I chose this community for my mom and I'm very pleased: the staff are genuinely caring and attentive (Shauna was especially helpful), meals are delicious with good portions and variety, activities keep residents active and engaged, apartments are bright, clean and well-laid out with on-site meals, weekly cleaning and accessible bathrooms, and medical/med-tech support plus responsive maintenance provide real peace of mind. It's safe, pet-friendly, welcoming, and I would recommend it.
Loved one of resident
Jul 2026
Pricing
Prices shown are estimates and subject to change. Contact your senior living advisor for current pricing.
Schedule a Tour
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
Special dietary restrictions
Room
Air-conditioning
Cable
Fully furnished
Housekeeping and linen services
Internet
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
3.66·(113)
Overall rating
5
4
3
2
1
Care
3.0
Staff
3.6
Meals
3.3
Amenities
3.8
Value
1.9
Pros
Compassionate, engaged caregiving staff
Responsive med tech and resident‑aide support
Friendly and personable front‑desk and reception staff
Restaurant‑style dining room and generous portions
High‑quality ingredients and menu variety
Dietary accommodations and menu adjustments
Active, well‑led activities program
Frequent organized outings and transportation
Bright, new construction with abundant natural light
Clean, well‑maintained common areas and grounds
Secure memory‑care unit with enhanced supervision
Pet‑friendly policies and enclosed outdoor spaces
Comfortable apartment layouts with accessible bathrooms
On‑site maintenance with generally prompt response
Salon/barber services available on site
Well‑stocked arts and crafts resources
Multiple social spaces and seating areas
Weekly apartment cleaning and laundry services
Attentive admissions and move‑in assistance
Convenient location near shopping and restaurants
Engaged activities director and resident‑run groups
Cons
Inconsistent staffing levels and reliance on temporary staff
High staff and leadership turnover
Gaps in clinical oversight and medication‑administration controls
Inconsistent housekeeping and sanitation practices
Billing errors and opaque fee/accounting practices
Communication gaps across shifts and with administration
Variability in meal delivery consistency and timeliness
Misalignment between sales promises and operational delivery
Limited individualized programming for residents with dementia
Resident property security and belongings‑tracking weaknesses
Maintenance delays during staffing shortages
Variable activity participation and occasional low engagement
Pest‑control and food‑service sanitation concerns
Summary of reviews
Brookdale Geary Street elicits a mixed but specific pattern of feedback. Strengths are concentrated at the frontline: reviewers frequently describe caregiving staff, med‑techs, and aides as compassionate, engaged, and responsive. Many families praised an active activities department, a variety of outings, and accessible common spaces that encourage socialization. The building itself is often characterized as bright, newer construction with natural light, well‑kept grounds, and apartment layouts that include accessible bathrooms and weekly cleaning services. Dining is a consistent positive theme for a large number of accounts: reviewers cite generous portions, quality ingredients, menu variety, and a restaurant‑style dining environment with options for dietary accommodations.
At the same time, multiple reviews point to systemic operational weaknesses that prospective residents and families should consider. Staffing stability is a recurrent concern: accounts indicate inconsistent staffing levels, use of temporary workers, and relatively frequent administrative turnover. Those workforce issues are linked in some reviews to delayed care tasks, slower housekeeping, and maintenance backlogs during busy periods. Communication gaps are also reported across shift changes and between families and administration, making care coordination and billing resolution more difficult for some families.
Clinical oversight and medication management are areas with mixed feedback. While many reviewers commend attentive med‑techs and nursing availability, others describe instances suggesting lapses in medication‑administration controls and care‑plan adherence; a number of reviews reference regulatory activity and inspections. Allegations concerning medication handling and property security have been raised in individual accounts, and families should review state survey history and facility corrective actions as part of due diligence.
Food service quality is generally praised but inconsistent in practice. Positive comments highlight good ingredients, pleasant dining rooms, and accommodating menus; contrasting comments point to repetitive offerings, late or missed meal deliveries, kitchen turnover, and occasional sanitation concerns. Activities programming is a strength overall, with organized events, arts and crafts, outings, and a praised activities director, yet some families noted limited individualized dementia‑appropriate activities and low resident participation in certain sessions.
Management and business practices draw mixed reactions. Admissions and marketing staff are often described as helpful and informative, but several reviews describe misalignment between sales promises and operational delivery, along with billing errors, unclear fee structures, and occasional difficulty reaching administration. Prospective residents should request written agreements for any negotiated terms, obtain a clear fee schedule, and ask how the community documents and communicates care plans and medication changes.
In summary, Brookdale Geary Street offers many elements that families value: an engaging activities program, capable frontline caregivers, attractive facilities, and generally good dining. However, recurring concerns about staffing stability, clinical oversight controls, housekeeping consistency, billing transparency, and property security introduce operational risk that prospective residents should evaluate. Recommended steps for families: review the facility’s latest state survey and corrective actions, ask for current staffing ratios and turnover data, confirm written guarantees for any sales commitments, and observe mealtime service and an activity session during a tour.
Reviews written on Mirador
We have no reviews to show about Brookdale Geary Street.
Help other families by writing a review about your experience with this community.
Location
Brookdale Geary Street is located at 2445 SE Geary St, Albany, OR, 97322.
About Brookdale Geary Street
Brookdale Geary Street sits over on Geary Street in Albany, Oregon, and offers 70 beds for residents who need different levels of care, whether someone needs assisted living, memory care for Alzheimer's or other dementia, independent living, skilled nursing, or at-home care services, and they do all sorts of things to make people feel welcome, with wheelchair accessibility throughout the building, accessible showers, and parking for both residents and visitors, so nobody has to worry much getting in or out, and they have a strict no smoking rule inside both private and public spaces to keep the air clean. They have meals prepared on site and make sure to offer vegetarian options, and the staff pay attention to health concerns by providing access to physical, occupational, and speech therapy, with licensed nurses, a doctor, and even a dentist available on call, and also a podiatrist for more specialized needs, plus they do hospice and respite care if someone needs that extra level of attention. Residents can bring their pets along since they're pet-friendly, which is important for folks who want to stay with a favorite animal; they've even made sure there's lots of outdoor and indoor common areas for socializing and relaxing, and they run an active schedule of social, educational, and entertainment activities, even including offsite outings and devotional services both on and off the property. Accommodations are available for both men and women, with certain programs that may serve only one gender depending on care needs, and their memory care area is designed to reduce confusion and keep people secure, with guidance and reminders for daily living. The facility provides transportation so residents can get to appointments or events easily, and they've got staff around 24 hours a day every single day in case there's an emergency or a need at odd hours. There are also beauty and barber services on site to help with grooming, and high-speed internet is available so residents can stay connected, maybe even read the Brookdale blogs or use video calls with family. The management team keeps things running smoothly and focuses on safety, wellness, and each resident's independence, making an effort to tailor support to each person's own needs and goals, with a structured list of activities to keep people physically and mentally active. For those interested in long-term planning, resources are available for long-term care, family caregiving, and insurance, and they offer continuing care as people's needs change, all while maintaining a resident-focused environment that emphasizes living well, so overall, Brookdale Geary Street is a place where a range of services meet people's needs in a straightforward, comfortable way, and it carries a rating of 3.8 from 19 reviews, showing that while it's not perfect, many residents and families find helpful support and a safe place there.
Brookdale Senior Living Inc. (NYSE: BKD) is the largest senior living operator in the United States, managing over 640 communities with capacity for approximately 59,000 residents across 41 states and employing around 36,000 associates. Founded in 1978 and publicly traded since 2005, Brookdale solidified its market leadership through major acquisitions including American Retirement Corporation (2006) and Emeritus Senior Living (2014), making it the only national full-spectrum senior living company. Headquartered in Nashville, Tennessee, Brookdale has topped the American Seniors Housing Association's ASHA 50 list and Argentum's largest providers list for multiple consecutive years.
The company's comprehensive care continuum includes independent living, assisted living, memory care, skilled nursing, and continuing care retirement communities (CCRCs). Brookdale's signature Clare Bridge program, developed over 30 years ago by dementia-care experts, provides specialized Alzheimer's and dementia care through two distinct levels: Clare Bridge communities for comprehensive memory support and the Clare Bridge Solace program for advanced-stage dementia residents. The program is recognized by the Alzheimer's Association® for incorporating evidence-based Dementia Care Practice Recommendations and features secure environments, enclosed courtyards, Daily Path programming with six structured activities daily, and the InTouch technology platform offering personalized brain-stimulating games and therapeutic content.
Brookdale's holistic Optimum Life® wellness approach balances six dimensions—Purposeful, Physical, Emotional, Social, Spiritual, and Intellectual—implemented through signature programs including B-Fit (eight exercise class options), Brain Fit (mental fitness workouts), My Life Story (resident storytelling), EngagementPlus (interest-based connections), Growing Together (collaborative learning), and The Ageless Spirit (kindness and gratitude practices). The Embrace Family Partnership provides caregiver education and support for families of memory care residents.
The company's Brookdale HealthPlus® care coordination model, winner of the 2024 Argentum Best of the Best Award placing it among the top 1% of operators, is a technology-enabled healthcare service featuring dedicated RN Care Managers who proactively manage residents' health, coordinate care transitions, and help prevent avoidable hospitalizations. Communities using HealthPlus report 78% fewer urgent care visits, 36% fewer hospitalizations, and 63% more completed annual wellness visits. The Personal Solutions program delivers hygiene products, medications, and daily necessities directly to residents' doors with discreet packaging and monthly billing convenience.
Following a strategic divestiture of its home health and hospice operations to HCA Healthcare (completed December 2023), Brookdale now focuses exclusively on senior living operations while maintaining its position as the industry's largest operator, committed to its mission of enriching lives with compassion, respect, excellence, and integrity.
People often ask...
Brookdale Geary Street offers competitive pricing, with rates starting at a cost of $5,259 per month.
Brookdale Geary Street offers independent living, assisted living, and memory care.
There are 37 photos of Brookdale Geary Street on Mirador.
Yes, Brookdale Geary Street allows residents to age in place and adjust their level of care as needed.
The full address for this community is 2445 SE Geary St, Albany, OR 97322.
No, Brookdale Geary Street 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.
Determined multiple deficiencies involving resident right to refuse medications, accuracy of ABST time reporting, and health care rule compliance.
Deficiency—Systems: Resident Right to Refuse
Deficiency—Acuity Based Staffing Tool - ABST Time
Deficiency—Administration Compliance
Deficiency—Compliance with Rules Health Care
19 Mar 2026Licensure
19 Mar 2026Licensure
Investigated found multiple deficiencies across resident rights to refuse, staffing accuracy, fire safety, interior environment, administration compliance, and health care services.
Deficiency—Systems: Resident Right to Refuse
Deficiency—Acuity Based Staffing Tool - ABST Time
Deficiency—Fire and Life Safety: Safety
Deficiency—Doors, Walls, Elevators, Odors
Deficiency—Administration Compliance
Deficiency—Compliance with Rules Health Care
16 Jan 2026Abuse: Neglect
16 Jan 2026Abuse: Neglect
Investigated and found neglect of care and abuse that led to injury after failing to intervene with a resident's behavioral symptoms; a fine was assessed.
Abuse—Failed to intervene when resident's condition changed
29 Dec 2025Abuse: Neglect
29 Dec 2025Abuse: Neglect
Determined that neglect of care occurred, constituting abuse, and assessed a $1,000 fine.
Abuse—Failed to properly plan care
20 Nov 2025Kitchen
20 Nov 2025Kitchen
Identified serious sanitation and administrative deficiencies in kitchen operations and meals service, with inadequate oversight posing risk to residents.
Identified serious sanitation deficiencies in the kitchen and inadequate administrative oversight of kitchen operations, with corrective actions started.
Identified deficiencies in care planning, evaluations, and a safe environment related to the use of a transfer pole.
Regulatory Action—Failed to properly plan care
14 Oct 2025Inspection
14 Oct 2025Inspection
Found deficiencies in service plans that did not reflect residents' needs and preferences and were not followed for implementing a supportive device.
Licensing—Failed to properly plan care
14 Oct 2025Inspection
14 Oct 2025Inspection
Found a deficiency for failing to provide a safe environment for residents. The violation was substantiated.
Licensing—Failed to provide safe environment
14 Oct 2025Inspection
14 Oct 2025Inspection
Found a deficiency in evaluating a resident's ability to use an assistive device.
Licensing—Failed to properly plan care
08 Oct 2025Inspection
08 Oct 2025Inspection
Found a failure to maintain an accurate Medication Administration Record (MAR) for all medications, including OTC medications ordered by a prescriber and administered by staff.
Licensing—Failed to provide a safe medication administration system
30 Sept 2025Abuse: Neglect
30 Sept 2025Abuse: Neglect
Investigated a neglect allegation and found the emergency call system was not maintained, resulting in a resident lying on the floor for over an hour after a fall before staff arrived.
Abuse—Failed to provide or maintain resident care equipment
15 Sept 2025Inspection
15 Sept 2025Inspection
Identified a deficiency in safety program development and implementation to prevent hazards to residents. Cited a rule violation.
Licensing—Failed to provide safe environment
11 Sept 2025Abuse: Neglect
11 Sept 2025Abuse: Neglect
Investigated allegations of neglect found failure to intervene when a resident's condition changed and to implement additional interventions after falls.
Abuse—Failed to intervene when resident's condition changed
14 Aug 2025Abuse: Neglect
14 Aug 2025Abuse: Neglect
Found a deficiency in the safe medication administration system due to missing on-site medication, leading to missed doses during July 2025 and earlier in June 2025, with a $500 fine assessed.
Abuse—Failed to provide a safe medication administration system
16 Jul 2025Abuse: Neglect
16 Jul 2025Abuse: Neglect
Found that the transfer-assistance care plan was not followed, causing two self-transfer falls, with a $375 fine assessed.
Abuse—Failed to follow care plan
13 Jul 2025Abuse: Neglect
13 Jul 2025Abuse: Neglect
Found that a resident with an exit-seeking history was not kept safe, allowing them to follow an outside vendor out of the facility and be found about a block away.
Abuse—Failed to provide safe environment
12 Jul 2025Abuse: Neglect
12 Jul 2025Abuse: Neglect
Found a failure to provide a safe medication administration system when a resident could not obtain PRN pain medication, leading to emergency hospital care.
Abuse—Failed to provide a safe medication administration system
15 Jun 2025Abuse: Neglect
15 Jun 2025Abuse: Neglect
Investigated and found that the resident's fall history was not properly addressed in care planning, contributing to a later fall and hip fracture and indicating neglect and abuse.
Abuse—Failed to properly plan care
04 Jun 2025Abuse: Neglect
04 Jun 2025Abuse: Neglect
Found a failure to provide a safe medication administration system by not administering an anticoagulation medication for about 13 days, increasing the risk of stroke.
Abuse—Failed to provide a safe medication administration system
16 Feb 2025Abuse: Neglect
16 Feb 2025Abuse: Neglect
Found that the care plan was not followed, resulting in a resident-to-resident altercation and injury; a fine was assessed.
Abuse—Failed to follow care plan
14 Feb 2025Abuse: Neglect
14 Feb 2025Abuse: Neglect
Found failures to properly plan care and interventions to prevent falls for a resident with a history of falls, resulting in a head injury.
Abuse—Failed to properly plan care
28 Jan 2025Inspection
28 Jan 2025Inspection
Identified a deficiency for failing to provide documentation upon request.
Licensing—Failed to cooperate with an investigation
10 Jan 2025Abuse: Neglect
10 Jan 2025Abuse: Neglect
Determined that proper care planning for a known fall history was not conducted, leading to an unwitnessed fall with injury; a $500 fine was assessed.
Abuse—Failed to properly plan care
06 Jan 2025Abuse: Neglect
06 Jan 2025Abuse: Neglect
Investigated and found that care planning did not address a resident's increased fall risk, resulting in injuries and a $750 fine.
Abuse—Failed to properly plan care
06 Jan 2025Abuse: Neglect
06 Jan 2025Abuse: Neglect
Found neglect due to failure to care plan for increased ADL needs after an injury fall, which contributed to a new pressure sore.
Abuse—Failed to properly plan care
27 Dec 2024Kitchen
27 Dec 2024Kitchen
Identified deficiencies in the quality improvement program and in dining services, including sanitation, food safety, and menu management.
Identified deficiencies in the quality improvement program and kitchen sanitation. Found failures to implement ongoing oversight and adequate food safety practices.
Investigated a records access issue and found documentation was not provided upon request.
Licensing—Failed to make facility or resident records accessible
21 Dec 2024Inspection
21 Dec 2024Inspection
Found a deficient safe medication administration system lacking professional approval. A resident who self-administered received medication intended for another resident.
Licensing—Failed to provide a safe medication administration system
21 Dec 2024Abuse: Neglect
21 Dec 2024Abuse: Neglect
Investigated a complaint and found failure to implement interventions to prevent a resident altercation, resulting in injury; a fine was assessed.
Abuse—Failed to properly plan care
17 Dec 2024Complaint
17 Dec 2024Complaint
Investigated found that an acuity-based staffing tool was not updated and not state-approved, and that the ADL portion was incomplete for residents.
Deficiency—Acuity-Based Staffing Tool
Deficiency—Acuity Based Staffing Tool - Updates & Plan
13 Dec 2024Abuse: Neglect
13 Dec 2024Abuse: Neglect
Investigated a complaint about hygiene care and found the Alleged Victim did not receive weekly showers as requested, resulting in neglect and abuse.
Abuse—Failed to provide or assist with hygiene
13 Dec 2024Abuse: Neglect
13 Dec 2024Abuse: Neglect
Investigated found that orders to provide a seat cushion were not followed, risking harm to a resident; a fine was assessed.
Abuse—Failed to provide medical treatment as ordered
10 Dec 2024Complaint
10 Dec 2024Complaint
Identified deficiencies related to treatment orders and the acuity-based staffing tool, with isolated potential for moderate harm.
Deficiency—Licensing Complaint Investigation
Deficiency—Systems: Treatment Orders
Deficiency—Acuity-Based Staffing Tool
02 Dec 2024Inspection
02 Dec 2024Inspection
Found failure to provide three daily, nutritious, palatable meals as required.
Licensing—Failed to assure resident rights
02 Dec 2024Inspection
02 Dec 2024Inspection
Found deficiencies in assuring resident rights and in maintaining a safe and homelike environment.
Licensing—Failed to assure resident rights
28 Nov 2024Inspection
28 Nov 2024Inspection
Found that the required service planning team did not develop a service plan and neither the resident nor their family were involved in creating the initial care plan.
Licensing—Failed to assure resident rights
10 Nov 2024Inspection
10 Nov 2024Inspection
Identified failure to fully implement an Acuity-Based Staffing Tool, with time and frequency for all required 22 ADLs not determinable.
Licensing—Failed to use an ABST
05 Nov 2024Abuse: Neglect
05 Nov 2024Abuse: Neglect
Found a failure to administer prescribed medication, resulting in missed doses and constituting neglect and abuse. A $1500 fine was assessed.
Abuse—Failed to provide a safe medication administration system
05 Nov 2024Abuse: Neglect
05 Nov 2024Abuse: Neglect
Investigated an allegation of neglect related to medication administration and found the resident did not receive a prescribed muscle relaxant, resulting in pain.
Abuse—Failed to provide a safe medication administration system
05 Nov 2024Abuse: Neglect
05 Nov 2024Abuse: Neglect
Found violations for failing to administer prescribed blood pressure medication and for not monitoring the resident's blood pressure, constituting neglect and abuse.
Abuse—Failed to provide a safe medication administration system
05 Nov 2024Inspection
05 Nov 2024Inspection
Investigated and concluded that the acuity-based staffing tool was not fully implemented or updated, constituting a rule violation. The issue involved minor harm or potential for moderate harm.
Licensing—Failed to use an ABST
04 Nov 2024Abuse: Neglect
04 Nov 2024Abuse: Neglect
Found neglect for failing to follow the incontinence care plan, leading to pain and discomfort and exposure to feces and urine, including on a catheter. A $500 fine was assessed.
Abuse—Failed to follow care plan
21 Oct 2024Inspection
21 Oct 2024Inspection
Determined that ABST was not fully implemented and that time and frequency for all 22 required ADLs could not be determined.
Licensing—Failed to use an ABST
15 Oct 2024Inspection
15 Oct 2024Inspection
Found a deficiency in implementing and updating an acuity-based staffing tool.
Licensing—Failed to use an ABST
14 Oct 2024Inspection
14 Oct 2024Inspection
Investigated allegation found that an acuity-based staffing tool was not fully implemented, making it impossible to determine staff time for all required care activities. Concluded that this violated Oregon Administrative Rules.
Licensing—Failed to use an ABST
21 Sept 2024Inspection
21 Sept 2024Inspection
Found insufficient direct care staff numbers to meet scheduled and unscheduled resident needs.
Licensing—Failed to provide safe environment
21 Sept 2024Inspection
21 Sept 2024Inspection
Investigated a complaint and found a deficiency in implementing and updating an Acuity Based Staffing Tool as required by OAR 411-054-0037.
Licensing—Failed to provide safe environment
21 Sept 2024Inspection
21 Sept 2024Inspection
Investigated a complaint and found that services were not provided per the service plan, including showers not performed according to resident preferences.
Licensing—Failed to assure resident rights
19 Sept 2024Inspection
19 Sept 2024Inspection
Investigated the allegation that resident rights were not assured and found that three daily nutritious, palatable meals were not provided seven days a week.
Licensing—Failed to assure resident rights
18 Sept 2024Inspection
18 Sept 2024Inspection
Found residents did not receive three daily nutritious meals with snacks seven days a week as required.
Licensing—Failed to assure resident rights
16 Sept 2024Inspection
16 Sept 2024Inspection
Determined that an acuity-based staffing tool was not fully implemented, preventing determination of staff time for all required ADLs.
Licensing—Failed to use an ABST
25 Aug 2024Inspection
25 Aug 2024Inspection
Investigated an allegation of failing to provide a safe environment and found deficiencies related to acuity-based staffing.
Licensing—Failed to provide safe environment
23 Aug 2024Inspection
23 Aug 2024Inspection
Found failure to fully implement and update an acuity-based staffing tool.
Licensing—Failed to use an ABST
23 Aug 2024Abuse: Neglect
23 Aug 2024Abuse: Neglect
Found failure to provide a safe medication administration system leading to missed doses and hospital transport; a $375 fine was assessed.
Abuse—Failed to provide a safe medication administration system
21 Aug 2024Abuse: Neglect
21 Aug 2024Abuse: Neglect
Investigated and found that insufficient staff training on safe transfer led to bruising of the resident; a fine was assessed.
Abuse—Failed to assist with transfer
19 Aug 2024Enhanced Oversight and Supervision
19 Aug 2024Enhanced Oversight and Supervision
Investigated an allegation of a failed safe environment and found a deficiency indicating unsafe environment.
Regulatory Action—Failed to provide safe environment
15 Aug 2024Inspection
15 Aug 2024Inspection
Investigated and determined a licensing violation occurred due to failure to fully implement and update an acuity-based staffing tool.
Licensing—Failed to provide safe environment
14 Aug 2024Abuse: Neglect
14 Aug 2024Abuse: Neglect
Investigated found that care planning failed to include progressive interventions to prevent further resident-to-resident altercations, leading to injury.
Abuse—Failed to properly plan care
13 Aug 2024Abuse: Neglect
13 Aug 2024Abuse: Neglect
Found that the care plan for fall prevention was not followed, resulting in a fall and a fractured hip requiring surgery.
Abuse—Failed to follow care plan
08 Aug 2024Inspection
08 Aug 2024Inspection
Found a failure to maintain an accurate MAR, including a PRN medication documented as scheduled.
Licensing—Failed to provide a safe medication administration system
07 Aug 2024Abuse: Neglect
07 Aug 2024Abuse: Neglect
Found neglect for failing to provide a safe environment, with a $375 fine assessed.
Abuse—Failed to provide safe environment
06 Aug 2024Inspection
06 Aug 2024Inspection
Investigated a complaint and found that medication orders were not carried out as prescribed, resulting in a resident receiving another resident's medication.
Licensing—Failed to provide safe environment
02 Aug 2024Abuse: Neglect
02 Aug 2024Abuse: Neglect
Investigated deficiencies in care planning to prevent resident-on-resident altercations, which led to an incident causing pain and discomfort.
Abuse—Failed to properly plan care
26 Jul 2024Abuse: Neglect
26 Jul 2024Abuse: Neglect
Found neglect due to failure to plan fall interventions, resulting in multiple falls and injuries, with a fine assessed.
Abuse—Failed to properly plan care
22 Jul 2024Inspection
22 Jul 2024Inspection
Investigated and found that an Acuity-Based Staffing Tool was not fully implemented, making time and frequency for care needs undeterminable for all required ADLs.
Licensing—Failed to use an ABST
20 Jul 2024Abuse: Neglect
20 Jul 2024Abuse: Neglect
Investigated found inadequate care planning for falls and failure to remove unowned footwear, which led to a fall with a skin tear and pain. Violations were cited.
Abuse—Failed to properly plan care
15 Jul 2024Abuse: Neglect
15 Jul 2024Abuse: Neglect
Found a failure to provide a safe medication administration system because pain medication was given over an hour late, causing increased pain; a $500 fine was assessed.
Abuse—Failed to provide a safe medication administration system
14 Jul 2024Abuse: Neglect
14 Jul 2024Abuse: Neglect
Investigated a failure to provide a safe medication administration system due to inadequate staff training, which led to a medication error and a fine.
Abuse—Failed to provide a safe medication administration system
10 Jul 2024Abuse: Neglect
10 Jul 2024Abuse: Neglect
Found deficiencies in care planning for a resident with a history of altercations and in documenting interventions after incidents, indicating neglect and abuse.
Abuse—Failed to properly plan care
10 Jul 2024Inspection
10 Jul 2024Inspection
Found that the acuity-based staffing tool wasn't fully implemented and updated as required. This reflected a deficiency cited under the rule.
Licensing—Failed to provide safe environment
03 Jul 2024Abuse: Neglect
03 Jul 2024Abuse: Neglect
Determined neglect due to failure to implement fall interventions, leading to multiple falls and pain.
Abuse—Failed to properly plan care
27 Jun 2024Inspection
27 Jun 2024Inspection
Investigated a complaint about medication administration and found a deficiency in carrying out medication orders.
Licensing—Failed to provide a safe medication administration system
24 May 2024Inspection
24 May 2024Inspection
Found that an ABST was not fully implemented, leaving time and frequency for the 22 required ADLs undetermined.
Licensing—Failed to use an ABST
16 May 2024Inspection
16 May 2024Inspection
Investigated an allegation and found a licensing violation involving failure to fully implement and update an acuity-based staffing tool. The violation was classified as minor harm or potential for moderate harm.
Licensing—Failed to provide safe environment
13 May 2024Abuse: Neglect
13 May 2024Abuse: Neglect
Investigated a complaint and found abuse and neglect from failing to provide a safe medication administration system by not administering prescribed antipsychotic medication.
Abuse—Failed to provide a safe medication administration system
13 May 2024License Condition
13 May 2024License Condition
Found a failure to provide a safe environment.
Regulatory Action—Failed to provide safe environment
12 May 2024Abuse: Neglect
12 May 2024Abuse: Neglect
Found a failure to provide a safe environment, resulting in a resident leaving the secured area unsupervised and being found in the parking lot; a fine was assessed.
Abuse—Failed to provide safe environment
08 May 2024Abuse: Neglect
08 May 2024Abuse: Neglect
Determined that a safe-environment standard was not met when a resident was found outside secured doors, indicating neglect and abuse.
Abuse—Failed to provide safe environment
29 Apr 2024Validation
29 Apr 2024Validation
Identified widespread deficiencies across administration, care planning, health services, staffing, and facility operations, including an initial immediate-threat situation that was abated, with substantial compliance later established on follow-up.
Deficiency—Resident Move-In and Eval: Res Evaluation
Deficiency—Service Plan: General
Deficiency—Service Plan: Service Planning Team
Deficiency—Change of Condition and Monitoring
Deficiency—Resident Health Services
Deficiency—Rn Delegation and Teaching
Deficiency—Res Hlth Srvc: On- and Off-Site Health Srvc
Deficiency—Systems: Medications and Treatments
Deficiency—Systems: Treatment Orders
Deficiency—Systems: Psychotropic Medication
Deficiency—Staffing Requirements and Training: Staffing
Deficiency—Acuity-Based Staffing Tool
Deficiency—Training Within 30 Days: Direct Care Staff
Deficiency—Inspections and Investigation: Insp Interval
Deficiency—Doors, Walls, Elevators, Odors
Deficiency—Individual Door Locks: Key Access
Deficiency—Administration Compliance
Deficiency—Compliance With Rules Health Care
Deficiency—Activities
Deficiency—Outside Area
23 Apr 2024License Condition
23 Apr 2024License Condition
Found a failure to provide a safe environment and cited multiple rule violations.
Regulatory Action—Failed to provide safe environment
17 Apr 2024Abuse: Neglect
17 Apr 2024Abuse: Neglect
Determined the narcotic medication was not re-ordered in time, causing missed doses and pain due to neglect and abuse.
Abuse—Failed to administer medication as ordered
09 Apr 2024Abuse: Neglect
09 Apr 2024Abuse: Neglect
Investigated and found that interventions were not placed on the Alleged Victim’s service plan for known behaviors, leading to multiple altercations with injuries. A fine was assessed.
Abuse—Failed to properly plan care
08 Apr 2024Abuse: Neglect
08 Apr 2024Abuse: Neglect
Found failures to implement appropriate safety interventions after falls, culminating in a fractured femur.
Abuse—Failed to properly plan care
08 Apr 2024Validation
08 Apr 2024Validation
Identified multiple deficiencies across administration, resident rights, care planning, medication administration, safety, and building operations during the relicensure process, with substantial compliance reached later in the process.
Found deficiencies in care planning for a resident with known aggressive behavior, resulting in resident-to-resident harm.
Abuse—Failed to properly plan care
14 Mar 2024Inspection
14 Mar 2024Inspection
Investigated a complaint and found failure to fully implement an Acuity-Based Staffing Tool, hindering determination of time and frequency for 22 required ADLs.
Licensing—Failed to use an ABST
14 Mar 2024Inspection
14 Mar 2024Inspection
Investigated and found that an Acuity-Based Staffing Tool was not fully implemented, preventing determination of staff time and frequency for 22 required ADLs.
Licensing—Failed to use an ABST
12 Mar 2024Licensure
12 Mar 2024Licensure
Identified extensive kitchen sanitation and food-handling deficiencies across multiple visits, with subsequent follow-up achieving substantial compliance.
Deficiency—Staffing Requirements and Training – Pre-Serv
Deficiency—Inspections and Investigation: Insp Interval
11 Mar 2024Abuse: Neglect
11 Mar 2024Abuse: Neglect
Investigated and found neglect and abuse due to failure to plan care, leading to a head injury after a fall; a fine was assessed.
Abuse—Failed to properly plan care
10 Mar 2024Abuse: Neglect
10 Mar 2024Abuse: Neglect
Investigated and found neglect of care and abuse due to failure to plan care and prevent a fall, resulting in injuries.
Abuse—Failed to properly plan care
06 Mar 2024Abuse: Neglect
06 Mar 2024Abuse: Neglect
Found that abuse and neglect occurred due to failure to follow the care plan, resulting in harm to a resident.
Abuse—Failed to follow care plan
06 Feb 2024Abuse: Neglect
06 Feb 2024Abuse: Neglect
Investigated found that care planning for fall interventions did not address the resident's known fall history, resulting in an unwitnessed fall and head injury; a fine was assessed.
Abuse—Failed to properly plan care
03 Feb 2024Abuse: Neglect
03 Feb 2024Abuse: Neglect
Found neglect and abuse due to failing to plan care for a resident's known fall history, leading to a fall with a bruise and discomfort. A $375 fine was assessed.
Abuse—Failed to properly plan care
13 Jan 2024Abuse: Neglect
13 Jan 2024Abuse: Neglect
Found deficiencies in care planning for repeated falls that caused injuries, supporting the allegation of neglect and abuse.
Abuse—Failed to properly plan care
14 Dec 2023Abuse: Neglect
14 Dec 2023Abuse: Neglect
Found a failure to provide a safe environment resulting in an individual sustaining a head injury outside the premises; a $250 fine was assessed.
Abuse—Failed to provide safe environment
06 Dec 2023Inspection
06 Dec 2023Inspection
Found verbal and emotional abuse toward a resident and a failure to provide a safe environment.
Licensing—Failed to protect resident from verbal abuse
04 Dec 2023Complaint
04 Dec 2023Complaint
Found deficiencies in meals service, daily activities, resident monitoring, and medication administration.
Found that residents did not receive three daily nutritious, palatable meals with snacks available seven days a week.
Licensing—Failed to provide proper food/nutrition
04 Dec 2023Inspection
04 Dec 2023Inspection
Found that a required daily program of social and recreational activities was not provided.
Licensing—Failed to provide safe environment
04 Dec 2023Inspection
04 Dec 2023Inspection
Concluded that oversight and monitoring of change of condition was not provided 24 hours a day.
Licensing—Failed to provide oversight and monitoring of change of condition
04 Dec 2023Inspection
04 Dec 2023Inspection
Investigated a complaint and found that medication administration did not ensure visual observation of the resident taking the medication.
Licensing—Failed to provide a safe medication administration system
10 Nov 2023Abuse: Neglect
10 Nov 2023Abuse: Neglect
Found neglect due to failure to properly plan care, resulting in an unwitnessed fall and hip injury with pain. A $500 fine was assessed.
Abuse—Failed to properly plan care
07 Nov 2023Inspection
07 Nov 2023Inspection
Found that three daily nutritious meals were not provided seven days a week.
Licensing—Failed to provide safe environment
19 Oct 2023Abuse: Neglect
19 Oct 2023Abuse: Neglect
Found safety and supervision deficiencies after a wandering incident that resulted in injury; a $250 fine was assessed.
Abuse—Failed to provide safe environment
17 Oct 2023Inspection
17 Oct 2023Inspection
Found that staff failed to protect a resident from physical abuse.
Licensing—Failed to protect resident from physical abuse
10 Oct 2023Inspection
10 Oct 2023Inspection
Investigated a records complaint and found snacks were not available seven days a week.
Licensing—Failed to provide service
09 Oct 2023Abuse: Neglect
09 Oct 2023Abuse: Neglect
Investigated a complaint alleging neglect and abuse due to failure to plan care for a resident’s fall history, which led to an unwitnessed fall and injuries.
Abuse—Failed to properly plan care
22 Aug 2023Complaint
22 Aug 2023Complaint
Identified a failure to terminate an employee promptly after a failed background check.
Deficiency—Licensing Complaint Investigation
Deficiency—Facility Administration: Criminal History
09 Aug 2023Abuse: Neglect
09 Aug 2023Abuse: Neglect
Identified deficiencies in planning and implementing care for a resident's fall history, leading to an unwitnessed fall and head injury; a $250 fine was assessed.
Abuse—Failed to properly plan care
18 Jul 2023Inspection
18 Jul 2023Inspection
Investigated the allegation and identified a deficiency for not completing a required background check.
Licensing—Failed to provide service
28 Jun 2023Abuse: Neglect
28 Jun 2023Abuse: Neglect
Found that medication was not administered as ordered, causing the resident discomfort. A violation related to medication administration and neglect/abuse was identified.
Abuse—Failed to administer medication as ordered
14 Jun 2023Complaint
14 Jun 2023Complaint
Investigated deficiencies in meals service and fireplace safety; found meals not consistently nutritious or palatable and temperatures poor, and fireplace area temperatures exceeded the 120°F limit.
Investigated a complaint and identified deficiencies related to plumbing systems and resident services with potential for moderate harm.
Deficiency—Licensing Complaint Investigation
Deficiency—Resident Services: Auxilary Services
Deficiency—Plumbing Systems
12 Jun 2023Inspection
12 Jun 2023Inspection
Found deficiencies in meal service, including failure to provide three daily, palatable meals, with breakfast served after 10:00 am and food delivered cold.
Licensing—Failed to provide proper food/nutrition
12 Jun 2023Inspection
12 Jun 2023Inspection
Found inadequate food storage, with only a one-week supply of dry staples and only two days' worth of perishable foods. Limited supply was noted after staff departure.
Licensing—Failed to provide proper food/nutrition
29 May 2023Inspection
29 May 2023Inspection
Investigated a complaint that some residents did not have hot water. Findings showed hot water temperatures did not meet the applicable rule.
Licensing—Failed to provide service
05 May 2023Inspection
05 May 2023Inspection
Investigated and identified a safety violation related to the fireplace area, where the glass and surrounding surfaces exceeded the 120-degree Fahrenheit limit.
Licensing—Failed to provide safe environment
28 Apr 2023License Condition
28 Apr 2023License Condition
Investigated the allegation of failing to use an ABST and found noncompliance with the ABST requirement.
Regulatory Action—Failed to use an ABST
04 Apr 2023Inspection
04 Apr 2023Inspection
Determined that three daily nutritious meals with snacks seven days a week were not provided as required.
Licensing—Failed to provide proper food/nutrition
04 Apr 2023Inspection
04 Apr 2023Inspection
Determined that transportation for social activities was not provided or arranged, with no activities bus/transportation available for the past nine months.
Licensing—Failed to provide service
28 Mar 2023Complaint
28 Mar 2023Complaint
Identified that the acuity-based staffing tool was not fully implemented or updated. Staffing details did not align with ADLs for residents and day-shift staffing appeared insufficient.
Deficiency—Licensing Complaint Investigation
Deficiency—Acuity-Based Staffing Tool
28 Mar 2023Complaint
28 Mar 2023Complaint
Identified a deficiency related to general building doors and walls needing to meet cleanable standards.
Found cleanliness deficiencies in interior and exterior surfaces, including an unclean resident room for weeks and dirty common areas.
Licensing—Failed to provide safe environment
30 Jan 2023License Condition
30 Jan 2023License Condition
Found failure to implement and update ABST as required. The finding cited noncompliance with ABST requirements.
Regulatory Action—Failed to staff as indicated by ABST
30 Jan 2023License Condition
30 Jan 2023License Condition
Found insufficient staffing to meet residents' needs and staff sleeping during the night shift, failing to assure a qualified caregiver was present.
Regulatory Action—Failed to assure a qualified caregiver was present
19 Jan 2023Inspection
19 Jan 2023Inspection
Investigated a complaint about meals and found that three daily nutritious meals with snacks seven days a week were not provided.
Licensing—Failed to provide proper food/nutrition
03 Jan 2023Inspection
03 Jan 2023Inspection
Found a deficiency for not keeping interior and exterior surfaces clean, including a dirty dining room and kitchen with tables not washed for two weeks, risking health and safety.
Licensing—Failed to provide safe environment
29 Dec 2022Inspection
29 Dec 2022Inspection
Found insufficient direct care staffing to meet scheduled and unscheduled resident needs, with call lights frequently unanswered and residents experiencing soiling.
Licensing—Failed to provide appropriate staffing
29 Dec 2022Inspection
29 Dec 2022Inspection
Found cleanliness deficiencies with rooms dirty, food scraps present, and sticky floors, indicating an unsafe environment.
Licensing—Failed to provide safe environment
29 Dec 2022Inspection
29 Dec 2022Inspection
Investigated and found failure to complete quarterly service plans after a resident moved in, and to review or update the plan.
Licensing—Failed to properly plan care
29 Dec 2022Inspection
29 Dec 2022Inspection
Investigated the complaint and identified a deficiency in providing three daily nutritious meals with snacks seven days a week.
Licensing—Failed to provide proper food/nutrition
29 Dec 2022Inspection
29 Dec 2022Inspection
Investigated an allegation of failing to cooperate with an investigation; found that records were not made available to the Department upon request.
Licensing—Failed to cooperate with an investigation
25 Dec 2022Abuse: Neglect
25 Dec 2022Abuse: Neglect
Investigated found neglect and abuse due to failure to follow a care plan, leaving a resident unattended in a secured courtyard for about five hours, who was found cold and in pain; a $500 fine was assessed.
Abuse—Failed to follow care plan
21 Dec 2022Inspection
21 Dec 2022Inspection
Found ABST not fully implemented, with required ADLs not fully accounted for in the internal assessment, and ABST unable to produce staff time per ADL.
Licensing—Failed to use an ABST
21 Dec 2022Inspection
21 Dec 2022Inspection
Investigated and identified a deficiency that quarterly service plans were not completed.
Licensing—Failed to perform adequate screening or assessment
21 Dec 2022Inspection
21 Dec 2022Inspection
Investigated and found direct care staffing was insufficient to meet residents' scheduled and unscheduled needs.
Licensing—Failed to meet the scheduled and unscheduled needs of residents
21 Dec 2022Inspection
21 Dec 2022Inspection
Found that records were not made available to the Department upon request.
Licensing—Failed to make facility or resident records accessible
29 Nov 2022Inspection
29 Nov 2022Inspection
Found insufficient direct care staffing to meet residents' needs, resulting in a delayed response to a resident's call light.
Licensing—Failed to answer call light in a timely manner
29 Nov 2022Inspection
29 Nov 2022Inspection
Found failure to provide three daily nutritious, palatable meals seven days a week.
Licensing—Failed to provide proper food/nutrition
29 Nov 2022Inspection
29 Nov 2022Inspection
Investigated the staffing allegation and found direct care staff insufficient in number to meet scheduled and unscheduled resident needs. The deficiency related to staffing under OAR 411-054-0070(1).
Licensing—Failed to provide appropriate staffing
29 Nov 2022Inspection
29 Nov 2022Inspection
Investigated the complaint and found failure to provide or arrange transportation for medical and social purposes.
Licensing—Failed to provide service
23 Nov 2022Inspection
23 Nov 2022Inspection
Found that three daily nutritious meals with snacks seven days a week were not provided and meals were served 2 to 3 hours late.
Licensing—Failed to provide proper food/nutrition
23 Nov 2022Inspection
23 Nov 2022Inspection
Found insufficient awake qualified direct care staff to meet scheduled and unscheduled resident needs, resulting in late meals.
Licensing—Failed to provide appropriate staffing
23 Nov 2022Complaint
23 Nov 2022Complaint
Investigated a complaint and identified deficiencies in meals service, transportation, staffing, acuity-based staffing, and building cleanliness.
Identified deficiencies in safety and cleanliness related to the resident environment. The call light system was not fully functional, boxes were stacked in hallways, and trash overflowed in the laundry rooms.
Licensing—Failed to provide safe environment
03 Nov 2022Abuse: Neglect
03 Nov 2022Abuse: Neglect
Found that care planning and placement for a resident were mishandled, resulting in unreasonable discomfort and loss of dignity; a $250 fine was assessed.
Abuse—Failed to follow care plan
02 Nov 2022Complaint
02 Nov 2022Complaint
Identified deficiencies related to staffing requirements and acuity-based staffing tools during the complaint investigation. The findings were deemed violations.
Deficiency—Licensing Complaint Investigation
Deficiency—Staffing Requirements and Training: Staffing
Deficiency—Acuity-Based Staffing Tool
02 Nov 2022Complaint
02 Nov 2022Complaint
Found the facility did not fully implement or update an acuity-based staffing tool, and the posted staffing plan did not match the tool's data.
Deficiency—Acuity-Based Staffing Tool
08 Sept 2022Inspection
08 Sept 2022Inspection
Investigated the staffing allegation and found insufficient staff to meet scheduled and unscheduled needs.
Licensing—Failed to provide appropriate staffing
31 Aug 2022Complaint
31 Aug 2022Complaint
Identified deficiencies in treatment orders, staffing requirements and training, and the acuity-based staffing tool.
Deficiency—Licensing Complaint Investigation
Deficiency—Systems: Treatment Orders
Deficiency—Staffing Requirements and Training: Staffing
Deficiency—Acuity-Based Staffing Tool
31 Aug 2022Complaint
31 Aug 2022Complaint
Found deficiencies in housekeeping services, staffing adequacy, ABST implementation, and interior cleanliness. The issues included weeks without housekeeping, slow call-light responses, incomplete ABST usage, and dirty rooms.
Deficiency—Licensing Complaint Investigation
Deficiency—Resident Services: Adls
Deficiency—Staffing Requirements and Training: Staffing
Investigated a failure to provide a safe environment, resulting in a resident becoming dehydrated after outdoor exposure during repeated checks.
Abuse—Failed to provide safe environment
11 Aug 2022Licensure
11 Aug 2022Licensure
Identified multiple sanitation and food-safety deficiencies in the kitchen and related areas across several visits, with a later finding of substantial compliance.
Deficiency—Inspections and Investigation: Insp Interval
01 Aug 2022Inspection
01 Aug 2022Inspection
Investigated a complaint and found housekeeping services were not provided as required.
Licensing—Failed to provide service
01 Aug 2022Inspection
01 Aug 2022Inspection
Investigated a complaint and found that interior materials and surfaces were not kept clean, with resident rooms dirty.
Licensing—Failed to provide safe environment
01 Aug 2022Inspection
01 Aug 2022Inspection
Investigated a failure to submit timely weekly vaccination reporting for residents and staff, resulting in a civil penalty.
Licensing—Failed to submit timely or adequate staffing documentation
28 Jul 2022Abuse: Neglect
28 Jul 2022Abuse: Neglect
Found neglect and abuse due to failure to provide timely emergency services, risking serious harm to a resident. A fine was assessed.
Abuse—Failed to provide service
20 Jul 2022Inspection
20 Jul 2022Inspection
Identified a deficiency for not maintaining a full-time on-site administrator as required by rule.
Licensing—Failed to provide safe environment
20 Jul 2022Inspection
20 Jul 2022Inspection
Found that a daily program of social and recreational activities based on individual and group interests and needs was not provided, limiting participation in the community.
Licensing—Failed to provide safe environment
01 Jul 2022Inspection
01 Jul 2022Inspection
Investigated failure to submit timely weekly reporting of vaccinated individuals, residents, and staff for June 1–30, 2022, and assessed a $7,500 fine.
Licensing—Failed to submit timely or adequate staffing documentation
25 Jun 2022Abuse: Neglect
25 Jun 2022Abuse: Neglect
Investigated and found that staff did not follow the resident’s care plan for a two-person assist during changing, leading to anger, discomfort, and loss of dignity, constituting abuse and neglect. A $500 fine was assessed.
Abuse—Failed to follow care plan
18 May 2022Inspection
18 May 2022Inspection
Investigated the allegation and found staffing levels insufficient to meet residents' needs, leading to delayed response to call lights.
Licensing—Failed to answer call light in a timely manner
13 Apr 2022Abuse: Neglect
13 Apr 2022Abuse: Neglect
Found that insulin was not administered as ordered on two dates, risking serious harm to a resident; one related allegation was not substantiated, and a $500 fine was assessed.
Abuse—Failed to administer medication as ordered
09 Apr 2022Abuse: Neglect
09 Apr 2022Abuse: Neglect
Found that the temporary care plan for a high fall-risk resident was not followed, resulting in an injury, and a fine was assessed.
Abuse—Failed to follow care plan
09 Apr 2022Abuse: Neglect
09 Apr 2022Abuse: Neglect
Found that care plans for a high fall risk resident were not followed, resulting in a head injury. A $1,000 fine was assessed.
Abuse—Failed to follow care plan
27 Mar 2022Abuse: Neglect
27 Mar 2022Abuse: Neglect
Identified deficiencies for failing to implement interventions and properly plan care for a resident's fall history, which resulted in injury and unreasonable discomfort.
Abuse—Failed to properly plan care
26 Mar 2022Abuse: Neglect
26 Mar 2022Abuse: Neglect
Investigated a complaint of abuse and neglect involving inappropriate contact; found failure to implement interventions and care planning for known inappropriate behaviors, resulting in loss of resident dignity.
Abuse—Failed to protect resident from inappropriate sexual contact
11 Mar 2022Abuse: Neglect
11 Mar 2022Abuse: Neglect
Found that appropriate services were not provided to meet the resident's needs, resulting in transportation to the hospital; assessed a $1,000 fine.
Abuse—Failed to provide service
05 Mar 2022Abuse: Neglect
05 Mar 2022Abuse: Neglect
Determined that care plans were not followed, resulting in weight loss and discomfort; a $1000 fine was assessed.
Abuse—Failed to follow care plan
24 Jan 2022Inspection
24 Jan 2022Inspection
Investigated a complaint and found a deficiency for not providing three daily nutritious meals with snacks seven days a week.
Licensing—Failed to provide proper food/nutrition
18 Jan 2022Inspection
18 Jan 2022Inspection
Found insufficient staffing to meet residents' scheduled and unscheduled needs, with long call-light response times and missed services.
Licensing—Failed to meet the scheduled and unscheduled needs of residents
18 Jan 2022Inspection
18 Jan 2022Inspection
Found that an acuity-based staffing tool was not fully implemented or updated, and documentation of the ABST had not been provided.
Licensing—Failed to use an ABST
22 Dec 2021Abuse: Neglect
22 Dec 2021Abuse: Neglect
Investigated and found a violation involving care planning for falls, constituting neglect and abuse, resulting in injury and discomfort; a $500 fine was assessed.
Abuse—Failed to properly plan care
16 Dec 2021Abuse: Neglect
16 Dec 2021Abuse: Neglect
Found failure to provide a safe environment, resulting in a substantiated abuse/neglect finding and a $500 fine.
Abuse—Failed to provide safe environment
16 Dec 2021Abuse: Neglect
16 Dec 2021Abuse: Neglect
Found a failure to provide a safe environment resulting in abuse and neglect, with a $500 fine assessed.
Abuse—Failed to provide safe environment
12 Dec 2021Abuse: Neglect
12 Dec 2021Abuse: Neglect
Found that a safe medication administration system was not provided, leading to the resident going without pain medication on two days and experiencing unreasonable discomfort.
Abuse—Failed to administer ordered medication
05 Dec 2021Inspection
05 Dec 2021Inspection
Investigated the allegation that medication was not administered over the weekend and found non-compliance with safe medication administration practices. The finding reflected a failure to provide a safe medication administration system.
Licensing—Failed to provide a safe medication administration system
05 Dec 2021Inspection
05 Dec 2021Inspection
Investigated staffing allegation and found insufficient staffing to meet residents' scheduled and unscheduled needs, including a period with no staff for a couple of hours.
Licensing—Failed to provide appropriate staffing
27 Nov 2021Abuse: Neglect
27 Nov 2021Abuse: Neglect
Investigated and found a failure to provide a safe medication administration system, causing the resident to go without prescribed pain medication on at least six occasions. A $500 fine was assessed.
Abuse—Failed to administer medication as ordered
23 Nov 2021Abuse: Neglect
23 Nov 2021Abuse: Neglect
Found failure to implement interventions and appropriately plan care for a resident’s fall history, resulting in a head injury.
Abuse—Failed to properly plan care
22 Nov 2021Abuse: Neglect
22 Nov 2021Abuse: Neglect
Found a failure to provide a safe medication administration system, resulting in neglect and abuse. A $500 fine assessed.
Abuse—Failed to administer medication as ordered
18 Nov 2021Abuse: Neglect
18 Nov 2021Abuse: Neglect
Found violations of resident rights due to neglect and abuse after an incident involving inappropriate contact; a $1,500 fine was assessed.
Abuse—Failed to protect resident from inappropriate sexual contact
17 Nov 2021Abuse: Neglect
17 Nov 2021Abuse: Neglect
Identified violations of safe medication administration and imposed a $1,500 fine.
Abuse—Failed to administer medication as ordered
17 Nov 2021Abuse: Neglect
17 Nov 2021Abuse: Neglect
Found deficiencies in care planning for a resident's head skin condition, causing unnecessary discomfort and loss of dignity, constituting neglect and abuse. A $1,500 fine was assessed.
Abuse—Failed to properly plan care
17 Nov 2021Abuse: Neglect
17 Nov 2021Abuse: Neglect
Investigated an allegation of neglect and abuse for failing to follow a resident's care plan for basic needs, including bathing and grooming, and improper denture care, resulting in discomfort and loss of dignity.
Abuse—Failed to follow care plan
13 Nov 2021Abuse: Neglect
13 Nov 2021Abuse: Neglect
Investigated and found neglect and abuse due to failure to plan and implement care related to a resident’s fall history. A $1,500 fine was assessed.
Abuse—Failed to properly plan care
10 Nov 2021Abuse: Neglect
10 Nov 2021Abuse: Neglect
Found that a safe environment was not provided, resulting in neglect and abuse; a $500 fine was assessed.
Abuse—Failed to provide safe environment
08 Nov 2021Abuse: Neglect
08 Nov 2021Abuse: Neglect
Investigated found that a staff member made inappropriate verbal comments toward a resident, causing loss of personal dignity, and protection from such comments failed, resulting in a fine.
Abuse—Failed to protect resident from verbal abuse
07 Nov 2021Abuse: Neglect
07 Nov 2021Abuse: Neglect
Found that care planning and interventions for a resident's fall history were not properly implemented, resulting in a witnessed fall with head injury and signaling neglect and abuse.
Abuse—Failed to properly plan care
29 Oct 2021License Condition
29 Oct 2021License Condition
Investigated and found that needed/necessary services were not provided. The response to repeated resident-to-resident sexual incidents was inadequate, resulting in an unsafe environment.
Regulatory Action—Failed to provide service
27 Oct 2021Abuse: Neglect
27 Oct 2021Abuse: Neglect
Identified a failure to implement interventions and care planning for known resident behaviors. This led to inappropriate touching and loss of resident dignity.
Abuse—Failed to protect resident from inappropriate sexual contact
26 Oct 2021Abuse: Neglect
26 Oct 2021Abuse: Neglect
Found violations involving neglect and abuse due to failure to protect a resident from involuntary seclusion; a $938 fine was assessed.
Abuse—Failed to protect resident from involuntary seclusion
26 Oct 2021Abuse: Neglect
26 Oct 2021Abuse: Neglect
Identified failures to protect a resident from involuntary seclusion, resulting in about a month without the ability to visit the resident.
Abuse—Failed to protect resident from involuntary seclusion
26 Oct 2021Abuse: Neglect
26 Oct 2021Abuse: Neglect
Found a deficient medication administration system that led to missed or extra doses for an individual, creating risk of harm.
Abuse—Failed to administer medication as ordered
25 Oct 2021Inspection
25 Oct 2021Inspection
Found insufficient awake direct care staff to meet residents' 24-hour needs.
Licensing—Failed to provide appropriate staffing
17 Oct 2021Abuse: Neglect
17 Oct 2021Abuse: Neglect
Found a failure to provide a safe medication administration system, resulting in agitation and discomfort for the resident. Violations of multiple Oregon Administrative Rules were identified.
Abuse—Failed to provide a safe medication administration system
16 Oct 2021Abuse: Neglect
16 Oct 2021Abuse: Neglect
Investigated the allegation of abuse and neglect; found that interventions and care plans for known behaviors were not implemented and an incident of inappropriate touching occurred, with a fine assessed.
Abuse—Failed to protect resident from inappropriate sexual contact
16 Oct 2021Abuse: Neglect
16 Oct 2021Abuse: Neglect
Identified a failure to protect a resident from inappropriate sexual contact, resulting in neglect and abuse findings and a fine assessed.
Abuse—Failed to protect resident from inappropriate sexual contact
16 Oct 2021Abuse: Neglect
16 Oct 2021Abuse: Neglect
Found that a resident was not protected from inappropriate sexual contact, constituting neglect and abuse; a fine was assessed.
Abuse—Failed to protect resident from inappropriate sexual contact
15 Oct 2021Abuse: Neglect
15 Oct 2021Abuse: Neglect
Investigated a report of abuse and neglect found that interventions and care planning were not implemented for known behaviors, and a person was found touching another resident, causing loss of dignity.
Abuse—Failed to protect resident from inappropriate sexual contact
13 Oct 2021Abuse: Neglect
13 Oct 2021Abuse: Neglect
Found violations of resident rights including abuse and neglect, with a fine assessed. Interventions and care plans for known behaviors were not adequately implemented.
Abuse—Failed to protect resident from inappropriate sexual contact
10 Oct 2021Abuse: Neglect
10 Oct 2021Abuse: Neglect
Investigated abuse and neglect allegation; found failure to protect a resident from inappropriate sexual contact, resulting in a $1500 fine.
Abuse—Failed to protect resident from inappropriate sexual contact
28 Sept 2021Inspection
28 Sept 2021Inspection
Found that there was no daily hydration program, resulting in inadequate hydration for residents.
Licensing—Failed to assure proper hydration
28 Sept 2021Abuse: Neglect
28 Sept 2021Abuse: Neglect
Found neglect and abuse due to failure to plan care and monitor falls, leading to unwitnessed falls and discomfort. A $500 fine was assessed.
Abuse—Failed to properly plan care
27 Sept 2021Abuse: Neglect
27 Sept 2021Abuse: Neglect
Investigated and found a violation for neglect and abuse involving failure to protect a resident from inappropriate sexual contact, with a fine assessed.
Abuse—Failed to protect resident from inappropriate sexual contact
27 Sept 2021Abuse: Neglect
27 Sept 2021Abuse: Neglect
Found that a resident experienced inappropriate sexual contact and that interventions and care planning were not properly implemented, resulting in abuse and neglect.
Abuse—Failed to protect resident from inappropriate sexual contact
20 Sept 2021Abuse: Neglect
20 Sept 2021Abuse: Neglect
Identified a failure to provide a safe environment and adequate supervision, causing a resident to wander into another resident's room and engage in a physical altercation with emotional injury; a $500 fine was assessed.
Abuse—Failed to provide safe environment
03 Sept 2021Abuse: Neglect
03 Sept 2021Abuse: Neglect
Found an unsafe medication administration system that left a resident without antibiotics and caused discomfort. A $2,000 fine was assessed.
Abuse—Failed to provide a safe medication administration system
02 Sept 2021Inspection
02 Sept 2021Inspection
Investigated the complaint and found failure to provide three daily nutritious meals with snacks seven days a week.
Licensing—Failed to provide proper food/nutrition
28 Aug 2021Abuse: Neglect
28 Aug 2021Abuse: Neglect
Found that a safe environment was not provided, leading to an Alleged Victim being struck by another resident.
Abuse—Failed to provide safe environment
16 Aug 2021Abuse: Neglect
16 Aug 2021Abuse: Neglect
Investigated and found failure to implement interventions and care planning related to fall history, resulting in injury and discomfort.
Abuse—Failed to properly plan care
13 Aug 2021Inspection
13 Aug 2021Inspection
Investigated and substantiated that resident records were not kept confidential as required by state rules.
Licensing—Failed to keep medication record current or accurate
06 Aug 2021Abuse: Neglect
06 Aug 2021Abuse: Neglect
Investigated a complaint and found neglect and abuse due to failing to assist with colostomy care, violating resident rights. A $2000 fine was assessed.
Abuse—Failed to provide service
06 Aug 2021Abuse: Neglect
06 Aug 2021Abuse: Neglect
Found a failure to monitor a resident’s fall history, which led to an unwitnessed fall and discomfort, constituting neglect and abuse.
Abuse—Failed to provide safe environment
06 Aug 2021Abuse: Neglect
06 Aug 2021Abuse: Neglect
Found that a safe medication administration system was not provided, creating risk of harm and constituting abuse; a $2000 fine was assessed.
Abuse—Failed to provide a safe medication administration system
28 Jul 2021Abuse: Neglect
28 Jul 2021Abuse: Neglect
Investigated a complaint and found that staff failed to follow a resident’s care plan to monitor another resident, resulting in neglect and abuse, with a nosebleed observed during the incident.
Abuse—Failed to follow care plan
23 Jul 2021Abuse: Neglect
23 Jul 2021Abuse: Neglect
Found that the facility failed to provide a safe environment, constituting abuse and neglect; a fine was assessed.
Abuse—Failed to provide safe environment
14 Jul 2021Abuse: Neglect
14 Jul 2021Abuse: Neglect
Found a failure to provide a safe environment and proper supervision, which allowed wandering and a physical altercation causing emotional distress and injury; a fine was assessed.
Abuse—Failed to provide safe environment
06 Jul 2021Abuse: Neglect
06 Jul 2021Abuse: Neglect
Investigated and found a failure to provide a safe environment, resulting in bruising and abrasions; assessed a $375 fine.
Abuse—Failed to provide safe environment
06 Jul 2021Abuse: Neglect
06 Jul 2021Abuse: Neglect
Investigated an allegation of neglect and abuse; found failure to provide appropriate services led to a resident's clothes smelling of urine.
Abuse—Failed to provide service
23 Jun 2021Abuse: Neglect
23 Jun 2021Abuse: Neglect
Found neglect and abuse due to failure to provide a safe environment, and a fine was assessed.
Abuse—Failed to provide safe environment
16 Jun 2021Abuse: Neglect
16 Jun 2021Abuse: Neglect
Found a failure to provide a safe environment resulting in heat exposure and sunburn. The incident occurred around late July 2021.
Abuse—Failed to provide safe environment
16 Jun 2021Abuse: Neglect
16 Jun 2021Abuse: Neglect
Found violations for failure to provide a safe environment, resulting in a resident sustaining a sunburn; a $1,000 fine assessed.
Abuse—Failed to provide safe environment
07 Jun 2021Abuse: Neglect
07 Jun 2021Abuse: Neglect
Investigated a complaint and found a substantiated neglect due to failure to provide a safe environment. A $500 fine was assessed.
Abuse—Failed to provide safe environment
07 Jun 2021Abuse: Neglect
07 Jun 2021Abuse: Neglect
Investigated an allegation of abuse and neglect and found a failure to provide a safe environment, resulting in a $500 fine.
Abuse—Failed to provide safe environment
05 May 2021Inspection
05 May 2021Inspection
Investigated a financial exploitation allegation and determined that a resident's funds were misappropriated and protections against exploitation were inadequate.
Licensing—Failed to protect resident from financial exploitation
30 Mar 2021Abuse: Neglect
30 Mar 2021Abuse: Neglect
Investigated allegations of neglect and abuse and found failure to protect a resident from inappropriate sexual contact, resulting in a substantiated finding and a $1,500 fine assessed.
Abuse—Failed to protect resident from inappropriate sexual contact
25 Mar 2021Inspection
25 Mar 2021Inspection
Found that a resident's money and personal property went missing due to theft by an unknown individual, and protection of the resident's property was inadequate.
Licensing—Failed to protect resident from financial exploitation
25 Mar 2021Inspection
25 Mar 2021Inspection
Concluded that a resident had money stolen by an unknown person and protection against theft was insufficient.
Licensing—Failed to protect resident from financial exploitation
23 Mar 2021Abuse: Neglect
23 Mar 2021Abuse: Neglect
Found neglect and abuse due to failure to provide a safe environment, resulting in a physical altercation and unreasonable discomfort, with a $375 fine assessed.
Abuse—Failed to provide safe environment
22 Mar 2021Inspection
22 Mar 2021Inspection
Investigated a complaint and found that a resident's money was stolen and diverted to an unknown bank account, constituting financial exploitation. Also identified a failure to protect resident property from theft.
Licensing—Failed to protect resident from financial exploitation
19 Mar 2021Inspection
19 Mar 2021Inspection
Identified neglect and abuse due to failure to assess a resident and intervene when the condition changed, resulting in hospital transport.
Licensing—Failed to intervene when resident's condition changed
16 Mar 2021Abuse: Neglect
16 Mar 2021Abuse: Neglect
Identified neglect and abuse due to failure to implement interventions and appropriate care planning for known behaviors, which led to a physical altercation and discomfort.
Abuse—Failed to provide safe environment
16 Feb 2021Abuse: Neglect
16 Feb 2021Abuse: Neglect
Investigated allegations of neglect and abuse related to resident safety; found failures to implement interventions and to lock a resident's door, resulting in a resident being pulled from bed and experiencing discomfort.
Abuse—Failed to provide safe environment
13 Jan 2021Abuse: Neglect
13 Jan 2021Abuse: Neglect
Investigated an allegation of abuse/neglect about care planning for a resident's known behaviors; found failures in planning and interventions that led to a physical altercation and unreasonable discomfort.
Abuse—Failed to properly plan care
07 Jan 2021Abuse: Neglect
07 Jan 2021Abuse: Neglect
Investigated and found failure to supervise during the night led to an unwitnessed fall with injury and was classified as abuse.
Abuse—Failed to follow care plan
20 Dec 2020Abuse: Neglect
20 Dec 2020Abuse: Neglect
Investigated and found failures to properly plan care and address wandering and repeated elopements, leading to hospital visits; a fine was assessed.
Abuse—Failed to properly plan care
06 Nov 2020Inspection
06 Nov 2020Inspection
Found violations related to safe medication administration that led to a resident receiving another resident's medication and requiring hospitalization.
Licensing—Failed to provide a safe medication administration system
01 Nov 2020Inspection
01 Nov 2020Inspection
Investigated the allegation of abuse and found that a staff member used a chemical restraint and failed to protect the resident from abuse.
Licensing—Failed to assure resident rights
01 Nov 2020Inspection
01 Nov 2020Inspection
Determined a licensing violation for neglect and abuse that put a resident at risk by exposure to COVID-19 from a staff member’s inhalation of marijuana oil vapor toward the resident.
Licensing—Failed to assure resident was safe
27 Oct 2020Abuse: Neglect
27 Oct 2020Abuse: Neglect
Investigated a complaint and found neglect and abuse due to failure to provide interventions for a resident's skin condition, which worsened and caused pain.
Abuse—Failed to provide service
17 Oct 2020Abuse: Neglect
17 Oct 2020Abuse: Neglect
Investigated a complaint and found a failure to provide a safe medication administration system, resulting in a resident experiencing discomfort after two days without needed medication.
Abuse—Failed to provide a safe medication administration system
07 Oct 2020Abuse: Neglect
07 Oct 2020Abuse: Neglect
Investigated a complaint and found neglect and abuse due to failure to provide services, resulting in the alleged victim transported to an outside provider with feces on clothes and a strong urine odor; a fine was assessed.
Abuse—Failed to provide service
10 Jul 2020Abuse: Neglect
10 Jul 2020Abuse: Neglect
Found that a safe medication administration system was not provided, causing pain medication to be given outside required time frames and risking harm; a $1,500 fine was assessed.
Abuse—Failed to provide a safe medication administration system
31 May 2020Abuse: Neglect
31 May 2020Abuse: Neglect
Investigated the allegation of neglect and abuse and found failures to treat and monitor a head wound, causing prolonged pain and infection risk.
Abuse—Failed to provide service
29 May 2020Abuse: Neglect
29 May 2020Abuse: Neglect
Found that insufficient supervision allowed inappropriate sexual contact, constituting abuse and neglect. A $500 fine was assessed.
Abuse—Failed to protect resident from inappropriate sexual contact
01 May 2020Abuse: Neglect
01 May 2020Abuse: Neglect
Investigated an allegation of neglect and abuse for failing to provide basic care and services, resulting in loss of personal dignity for a resident.
Abuse—Failed to provide service
18 Mar 2020Abuse: Neglect
18 Mar 2020Abuse: Neglect
Found violations of neglect and abuse and assessed a $375 fine.
Abuse—Failed to provide safe environment
19 Jan 2020Abuse: Neglect
19 Jan 2020Abuse: Neglect
Found neglect and abuse due to failure to properly plan care for a known fall history, resulting in about 31 falls over eight months and repeated discomfort.
Abuse—Failed to properly plan care
11 Jan 2020Inspection
11 Jan 2020Inspection
Found that residents' privacy and dignity were not adequately protected in service delivery.
Licensing—Failed to assure resident was safe
08 Jan 2020Abuse: Neglect
08 Jan 2020Abuse: Neglect
Found neglect and abuse due to failure to plan and implement care in response to a resident's change in condition, resulting in repeated discomfort.
Abuse—Failed to properly plan care
31 Dec 2019Inspection
31 Dec 2019Inspection
Investigated the allegation that resident records were not kept current or accurate. Found substantiated that the records were not current or accurate.
Licensing—Failed to keep resident record current or accurate
31 Dec 2019Inspection
31 Dec 2019Inspection
Found that medication was not administered as ordered.
Licensing—Failed to administer medication as ordered
31 Dec 2019Inspection
31 Dec 2019Inspection
Found failure to follow the care plan.
Licensing—Failed to follow care plan
31 Dec 2019Inspection
31 Dec 2019Inspection
Investigated the allegation of failing to administer medication as ordered and identified a violation.
Licensing—Failed to administer medication as ordered
31 Dec 2019Inspection
31 Dec 2019Inspection
Investigated the allegation that records were not accessible and found a records access violation that was substantiated.
Licensing—Failed to make facility or resident records accessible
29 Dec 2019Abuse: Neglect
29 Dec 2019Abuse: Neglect
Found that failure to plan and implement care led to an unwitnessed fall and discomfort, constituting neglect and abuse; a fine was assessed.
Abuse—Failed to properly plan care
13 Dec 2019Abuse: Neglect
13 Dec 2019Abuse: Neglect
Investigated and found neglect of care; a resident was left soaked in urine, causing discomfort and loss of dignity, and a $250 fine was assessed.
Abuse—Failed to provide service
21 Nov 2019Abuse: Neglect
21 Nov 2019Abuse: Neglect
Investigated found that a staff member in training failed to keep a resident safe when transported in a wheelchair without adjusting the foot rests, resulting in a fall and injury. A $500 fine was assessed.
Abuse—Failed to assure resident was safe
02 Aug 2019Abuse: Financial abuse
02 Aug 2019Abuse: Financial abuse
Investigated a financial exploitation allegation and found neglect of safety that created a risk of serious harm to a resident.
Abuse—Failed to protect resident from financial exploitation
10 Jun 2019Inspection
10 Jun 2019Inspection
Found a failure to report suspected abuse.
Licensing—Failed to report potential or suspected abuse
10 Jun 2019Abuse: Neglect
10 Jun 2019Abuse: Neglect
Determined a neglect violation occurred that resulted in harm and assessed a $1,500 fine.
Abuse—Failed to provide service
10 Jun 2019Inspection
10 Jun 2019Inspection
Investigated and found a sanitation violation related to food preparation and service. Molded food was observed in common areas.
Licensing—Failed to provide sanitary food service conditions
08 Jun 2019Abuse: Neglect
08 Jun 2019Abuse: Neglect
Found neglect due to failure to provide basic care, resulting in unreasonable discomfort. A $500 fine was assessed.
Abuse—Failed to provide a safe medication administration system
08 Jun 2019Inspection
08 Jun 2019Inspection
Found failure to report suspected abuse. Assessed a $750 fine.
Licensing—Failed to report potential or suspected abuse
07 Jun 2019Abuse: Neglect
07 Jun 2019Abuse: Neglect
Investigated an allegation of failing to provide a safe medication administration system. Found neglect of basic care and safety that could lead to serious harm, with a $375 fine assessed.
Abuse—Failed to provide a safe medication administration system
07 Jun 2019Inspection
07 Jun 2019Inspection
Investigated the allegation and found neglect in basic care and safety related to medication administration, creating a risk of serious harm.
Licensing—Failed to provide a safe medication administration system
24 May 2019Inspection
24 May 2019Inspection
Investigated the complaint and found that three daily nutritious meals were not provided in accordance with the Food Sanitation Rules. The complainant reported meals were served cold for tray service upstairs.
Licensing—Failed to provide proper food/nutrition
23 May 2019Inspection
23 May 2019Inspection
Investigated the allegation of failing to report suspected abuse and found a deficiency, with a $1,000 fine assessed.
Licensing—Failed to report potential or suspected abuse
23 May 2019Abuse: Neglect
23 May 2019Abuse: Neglect
Found neglect due to failing to provide a safe medication administration system, resulting in physical harm and unreasonable discomfort.
Abuse—Failed to provide a safe medication administration system
07 Apr 2019Abuse: Neglect
07 Apr 2019Abuse: Neglect
Investigated an abuse/neglect allegation and found that safety was not provided to a resident, resulting in unnecessary discomfort; a fine was assessed.
Abuse—Failed to protect resident from rough treatment
07 Apr 2019Inspection
07 Apr 2019Inspection
Investigated a failure to report suspected abuse and assessed a $1,000 fine.
Licensing—Failed to report potential or suspected abuse
25 Feb 2019Abuse: Neglect
25 Feb 2019Abuse: Neglect
Found neglect that caused physical harm and assessed a $1,500 fine.
Abuse—Failed to assure resident was safe
25 Feb 2019Inspection
25 Feb 2019Inspection
Found failure to report suspected abuse. A $750 fine was assessed.
Licensing—Failed to report potential or suspected abuse
07 Nov 2018Inspection
07 Nov 2018Inspection
Determined there was a failure to provide a safe environment, causing harm, and a $500 fine was assessed.
Licensing—Failed to provide safe environment
01 Sept 2018Inspection
01 Sept 2018Inspection
Found failure to report suspected abuse and assessed a $1,000 fine.
Licensing—Failed to report potential or suspected abuse
01 Sept 2018Abuse: Neglect
01 Sept 2018Abuse: Neglect
Found neglect of a resident by failing to provide basic care, resulting in unreasonable discomfort; a $500 fine was assessed.
Abuse—Failed to provide or assist with hygiene
07 May 2018Inspection
07 May 2018Inspection
Identified a licensing violation for failing to provide or maintain resident care equipment. The finding was classified as Level 1 with no harm or potential for minor harm.
Licensing—Failed to provide or maintain resident care equipment
04 Apr 2018Inspection
04 Apr 2018Inspection
Found failure to follow the care plan and to assess and intervene, resulting in a level 2 licensing violation and a $500 fine.
Licensing—Failed to follow care plan
27 Feb 2018Abuse: Neglect
27 Feb 2018Abuse: Neglect
Investigated a neglect allegation and found failure to follow the care plan.
Abuse—Failed to follow care plan
22 Nov 2017Abuse: Financial abuse
22 Nov 2017Abuse: Financial abuse
Found a failure to provide a secure medication system, resulting in stolen medications. The financial abuse allegation related to this issue is part of the case.
Abuse—Failure to provide a system that prevents theft or misuse of medication
27 Oct 2017Abuse: Neglect
27 Oct 2017Abuse: Neglect
Investigated a complaint alleging neglect in falls care and found a failure to provide appropriate care for a resident.
Abuse—Failed to adequately care plan related to falls
16 Sept 2017Inspection
16 Sept 2017Inspection
Concluded that a secured environment was not provided. The finding involved failure to maintain a safe physical environment.
Licensing—Failed to maintain a safe physical environment
12 Jul 2017Abuse: Financial abuse
12 Jul 2017Abuse: Financial abuse
Found that a resident was not protected from theft, indicating a financial exploitation issue.
Abuse—Failed to protect resident from financial exploitation
09 Jul 2017Abuse: Financial abuse
09 Jul 2017Abuse: Financial abuse
Investigated the financial exploitation allegation and substantiated a failure to provide a secure enviroment.
Abuse—Failed to protect resident from financial exploitation
09 Jun 2017Inspection
09 Jun 2017Inspection
Determined that inadequate staffing occurred. The finding related to staffing requirements.
Licensing—Failed to provide appropriate staffing
03 Jun 2017Abuse: Neglect
03 Jun 2017Abuse: Neglect
Investigated abuse/neglect allegation and found failure to follow a care plan and failure to protect a resident, with a $300 fine assessed.
Abuse—Failed to follow care plan
28 Mar 2017Inspection
28 Mar 2017Inspection
Identified a licensing violation for failing to make records accessible.
Licensing—Failed to make facility or resident records accessible
28 Mar 2017Inspection
28 Mar 2017Inspection
Found a failure to provide a safe medication administration system.
Licensing—Failed to provide a safe medication administration system
28 Mar 2017Inspection
28 Mar 2017Inspection
Determined that a safe medication administration system was not provided.
Licensing—Failed to provide a safe medication administration system
28 Mar 2017Inspection
28 Mar 2017Inspection
Investigated the allegation and substantiated a staffing deficiency.
Licensing—Failed to provide appropriate staffing
28 Mar 2017Inspection
28 Mar 2017Inspection
Found a licensing violation for failing to properly plan care.
Licensing—Failed to properly plan care
27 Jan 2017Inspection
27 Jan 2017Inspection
Investigated an allegation of unsafe medication administration and found a failure to maintain an adequate medication system.
Licensing—Failed to provide a safe medication administration system
11 Jan 2017Inspection
11 Jan 2017Inspection
Concluded that a resident experienced emotional abuse due to failure to provide a safe environment.
Licensing—Failed to provide safe environment
11 Jan 2017Inspection
11 Jan 2017Inspection
Investigated allegations of failure to provide a safe environment and determined that a resident was exposed to inappropriate sexual behavior by staff.
Licensing—Failed to provide safe environment
09 Sept 2016Abuse: Neglect
09 Sept 2016Abuse: Neglect
Found failure to follow the care plan related to falls.
Abuse—Failed to adequately care plan related to falls
08 Sept 2016Inspection
08 Sept 2016Inspection
Investigated the allegation and found deficiencies for failing to answer a call light promptly and for providing inappropriate care to RV1 and RV2.
Licensing—Failed to answer call light in a timely manner
15 Aug 2016Abuse: Neglect
15 Aug 2016Abuse: Neglect
Determined neglect due to failure to properly plan care and to assess and intervene, with a $2,500 fine assessed.
Abuse—Failed to properly plan care
22 Jun 2016Inspection
22 Jun 2016Inspection
Investigated an allegation of failing to follow the care plan. Found a deficiency related to providing a safe environment.
Licensing—Failed to follow care plan
21 Apr 2016Inspection
21 Apr 2016Inspection
Found insufficient staffing on the swing shift to meet residents' 24-hour needs.
Licensing—Failed to provide appropriate staffing
14 Apr 2016Abuse: Neglect
14 Apr 2016Abuse: Neglect
Investigated a neglect allegation and found failure to follow the care plan, with potential for moderate harm.
Abuse—Failed to follow care plan
23 Mar 2016Abuse: Verbal/Mental abuse
23 Mar 2016Abuse: Verbal/Mental abuse
Investigated an allegation of verbal/mental abuse and a failure to provide a safe environment; findings confirmed that a staff member videotaped a resident and safety was not maintained.
Abuse—Failed to provide safe environment
11 Mar 2016Abuse: Neglect
11 Mar 2016Abuse: Neglect
Investigated the allegation that a safe environment was not provided. Findings showed residents were not kept safe due to resident-to-resident issues.
Abuse—Failed to provide safe environment
04 Mar 2016Abuse: Financial abuse
04 Mar 2016Abuse: Financial abuse
Investigated and found financial exploitation involving failure to protect residents' medications from theft.
Abuse—Failed to provide safe environment
11 Feb 2016Abuse: Neglect
11 Feb 2016Abuse: Neglect
Investigated the allegation of failure to properly plan care and identified insufficient administrative oversight.
Abuse—Failed to properly plan care
18 Jan 2016Inspection
18 Jan 2016Inspection
Investigated the allegation and found an inadequate medication administration system.
Licensing—Failed to provide a safe medication administration system
03 Jan 2016Abuse: Neglect
03 Jan 2016Abuse: Neglect
Identified a failure to provide a safe environment for residents; a $300 fine was assessed.
Abuse—Failed to provide safe environment
04 Sept 2015Abuse: Neglect
04 Sept 2015Abuse: Neglect
Investigated a record of alleged neglect and found failure to provide a safe environment and protect a resident from unexplained injury.
Abuse—Failed to provide safe environment
20 Jul 2015Abuse: Financial abuse
20 Jul 2015Abuse: Financial abuse
Investigated a financial abuse allegation and found a failure to protect residents from financial exploitation, including theft of medication.
Abuse—Failed to provide safe environment
28 Mar 2015Abuse: Neglect
28 Mar 2015Abuse: Neglect
Investigated an allegation of failing to provide a safe environment and identified violations related to maintaining a safe environment.
Abuse—Failed to provide safe environment
19 Feb 2015Inspection
19 Feb 2015Inspection
Investigated and found a failure to provide a safe environment.
Licensing—Failed to provide safe environment
28 Oct 2014Inspection
28 Oct 2014Inspection
Investigated allegation of improper care planning and identified deficiencies related to care planning and prevention.
Licensing—Failed to properly plan care
05 Oct 2014Inspection
05 Oct 2014Inspection
Investigated the allegation of not providing a safe medication administration system and found a failure to keep medication records current.
Licensing—Failed to provide a safe medication administration system
24 Jul 2014Inspection
24 Jul 2014Inspection
Investigated a failure to follow the care plan and found a deficiency in providing or assisting with hygiene.
Licensing—Failed to follow care plan
07 May 2014Inspection
07 May 2014Inspection
Concluded that a safe environment was not provided to a resident. This represented a Level 2 safety concern.
Licensing—Failed to provide safe environment
18 Nov 2013Inspection
18 Nov 2013Inspection
Investigated and found a deficiency in safe medication administration that could allow theft or misuse of medications.
Licensing—Failure to provide a system that prevents theft or misuse of medication
07 Jun 2013Inspection
07 Jun 2013Inspection
Found that staff failed to intervene when a resident's condition changed.
Licensing—Failed to intervene when resident's condition changed
12 Aug 2012Abuse: Neglect
12 Aug 2012Abuse: Neglect
Concluded that a failure to assure resident safety occurred and a safe environment was not provided.
Abuse—Failed to assure resident was safe
29 Jul 2011Abuse: Neglect
29 Jul 2011Abuse: Neglect
Investigated an abuse/neglect allegation that was substantiated. Found failure to provide a safe environment; a $300 fine was assessed.
Abuse—Failed to address resident's behavior
20 Jul 2011Inspection
20 Jul 2011Inspection
Investigated an allegation of failing to administer medication as ordered and found that medical treatment was not provided as ordered.
Licensing—Failed to administer medication as ordered
20 Jul 2011Inspection
20 Jul 2011Inspection
Found a deficiency in the medication administration system that could prevent medication errors.
Licensing—Failed to provide a safe medication administration system
30 Oct 2010Inspection
30 Oct 2010Inspection
Investigated the allegation of failing to provide a safe medication administration system and found that medication was not administered as ordered.
Licensing—Failed to provide a safe medication administration system
15 Sept 2010Inspection
15 Sept 2010Inspection
Investigated the allegation and found a failure to provide a safe medication administration system and MAR falsification.
Licensing—Failed to provide a safe medication administration system
15 Sept 2010Inspection
15 Sept 2010Inspection
Investigated and found a failure to provide a safe medication administration system.
Licensing—Failed to provide a safe medication administration system
Disclaimer
Mirador Living is not affiliated with the owner or operator(s) of Brookdale Geary Street. The information above has not been verified or approved by the owner or operator. For exact information, please contact Brookdale Geary Street directly. There is no cost for this service. We are compensated by the community you select.
Are you an owner or operator of this community?
Claim this listing to receive messages from prospective customers and manage your community page.
