Bonaventure of Albany

    420 NW Geri St, Albany, OR 97321
    • Independent Living
    • Assisted Living
    • Memory Care

    Beautiful new community, caring staff.

    I toured the community and was impressed by the beautiful, brand-new building, clean well-appointed apartments (studios to two-bedrooms) and plentiful amenities - theater, salon, library, exercise and game rooms, outings and shuttle. Staff were consistently friendly, communicative and accommodating; my parent felt comfortable, engaged, and well cared for. Overall a very nice, well-maintained community with great activities and dining - I would recommend it for independent or assisted living.

    Loved one of resident
    Jul 2026

    Pricing

    Prices shown are estimates and subject to change. Contact your senior living advisor for current pricing.

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    Amenities

    Healthcare services

    • Activities of daily living assistance
    • Assistance with bathing
    • Assistance with dressing
    • Assistance with transfers
    • Coordination with health care providers
    • Medication management
    • Mental wellness program

    Healthcare staffing

    • 12-16 hour nursing
    • 24-hour call system
    • 24-hour supervision

    Meals and dining

    • Diabetes diet
    • Meal preparation and service
    • Restaurant-style dining
    • Special dietary restrictions

    Room

    • Air-conditioning
    • Cable
    • Fully furnished
    • Housekeeping and linen services
    • Kitchenettes
    • Private bathrooms
    • Telephone
    • Wifi

    Memory care community services

    • Mild cognitive impairment
    • Specialized memory care programming

    Transportation

    • Community operated transportation
    • Transportation arrangement
    • Transportation arrangement (medical)
    • Transportation arrangement (non-medical)
    • Transportation to doctors appointments

    Common areas

    • Beauty salon
    • Computer center
    • Dining room
    • Fitness room
    • Gaming room
    • Garden
    • Outdoor space
    • Small library
    • Wellness center

    Community services

    • Concierge services
    • Fitness programs
    • Move-in coordination

    Activities

    • Community-sponsored activities
    • Planned day trips
    • Resident-run activities
    • Scheduled daily activities

    Reviews

    3.90·(84)

    Overall rating

    1. 5
    2. 4
    3. 3
    4. 2
    5. 1
    • Care

      3.3
    • Staff

      3.8
    • Meals

      3.0
    • Amenities

      4.1
    • Value

      2.3

    Pros

    • Friendly, caring staff
    • Engaging and varied activity program
    • Extensive on-site amenities (salon, movie theater, library)
    • Clean, modern, well‑appointed building
    • Spacious and varied apartment floorplans
    • Supportive transition and end‑of‑life assistance
    • On-site transportation and organized outings
    • Restaurant-style dining options reported by some
    • Pet-friendly community
    • Pleasant location and campus landscaping

    Cons

    • High frontline staff turnover
    • Inconsistent staff training and competency
    • Staffing shortages causing delays in care
    • Inconsistent medication administration and clinical oversight
    • Unreliable meal quality, availability, and service timing
    • Inconsistent housekeeping and sanitation practices
    • Weak communication and follow-through from management
    • Billing, deposit, and fee transparency concerns
    • Limited disclosure about Medicaid policies
    • Insufficient outdoor and pet amenities and perimeter safety
    • Inconsistent enforcement of smoke‑free policies
    • Variable suitability for higher‑acuity clinical needs

    Summary of reviews

    Bonaventure of Albany presents a split picture: the campus and apartment offerings receive consistent praise for being modern, well‑appointed, and comfortable, and the community features a broad range of amenities (salon, theater, library, shuttle and outings) that many residents and families find attractive. Reviewers frequently commend individual caregiving staff, activity teams, and several administrative employees for being personable and supportive; some families specifically noted strong assistance around hospital transitions and end‑of‑life support.

    At the same time, a recurrent operational theme is instability in staffing. Multiple accounts indicate high turnover among frontline caregivers and care coordinators, with associated gaps in training and continuity. That instability is linked in reviews to delays in attending to residents, inconsistent bathing and escorting for walks, and concerns about medication administration and clinical oversight. While some reviewers highlight long‑tenured or especially attentive employees, others describe variability in competence and responsiveness across shifts.

    Dining and environmental services are another area of mixed performance. Several families describe appealing, restaurant‑style meals and an engaged kitchen staff, while others report frequent menu substitutions, limited availability of advertised entrees, reliance on premade items, long service waits, and inconsistent presentation. Housekeeping and sanitation practices are similarly variable: the building and common areas are often described as clean and well maintained, but there are repeated notes about inconsistent room cleaning schedules, missed housekeeping, and isolated sanitation concerns.

    Activities and amenities are a clear strength for many residents. The site offers a robust calendar, regular social events, outings, and multiple indoor recreational spaces that contribute to an active community atmosphere. The campus is largely described as welcoming and bright, and pet‑friendly policies are a positive for many families. However, reviewers also flagged limited or unsafe outdoor resident spaces and concerns about perimeter safety and dog access near a busy highway.

    Management and administrative performance shows uneven results. Positive accounts point to helpful, accessible administrative staff and effective local leadership; negative accounts cite weak communication, poor follow‑through on promises, and cases of billing or deposit handling problems — including allegations of deposit and fee disputes. There are also comments about unclear disclosure of Medicaid policies and of additional fees for certain care levels, which prospective residents should clarify in writing.

    In summary, Bonaventure of Albany offers a high‑quality physical environment, substantial activities programming, and notable individual staff strengths. These positives coexist with operational weaknesses that have affected clinical consistency, dining service reliability, housekeeping regularity, and administrative transparency. Prospective residents and families should verify current staffing levels and turnover, observe meal service and housekeeping routines, review medication‑administration and higher‑acuity care protocols, and obtain clear, written explanations of billing, deposit, and Medicaid policies before committing.

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    Location

    Map showing location of Bonaventure of Albany

    Bonaventure of Albany is located at 420 NW Geri St, Albany, OR, 97321.

    About Bonaventure of Albany

    Bonaventure of Albany sits near a river and open green fields, offering a mix of independent living, assisted living, and memory care. The building features enhanced front door security, so residents can feel safe. The staff stays on duty around the clock, and every unit has a nurse call system for emergencies. The facility takes care of chores like weekly housekeeping, linen service, maintenance, and all-inclusive utilities, so there's no need to worry about bills piling up. Suites come in different sizes, including studios, one-bedroom, and two-bedroom units, and memory care has its own private suites too, with safety in mind like wall safes, microwaves in the units, and washer/dryer hookups.

    Residents can set their own temperature with individually controlled thermostats, which suits a lot of folks who run hot or cold these days. The facility offers anytime dining, and there's a restaurant-style dining room, a café with coffee, pastries, and frozen yogurt, plus meal service with snacks, so you won't go hungry no matter your schedule. There's a monthly wellness clinic for check-ups, and a nurse on hand helps keep an eye on everyone's well-being. For relaxation or therapy, there's a whirlpool room.

    Activities go on seven days a week-puzzles in the puzzle room, cards in the hospitality suite with shuffleboard and poker tables, TV and movie time in the TV and theater rooms, billiards, or a stop at the fitness center or activity center if you want to keep moving. Outdoor walking paths and garden areas let people get fresh air, and the patios and balconies in independent living units make for a nice spot to relax. There's also a beauty/barber salon and a full-service salon if someone wants a haircut or just a bit of pampering.

    Transportation comes free for residents, making appointments and trips to town much easier for those who don't drive. There's private mailboxes, a private dining room for family visits, plenty of indoor and outdoor leisure spaces, and a library for quiet reading. Residents can use computers at work stations or enjoy fireplaces and comfortable sitting areas.

    Bonaventure of Albany tries to give residents community, care, and comfort with a straightforward approach, focusing on daily life and keeping things simple and safe. Memory care services support those with Alzheimer's or other dementia, with staff who help each person according to their needs. With 54 beds and many different amenities, it's a place that covers the basics while offering a few special touches here and there for daily enjoyment.

    About Bonaventure

    Bonaventure of Albany is managed by Bonaventure.

    Founded in 1999 and headquartered in Salem, Oregon, Bonaventure Senior Living is a family-owned company operating 28 communities across Washington, Oregon, and Colorado. They offer independent living, assisted living, and memory care services with their "Retirement Perfected™" philosophy.

    People often ask...

    Bonaventure of Albany offers competitive pricing, with rates starting at a cost of $4,440 per month.

    Bonaventure of Albany offers independent living, assisted living, and memory care.

    There are 35 photos of Bonaventure of Albany on Mirador.

    Yes, Bonaventure of Albany allows residents to age in place and adjust their level of care as needed.

    The full address for this community is 420 NW Geri St, Albany, OR 97321.

    No, Bonaventure of Albany does not offer respite care. Respite care in assisted living communities provides temporary, short-term relief for primary caregivers by offering professional care for their loved ones. It allows individuals to stay in an assisted living community for a limited time, giving caregivers a break while ensuring residents receive necessary support and assistance with daily activities.

    Safety & Compliance

    In Oregon, the Department of Human Services' Aging & People with Disabilities program licenses assisted living and residential care facilities, conducting inspections, complaint investigations, and renewals.

    License number50R430
    StatusActive
    Facility typeResidential Care Facility
    Capacity23 residents
    LicenseeBonaventure Of Albany LLC
    EffectiveDecember 7th, 2015
    Special certificationMemory Care
    View the official license record

    Inspection Reports

    156

    Reports

    0

    Type A Citations

    0

    Type B Citations

    6

    Complaints

    10

    Years

    01 Dec 2025Inspection
    Investigated the allegation and identified a failure to provide documentation upon request. The finding constitutes a rule violation.
    • LicensingFailed to cooperate with an investigation
    04 Aug 2025Kitchen
    Identified multiple sanitation and food-handling deficiencies in the kitchen, indicating noncompliance with required food sanitation rules.
    • DeficiencyResident Services Meals, Food Sanitation Rule
    • DeficiencyInspections and Investigation: Insp Interval
    04 Aug 2025Kitchen
    Identified multiple sanitation and food safety deficiencies in the kitchen and memory care areas, with repeated findings and ongoing corrective actions planned and implemented.
    • DeficiencyResident Services Meals, Food Sanitation Rule
    • DeficiencyInspections and Investigation: Insp Interval
    • DeficiencyAdministration Compliance
    04 Jul 2025Inspection
    Investigated and determined a violation of Oregon Administrative Rules due to an outdated ABST and inconsistencies between the resident roster, care plans, and ABST data.
    • LicensingFailed to use an ABST
    24 Apr 2025Licensure
    Found staffing and fire-safety deficiencies: night shifts lacked adequate awake direct care staff to meet residents' needs and evacuation requirements; fire drills and related staff safety instruction were not conducted according to the required schedule.
    • DeficiencyStaffing Requirements and Training: Staffing
    • DeficiencyFire and Life Safety: Safety
    10 Apr 2025Licensure
    Identified multiple deficiencies across service planning, infection control, psychotropic medication, administration, staffing, environment, and nutrition with inadequate updates, monitoring, and compliance.
    • DeficiencyService Plan: General
    • DeficiencyChange of Condition and Monitoring
    • DeficiencyInfection Prevention & Control
    • DeficiencySystems: Psychotropic Medication
    • DeficiencyAdministrator Qualification and Requirements
    • DeficiencyAcuity Based Staffing Tool - ABST Time
    • DeficiencyAcuity Based Staffing Tool - Updates & Staffing Plan
    • DeficiencyInspections and Investigation: Insp Interval
    • DeficiencyDoors, Walls, Elevators, Odors
    • DeficiencyHeating and Ventilation
    • DeficiencyAdministration Compliance
    • DeficiencyCompliance with Rules Health Care
    • DeficiencyNutrition and Hydration
    06 Feb 2025Abuse: Neglect
    Found that a safe environment was not provided, creating fall risk for the individual. A $500 fine was assessed.
    • AbuseFailed to provide safe environment
    04 Dec 2024Abuse: Neglect
    Investigated a medication administration incident and found the provider failed to ensure a safe medication administration system, resulting in abuse and neglect.
    • AbuseFailed to provide a safe medication administration system
    24 Oct 2024Inspection
    Investigated and found violations for failing to provide a safe medication administration system. A staff member administered the wrong hormone dosage, resulting in hospitalization.
    • LicensingFailed to provide a safe medication administration system
    13 Oct 2024Abuse: Neglect
    Found that the care provider failed to properly plan and mitigate a resident's fall risk, resulting in multiple falls and a fracture, constituting abuse and neglect.
    • AbuseFailed to properly plan care
    09 Aug 2024Abuse: Neglect
    Found a neglect violation for failing to provide a safe environment, resulting in an injury. A $500 fine was assessed.
    • AbuseFailed to provide safe environment
    06 Aug 2024Licensure
    Identified deficiencies in kitchen sanitation and infection control; follow-up showed substantial compliance.
    • DeficiencyComment
    • DeficiencyResident Services Meals, Food Sanitation Rule
    • DeficiencyInfection Prevention & Control
    • DeficiencyAdministration Compliance
    06 Aug 2024Licensure
    Identified sanitation and infection prevention deficiencies in the kitchen, with a follow-up visit showing substantial compliance.
    • DeficiencyComment
    • DeficiencyResident Services Meals, Food Sanitation Rule
    • DeficiencyInfection Prevention & Control
    27 Apr 2024Inspection
    Investigated allegations of unsafe medication administration and found a failure to provide a safe system that led to a urinary tract infection.
    • LicensingFailed to provide a safe medication administration system
    05 Apr 2024Abuse: Neglect
    Found safety deficiencies that led to multiple falls and injuries; abuse and neglect were substantiated.
    • AbuseFailed to provide safe environment
    23 Dec 2023Abuse: Neglect
    Investigated a complaint and found a resident fell in an unsafe doorway causing a head injury, indicating neglect and abuse; a $2,500 fine was assessed.
    • AbuseFailed to provide safe environment
    02 Dec 2023Abuse: Neglect
    Investigated the complaint and found a safety deficiency resulting in neglect and abuse, with a $2,500 fine assessed.
    • AbuseFailed to provide safe environment
    30 Nov 2023Abuse: Neglect
    Investigated and found that a safety failure allowed an aggressive resident to harm another resident, constituting abuse and neglect.
    • AbuseFailed to provide safe environment
    28 Nov 2023Abuse: Neglect
    Found that a resident did not receive a safe environment, resulting in a head injury and left hip pain from a fall, indicating neglect and abuse.
    • AbuseFailed to provide safe environment
    18 Nov 2023Abuse: Neglect
    Found a failure to provide a safe environment that led to injuries. Substantiated abuse/neglect; a $2,500 fine was assessed.
    • AbuseFailed to provide safe environment
    05 Nov 2023Abuse: Neglect
    Investigated an allegation of neglect and found an unsafe environment that led to a resident injury; a $2,500 fine was assessed.
    • AbuseFailed to provide safe environment
    23 Oct 2023Abuse: Neglect
    Identified neglect of care and abuse due to failure to properly plan care and update the resident's service plan to manage metabolic risks, which led to multiple falls. A $1,125 fine was assessed.
    • AbuseFailed to properly plan care
    09 Oct 2023Abuse: Neglect
    Found that a safe environment was not provided, resulting in a bruise to a resident from a resident-to-resident altercation. A fine was assessed.
    • AbuseFailed to provide safe environment
    04 Oct 2023Abuse: Neglect
    Found violations for failing to follow the care plan and monitor metabolic markers, resulting in four falls and an elbow laceration. A $250 fine was assessed.
    • AbuseFailed to follow care plan
    24 Sept 2023Abuse: Neglect
    Found failure to provide a safe environment, as a resident exited the secured area without an alarm, risking harm. A $375 fine was assessed.
    • AbuseFailed to provide safe environment
    04 Sept 2023Abuse: Neglect
    Investigated the incident and found a failure to provide a safe environment resulting in minor harm; a $375.00 fine was assessed.
    • AbuseFailed to provide safe environment
    24 Jul 2023Abuse: Neglect
    Found a failure to provide a safe environment that led to resident injuries; a $500 fine was assessed.
    • AbuseFailed to provide safe environment
    06 Jul 2023Licensure
    Identified extensive sanitation and maintenance deficiencies in the kitchen during the initial survey, including debris, damaged equipment, and improper food storage. A follow-up visit determined substantial compliance.
    • DeficiencyComment
    • DeficiencyResident Services Meals, Food Sanitation Rule
    06 Jul 2023Licensure
    Identified sanitation and staffing deficiencies in kitchen operations, with a follow-up showing substantial compliance after remediation.
    • DeficiencyComment
    • DeficiencyResident Services Meals, Food Sanitation Rule
    • DeficiencyStaffing Requirements and Training – Pre-Serv
    • DeficiencyAdministration Compliance
    03 Jul 2023Abuse: Neglect
    Investigated found a failure to provide a safe medication administration system, leading to missed pain medication doses and patient discomfort.
    • AbuseFailed to provide a safe medication administration system
    03 Jul 2023Abuse: Neglect
    Identified a failure to provide a safe medication administration system that led to two missed doses of pain medication and resulting pain.
    • AbuseFailed to provide a safe medication administration system
    24 May 2023Inspection
    Investigated and found that a staff member failed to protect a resident from financial exploitation, allowing theft of prescribed opioids.
    • LicensingFailed to protect resident from financial exploitation
    15 May 2023Abuse: Neglect
    Found a violation of resident rights and neglect/abuse due to failure to protect a resident from verbal abuse and to address increasing behavioral needs.
    • AbuseFailed to properly plan care
    04 May 2023Inspection
    Determined a resident was financially exploited due to failure to protect from exploitation; the perpetrator could not be identified. Found protection failures violated Oregon Administrative Rules.
    • LicensingFailed to protect resident from financial exploitation
    21 Apr 2023Complaint
    Found deficiencies in mobility assistance and staffing levels.
    • DeficiencyLicensing Complaint Investigation
    • DeficiencyResident Services: Adls
    • DeficiencyStaffing Requirements and Training: Staffing
    04 Apr 2023Inspection
    Found mobility assistance not provided, with minor-harm potential. The allegation was substantiated.
    • LicensingFailed to provide service
    28 Mar 2023Abuse: Neglect
    Found a violation of a safe medication administration system leading to neglect and abuse; a $250 fine was assessed.
    • AbuseFailed to provide a safe medication administration system
    28 Feb 2023License Condition
    Investigated the allegation of not using an ABST and found noncompliance with the ABST requirement.
    • Regulatory ActionFailed to use an ABST
    15 Feb 2023Abuse: Neglect
    Found deficiencies in planning care for exit seeking, creating risk of harm and constituting neglect and abuse; a fine was assessed.
    • AbuseFailed to properly plan care
    01 Feb 2023Inspection
    Found insufficient qualified awake direct care staff to meet residents' 24-hour needs.
    • LicensingFailed to provide appropriate staffing
    13 Jan 2023Complaint
    Identified deficiencies in maintaining an up-to-date ABST; it was not updated timely, former residents were not archived, new residents were not added, and changes in residents’ conditions were not reflected promptly.
    • DeficiencyLicensing Complaint Investigation
    • DeficiencyAcuity-Based Staffing Tool
    13 Jan 2023Complaint
    Found that staff did not wipe residents during toileting, indicating failure to exercise reasonable precautions.
    • DeficiencyLicensing Complaint Investigation
    • DeficiencyReasonable Precautions
    09 Jan 2023Abuse: Neglect
    Found abuse and neglect due to failure to protect a resident from emotional and physical harm caused by ongoing verbal and physical aggression by another resident.
    • AbuseFailed to properly plan care
    03 Jan 2023Abuse: Neglect
    Investigated an allegation of neglect about falls and found failure to plan for falls, creating safety risks; a fine was assessed.
    • AbuseFailed to properly plan care
    03 Jan 2023Abuse: Neglect
    Found abuse and neglect for failing to provide a homelike environment; assessed a $188 fine.
    • AbuseFailed to provide a homelike environment
    03 Jan 2023Abuse: Neglect
    Found neglect and abuse for failing to keep a resident safe; a $938 fine was assessed.
    • AbuseFailed to assure resident was safe
    03 Jan 2023Abuse: Neglect
    Found neglect due to failure to plan fall-related care, with a civil penalty assessed.
    • AbuseFailed to properly plan care
    08 Dec 2022License Condition
    Investigated and found a deficiency for failing to use an ABST.
    • Regulatory ActionFailed to use an ABST
    15 Nov 2022Inspection
    Investigated and identified a hygiene-related deficiency that could threaten residents' health and safety.
    • LicensingFailed to provide or assist with hygiene
    07 Sept 2022Licensure
    Identified deficiencies in kitchen cleanliness and administration during the visits; follow-up showed substantial compliance.
    • DeficiencyComment
    • DeficiencyResident Services Meals, Food Sanitation Rule
    • DeficiencyAdministration Compliance
    07 Sept 2022Licensure
    Found kitchen cleanliness deficiencies and equipment issues during the initial visit; a follow-up determined substantial compliance with the rules.
    • DeficiencyComment
    • DeficiencyResident Services Meals, Food Sanitation Rule
    01 Sept 2022Inspection
    Found a violation for failing to submit timely or adequate staffing documentation; a $6,750 fine was assessed.
    • LicensingFailed to submit timely or adequate staffing documentation
    24 Aug 2022Complaint
    Identified deficiencies related to reasonable precautions during the complaint investigation.
    • DeficiencyLicensing Complaint Investigation
    • DeficiencyReasonable Precautions
    24 Aug 2022Complaint
    Identified multiple deficiencies in service delivery, staffing, and medication practices that could cause moderate harm to residents.
    • DeficiencyLicensing Complaint Investigation
    • DeficiencyService Plan: General
    • DeficiencySystems: Treatment Orders
    • DeficiencyStaffing Requirements and Training: Staffing
    • DeficiencyAcuity-Based Staffing Tool
    10 Aug 2022Inspection
    Investigated an allegation of hygiene service noncompliance and found residents received only one shower per week despite service plans calling for 2–3 showers.
    • LicensingFailed to provide or assist with hygiene
    10 Aug 2022Inspection
    Found that the acuity-based staffing tool was not fully implemented or updated to reflect current census and staffing needs.
    • LicensingFailed to update staffing plan based on ABST
    10 Aug 2022Inspection
    Identified insufficient staffing that violated Oregon Administrative Rules.
    • LicensingFailed to provide appropriate staffing
    01 Aug 2022Inspection
    Investigated that the licensee failed to submit timely weekly reporting of vaccinated individuals, residents, and staff to the proper authority for July 2022.
    • LicensingFailed to submit timely or adequate staffing documentation
    28 Jul 2022Abuse: Neglect
    Investigated the complaint and found a failure to provide a safe environment, resulting in an injury and a fine.
    • AbuseFailed to provide safe environment
    26 Jul 2022Complaint
    Investigated and identified deficiencies related to acuity-based staffing.
    • DeficiencyLicensing Complaint Investigation
    • DeficiencyAcuity-Based Staffing Tool
    22 Jul 2022Inspection
    Investigated the allegation of failing to provide a safe environment and concluded there was a failure to exercise reasonable precautions.
    • LicensingFailed to provide safe environment
    08 Jul 2022Abuse: Neglect
    Investigated an allegation of abuse and neglect; found a resident suffered multiple falls and a hip fracture due to an unsafe environment.
    • AbuseFailed to provide safe environment
    08 Jun 2022Abuse: Neglect
    Found that a provider failed to provide a safe medication administration system, leading to a medication error that required hospitalization; a $375 fine was assessed.
    • AbuseFailed to provide a safe medication administration system
    01 Apr 2022Inspection
    Investigated and found failure to submit timely weekly reporting of vaccinated individuals, residents, and staff.
    • LicensingFailed to submit timely or adequate staffing documentation
    01 Apr 2022Inspection
    Identified a failure to submit timely weekly reporting of vaccinated individuals, residents, and staff for 30 days, and assessed a $6,750 fine.
    • LicensingFailed to submit timely or adequate staffing documentation
    01 Mar 2022Inspection
    Found a violation for failing to submit timely staffing documentation and weekly vaccination reporting; assessed a fine.
    • LicensingFailed to submit timely or adequate staffing documentation
    01 Mar 2022Inspection
    Fined for failing to submit timely staffing documentation and weekly vaccination reporting. The finding documented ongoing noncompliance with reporting requirements.
    • LicensingFailed to submit timely or adequate staffing documentation
    28 Feb 2022Abuse: Neglect
    Investigated a complaint and found delays in answering call lights, constituting neglect and abuse; a $500 fine was assessed.
    • AbuseFailed to answer call light in a timely manner
    25 Feb 2022Abuse: Neglect
    Found a failure to provide a safe medication administration system that endangered a resident by not administering prescribed antipsychotic medication and denying sleep medication, leading to distress and elopement.
    • AbuseFailed to provide a safe medication administration system
    24 Feb 2022Abuse: Neglect
    Investigated and found neglect and abuse due to failure to monitor a change in condition after insomnia treatment, leading to elopement and distress; a $2,000 fine was assessed.
    • AbuseFailed to provide oversight and monitoring of change of condition
    18 Jan 2022Inspection
    Identified a violation related to medication administration not carried out as prescribed. The finding carried a minor-harm risk.
    • LicensingFailed to provide a safe medication administration system
    18 Nov 2021Abuse: Neglect
    Investigated and found a failure to adequately care plan for falls, resulting in multiple falls without new safety measures and constituting neglect and abuse.
    • AbuseFailed to properly plan care
    15 Nov 2021Validation
    Determined substantial compliance with state rules, but cited multiple deficiencies in kitchen sanitation, service plans, monitoring of changes of condition, staff training, fire safety, and housekeeping.
    • DeficiencyComment
    • DeficiencyResident Services Meals, Food Sanitation Rule
    • DeficiencyService Plan: General
    • DeficiencyChange of Condition and Monitoring
    • DeficiencyTraining Within 30 Days: Direct Care Staff
    • DeficiencyAnnual and Biennial Inservice For All Staff
    • DeficiencyFire and Life Safety: Safety
    • DeficiencyFire and Life Safety: Training For Residents
    • DeficiencyGeneral Building: Doors-Walls, Cleanable
    • DeficiencyHouse Keeping and Sanitation
    15 Nov 2021Validation
    Identified multiple deficiencies across resident care, safety, and environmental health, including inadequate abuse and incident investigations, medication documentation gaps, missing activity programming, and unsafe building conditions.
    • DeficiencyComment
    • DeficiencyReporting & Investigating Abuse-Other Action
    • DeficiencyResident Services Meals, Food Sanitation Rule
    • DeficiencyResident Services: Activities
    • DeficiencyService Plan: General
    • DeficiencySystems: Tracking Control Substances
    • DeficiencySystems: Treatment Orders
    • DeficiencyRestraints and Supportive Devices
    • DeficiencyTraining Within 30 Days: Direct Care Staff
    • DeficiencyFire and Life Safety: Safety
    • DeficiencyFire and Life Safety: Training For Residents
    • DeficiencyGeneral Building Exterior
    • DeficiencyDoors, Walls, Elevators, Odors
    • DeficiencyIndividual Door Locks: Key Access
    • DeficiencyAdministration Compliance
    • DeficiencyStaff Training Requirements
    • DeficiencyCompliance With Rules Health Care
    14 Nov 2021Abuse: Neglect
    Investigated found neglect and abuse due to failure to assess and intervene when a resident's condition changed. A $1500.00 fine was assessed.
    • AbuseFailed to intervene when resident's condition changed
    11 Nov 2021Abuse: Neglect
    Investigated a case of abuse/neglect and found violations for failing to protect a resident from inappropriate sexual contact, leading to a resident-to-resident interaction and an unsafe environment; a fine was assessed.
    • AbuseFailed to protect resident from inappropriate sexual contact
    19 Sept 2021Abuse: Neglect
    Found neglect and abuse due to failure to properly plan care and implement fall prevention for a resident with a history of falls, leading to an unwitnessed fall and injury.
    • AbuseFailed to properly plan care
    13 Sept 2021Inspection
    Investigated a complaint and found a failure to provide a safe medication administration system, resulting in narcotics being replaced with an over-the-counter medication.
    • LicensingFailed to provide a safe medication administration system
    28 Aug 2021Abuse: Neglect
    Investigated the complaint and found failures to plan care and intervene for refusals of wound care, resulting in infection and abuse.
    • AbuseFailed to properly plan care
    27 Aug 2021Abuse: Neglect
    Concluded that a safe environment was not provided to a resident, with substantiated abuse/neglect and a $500 fine assessed.
    • AbuseFailed to provide safe environment
    10 Aug 2021Abuse: Neglect
    Found deficiencies in care, including unsafe medication administration and inadequate fall prevention, leading to missed pain doses and multiple falls.
    • AbuseFailed to properly plan care
    14 Jun 2021Abuse: Neglect
    Investigated and found that essential services were not provided as needed, resulting in neglect and abuse and risk of harm.
    • AbuseFailed to provide service
    22 Apr 2021Abuse: Neglect
    Investigated an incident where an outside helper opened windows during carpet cleaning, creating a safety risk for a resident with elopement history. Found violations for failing to provide a safe environment, with a fine assessed.
    • AbuseFailed to provide safe environment
    20 Apr 2021Abuse: Neglect
    Found repeated untimely responses to a resident's call lights, resulting in substantiated abuse and neglect findings and a $1,000 fine.
    • AbuseFailed to answer call light in a timely manner
    01 Apr 2021Abuse: Neglect
    Found failure to plan and implement care for a fall history, leading to unwitnessed falls and injuries and indicating neglect and abuse.
    • AbuseFailed to properly plan care
    12 Mar 2021Abuse: Neglect
    Found neglect and abuse due to failure to plan care around a resident’s refusals to reposition. A $1,000 fine was assessed.
    • AbuseFailed to properly plan care
    11 Jan 2021Inspection
    Investigated a licensing complaint and concluded a violation involving failure to provide a safe environment and financial exploitation.
    • LicensingFailed to provide safe environment
    02 Dec 2020Abuse: Neglect
    Identified neglect due to failure to provide mobility and incontinence care, leading to several falls and undue discomfort; a $500 fine was assessed.
    • AbuseFailed to provide service
    01 Dec 2020Inspection
    Found a safety deficiency due to failure to exercise reasonable precautions to protect residents' health, safety, or welfare.
    • LicensingFailed to assure resident was safe
    19 Nov 2020Abuse: Neglect
    Found that a resident eloped due to failure to maintain a secured environment, violating resident rights.
    • AbuseFailed to provide safe environment
    09 Nov 2020Abuse: Neglect
    Concluded that inadequate supervision allowed a resident to elope and be unattended, risking significant harm, with a $500 fine assessed.
    • AbuseFailed to provide safe environment
    05 Oct 2020Abuse: Neglect
    Determined that staff failed to properly plan care and mitigate fall risk, constituting abuse and neglect. A $2,500 fine was assessed.
    • AbuseFailed to properly plan care
    29 Sept 2020Abuse: Neglect
    Cited violations for failing to provide a safe environment due to inadequate supervision, which allowed an elopement and placed an individual at risk of harm.
    • AbuseFailed to provide safe environment
    15 Sept 2020Abuse: Neglect
    Investigated and found that a resident's higher level of care was not planned or provided, constituting neglect and abuse.
    • AbuseFailed to properly plan care
    04 Sept 2020Abuse: Neglect
    Investigated a complaint and found failures to plan and monitor care for a resident with a history of falls, resulting in unwitnessed falls and discomfort, constituting neglect and abuse. A $500 fine was assessed.
    • AbuseFailed to properly plan care
    28 Aug 2020Abuse: Neglect
    Investigated found that a resident sustained bruising and an abrasion after a nighttime fall, with no EMS call or timely medical assessment, indicating neglect and abuse.
    • AbuseFailed to perform adequate screening or assessment
    20 Jan 2020Abuse: Neglect
    Investigated an allegation of neglect and found a failure to provide a safe environment when a resident eloped from the secure unit, placing them at risk.
    • AbuseFailed to provide safe environment
    17 Dec 2019Abuse: Neglect
    Investigated a complaint about oversight of a resident's change in condition. Found that inadequate monitoring led to multiple falls and a fracture, constituting neglect and abuse, with a $1500 fine assessed.
    • AbuseFailed to provide oversight and monitoring of change of condition
    16 Nov 2019Abuse: Neglect
    Found violations of resident rights due to failure to perform hourly checks after fall history, resulting in an unwitnessed fall and about four hours without a check.
    • AbuseFailed to assure resident was safe
    04 Nov 2019Abuse: Neglect
    Identified neglect and abuse from failure to monitor residents, leading to an altercation and discomfort; a fine was assessed.
    • AbuseFailed to provide safe environment
    11 Oct 2019Abuse: Neglect
    Found a failure to provide a safe environment that placed a resident at serious risk, constituting neglect and abuse.
    • AbuseFailed to provide safe environment
    19 Sept 2019Abuse: Neglect
    Investigated an allegation of neglect and found that basic care and safety were not provided, resulting in unreasonable discomfort; a fine was assessed.
    • AbuseFailed to provide service
    14 Jul 2019Abuse: Neglect
    Investigated allegation of neglect and found a failure to provide basic care and safety, creating risk of serious harm.
    • AbuseFailed to assure resident was safe
    04 Jul 2019Abuse: Neglect
    Identified a failure to provide a safe medication administration system, creating risk of serious harm.
    • AbuseFailed to provide a safe medication administration system
    30 Jun 2019Inspection
    Investigated the allegation of failing to report potential or suspected abuse and found a failure to report.
    • LicensingFailed to report potential or suspected abuse
    30 Jun 2019Abuse: Neglect
    Investigated a neglect allegation and found safety was not provided, causing unreasonable discomfort; a $250 fine was assessed.
    • AbuseFailed to provide service
    26 May 2019Abuse: Neglect
    Determined neglect by failing to provide safety to a resident, creating risk of serious harm.
    • AbuseFailed to assure resident was safe
    17 May 2019Abuse: Neglect
    Found neglect of a resident by failing to provide basic care, services, or safety, creating risk of serious harm.
    • AbuseFailed to assure resident was safe
    08 Apr 2019Abuse: Neglect
    Found neglect by passively failing to provide safety, resulting in physical harm; a fine was assessed.
    • AbuseFailed to provide safe environment
    04 Apr 2019Abuse: Neglect
    Found neglect that resulted in physical harm by failing to provide basic care and safety.
    • AbuseFailed to follow care plan
    27 Mar 2019Abuse: Neglect
    Found violations of the care plan that led to neglect and abuse, and a $375 fine was assessed. The findings described a failure to keep residents separated, resulting in a physical altercation and discomfort.
    • AbuseFailed to follow care plan
    27 Mar 2019Abuse: Neglect
    Concluded neglect occurred, resulting in harm, and a $375 fine was assessed.
    • AbuseFailed to provide safe environment
    14 Mar 2019Abuse: Neglect
    Found neglect related to falls care that could cause harm to a resident. The finding substantiated failure to provide basic care and safety.
    • AbuseFailed to adequately care plan related to falls
    10 Mar 2019Abuse: Neglect
    Investigated a neglect allegation related to falls care planning; found that safety was not provided, resulting in physical harm.
    • AbuseFailed to adequately care plan related to falls
    05 Mar 2019Abuse: Neglect
    Found neglect by failing to provide basic care and safety, resulting in risk of serious harm; a $188 fine was assessed.
    • AbuseFailed to follow care plan
    26 Feb 2019Abuse: Neglect
    Investigated a complaint about inadequate care planning related to falls; found neglect.
    • AbuseFailed to adequately care plan related to falls
    13 Feb 2019Abuse: Neglect
    Found neglect of safety that created a risk of serious harm. The finding noted passive failure to provide safety.
    • AbuseFailed to provide safe environment
    08 Feb 2019Abuse: Neglect
    Found neglect by failing to provide a safe environment, creating risk of serious harm to a resident. A $375 fine was assessed.
    • AbuseFailed to provide safe environment
    31 Jan 2019Abuse: Neglect
    Investigated a neglect allegation and found a safety failure that put a resident at risk of serious harm. Multiple rule violations were identified.
    • AbuseFailed to assure resident was safe
    24 Jan 2019Abuse: Neglect
    Found neglect by failing to provide basic care and safety, risking serious harm to a resident; a fine was assessed.
    • AbuseFailed to assure resident was safe
    23 Jan 2019Abuse: Neglect
    Investigated an allegation of neglect and found that basic care was withheld, resulting in harm and loss of dignity. A fine was assessed.
    • AbuseFailed to provide service
    14 Jan 2019Abuse: Neglect
    Investigated an allegation of neglect and found a failure to provide safety that resulted in physical harm.
    • AbuseFailed to assure resident was safe
    13 Jan 2019Abuse: Neglect
    Investigated the neglect allegation and found that basic care and safety were not provided, risking serious harm. The issue was substantiated in the record.
    • AbuseFailed to assure resident was safe
    13 Jan 2019Abuse: Neglect
    Investigated a resident safety allegation and found neglect by staff that led to risk of serious harm. A $375 fine was assessed.
    • AbuseFailed to assure resident was safe
    11 Jan 2019Abuse: Neglect
    Investigated a complaint of neglect related to falls care planning; found failure to provide basic care and safety resulting in physical harm, and a fine was assessed.
    • AbuseFailed to adequately care plan related to falls
    12 Dec 2018Inspection
    Investigated a complaint and found a failure to provide a safe medication administration system that resulted in physical harm. A $500 fine was assessed.
    • LicensingFailed to provide a safe medication administration system
    10 Dec 2018Abuse: Neglect
    Found a failure to provide a safe medication administration system that risked serious harm to a resident.
    • AbuseFailed to provide a safe medication administration system
    10 Dec 2018Abuse: Neglect
    Found neglect due to failing to provide basic safety, creating risk of serious harm; a fine of $375 was assessed.
    • AbuseFailed to provide safe environment
    08 Dec 2018Abuse: Neglect
    Found neglect that failed to provide for a resident's safety, resulting in physical harm. A $375 fine was assessed.
    • AbuseFailed to provide safe environment
    28 Nov 2018Abuse: Neglect
    Investigated a complaint and found neglect by passively failing to provide basic safety, which caused unreasonable discomfort.
    • AbuseFailed to provide safe environment
    24 Nov 2018Inspection
    Found failure to report suspected abuse. A $750 fine was assessed.
    • LicensingFailed to report potential or suspected abuse
    24 Nov 2018Abuse: Neglect
    Investigated a neglect allegation; found that basic care was not provided and medication was not administered as ordered, risking serious harm, with a $1500 fine assessed.
    • AbuseFailed to administer medication as ordered
    19 Nov 2018Inspection
    Investigated a complaint about the presence of a qualified caregiver and staff training; identified deficiencies related to staff training.
    • LicensingFailed to assure that a qualified caregiver was present
    17 Nov 2018Abuse: Neglect
    Investigated and identified neglect of a vulnerable adult that resulted in physical harm, with a fine assessed.
    • AbuseFailed to properly plan care
    08 Nov 2018Inspection
    Found insufficient staffing to meet residents' scheduled and unscheduled needs.
    • LicensingFailed to provide appropriate staffing
    08 Nov 2018Inspection
    Investigated and substantiated a staffing deficiency related to insufficient personnel to support two-person transfers for residents.
    • LicensingFailed to provide appropriate staffing
    08 Nov 2018Inspection
    Found facility failed to complete fire evacuation drills and training as required.
    • LicensingFailed to provide safe environment
    07 Nov 2018Inspection
    Found that suspected abuse was not reported. A $750 fine was assessed.
    • LicensingFailed to report potential or suspected abuse
    07 Nov 2018Abuse: Neglect
    Investigated a complaint about falls care planning and found neglect resulting in risk of serious harm; a $250 fine was assessed.
    • AbuseFailed to adequately care plan related to falls
    27 Aug 2018Inspection
    Investigated the allegation and substantiated a failure to provide a safe environment. This was classified as a licensing violation.
    • LicensingFailed to provide safe environment
    18 Aug 2018Abuse: Physical Abuse
    Investigated the allegation of abuse and found that physical force was used against a resident, causing injury.
    • AbuseFailed to protect resident from rough treatment
    31 Jul 2018Inspection
    Found quarterly service plans overdue and not reviewed as required.
    • LicensingFailed to provide service
    27 Jul 2018Abuse: Neglect
    Investigated a neglect allegation and found a failure to provide a safe environment.
    • AbuseFailed to provide safe environment
    14 Jul 2018Abuse: Neglect
    Investigated an allegation of neglect related to delayed call-light response; found a deficiency and a fine was assessed.
    • AbuseFailed to answer call light in a timely manner
    07 Jul 2018Inspection
    Found a licensing violation for failing to provide a secure environment, creating a risk of serious harm. A $375 fine was assessed.
    • LicensingFailed to provide safe environment
    05 Jul 2018Abuse: Neglect
    Determined neglect due to failure to monitor change of condition and follow care plans, which resulted in physical harm; a $1,500 fine was assessed.
    • AbuseFailed to provide oversight and monitoring of change of condition
    14 May 2018Inspection
    Investigated and found deficiencies in the medication management system that could pose harm.
    • LicensingFailed to provide a safe medication administration system
    12 Feb 2018Inspection
    Found that medication orders were not carried out as prescribed, with multiple medications missed.
    • LicensingFailed to administer medication as ordered
    24 Nov 2017Inspection
    Investigated the allegation and found a failure to provide a secure environment.
    • LicensingFailed to provide safe environment
    25 Sept 2017Abuse: Neglect
    Investigated an abuse/neglect allegation and found a failure to maintain an adequate medication system.
    • AbuseFailed to provide a safe medication administration system
    14 Jun 2017Abuse: Neglect
    Found that timely medical treatment was not provided, and a $15,000 fine was assessed.
    • AbuseFailed to assure timely medical treatment
    07 Jun 2017Abuse: Neglect
    Found deficiencies in maintaining an adequate medication system after an allegation of not administering medication as ordered.
    • AbuseFailed to administer medication as ordered
    02 Jun 2017Inspection
    Investigated the allegation of an unsafe medication administration system and found an inadequate medication system.
    • LicensingFailed to provide a safe medication administration system
    06 May 2017Inspection
    Investigated the allegation of failing to provide a secure environment and found a deficiency.
    • LicensingFailed to provide safe environment
    08 Nov 2016Inspection
    Investigated the complaint and found residents' scheduled and unscheduled needs were not met due to insufficient staff.
    • LicensingFailed to provide service
    09 Jun 2016Abuse: Neglect
    Investigated the allegation of abuse/neglect and identified a failure to provide a safe environment.
    • AbuseFailed to provide safe environment

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