Print Violation: 00409542-AP-360612

Provider Information

Tanner Spring Memory Care

23000 HORIZON DRIVE
West Linn, OR 97068

Date: 6/22/2025
Report number: 00409542-AP-360612
Type: Licensing Violation
Level: 3 - Moderate harm or potential for serious harm
Allegation: Failed to provide safe environment
Result: Substantiated
Rule(s) Violated: External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0036(2)(g)
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.