Wellsprings Assisted Living Facility

Last inspection

June 5, 2025

Inspections

5, 34 deficiencies cited

Substantiated abuse

3

Substantiated licensing violations

13

Regulatory actions

2

Fines assessed

$813.00 (3 violations)

Current owner since

May 1, 2023

License conditions and other regulatory actions

• October 8, 2024 to July 3, 2025: License Condition, Failed to provide safe environment ALFCD24-00796; incident: CALMS - 00063202
  The facility allegedly failed to operate is substantial compliance with Oregon Administrative Rules.
  Rules: 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0034 (Resident Move-In and Evaluation); 411-054-0036 (Service Plan – General); 411-054-0040 (Change of Condition and Monitoring); 411-054-0045 (Resident Health Services)
• December 27, 2022 to June 25, 2024: License Condition, Failed to provide a safe medication administration system ALFCD22-01180; 2 incidents: OR0003707401, OR0003707400
  Every facility shall adopt an acuity-based staffing tool (ABST) to determine appropriate staffing levels for the facility. Each facility may choose to adopt the Department ' s ABST or may choose to adopt a different ABST per OAR 411-054-0037(1).
  Rules: 411-054-0037 (Acuity-Based Staffing Tool); 411-054-0055 (Medications and Treatments)

Inspections

• June 5, 2025: Kitchen, 1 deficiency cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
• September 19, 2024: Change of Owner, 28 deficiencies cited report
  • C0156: Facility Administration: Quality Improvement severity level 2, scope L2 Widespread
  • C0200: Resident Rights and Protection severity level 2, scope L2 Pattern
  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Isolated
  • C0252: Resident Move-in and Eval: Res Evaluation severity level 2, scope L2 Isolated
  • C0260: Service Plan: General severity level 2, scope L2 Pattern
  Show all 29

  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Pattern
  • C0280: Resident Health Services severity level 2, scope L2 Pattern
  • C0282: RN Delegation and Teaching severity level 2, scope L2 Isolated
  • C0290: Res Hlth Srvc: On- and Off-Site Health Srvc severity level 2, scope L2 Isolated
  • C0295: Infection Prevention & Control severity level 2, scope L2 Widespread
  • C0300: Systems: Medications and Treatments severity level 2, scope L2 Widespread
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Pattern
  • C0305: Systems: Resident Right to Refuse severity level 2, scope L2 Isolated
  • C0310: Systems: Medication Administration severity level 2, scope L2 Pattern
  • C0320: Systems: Medication & Treatment-General severity level 2, scope L2 Widespread
  • C0325: Systems: Self-Administration of Meds severity level 2, scope L2 Pattern
  • C0330: Systems: Psychotropic Medication severity level 2, scope L2 Isolated
  • C0340: Restraints and Supportive Devices severity level 2, scope L2 Isolated
  • C0365: Staffing Rqmt and Training: Training Rqmts severity level 2, scope L2 Widespread
  • C0370: Staffing Rqmts and Training: Caregiver Rqmts severity level 2, scope L2 Pattern
  • C0372: Training within 30 days: Direct Care Staff severity level 2, scope L2 Pattern
  • C0374: Annual Training and Other Requirements severity level 2, scope L2 Pattern
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread
  • C0613: General Building: Doors-Walls, Cleanable severity level 2, scope L2 Widespread
  • H1510: Individual Rights Settings: Privacy, Dignity severity level 2, scope L2 Pattern
  • H1515: Physical Setting: Individual Accessible severity level 2, scope L2 Widespread
  • H1521: Individual Visitors: Any Time severity level 2, scope L2 Pattern
  • H1580: Limitations: Threats To Health And Safety severity level 2, scope L2 Pattern
• December 18, 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 February 28, 2024
• October 6, 2022: Complaint Investig., 3 deficiencies cited report
  • C0010: Licensing Complaint Investigation severity level 2, scope L2 Isolated
  • C0301: Systems: Medication Administration severity level 2, scope L2 Isolated
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Isolated
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Pattern
• August 18, 2022: 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 October 17, 2022

Substantiated abuse or neglect

• November 22, 2023: Failed to provide safe environment 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); 411-054-0036 (Service Plan – General)
  State’s findings

  According to the documentation, the facility failed to provide a safe environment for the Alleged Victim (AV) who has a history of leaving the facility without assistance. On or about November 22, 2023, the AV left the facility without assistance in inclement weather causing unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• December 26, 2022: Failed to provide a safe medication administration system Abuse: Neglect; Level 2 - Minor harm or potential for moderate 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 facility failed to provide a safe medication administration system to ensure PRN pain medication was ordered timely. The failure resulted in the Alleged Victim to not have PRN pain medication available for approximately two (2) days causing increased pain, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• April 5, 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: 411-054-0025 (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 April 4, 2022, the Alleged Victim (AV) was given his/her last medication for a cardiac condition. The facility failed to timely re-order AV's medication from the pharmacy to allow for updated prescription to come from AV's care provider in time to allow for the refill. AV's family had to go to the pharmacy to pick up the medication and deliver it to the facility so AV would not miss his/her medication. AV was not injured, however, AV was placed at risk for harm. The facility's failure to provide a safe medication administration system is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• July 30, 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 complete or update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly as required. The facility’s failure is a violation of Oregon Administrative Rules.

• July 6, 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 complete or update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly as required. The facility’s failure is a violation of Oregon Administrative Rules.

• January 8, 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 update staffing plan based on ABST. The facility’s failure is a violation of Oregon Administrative Rules.

• January 7, 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 update the staffing plan based on ABST. The facility’s failure is a violation of Oregon Administrative Rules.

• January 6, 2025: Failed to administer medication as ordered 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 medications as prescribed to the Alleged Victim (AV) placing them at risk for harm. On or about January 06, 2025, the AV was given their morning dose of a medication instead of their evening dose. The morning dose is almost five times more medication than the evening dose. The facility staff contacted the facility administration on next steps and implemented safety checks. The side effects the AV experienced due to the over medication was dizzy and they felt sick, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to ensure all medication was administered as prescribed 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 38 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.