The Springs at Greer Gardens

Last inspection

October 21, 2025

Inspections

8, 22 deficiencies cited

Substantiated abuse

9

Substantiated licensing violations

21

Regulatory actions

2

Fines assessed

$42,357.00 (14 violations)

Current owner since

July 7, 2017

License conditions and other regulatory actions

• June 9, 2026 to September 11, 2026: License Condition, Failed to provide safe environment ALFCD26-00226; incident: CALMS - 00112647
  The following statement of violations stem from evidence and interviews collected from the licensing complaint unit investigation CC-79197 conducted on June 2, 2026.
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0036 (Service Plan – General); 411-054-0037 (Acuity-Based Staffing Tool); 411-054-0040 (Change of Condition and Monitoring); 411-054-0060 (Restraints and Supportive Devices); 411-054-0070 (Staffing Requirements and Training)
• July 21, 2023 to November 6, 2023: License Condition, Failed to use an ABST ALFCD23-00400; 4 incidents: OR0004044405, OR0004044403, OR0004044402, OR0004044401
  Facility failed to have a training program that includes methods to determine competency of direct care staff , documentation regarding each direct care staff ' s demonstrated competency and maintain written documentation of all trainings completed by each employee in accordance with OAR 411-054-0070(2)(a)(b).
  Rules: 411-054-0037 (Acuity-Based Staffing Tool); 411-054-0070 (Staffing Requirements and Training)

Inspections

• October 21, 2025: Kitchen, 1 deficiency cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
• May 27, 2025: Complaint Investig., 2 deficiencies cited report
  • C0362: Acuity Based Staffing Tool - Abst Time severity level 2, scope L2 Widespread
  • C0363: Acuity Based Staffing Tool - Updates & Plan severity level 2, scope L2 Widespread
• March 20, 2025: Re-Licensure, 5 deficiencies cited report
  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Isolated
  • C0360: Staffing Requirements and Training: Staffing severity level 2, scope L2 Widespread
  • C0363: Acuity Based Staffing Tool - Updates & Staffing Plan severity level 2, scope L2 Widespread
  • C0422: Fire and Life Safety: Training for Residents severity level 2, scope L2 Widespread
  • C0435: Emergency and Disaster Planning severity level 2, scope L2 Widespread
• October 9, 2024: Kitchen, 2 deficiencies cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
  • C0370: Staffing Requirements and Training ? Pre-service severity level 2, scope L2 Pattern
• February 13, 2024: Complaint Investig., 4 deficiencies cited report
  • C0301: Systems: Medication Administration severity level 2, scope L2 Isolated
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Isolated
  • C0340: Restraints and Supportive Devices severity level 2, scope L2 Isolated
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Isolated

Substantiated abuse or neglect

• May 20, 2026: 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); 411-054-0036 (Service Plan – General); 411-054-0060 (Restraints and Supportive Devices)
  State’s findings

  On or about May 20, 2026, the Alleged Victim (AV) was found on the floor of his/her room, wedged between his/her transfer pole and bed. AV's skin was a blue/ purple color and AV was gasping for air. AV was transferred to the hospital and admitted after his/her emergency room visit. The transfer pole in AV's room was not care planned, nor was it assessed or the resident informed of the risks and benefits of the device. At the time of this incident, AV was no longer able to use the transfer pole, and it should have been removed from the room. Respondent failed to ensure a safe environment for AV, by allowing the transfer pole to remain in place without properly assessing the device at any time, training staff, or documenting the use of the transfer pole. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

• August 21, 2024: Failed to provide inservice Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $169.00; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0070 (Staffing Requirements and Training)
  State’s findings

  According to the documentation, the facility failed to provide training to staff on how to safely transfer a resident resulting in the Alleged Victim (AV) to receive bruises on their hands. On or about August 21, 2024, the AV was found to have multiple bruises on both hands and forearms. These bruises were found on or about August 22, 2024. An internal investigation determined the facility staff were not being trained consistently on how to transfer residents safely without causing potential injury. The failure resulted in the AV sustaining numerous bruises and feeling pain or unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• July 7, 2023: Failed to perform adequate screening or assessment Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $188.00; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0060 (Restraints and Supportive Devices)
  State’s findings

  According to the documentation, the facility failed to obtain an order from their PCP for a bed rail for the Alleged Victim (AV) before installing the bed rail onto the AV’s bed. The failure resulted in the AV getting tangled in the bed rail causing skin tears and bruising, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• June 25, 2022: Failed to provide a safe medication administration system Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $250.00; report
  Rules: 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0055 (Medications and Treatments)
  State’s findings

  The facility failed to provide a safe medication administration system to ensure The Alleged Victim’s (AV) medications were administered as ordered. The failure resulted in AV being at serious risk of harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• May 13, 2022: Failed to assist with toileting Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $250.00; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0030 (Resident Services)
  State’s findings

  On or about May 13, 2022, the Alleged Victim (AV) was left in the same brief for over 24 hours without being changed. Staff arrived at the facility 24 hours later and AV was still in the same brief he/she was in when staff left. Alleged Perpetrator #2 (AP2) was assigned to AV's floor and did not change AV's brief during his/her shift, causing unreasonable discomfort. AP2's actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility failed to ensure AV's care needs were met or respond to internal allegations that AV's briefs weren't being changed. The facility failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• June 5, 2026: Failed to protect resident from financial exploitation Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare)
  State’s findings

  On or about June 5, 2026, the facility received information from a friend of the Alleged Victim (AV) that Alleged Perpetrator #2 (AP2) had accepted a tablet, along with keys to AV's house and car from AV. AP2 had access to AV's house, car, bank records, checkbooks, etc. AV passed away a few days after giving the items to AP2, so AV was not able to participate in the investigation. AP2 had full training and was aware they were not to accept any items from residents at the facility. AP2's actions are a violation of resident rights, are considered neglect of care and constitute financial abuse. The facility's failure to ensure AV's safety from financial abuse is a violation of Oregon Administrative Rules.

• June 2, 2026: Failed to provide safe environment Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0025 (Facility Administration)
  State’s findings

  The Executive Director failed to be responsible for the overall operation, quality of service, supervision, and ensuring facility conduct, which is a violation of Oregon Administrative Rules.

• June 2, 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 comply with Change of Condition and Monitoring requirements, which is a violation of Oregon Administrative Rules.

• June 2, 2026: Failed to provide safe environment Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0025 (Facility Administration)
  State’s findings

  Facility failed to ensure reasonable precautions must be exercised against any condition that may threaten the health, safety, or welfare of residents, which is a violation of Oregon Administrative Rules.

• May 20, 2026: Failed to use an ABST Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)
  State’s findings

  The facility failed to implement and maintain an Acuity-Based Staffing Tool in accordance with OAR 411-054-0037(1-7), 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 100 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.