked memory care unit during a staff shift exchange when staff were preoccupied with other duties. The facility's failure resulted in AV eloping the secured building, without staff knowledge, placing him/her at risk of harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• June 18, 2024: Failed to provide safe environment Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $375.00; report
  Rules: 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General)
  State’s findings

  On or about the evening of June 18, 2024, Alleged Victim (AV) and Witness 1 (W1), both residents of the facility and roommates, were involved in a physical altercation in which W1 pulled AV's hair during the encounter causing AV unreasonable discomfort. Based on facility documentation and interviews, AV moved into the facility on the same day as the incident. It was observed and reported that W1 immediately showed signs of having a negative reaction towards AV moving into the same apartment. As W1's behavior escalated towards AV, it was determined that the facility failed to implement appropriate interventions to protect AV from W1's aggressive behavior as they became acquainted with each other as new roommates. The facility failed to appropriately monitor W1 according to his/her known behavior and prior altercations. The failure resulted in a physical altercation, causing unreasonable discomfort to the AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• February 15, 2024: Failed to provide safe environment 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); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General)
  State’s findings

  On or about February 15, 2024, Alleged Perpetrator 2 (AP2), Alleged Perpetrator 3 (AP3), and Alleged Perpetrator 4 (AP4) transferred Alleged Victim (AV) against AV's wishes which led to a physical altercation. Based on facility documentation and interviews, at time of incident, AV was sitting in a chair in another resident's bathroom. AV became agitated and physically aggressive towards AP3 when AP3 asked AV to leave the bathroom and/or be escorted by AP3. Instead of leaving AV alone, AP3 went and got AP2 and AP4 to assist in getting AV out of the bathroom. Even though AV was swinging not wanting to stand up, AP2 and AP4 placed AV into a wheelchair that AP3 was holding. AV is care planned as independent with transfers and mobility. AP2, AP3, and AP4 forcibly removed AV in a rough manner and handled AV as a two-person transfer when AV is not care planned as a two person assist. AP2, AP3, and AP4 forcible actions caused a physical altercation between AV, AP2, AP3, and AP4 resulting in emotional harm and unreasonable discomfort for AV. AP2's, AP3's, and AP4's actions are considered physical abuse against AV. AP2, AP3, and AP4 failed to allow AV to exercise his/her resident rights by failing to treat AV with respect and dignity, failing to allow AV to refuse service, and failing to allow AV to receive services in a manner that protects privacy and dignity. AP2, AP3, and AP4 moderately violated AV's resident rights, which caused AV emotional harm. The facility is responsible for the supervision, training, and overall conduct of AP2, AP3, and AP4 when AP2, AP3, and AP4 are acting within the scope of his or her employment duties. The facility failed to provide AV with a safe home-like environment resulting in an incident in which the facility's staff moderately violated AV's resident rights, which constitutes abuse and is considered neglect of care.

• February 15, 2024: Failed to properly plan care Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $375.00; report
  Rules: 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0036 (Service Plan – General)
  State’s findings

  On or about February 15, 2024, the Alleged Victim (AV) suffered from at least 3 unwitnessed falls in the same day. Based on facility documentation and interviews, AV experienced multiple falls from January 25, 2024, through February 8, 2024, in which it was determined in the investigation that the facility failed to implement interventions and provide appropriate supervision related to AV's falls. The facility's failure resulted in AV experiencing several unwitnessed falls, causing unreasonable discomfort and knee pain, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• February 11, 2024: Failed to provide safe environment Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $1,125.00; report
  Rules: 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General)
  State’s findings

  The facility failed to provide appropriate supervision to the Alleged Victim (AV) according to his/her care needs. AV is care planned for mild to moderate disorientation and displays deficits in judgement. AV has a known history of wandering and exit seeking. On February 11, 2024, AV eloped from a secure unit twice; first incident occurred at 3 am and second incident occurred shortly after the first incident around 4:46am. The first incident, AV exited the facility without an escort and was found by assisted living staff who brought AV back to the memory care unit. The second incident, AV exited the facility without an escort after being toileted and shortly after the first incident and was found by maintenance workers who escorted AV back to the memory care unit. At time of incident, the weather forecast was rain with outside temperature around 44 degrees. Based on facility documentation and interviews, AV exited the memory care through a malfunctioning door. The facility's failure resulted in AV eloping the secured building, without staff knowledge, placing him/her at risk of harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• January 25, 2026: Failed to staff as indicated by ABST Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)
  State’s findings

  Based on interview and record review conducted during an investigation on 09/08/26, the facility’s failure to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident was substantiated. Findings include, but are not limited to: The facility’s posted staffing plan indicated: • For Day shift, 5 direct care staff; • For Swing shift, 4 direct care staff; and • For Night shift, 3 direct care staff. The facility’s staffing schedule dated 01/25/26 indicated the facility was not staffing to its posted staffing plan for 1 of 3 shifts reviewed. The facility’s failure to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident is a violation of Oregon Administrative Rules.

• December 25, 2025: Failed to staff as indicated by ABST Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)
  State’s findings

  Based on interview and record review conducted during an investigation on 09/08/26, the facility’s failure to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident was substantiated. Findings include, but are not limited to: The facility’s posted staffing plan indicated: • For Day shift, 5 direct care staff; • For Swing shift, 4 direct care staff; and • For Night shift, 3 direct care staff. The facility’s staffing schedule dated 12/25/25 indicated the facility was not staffing to its posted staffing plan for 1 of 3 shifts reviewed. The facility’s failure to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident is a violation of Oregon Administrative Rules.

• June 22, 2025: Failed to provide safe environment Licensing Violation; Level 3 - Moderate harm or potential for serious harm; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0036 (Service Plan – General)
  State’s findings

  On June 22, 2025, the Alleged Victim (AV) sustained a fracture to his/her left wrist as a result of an unwitnessed fall in the bathroom. According to facility documentation and staff interviews, AV attempted to transfer without assistance, which led to the fall. Per AV’s Service Plan, AV requires standby assistance for toileting. At the time of the incident, AV had been left alone in the bathroom by Alleged Perpetrator 2 (AP2), despite AP2 being aware of AV's required level of care. During the investigation, AP2 admitted to not following AV’s Service Plan at time of incident. AP2’s failure to provide the documented toileting assistance outlined in AV’s care plan constitutes neglect of care, which meets the definition of abuse. The facility failed to provide a safe environment for AV which is a violation of Oregon Administrative Rules.

• December 30, 2024: Failed to staff as indicated by 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 consistently staff to the levels, intensity and qualifications indicated by the Acuity-Based Staffing Tool (ABST). Inconsistencies were identified between the staffing schedule and the data produced by the ABST. Facility was not staffing to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

• November 23, 2024: Failed to staff as indicated by ABST Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)
  State’s findings

  On or about November 23, 2024, the facility failed to consistently staff to the levels, intensity and qualifications indicated by the Acuity-Based Staffing Tool (ABST). Inconsistencies were identified between the staffing schedule and the data produced by the ABST. Facility was not staffing to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

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 52 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.