The Springs at Lake Oswego

Last inspection

January 21, 2026

Inspections

6, 17 deficiencies cited

Substantiated abuse

11

Substantiated licensing violations

16

Regulatory actions

0

Fines assessed

$8,326.00 (10 violations)

Current owner since

April 2, 2026

Inspections

• January 21, 2026: Kitchen, 1 deficiency cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
• April 30, 2025: Complaint Investig., 1 deficiency cited report
  • C0010: Licensing Complaint Investigation severity level 0
  • C0363: Acuity Based Staffing Tool - Updates & Plan severity level 2, scope L2 Widespread
• January 28, 2025: Kitchen, 1 deficiency cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
• April 15, 2024: Complaint Investig., 3 deficiencies cited report
  • C0260: Service Plan: General severity level 2, scope L2 Widespread
  • C0270: Change of Condition and Monitoring severity level 3, scope L3 Widespread
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Widespread
• January 29, 2024: Validation, 11 deficiencies cited report
  • C0000: Comment severity level 0
  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Isolated, corrected April 1, 2024
  • C0260: Service Plan: General severity level 2, scope L2 Pattern, corrected April 1, 2024
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Pattern, corrected April 1, 2024
  • C0300: Systems: Medications and Treatments severity level 2, scope L2 Pattern, corrected April 1, 2024
  Show all 14

  • C0303: Systems: Treatment Orders severity level 2, scope L2 Pattern, corrected April 1, 2024
  • C0305: Systems: Resident Right to Refuse severity level 2, scope L2 Isolated, corrected September 15, 2024
  • C0310: Systems: Medication Administration severity level 2, scope L2 Pattern, corrected April 1, 2024
  • C0325: Systems: Self-Administration of Meds severity level 2, scope L2 Isolated, corrected April 1, 2024
  • C0330: Systems: Psychotropic Medication severity level 2, scope L2 Isolated, corrected September 15, 2024
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Widespread, corrected April 1, 2024
  • C0372: Training Within 30 Days: Direct Care Staff severity level 2, scope L2 Widespread, corrected April 1, 2024
  • C0374: Annual and Biennial Inservice For All Staff severity level 2, scope L2 Widespread, corrected April 1, 2024
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Isolated, corrected September 15, 2024
• March 8, 2023: State Licensure, 0 deficiencies cited report
  • C0000: Comment severity level 0

Substantiated abuse or neglect

• February 4, 2025: 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); 411-054-0028 (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 a safe medication system by not following orders for the Alleged Victim’s (AV) Parkinson’s medication. Orders for the AV’s 3:30 pm Parkinson’s medication was not entered into the system, causing the AV to miss doses from approximately January 31, 2025, through February 03, 2025. The missed doses increased the AV’s Parkinson’s side effects, including tremors and difficulty sleeping causing the AV unreasonable discomfort and disruption in their daily routine, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• October 2, 2024: Failed to provide a safe medication administration system 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); 411-054-0055 (Medications and Treatments)
  State’s findings

  According to the documentation, the Alleged Perpetrator 2 (AP2) missed new orders to hold blood thinning medication after the Alleged Victim (AV) was discharged from the hospital after being diagnosed with a brain bleed. On or about October 01, 2024, the AV suffered a fall and hit their head. They were taken to the hospital and were diagnosed with a small brain bleed. The AV was discharged back to the facility on or about October 02, 2024. At approximately 3:24 PM, the hospital faxed new orders to the fax number provided by AP2. The hospital also called and left a voicemail for the AP2 stating new orders were being sent via fax. AP2 did not make the changes to hold the AV’s two blood thinning medications on the MAR and staff administered these medications after the AV returned. On or about October 03, 2024, the AP2 found the new orders and noticed the staff had administered the blood thinning medication. The AP2 sent the AV back to the hospital and was diagnosed with a medium sized brain bleed. The administration of the blood thinning medication caused the AV’s condition to worsen and required medical intervention, 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 resident rights, is considered neglect of care and constitutes abuse.

• September 30, 2024: Failed to properly plan care 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); 411-054-0036 (Service Plan – General)
  State’s findings

  According to the documentation, the facility failed to appropriately care plan interventions for the Alleged Victim’s (AV) change of condition. On or about August 29, 2024, the AV experienced a change of condition which triggered them to spend more time in the seated position. The facility did not update the service plan for interventions to do skin checks on the AV after the change of condition. On or about September 30, 2024, the facility was notified by a family member of a red spot on the AV’s buttocks. The facility found a red spot on the buttocks and notified the facility RN of the skin issue. On or about October 1, 2024, the facility nurse looked at the spot and found a dime sized red spot with skin peeling around the skin wound. The AV was then admitted to the hospital on or about October 2, 2024. An RN from the hospital called the facility on this date and notified them of the three pressure wounds, two of which needed to be drained. The facility’s failure to implement appropriate interventions after the AV experienced a change of condition resulted in multiple pressure wounds, two of which needed to be drained, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• May 8, 2024: Failed to properly plan care Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $1,013.00; 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

  According to the documentation, the facility failed to implement appropriate interventions for the Alleged Victim’s (AV) history of falls with injury. On or about May 08, 2024, the AV was found in the bathroom of their apartment on the ground. The AV was assessed for injuries and EMS was called to get further evaluations at the hospital. The hospital diagnosed the AV with Fractures to their L1, L2 and T11 vertebrae as a result from this fall. This was the second fall with fractures since approximately March 19, 2024, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• April 9, 2024: Failed to follow care plan Abuse: Neglect; Level 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance; fine $1,500.00; 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

  According to the documentation, the facility failed to follow the care plan and assure adequate equipment by not providing the Alleged Victim (AV) their call pendant after they changed the battery. On or about April 08, 2024, the facility staff replaced the battery in the AV’s call pendant but failed to give it back. On the morning of April 09, 2024, the AV was found on the floor, unresponsive and was unable to call for help because they didn’t have their call pendant. The facility staff called emergency services to assist the AV. The AV was sent to the hospital where they passed away which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• April 13, 2025: 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 have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules.

• April 13, 2025: 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 develop, maintain, and implement an Acuity-Based Staffing Tool in accordance with OAR 411-054-0037(1-7).

• April 11, 2025: 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 develop, maintain, and implement an Acuity Based Staffing Tool in accordance with OAR 411-054-0037(1-7).

• March 4, 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 the correct dose of blood thinning medication, placing he Alleged Victim (AV) at risk of serious harm. The AV was prescribed a higher dose of blood thinning medication on March 04 and 05 2025. The AP2 did not follow the updated physician’s orders and administered the incorrect dose for these two days. The failure to administer the correct dose delayed the AV’s treatment and placed them at risk for serious harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to administer the correct dose of medication, which is a violation of Oregon Administrative Rules.

• March 4, 2025: 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 have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this 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 97 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.