Skylark Assisted Living

    900 Skylark Pl, Ashland, OR 97520
    • Assisted Living
    • Memory Care

    Compassionate, attentive, clean, engaging care

    I placed my mom at Skylark and have been very pleased. The staff are compassionate, attentive and professional-Tish's leadership and nurses like Cindy respond quickly. Our spacious, modern room was kept clean; the gardens, garden therapy, good meals and plentiful activities (monthly family dinners with live music) kept her engaged and happy. Memory care is thoughtful and secure, maintenance (Mike) was responsive, and onboarding was smooth-I'd recommend touring Skylark.

    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
    • 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 (non-medical)

    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

    2.84·(31)

    Overall rating

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

      3.0
    • Staff

      3.2
    • Meals

      2.8
    • Amenities

      4.0
    • Value

      1.0

    Pros

    • Compassionate, attentive caregiving staff
    • Responsive nursing leadership and clinicians
    • Engaging activities and robust events calendar
    • Specialized memory-care programming
    • Well-maintained grounds, gardens, and outdoor spaces
    • Responsive maintenance and janitorial support
    • Smooth admissions and onboarding process
    • Family-oriented events and social programming
    • Improvements to food program and use of local produce
    • Clean, modern resident rooms and common areas

    Cons

    • Inconsistent staffing levels and high staff turnover
    • Variability in staff training and professionalism
    • Gaps in family communication and follow-through
    • Medication-administration and charting process weaknesses
    • Inconsistent meal quality and service continuity
    • Laundry, wardrobe, and personal-item management issues
    • Sanitation and odor concerns in select rooms and areas
    • Safety-process gaps related to elopement and transfers
    • Billing, paperwork, and administrative coordination problems
    • Construction-related disruption and facility readiness issues

    Summary of reviews

    Skylark Assisted Living presents a mixed picture where strong, consistent individual caregiving is a clear strength alongside operational inconsistencies. Many families describe warm, attentive care from long-term staff, responsive nurses, and engaged activities staff; specific staff members and leadership were repeatedly praised for compassion and effective responses to acute health changes. The community offers a broad activities program (including live music, family dinners, garden therapy, and memory-care programming) and attractive outdoor spaces that residents and families often cite as meaningful contributors to quality of life.

    At the same time, a pattern of operational weaknesses appears across reviews. Staffing levels and turnover are ongoing concerns: reviewers note periods of understaffing, reliance on less-experienced employees, and variability in professionalism and responsiveness. These staffing gaps are linked to discrete clinical and care-process concerns, including delays in attending to resident needs, inconsistencies in bathing and personal-care routines, and problems with laundry and clothing management. Families also described issues with medication handling and charting accuracy; a few serious allegations about medication and wound-management practices were raised and contributed to elevated family concern.

    Dining and housekeeping feedback is mixed. Some reviewers praise recent improvements to the food program and use of local produce, along with special events and desserts; others describe instances of institutional-style meals and inconsistent temperature or texture/quality at service. Cleanliness is generally reported as adequate in many areas, and maintenance staff are often described as responsive; however, select rooms and areas were identified with sanitation or odor concerns, and reviewers suggested that standards are uneven across the building. Ongoing construction and occasional disarray have also been mentioned as affecting the resident environment at times.

    Management and administration receive both positive and critical comments. Several families found admissions and paperwork processes smooth and administrators responsive when engaged; others cited communication gaps, unanswered calls, billing or late-fee issues, and follow-through failures. Reviewers noted an observable change in care continuity after ownership or leadership transitions in some cases, with management actively addressing some concerns but not consistently resolving others.

    For prospective residents and families: Skylark offers clear strengths in compassionate direct care, activities, and outdoor amenities, which can provide a comfortable, community-focused experience for many residents. To evaluate fit, visitors should tour during a full activity period, meet nursing leadership, ask about staffing ratios and turnover, review medication-safety and charting protocols, inquire about laundry and wardrobe processes, sample meals, and confirm billing procedures and construction timelines. These targeted questions can help determine whether the facility’s current operations align with a prospective resident’s care and safety needs.

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    Location

    Map showing location of Skylark Assisted Living

    Skylark Assisted Living is located at 900 Skylark Pl, Ashland, OR, 97520.

    About Skylark Assisted Living

    Skylark Assisted Living provides a specialized and welcoming community for seniors in Ashland, Oregon, offering a full spectrum of services designed to support residents as their needs change over time. With options for Assisted Living, Memory Care, and short-term Respite Care, Skylark ensures that each resident finds the level of support that is just right for them. Customized service plans are crafted for every individual, allowing seniors to age in place within a familiar and home-like environment while maintaining as much independence as possible.

    The philosophy at Skylark Assisted Living centers on treating each resident like family, emphasizing connection, respect, and personalized care. Residents benefit from around-the-clock assistance and encouragement from compassionate caregivers who take the time to truly understand each person’s personality, interests, and unique requirements. This supportive atmosphere helps residents rediscover independence and self-reliance, even as they receive help with daily living tasks or specialized support for conditions such as Alzheimer’s disease or dementia. End-of-life care is approached with dignity and compassion, allowing individuals and their families peace of mind during sensitive times.

    Life at Skylark Assisted Living is both engaging and tranquil, offering a blend of stimulating activities and relaxing comforts. Specially curated daily events and programs invite residents to nurture their minds, bodies, and spirits, fostering a sense of purpose and fulfillment. The community makes it convenient for residents to access their preferred local healthcare providers as needed, further supporting their desire to maintain personal routines and independence.

    Dining at Skylark is a pleasurable experience, with fresh, made-to-order meals and tasty snacks available every day. The onsite culinary team prepares delicious, restaurant-style dishes, allowing residents to enjoy meals in the privacy and comfort of their own homes or gather with friends in the cozy dining room. The focus on quality, nourishing food extends to both nutrition and the social experience of sharing a meal.

    Ultimately, Skylark Assisted Living offers a warm, vibrant, and safe environment where seniors can thrive, supported by a dedicated team that honors each resident’s individuality. The range of amenities, compassionate care, and commitment to encouraging independence make it a special place to call home.

    People often ask...

    Skylark Assisted Living offers competitive pricing, with rates starting at a cost of $5,301 per month.

    Skylark Assisted Living offers assisted living and memory care.

    There are 9 photos of Skylark Assisted Living on Mirador.

    The full address for this community is 900 Skylark Pl, Ashland, OR 97520.

    No, Skylark Assisted Living 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 number70M085
    StatusActive
    Facility typeAssisted Living Facility
    Capacity87 residents
    LicenseeSkylark Operating Group, LLC
    EffectiveOctober 24th, 1997
    View the official license record

    Inspection Reports

    160

    Reports

    0

    Type A Citations

    0

    Type B Citations

    4

    Complaints

    16

    Years

    25 Mar 2026Licensure
    Identified deficiencies in residents' rights protection, medication administration, restraints, and acuity-based staffing, with care documentation not consistently compliant.
    • DeficiencyResident Rights and Protection - General
    • DeficiencySystems: Medication Administration
    • DeficiencyRestraints and Supportive Devices
    • DeficiencyAcuity Based Staffing Tool - ABST Time
    05 Jan 2026Abuse: Neglect
    Investigated a medication management failure that led to unadministered prescribed psychotropic medication. A $500 fine was assessed.
    • AbuseFailed to provide a safe medication administration system
    21 Oct 2025Kitchen
    Identified sanitation and maintenance deficiencies in the kitchen and dining areas, including dirty surfaces, improper storage, and equipment concerns.
    • DeficiencyResident Services Meals, Food Sanitation Rule
    01 Oct 2025Inspection
    Found that medication orders were not carried out as prescribed.
    • LicensingFailed to administer medication as ordered
    21 Sept 2025Abuse: Neglect
    Investigated a medication administration error where a short-acting insulin was given in error due to an unsafe medication system, resulting in hospitalization and a $375 fine.
    • AbuseFailed to provide a safe medication administration system
    04 Feb 2025Inspection
    Investigated the allegation and found a failure to provide a safe environment that created a choking risk. A wrong tray was served, and staff intervened when the AV began choking.
    • LicensingFailed to provide safe environment
    21 Aug 2024Abuse: Neglect
    Investigated and found that there were no temporary service plans to safeguard a resident from falls after hospital return, resulting in injuries and a finding of neglect and abuse.
    • AbuseFailed to properly plan care
    30 Jul 2024Abuse: Neglect
    Found a failure to maintain a safe medication administration system that led to a medication shortage and an emergency department visit. A $450 fine was assessed.
    • AbuseFailed to provide a safe medication administration system
    24 Jul 2024Licensure
    Identified multiple deficiencies in kitchen sanitation and maintenance; follow-up verification found substantial compliance.
    • DeficiencyComment
    • DeficiencyResident Services Meals, Food Sanitation Rule
    02 Jul 2024Abuse: Neglect
    Found neglect and abuse due to failing to obtain a physician order for a resident's CPAP, placing the resident at risk of harm.
    • AbuseFailed to obtain medical order
    30 Jun 2024Abuse: Neglect
    Found that a known fall risk was not reflected in the care plan, leading to a fracture and discomfort.
    • AbuseFailed to properly plan care
    02 Apr 2024Abuse: Neglect
    Investigated and found violations of neglect and abuse after a resident was injured when the call system failed and staff did not provide timely assistance.
    • AbuseFailed to maintain functional door alarm or call system
    20 Mar 2024Inspection
    Investigated and identified a vaccination status reporting deficiency for January and February, with a civil penalty assessed.
    • LicensingFailed to report vaccination status
    31 Jan 2024Abuse: Neglect
    Identified that the care plan to change the resident's brief every two hours was not followed, leaving the resident in soiled bedding and at risk for harm. A $188 fine was assessed.
    • AbuseFailed to follow care plan
    28 Dec 2023Abuse: Neglect
    Investigated a failure to provide a safe medication administration system that led to a resident going without prescribed medications for depression and mood stabilization, resulting in suicidal behaviors.
    • AbuseFailed to provide a safe medication administration system
    06 Dec 2023Inspection
    Concluded that the provider failed to carry out medication orders as prescribed, compromising a safe medication administration system.
    • LicensingFailed to provide a safe medication administration system
    10 Oct 2023Inspection
    Found violations of medication administration safety due to failure to reorder medications in time, causing shortages and missed doses.
    • LicensingFailed to provide a safe medication administration system
    25 Aug 2023Inspection
    Investigated and found that a resident was financially exploited when another person took and used the resident's product, and protections against exploitation were not in place.
    • LicensingFailed to protect resident from financial exploitation
    14 Aug 2023Licensure
    Determined substantial compliance with meals-related requirements and food sanitation standards.
    • DeficiencyComment
    05 Jul 2023Abuse: Neglect
    Investigated an abuse/neglect allegation related to medication administration and found a failure to provide a safe system and proper training, resulting in a $338 fine.
    • AbuseFailed to provide a safe medication administration system
    19 Jun 2023Inspection
    Found violations of resident rights due to delayed call-light response, resulting in neglect and abuse when staff did not answer for almost two hours.
    • LicensingFailed to answer call light in a timely manner
    20 May 2023Abuse: Neglect
    Identified neglect of care and abuse due to failing to provide needed services, including denial of emergency medical requests. A $225 fine was assessed.
    • AbuseFailed to provide service
    19 Apr 2023Abuse: Neglect
    Investigated a complaint about missing timely pain medications and delays in ordering; found at-risk medication administration that violated resident rights and led to a fine.
    • AbuseFailed to provide a safe medication administration system
    24 Mar 2023Inspection
    Found deficiencies in the Acuity-Based Staffing Tool that failed to reflect resident needs, with inconsistencies between the roster, care plans, and ABST data.
    • LicensingFailed to use an ABST
    20 Jan 2023Abuse: Neglect
    Found neglect and abuse due to failure to properly plan care, resulting in multiple falls and injuries; a fine was assessed.
    • AbuseFailed to properly plan care
    19 Jan 2023Abuse: Neglect
    Investigated and found that a resident experienced unreasonable discomfort and loss of dignity due to inadequate incontinence care. A call light was not answered for about 30 minutes, and soiled bedding with urine odor was observed.
    • AbuseFailed to provide service
    19 Jan 2023Inspection
    Investigated and found that a resident's ability to safely self-administer medications was not evaluated.
    • LicensingFailed to properly secure or store medication
    09 Dec 2022License Condition
    Investigated the allegation and found not in substantial compliance, with multiple rule violations and failure to provide needed services.
    • Regulatory ActionFailed to provide service
    28 Nov 2022Validation
    Investigated findings showed numerous deficiencies across governance, documentation, medication management, infection control, safety, and staffing; follow-up later confirmed substantial compliance.
    • DeficiencyComment
    • DeficiencyFacility Administration: Operation
    • DeficiencyFacility Administration: Required Postings
    • DeficiencyFacility Administration: Records
    • DeficiencyReasonable Precautions
    • DeficiencyReporting & Investigating Abuse-Other Action
    • DeficiencyResident Move-In and Eval: Res Evaluation
    • DeficiencyService Plan: General
    • DeficiencyService Plan: Service Planning Team
    • DeficiencyChange of Condition and Monitoring
    • DeficiencyRn Delegation and Teaching
    • DeficiencyRes Hlth Srvc: On- and Off-Site Health Srvc
    • DeficiencyInfection Prevention & Control
    • DeficiencySystems: Medications and Treatments
    • DeficiencySystems: Medication Administration
    • DeficiencySystems: Treatment Orders
    • DeficiencySystems: Resident Right to Refuse
    • DeficiencySystems: Medication Administration
    • DeficiencySystems: Self-Administration of Meds
    • DeficiencySystems: Psychotropic Medication
    • DeficiencyRestraints and Supportive Devices
    • DeficiencyAcuity-Based Staffing Tool
    • DeficiencyStaffing Requirements and Training – Pre-Serv
    • DeficiencyTraining Within 30 Days: Direct Care Staff
    • DeficiencyFire and Life Safety: Safety
    • DeficiencyFire and Life Safety: Training For Residents
    • DeficiencyInspections and Investigation: Insp Interval
    • DeficiencyGeneral Building Exterior
    • DeficiencyGeneral Building: Doors-Walls, Cleanable
    22 Nov 2022Abuse: Neglect
    Investigated an abuse/neglect allegation about medication administration and found failures to provide medications as prescribed, causing pain.
    • AbuseFailed to provide a safe medication administration system
    19 Nov 2022Abuse: Neglect
    Found neglect for not following the care plan for incontinence care, resulting in a resident sitting in soiled briefs and discomfort.
    • AbuseFailed to follow care plan
    15 Nov 2022Complaint
    Identified deficiencies in multiple areas related to resident evaluation, service planning, health services, medication and treatment review, and staffing, with isolated/minimal potential for harm.
    • DeficiencyLicensing Complaint Investigation
    • DeficiencyReasonable Precautions
    • DeficiencyResident Move-In and Eval: Res Evaluation
    • DeficiencyService Plan: General
    • DeficiencyResident Health Services
    • DeficiencySystems: Medication and Treatment Review
    • DeficiencyStaffing Requirements and Training: Staffing
    • DeficiencyAcuity-Based Staffing Tool
    • DeficiencyStaffing Requirements and Training – Pre-Serv
    15 Nov 2022Complaint
    Identified a deficiency related to staffing requirements and training during the investigation.
    • DeficiencyLicensing Complaint Investigation
    • DeficiencyStaffing Requirements and Training: Staffing
    15 Nov 2022Complaint
    Investigated and found deficiencies in several program areas related to safety, health services, and staffing.
    • DeficiencyLicensing Complaint Investigation
    • DeficiencyReasonable Precautions
    • DeficiencyResident Move-In and Eval: Res Evaluation
    • DeficiencyResident Health Services
    • DeficiencyRn Delegation and Teaching
    • DeficiencySystems: Medication and Treatment Review
    • DeficiencyStaffing Requirements and Training: Staffing
    • DeficiencyAcuity-Based Staffing Tool
    • DeficiencyStaffing Rqmt and Training: Training Rqmts
    14 Nov 2022Inspection
    Determined a licensing violation occurred due to failure to provide a regularly scheduled Oregon licensed nurse onsite and available for phone consultation.
    • LicensingFailed to provide appropriate staffing
    14 Nov 2022Inspection
    Determined that a licensing violation occurred due to failure to document observation and evaluation of an individual's ability to perform safe medication and treatment administration unsupervised.
    • LicensingFailed to assure a qualified caregiver was present
    14 Nov 2022Inspection
    Investigated a staffing allegation and found insufficient direct care staffing to meet residents' needs, with delays in responding to call lights.
    • LicensingFailed to provide appropriate staffing
    14 Nov 2022Inspection
    Found that the provider failed to contact a resident's emergency contact, constituting a licensing violation.
    • LicensingFailed to provide safe environment
    13 Nov 2022Inspection
    Identified inconsistencies between the resident roster, care plans, and staffing data and found staffing not aligned with the ABST.
    • LicensingFailed to use an ABST
    13 Nov 2022Inspection
    Investigated the allegation and found a deficiency related to failing to provide a safe environment for residents.
    • LicensingFailed to provide safe environment
    13 Nov 2022Inspection
    Found insufficient staff to meet the scheduled and unscheduled needs of residents.
    • LicensingFailed to meet the scheduled and unscheduled needs of residents
    13 Nov 2022Inspection
    Found a deficiency in professional oversight of the medication administration system.
    • LicensingFailed to provide a safe medication administration system
    13 Nov 2022Inspection
    Investigated and found insufficient direct care staff to meet residents' scheduled and unscheduled needs.
    • LicensingFailed to meet the scheduled and unscheduled needs of residents
    13 Nov 2022Inspection
    Found a deficiency for not having a training program to determine direct care staff competency.
    • LicensingFailed to assure a qualified caregiver was present
    11 Nov 2022Inspection
    Investigated the allegation of failing to assist with ambulation or mobility and determined that a violation occurred.
    • LicensingFailed to assist with ambulation or mobility
    11 Nov 2022Inspection
    Determined that care planning did not align with the assessment. This constitutes a violation.
    • LicensingFailed to care plan in accordance with assessment
    11 Nov 2022Inspection
    Found deficiencies in the use of an acuity-based staffing tool. Inconsistencies were identified between the roster, care plans, and ABST data, and staffing did not align with ABST indicators.
    • LicensingFailed to use an ABST
    11 Nov 2022Inspection
    Investigated and determined there was a staffing deficiency due to insufficient direct care staff to meet residents' scheduled and unscheduled needs.
    • LicensingFailed to meet the scheduled and unscheduled needs of residents
    10 Nov 2022Abuse: Neglect
    Found a failure to provide a safe medication administration system, risking serious harm by not administering metabolic medications as ordered.
    • AbuseFailed to provide a safe medication administration system
    08 Nov 2022Abuse: Neglect
    Found a failure to provide a safe medication administration system, resulting in missed insulin doses and undocumented medications that led to diabetic ketoacidosis hospitalizations.
    • AbuseFailed to provide a safe medication administration system
    19 Oct 2022Complaint
    Found deficiencies in meals service timeliness, laundry, toileting/ADL assistance, staffing adequacy, and updates to the acuity-based staffing tool.
    • DeficiencyLicensing Complaint Investigation
    • DeficiencyResident Services Meals, Food Sanitation Rule
    • DeficiencyResident Services: Laundry
    • DeficiencyResident Services: Adls
    • DeficiencyStaffing Requirements and Training: Staffing
    • DeficiencyAcuity-Based Staffing Tool
    11 Oct 2022Inspection
    Investigated and identified a violation for failing to provide personal and other laundry services.
    • LicensingFailed to assure resident rights
    11 Oct 2022Inspection
    Found direct care staff were insufficient in number to meet residents' scheduled and unscheduled needs.
    • LicensingFailed to meet the scheduled and unscheduled needs of residents
    11 Oct 2022Inspection
    Found that essential housekeeping services were not provided. This violated applicable rules.
    • LicensingFailed to provide appropriate housekeeping services
    11 Oct 2022Inspection
    Investigated and found that an acuity-based staffing tool did not accurately reflect residents' needs, with inconsistencies between the roster, care plans, and ABST data.
    • LicensingFailed to use an ABST
    09 Oct 2022Inspection
    Found insufficient direct care staffing to meet scheduled and unscheduled resident needs, creating potential for harm.
    • LicensingFailed to provide appropriate staffing
    05 Oct 2022Inspection
    Found a licensing violation due to insufficient direct care staff to meet residents' scheduled and unscheduled needs.
    • LicensingFailed to provide safe environment
    05 Oct 2022Inspection
    Investigated an allegation and determined a deficiency in assisting residents with toileting and bowel and bladder management.
    • LicensingFailed to assure resident rights
    02 Oct 2022Abuse: Neglect
    Found that a safe medication administration system was not provided, resulting in missed blood pressure medications and risk of serious harm.
    • AbuseFailed to provide a safe medication administration system
    06 Sept 2022Abuse: Neglect
    Found a failure to provide a safe medication administration system, resulting in missed diabetic doses and risk of harm, with a fine assessed.
    • AbuseFailed to provide a safe medication administration system
    28 Aug 2022Abuse: Neglect
    Investigated the allegation of financial exploitation; found unaccounted narcotic pills and a deficient medication system, indicating neglect.
    • AbuseFailed to protect resident from financial exploitation
    02 Aug 2022Abuse: Neglect
    Found that the provider failed to provide a safe environment, leading to a severe injury and a $1125 fine.
    • AbuseFailed to provide safe environment
    27 Jul 2022Abuse: Neglect
    Found a failure to provide a safe medication administration system, with medications not onsite for a resident from May through July 2022. This resulted in neglect and abuse.
    • AbuseFailed to provide a safe medication administration system
    15 Jul 2022Abuse: Neglect
    Investigated a medication administration incident and found a failure to provide a safe medication administration system, leading to desaturation and hospital observation for a resident.
    • AbuseFailed to provide a safe medication administration system
    27 May 2022Abuse: Neglect
    Investigated allegations of neglect and abuse related to hygiene and care, resulting in a pressure ulcer.
    • AbuseFailed to provide service
    17 May 2022Abuse: Neglect
    Found that a safe medication administration system was not provided, placing a resident at risk of serious harm; a $1,500 fine was assessed.
    • AbuseFailed to provide a safe medication administration system
    30 Apr 2022Abuse: Neglect
    Investigated a complaint and found a failure to provide a safe medication administration system, resulting in anxiety, shakiness, and discomfort. The findings identified a pattern of medication management deficiencies affecting a resident.
    • AbuseFailed to provide a safe medication administration system
    27 Apr 2022Abuse: Neglect
    Found a violation for neglect and abuse due to failure to provide a safe environment, leading to a medical emergency and delayed response; a $250 fine was assessed.
    • AbuseFailed to provide safe environment
    12 Apr 2022Inspection
    Determined the allegation that the resident service plan was not completed before move-in to be substantiated.
    • LicensingFailed to properly plan care
    05 Apr 2022Inspection
    Investigated the allegation and determined no licensing violation or abuse occurred.
    • LicensingFailed to administer medication as ordered
    05 Apr 2022Abuse: Neglect
    Investigated the complaint and found a failure to provide a safe medication administration system, with an abuse/neglect finding and a fine.
    • AbuseFailed to provide a safe medication administration system
    22 Dec 2021Inspection
    Determined that the allegation of failing to administer medication as ordered was verified.
    • LicensingFailed to administer medication as ordered
    18 Nov 2021Abuse: Neglect
    Found failures in safe medication administration that placed a resident at risk for harm, including abuse and neglect.
    • AbuseFailed to provide a safe medication administration system
    08 Oct 2021Inspection
    Investigated the allegation and determined no licensing violation occurred.
    • LicensingFailed to answer call light in a timely manner
    01 Oct 2021Abuse: Neglect
    Found that barrier cream instructions were not included in the care plan, so the cream was not applied as ordered, contributing to a stage 2 pressure ulcer and a fine assessed.
    • AbuseFailed to properly plan care
    30 Sept 2021Inspection
    Found that appropriate staffing was not provided.
    • LicensingFailed to provide appropriate staffing
    28 Sept 2021Inspection
    Investigated an allegation of not providing a homelike environment and found it verified.
    • LicensingFailed to provide a homelike environment
    28 Sept 2021Inspection
    Determined that the allegation of an inadequate food supply was verified.
    • LicensingFailed to assure adequate food supply
    28 Sept 2021Inspection
    Investigated an allegation that services were not provided and verified that this occurred.
    • LicensingFailed to provide service
    10 Sept 2021Inspection
    Determined that a failure to provide or assist with hygiene occurred.
    • LicensingFailed to provide or assist with hygiene
    10 Sept 2021Inspection
    Investigated the allegation of failing to administer medication as ordered and verified the failure.
    • LicensingFailed to administer medication as ordered
    10 Sept 2021Inspection
    Verified the allegation that a call light was not answered in a timely manner.
    • LicensingFailed to answer call light in a timely manner
    08 Sept 2021Inspection
    Confirmed the allegation that medication was not administered as ordered.
    • LicensingFailed to administer medication as ordered
    08 Sept 2021Inspection
    Determined that proper food / nutrition was not provided to the Alleged Victim.
    • LicensingFailed to provide proper food/nutrition
    08 Sept 2021Inspection
    Verified the allegation that resident rights were not assured. Identified a licensing violation related to resident rights.
    • LicensingFailed to assure resident rights
    08 Sept 2021Inspection
    Investigated the staffing allegation and found a deficiency.
    • LicensingFailed to provide appropriate staffing
    11 Aug 2021Inspection
    Investigated the staffing allegation and found that appropriate staffing was not provided.
    • LicensingFailed to provide appropriate staffing
    30 Jul 2021Abuse: Neglect
    Found that a provider failed to provide a safe environment, resulting in neglect and abuse toward a resident; a $500 fine was assessed.
    • AbuseFailed to protect resident from mental or emotional abuse
    20 Jul 2021Inspection
    Investigated and found insufficient staffing to meet residents' needs.
    • LicensingFailed to provide appropriate staffing
    21 Jun 2021Abuse: Neglect
    Investigated and found failure to follow the care plan led to neglect and abuse, with a $500 fine assessed.
    • AbuseFailed to follow care plan
    14 Jun 2021Inspection
    Investigated an allegation of inadequate staffing and confirmed staffing levels were not adequate.
    • LicensingFailed to provide appropriate staffing
    10 Jun 2021Inspection
    Investigated the allegation of inadequate staffing and verified it.
    • LicensingFailed to provide appropriate staffing
    10 Jun 2021Inspection
    Found a medication administration deficiency after investigation.
    • LicensingFailed to administer medication as ordered
    31 May 2021Abuse: Neglect
    Investigated an allegation of neglect for not following the care plan, with residents missing showers and developing skin rashes; findings substantiated with no fine assessed.
    • AbuseFailed to follow care plan
    24 May 2021Inspection
    Investigated the staffing adequacy allegation and verified a staffing deficiency.
    • LicensingFailed to provide appropriate staffing
    24 May 2021Inspection
    Verified the allegation that assistance with hygiene was not provided.
    • LicensingFailed to provide or assist with hygiene
    09 Jan 2021Abuse: Neglect
    Found a failure to provide a safe medication administration system, resulting in three days without anxiety medication and causing undue stress and discomfort.
    • AbuseFailed to provide a safe medication administration system
    01 Dec 2020Inspection
    Investigated the allegation that a safe medication administration system was not provided; findings verified.
    • LicensingFailed to provide a safe medication administration system
    01 Dec 2020Inspection
    Investigated and found a failure to provide a system that prevents theft or misuse of medications.
    • LicensingFailure to provide a system that prevents theft or misuse of medication
    27 Aug 2020Inspection
    Investigated and found that visitors were not screened in, creating a safety risk and violating state rules.
    • LicensingFailed to provide safe environment
    18 Aug 2020Abuse: Neglect
    Determined that staff failed to follow the care plan, resulting in inadequate cleansing before applying wound cream, insufficient coordination of nail care, and ongoing incontinence hygiene issues that created risk of moderate harm.
    • AbuseFailed to follow care plan
    15 Jul 2020Abuse: Neglect
    Identified a safety violation resulting in neglect and abuse, and assessed a $500 fine.
    • AbuseFailed to provide safe environment
    09 Apr 2020Inspection
    Confirmed an allegation that medications and treatment orders were not administered as ordered.
    • LicensingFailed to administer medication as ordered
    08 Apr 2020Inspection
    Investigated an allegation that ordered medication was not administered and confirmed the finding.
    • LicensingFailed to administer ordered medication
    02 Apr 2020Inspection
    Investigated allegation of failing to administer medication as ordered. Found failure to administer medication as ordered.
    • LicensingFailed to administer medication as ordered
    30 Dec 2019Abuse: Neglect
    Concluded unsafe food storage and inadequate care planning around an individual's safety. A $250 fine was assessed.
    • AbuseFailed to provide safe environment
    28 Nov 2019Abuse: Neglect
    Determined that neglect and abuse occurred, and a $500 fine was assessed.
    • AbuseFailed to provide service
    28 Oct 2019Abuse: Neglect
    Investigated a narcotics-related complaint and found that the medication could not be accounted for after delivery, indicating a failure in the medication administration system and resulting in abuse and neglect concerns.
    • AbuseFailed to provide a safe medication administration system
    12 Sept 2019Abuse: Neglect
    Investigated and substantiated that inadequate care planning contributed to multiple falls and injuries, with a fine assessed.
    • AbuseFailed to properly plan care
    11 Aug 2019Abuse: Neglect
    Found neglect by the alleged perpetrator created a risk of serious harm; a $375 fine was assessed.
    • AbuseFailed to provide a safe medication administration system
    19 Jul 2019Inspection
    Found that suspected abuse was not reported; a $750 fine was assessed.
    • LicensingFailed to report potential or suspected abuse
    19 Jul 2019Abuse: Neglect
    Found neglect that posed a risk of serious harm and assessed a $1500.00 fine.
    • AbuseFailed to provide a safe medication administration system
    26 May 2019Abuse: Neglect
    Found that the provider failed to provide a safe medication administration system, risking serious harm when a resident received another resident's medications.
    • AbuseFailed to provide a safe medication administration system
    10 Apr 2019Inspection
    Investigated the allegation and found that medication orders were not carried out as prescribed, with a dose given too early.
    • LicensingFailed to administer medication as ordered
    11 Dec 2018Inspection
    Investigated an allegation that a narcotic was not secured properly and identified a deficiency in safe medication administration practices.
    • LicensingFailed to provide a safe medication administration system
    11 Dec 2018Inspection
    Investigated the allegation of an unsafe environment; substantiated and found substantial noncompliance.
    • LicensingFailed to provide safe environment
    25 Oct 2018Abuse: Neglect
    Found a deficient medication administration system that caused physical harm and risk of serious harm. A fine was assessed.
    • AbuseFailed to provide a safe medication administration system
    17 Aug 2018Inspection
    Found inadequate supervision due to failure to oversee change of condition.
    • LicensingFailed to provide oversight and monitoring of change of condition
    24 Jul 2018Inspection
    Investigated a medication administration allegation and found an inadequate medication system, with a $500 fine assessed.
    • LicensingFailed to administer medication as ordered
    22 Jun 2018Inspection
    Investigated the allegation and found neglect in resident care by placing the resident in memory care to avoid addressing behaviors, resulting in significant emotional harm.
    • LicensingFailed to keep resident record current or accurate
    14 Jun 2018Inspection
    Found a deficiency in hygiene assistance related to bathing and washing hair, with a resident not receiving showers.
    • LicensingFailed to provide or assist with hygiene
    21 May 2018Inspection
    Found a failure to provide a safe medication administration system. A $500 fine was assessed.
    • LicensingFailed to provide a safe medication administration system
    20 Mar 2018Abuse: Neglect
    Identified a deficiency in the safe medication administration system.
    • AbuseFailed to provide a safe medication administration system
    12 Mar 2018Inspection
    Found a deficient medication administration system that could pose safety risks.
    • LicensingFailed to provide a safe medication administration system
    13 Nov 2017Inspection
    Investigated an allegation of failing to provide service and found that caregivers did not have required background checks and some worked unsupervised.
    • LicensingFailed to provide service
    25 Jul 2017Abuse: Neglect
    Determined that care was not properly planned and residents did not receive appropriate care.
    • AbuseFailed to properly plan care
    20 Nov 2016Abuse: Financial abuse
    Investigated and substantiated the financial abuse allegation; found residents' resources were at risk.
    • AbuseFailed to provide safe environment
    02 Nov 2016Inspection
    Investigated a complaint alleging failure to provide a safe environment; findings substantiated that a resident's resources were wrongfully taken.
    • LicensingFailed to provide safe environment
    16 Sept 2016Abuse: Neglect
    Identified a failure to provide an adequate medication administration system. A $300 fine was assessed.
    • AbuseFailed to provide a safe medication administration system
    19 Aug 2016Inspection
    Determined that a safe medication administration system was not provided.
    • LicensingFailed to provide a safe medication administration system
    15 Aug 2016Abuse: Neglect
    Investigated an allegation of neglect related to falls and found a failure to protect a resident from physical harm.
    • AbuseFailed to adequately care plan related to falls
    15 Aug 2016Inspection
    Investigated the allegation of an unsafe medication administration system and found a failure to provide a safe medication administration system.
    • LicensingFailed to provide a safe medication administration system
    28 Jul 2016Inspection
    Investigated a complaint and determined failure to provide a safe environment and lack of administrative oversight.
    • LicensingFailed to provide safe environment
    08 Jun 2016Inspection
    Investigated the medication administration allegation and found program staff did not administer medications as prescribed.
    • LicensingFailed to administer medication as ordered
    08 Jun 2016Inspection
    Found insufficient staff to respond to call lights promptly.
    • LicensingFailed to answer call light in a timely manner
    03 Mar 2016Inspection
    Investigated an allegation of insufficient staffing. Identified a staffing deficiency.
    • LicensingFailed to provide appropriate staffing
    03 Mar 2016Inspection
    Investigated a medication administration allegation and found that medications were not administered as ordered.
    • LicensingFailed to administer medication as ordered
    18 Feb 2016Abuse: Financial abuse
    Investigated a financial abuse allegation and found that a resident was not protected from loss of medication.
    • AbuseFailed to provide safe environment
    11 Jan 2016Inspection
    Identified deficiencies in food safety related to how food was prepared. The finding cited noncompliance with safety rules.
    • LicensingFailed to assure food safety
    20 Nov 2015Inspection
    Identified insufficient staffing that failed to meet residents' needs and violated staffing requirements.
    • LicensingFailed to provide appropriate staffing
    17 Nov 2015Abuse: Financial abuse
    Found that a resident was not protected from loss of medication.
    • AbuseFailed to provide safe environment
    13 Nov 2015Inspection
    Found that program staff failed to track controlled substances as required.
    • LicensingFailed to provide a safe medication administration system
    02 Nov 2015Inspection
    Investigated a failure to provide a system that prevents theft or misuse of medication. Substantiated violations identified.
    • LicensingFailure to provide a system that prevents theft or misuse of medication
    08 Sept 2015Abuse: Neglect
    Investigated an allegation of neglect related to falls care planning and found that appropriate care was not provided.
    • AbuseFailed to adequately care plan related to falls
    05 Aug 2015Inspection
    Investigated and found a failure to maintain a safe medication administration system.
    • LicensingFailed to provide a safe medication administration system
    20 Jul 2015Abuse: Financial abuse
    Investigated and substantiated financial abuse and a failure to provide a safe environment. Found that a resident's resources were wrongfully taken and the resident was not protected.
    • AbuseFailed to provide safe environment
    05 Oct 2014Inspection
    Found that resident rights were not protected due to inappropriate comments.
    • LicensingFailed to assure resident rights
    05 Oct 2014Inspection
    Investigated alleged failure to assist with toileting and found a deficiency in providing appropriate care.
    • LicensingFailed to assist with toileting
    21 Aug 2014Inspection
    Investigated and found deficiencies in supervising residents.
    • LicensingFailed to address resident's behavior
    09 Dec 2013Abuse: Neglect
    Investigated the allegation and identified a failure to protect residents from unwanted physical contact.
    • AbuseFailed to provide safe environment
    04 Nov 2013Inspection
    Found that staff failed to protect residents from inappropriate interaction.
    • LicensingFailed to address resident's behavior
    26 May 2013Abuse: Financial abuse
    Found substantiated financial abuse and a failure to provide a safe environment, with resources taken from RV1 and RV2.
    • AbuseFailed to provide safe environment
    03 Apr 2013Abuse: Neglect
    Investigated a medication administration allegation and found an inadequate medication management system. A $300 fine was assessed.
    • AbuseFailed to administer medication as ordered
    02 Apr 2013Inspection
    Identified an inadequate medication system and substantiated violations related to safe medication administration.
    • LicensingFailed to provide a safe medication administration system
    26 Feb 2013Abuse: Financial abuse
    Investigated the alleged financial abuse and found a failure to protect a resident from financial loss.
    • AbuseFailed to provide safe environment
    30 Aug 2012Abuse: Financial abuse
    Investigated a financial abuse allegation and found that a resident's funds were not protected.
    • AbuseFailed to provide safe environment
    06 May 2012Inspection
    Found failure to follow the care plan, resulting in a licensing violation.
    • LicensingFailed to follow care plan
    18 Dec 2010Inspection
    Found a deficiency in the safe medication administration system.
    • LicensingFailed to provide a safe medication administration system
    29 Mar 2010Inspection
    Investigated the allegation and found that adequate care was not provided.
    • LicensingFailed to provide service
    08 Jan 2010Inspection
    Found that residents' rights were not protected from inappropriate verbalizations by another resident.
    • LicensingFailed to assure resident rights

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