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Clint Wolf still has flashbacks to what he witnessed at Willamette Springs Memory Care.
“I guess it’s PTSD,” he says. “Things no person should see.”
Wolf was there for his wife, Michelle. She was diagnosed with early-onset dementia eight years ago, at age 52. The bubbling grandmother and former pediatric medical assistant became increasingly confused and, as is common with this disease, sometimes violent.
After caring for Michelle at home for years, her kids began hunting for a specialized care facility. They found Willamette Springs, which checked all the boxes. It was near their Corvallis home, took Medicaid, and had an opening. They placed Michelle there in March 2023.
What the Wolfs didn’t know was that Willamette Springs was under “enhanced supervision” after regulators had discovered dozens of instances of serious abuses.
But the probational status of Willamette Springs was buried on a state website.
“It was like a bad bill of sale,” says Michelle’s son, Andrew. “We had no idea what we were getting into.”
State Sen. Sara Gelser Blouin (D-Corvallis) did. In 2021, problems at Willamette Springs spurred Gelser Blouin to spearhead legislation to address short-staffing at senior care facilities.
Two years later, little seemed to have changed when Michelle Wolf entered the memory care facility.
What happened next helped spur a rare move by the Oregon Department of Human Services. Its regulators are now threatening to shut the facility down by denying a routine license renewal. But Willamette Springs continues to operate under its current owners, much to the chagrin of a state senator and the family who was unaware of the conditions the wife and mother would encounter.
When Gelser Blouin heard Michelle’s story, she remembers thinking, how is this happening again?
Soon after placing their mother there, Andrew Wolf and his sister, Taylor, noticed conditions at Willamette Springs changed after dark, when the day shift went home and the facility’s roughly 70 residents had to be put to bed. “Patients pushing around other patients,” Taylor says, “Evenings were mayhem.”
Clint became so concerned about his wife’s care that he was eventually spending every day at Michelle’s side.
It was what he witnessed then that haunts him now. Staff members were scarce. Fecal matter was left ignored on the carpet. Residents wandered lost in various states of undress. At least once a week, he says, he’d watch someone fall with no caregiver in sight.
Within months, Michelle developed unexplained bruises, lost nearly 60 pounds, and suffered a brain hemorrhage after a bad fall in August 2023. She’d been given a sedative before bed and then left alone, in violation of state rules, inspectors later determined. Staff wasn’t helping her eat, contrary to doctor’s orders. Michelle died last March—an end hastened, her family believes, by her treatment at Willamette Springs.
The Wolfs reported what they saw to the state, which eventually substantiated three of their claims of abuse.
And the Wolfs weren’t the only ones raising concerns. Over the past two years, the state has cited the facility for 50 substantiated instances of abuse. The state said in September that its owners owe nearly $19,000 in unpaid fines.
Willamette Springs Memory Care was opened in 2016 by a Salem company, Mosaic Management Inc., which operates several dozen senior living facilities across the Western United States. Mosaic operates its communities in compliance with regulatory requirements, a spokesperson said in a statement.
It’s run by Doug Sproul, who ran a construction business prior to making the switch to managing senior living facilities in the 2000s. Sproul didn’t take WW up on a request for an interview, but court records show he has done well for himself. As of 2020, Sproul was making $360,000 a year. In 2022, he bought a $5 million home in Salem on a private lake.
Mosaic is currently hiring at its Salem facility, where entry level pay is $15.75 an hour. That’s a few dimes more than what’s advertised at a nearby Starbucks, although job duties at the coffee shop don’t involve wiping seniors’ behinds.
The low pay has led to a steady stream of disgruntled employees, who sometimes leave scathing reviews online. Recent examples abound on Indeed, where one poster, identified as a former Mosaic caregiver in Corvallis, wrote in 2023: “chronically understaffed, underpaid, disrespected and overworked.”
Short-staffing is rampant in the senior living industry, a fact that Sproul emphasized in a written statement to WW. “Our priority has always been resident care, and we continue to work diligently to ensure residents receive the care they need,” he said.
At Willamette Springs, the Wolf family says, the problem was exacerbated by high turnover. Michelle’s caregivers tended to be very young and rarely seemed to stick around long, the Wolfs noted. “It’s a hard job,” Taylor Wolf says. “I don’t think they were compensated enough to make them want to stay.”
Over the years, several former employees have taken their concerns to court. Most notable was Cynthia Scholer, a former sales director who joined Mosaic in 2016. She was responsible for filling beds.
In her legal complaint, filed in 2020, a few years after she was laid off, she described a company undergoing rapid growth and reaping “exceptional profits” but short-staffing its facilities, “which resulted in compliance and safety issues for the residents and staff members.”
After a series of failed inspections led the state to restrict admissions to Willamette Springs, Scholer says she was sent there in 2018 to fix the problems. What she discovered was alarming. “The existing staff was overworked, and the schedule logs posted for DHS appeared to have been falsified,” she says.
She told her boss, and word reached Sproul, who was “livid” and demanded that she not to go back, she alleged. “[Scholer] believes that her involvement with the incident at Willamette Springs was ended because of her complaints about compliance issues and [management’s] attempted cover-up of the incident,” reads the legal complaint. At one point, Sproul allegedly told Scholer he was considering filing bankruptcy to avoid paying state fines. Scholer took a job at another senior living chain.
Mosaic has denied her allegations, and the parties later agreed to drop the suit.
Regulators began taking a closer look at Willamette Springs in 2022, after it had accumulated 37 serious abuse violations and was slow to implement fixes. The state enrolled the facility in a program called “Enhanced Oversight & Supervision.”
That program is supposed to weed out problems by amping up inspections.
But it didn’t draw regulators’ attention to the conditions Michelle Wolf encountered at Willamette Springs. In September 2023, only a month after she hit her head, inspectors came by and found conditions so satisfactory that they removed Willamette Springs’ enhanced supervision.
It didn’t take long before the facility was back on regulators’ radar. In March, an inspector arrived to find residents struggling to eat in the dining room with no caregivers in sight.
“Multiple residents were observed wandering the halls, walking into other residents’ rooms, and asking this surveyor where they should go, with no caregivers to assist,” the inspector noted.
Another inspector noticed similar short-staffing in July. By this time, the state had also investigated the Wolf family’s complaints. Citing a “pattern of repeated substantial noncompliance,” the state warned in September that it would seek to deny the facility’s routine request to renew its license.
Whether the state follows through with its threat remains to be seen. Willamette Springs administrators have demanded a hearing, which has yet to be scheduled.
Gelser Blouin faults the Department of Human Services for not moving more quickly to oust Willamette Springs’ owners. “This should have been done years ago,” she says.
In response to questions, a spokesperson for DHS said the agency was in the process of tightening regulatory oversight of facilities like Willamette Springs. The agency hired a new deputy director to lead the effort last year, and is currently “updating rules and guidelines for how long a facility can demonstrate on-again, off-again compliance before it is at risk of losing its license.”
The facility once again passed its latest inspection in November. The state lifted its restriction on admissions, and Willamette Springs is no longer listed on the state’s website for troubled facilities.
Clint Wolf says that’s wrong. “They should have to have a scarlet letter on their door for everybody to see.”