Pricing ranges from
    $6,037 – 7,848/month

    Waterhouse Ridge Memory Care

    1115 NW 158th Ave, Beaverton, OR 97006
    • Assisted Living
    • Memory Care
    3.8·82 reviews
    For the front desk(971) 451-2156

    Pricing

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

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    Tour Type

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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

    3.84·(82)

    Overall rating

    1. 5
    2. 4
    3. 3
    4. 2
    5. 1

    • Care

      3.0

    • Staff

      3.4

    • Meals

      3.1

    • Amenities

      3.2

    • Value

      1.2

    Pros

    • Attractive, recently built facility with thoughtful design
    • Home-like, well-furnished interiors and private-room options
    • Secure outdoor courtyard and garden space
    • Compassionate, long-term caregiving staff and attentive med techs
    • Active programming available (music, crafts, themed parties, gardening)
    • On-site transportation for outings
    • Proactive family communication in many cases
    • Occasional high-quality, fresh meals prepared by an engaged chef
    • Helpful move-in coordination and welcoming tour experiences
    • Dementia-focused training and social-oriented memory-care layout

    Cons

    • High staff turnover with heavy reliance on agency caregivers
    • Inconsistent staff training and professional conduct
    • Insufficient caregiver-to-resident staffing ratios, especially overnight
    • Gaps in medication management and controlled-substance security
    • Inconsistent dining quality and meal-service reliability
    • Limited and uneven activity engagement across shifts
    • Sanitation and laundry management inconsistencies
    • Inadequate maintenance and room-readiness processes
    • Weak leadership continuity and management responsiveness
    • Security and access-control gaps around doors and courtyards
    • Billing and fee-administration inconsistencies
    • Challenges in regulatory compliance and inspection outcomes

    Summary of reviews

    Waterhouse Ridge Memory Care presents a contrast between a modern, thoughtfully designed physical environment and recurring operational challenges. Many families praise the facility's new construction, homelike furnishings, private-room options, and secure outdoor spaces. When staffing is stable, reviewers describe compassionate caregivers, attentive med techs, proactive communication, engaging activities such as music, gardening, and themed events, and, in some instances, high-quality dining prepared by an invested chef.

    However, a persistent theme across reviews is operational inconsistency tied to staffing and management. High turnover and a substantial use of agency staff are repeatedly noted, and reviewers describe uneven caregiver training, variable professionalism, and inadequate overnight coverage. These patterns are associated with delays in routine care tasks, inconsistent activity engagement for residents, and concerns about how personal belongings and laundry are handled.

    Clinical-operations concerns appear in several areas: families described issues with medication administration controls and with continuity of clinical oversight, and there are references to problematic outcomes from state inspection processes. Dining service is inconsistent—some families report excellent, fresh meals, while others describe substitutions, cold plates, or meal interruptions tied to kitchen staffing. Maintenance and room-readiness processes also surface as a weakness, including delayed move-ins, slow repairs, and intermittent sanitation shortcomings.

    Management and communication present a mixed picture. Some reviewers note strong, responsive leadership that improved operations over time; others describe frequent leadership turnover, delayed responses to serious concerns, and frustration over billing or fee adjustments. Security and access-control practices were questioned in a few accounts, creating anxiety for families about resident safety. Financial expectations are another recurring issue—families perceive the community as premium-priced and express concern when services or room features do not match initial promises.

    For prospective residents and families: Waterhouse Ridge offers an attractive, dementia-focused physical environment and a core of caring staff, and it can deliver a high-quality experience when leadership and staffing are stable. The principal risks are operational: staffing instability, inconsistent training/oversight, uneven dining and activity delivery, and management continuity. Visitors should evaluate current staffing patterns (including agency staffing percentages), review recent inspection results and corrective actions, clarify billing and room-readiness policies in writing, and tour during different shifts to assess day-to-day consistency before deciding.

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    Location

    Waterhouse Ridge Memory Care is located at 1115 NW 158th Ave, Beaverton, OR, 97006.

    About Waterhouse Ridge Memory Care

    Waterhouse Ridge Memory Care is a premier residential community dedicated to providing specialized support for individuals living with Alzheimer’s Disease, dementia, and other forms of memory loss. Nestled in the Bethany area of Beaverton, Waterhouse Ridge offers a welcoming and accessible location for families from nearby Portland, Aloha, Hillsboro, Tigard, and Forest Grove. The community’s expertise in memory care is demonstrated through its individualized approach, developing first-class personalized care plans that address each resident’s unique needs. Residents are greeted with an environment that feels safe, nurturing, and comfortable, providing the ideal setting for both living and healing.

    Inside Waterhouse Ridge Memory Care, residents enjoy the comforts of home in beautifully appointed "neighborhoods," each designed to foster connection while maintaining a sense of privacy. The community features a variety of inviting spaces, including indoor and outdoor lounge areas, dining rooms, a study, and secure courtyards. Outdoor gardens and walking paths encourage residents to enjoy fresh air and gentle activity, while secure surroundings offer peace of mind for families concerned about safety. The living quarters are thoughtfully designed with options for both private and shared suites, accommodating individual preferences and budget. No buy-in fees or long-term leases are required, making the transition as smooth as possible for families and residents.

    Daily life at Waterhouse Ridge is enriched with an engaging calendar of events, activities, and classes thoughtfully designed to keep both minds and bodies active. Staff members take special care to develop creative programming, encouraging family and friends to join in during visits. The community can also provide private spaces for special gatherings, ensuring that important occasions like birthday parties, anniversaries, movie nights, and live musical entertainment feel especially meaningful for residents. In each neighborhood, Life Enrichment Kits are available to assist both staff and visitors in spending quality, purposeful time with residents, ensuring that every day offers opportunities for connection and fulfillment.

    Dining at Waterhouse Ridge is a highlight, featuring chef-prepared meals crafted with from-scratch cooking techniques, seasonal fruits and vegetables, and natural herbs and spices. The culinary team takes pleasure in preparing residents’ favorite dishes and is attentive to special dietary needs, always striving to incorporate foods that promote brain health and overall wellness. Family members are welcome to contribute menu suggestions, further personalizing the dining experience and making meals a source of comfort and joy.

    Central to the community’s mission is adapting care to each resident’s evolving needs through comprehensive nursing assessments and individualized plans. The professional, caring staff provides essential personal care and offers ongoing support designed to enrich daily life and promote dignity. The staff’s attention and compassion ensure that every resident is treated with respect and receives assistance tailored to their abilities and interests.

    Waterhouse Ridge Memory Care is committed to enriching the lives of its residents, staff, and families, creating an atmosphere of support, empowerment, and meaningful engagement. Whether strolling through the gardens, socializing in the beautifully outfitted common areas, or savoring a nutritious meal, residents are surrounded by warmth, security, and understanding. With its focus on individualized care and a vibrant, resident-centered community atmosphere, Waterhouse Ridge Memory Care offers families peace of mind and loved ones a place to thrive.

    People often ask...

    Waterhouse Ridge Memory Care offers competitive pricing, with rates starting at a cost of $6,037 per month.

    Waterhouse Ridge Memory Care offers assisted living and memory care.

    There are 35 photos of Waterhouse Ridge Memory Care on Mirador.

    The full address for this community is 1115 NW 158th Ave, Beaverton, OR 97006.

    No, Waterhouse Ridge Memory Care 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 number50R433
    StatusActive
    Facility typeResidential Care Facility
    Capacity68 residents
    LicenseeWaterhouse Ridge Memory Care, LLC
    EffectiveMarch 3rd, 2016
    Special certificationMemory Care
    View the official license record

    Inspection Reports

    210

    Reports

    0

    Type A Citations

    0

    Type B Citations

    12

    Complaints

    10

    Years

    14 Sept 2026License Condition
    Found failure to use an ABST as alleged, violating acuity-based staffing requirements.
    • Regulatory Action—Failed to use an ABST
    14 Jun 2026Inspection
    Found a licensing violation due to inadequate supervision that allowed an Alleged Victim to elope from a secured area, risking harm.
    • Licensing—Failed to provide safe environment
    14 May 2026Inspection
    Investigated and found a violation for failing to provide documentation upon request.
    • Licensing—Failed to cooperate with an investigation
    04 Mar 2026Licensure
    Identified deficiencies in resident care planning, infection control, fire safety, and administration compliance. Found service plans did not reflect current needs, infection control practices were inadequate, fire drills lacked required documentation, and licensing rules for health care and administration were not followed.
    • Deficiency—Service Plan: General
    • Deficiency—Infection Prevention & Control
    • Deficiency—Fire and Life Safety: Safety
    • Deficiency—Administration Compliance
    • Deficiency—Compliance with Rules Health Care
    24 Feb 2026Kitchen
    Identified deficiencies in kitchen sanitation practices and administration compliance. Violations were cited.
    • Deficiency—Resident Services Meals, Food Sanitation Rule
    • Deficiency—Administration Compliance
    18 Jan 2026Inspection
    Found an outdated Acuity-Based Staffing Tool with inconsistencies between the resident roster, care plans, and ABST, indicating inadequate staffing data.
    • Licensing—Failed to use an ABST
    18 Jan 2026Inspection
    Found a failure to provide a safe environment that allowed a resident to elope due to an unlocked reception door.
    • Licensing—Failed to provide safe environment
    11 Jan 2026Inspection
    Investigated and found a deficiency in updating an acuity-based staffing tool.
    • Licensing—Failed to use an ABST
    13 Nov 2025Inspection
    Investigated a staffing-related allegation and found a deficiency in implementing and updating an acuity-based staffing tool.
    • Licensing—Failed to use an ABST
    09 Nov 2025Inspection
    Found a licensing violation due to not fully implementing and updating an acuity-based staffing tool.
    • Licensing—Failed to use an ABST
    19 Mar 2025Kitchen
    Identified deficiencies in kitchen sanitation and administration compliance during two visits.
    • Deficiency—Resident Services Meals, Food Sanitation Rule
    • Deficiency—Administration Compliance
    29 Dec 2024Abuse: Neglect
    Investigated a complaint and found that staff did not follow the two-person transfer care plan, causing a fall and injury; identified as neglect and abuse, with a $188 fine assessed.
    • Abuse—Failed to follow care plan
    04 Nov 2024Inspection
    Investigated the allegation that care was not properly planned and found a violation of Oregon Administrative Rules.
    • Licensing—Failed to properly plan care
    02 Nov 2024Abuse: Neglect
    Found violations involving improper medication handling and theft from a resident, including missing meds and an alleged perpetrator; a fine was assessed.
    • Abuse—Failed to protect resident from financial exploitation
    28 Oct 2024Inspection
    Investigated an allegation of not administering medication as ordered and determined a violation of Oregon Administrative Rules.
    • Licensing—Failed to administer medication as ordered
    14 Oct 2024Abuse: Neglect
    Investigated a safety concern and found a failure to provide a safe environment resulting in a resident injury. The finding was substantiated and a fine was assessed.
    • Abuse—Failed to provide safe environment
    10 Oct 2024Inspection
    Investigated a complaint and found a violation for failing to provide a safe medication administration system.
    • Licensing—Failed to provide a safe medication administration system
    07 Jul 2024Abuse: Neglect
    Found a failure to provide a safe environment that resulted in neglect and abuse; a fine was assessed.
    • Abuse—Failed to provide safe environment
    05 Jul 2024Inspection
    Found a violation for failure to administer medication as ordered; the resident experienced no negative outcome.
    • Licensing—Failed to administer medication as ordered
    21 May 2024Inspection
    Identified a failure to provide a safe medication administration system.
    • Licensing—Failed to provide a safe medication administration system
    30 Apr 2024Inspection
    Investigated an allegation of inadequate tracking and disposal of controlled substances and concluded no licensing violation or abuse occurred.
    • Licensing—Failure to provide a system that prevents theft or misuse of medication
    30 Apr 2024Complaint
    Identified deficiencies related to abuse reporting, tracking controlled substances, treatment orders, and acuity-based staffing.
    • Deficiency—Definitions
    • Deficiency—Reporting & Investigating Abuse-Other Action
    • Deficiency—Systems: Tracking Control Substances
    • Deficiency—Systems: Treatment Orders
    • Deficiency—Acuity-Based Staffing Tool
    24 Apr 2024Inspection
    Found deficiencies in transfer practices that placed a non-ambulatory resident at risk; a staff member lifted the resident without adequate assistance or use of safety devices during transfer.
    • Licensing—Failed to assist with transfer
    21 Mar 2024Inspection
    Found deficiencies in the Acuity-Based Staffing Tool, with inconsistencies between the resident roster, care plans, and ABST data.
    • Licensing—Failed to use an ABST
    15 Mar 2024Abuse: Neglect
    Investigated found neglect and abuse due to failure to plan and monitor care for a resident with a known history of falls, resulting in unwitnessed falls and skin injuries.
    • Abuse—Failed to properly plan care
    04 Mar 2024Validation
    Investigated findings identified widespread deficiencies across resident rights, health services, medication management, infection control, and safety, resulting in multiple violations cited during licensure activities.
    • Deficiency—Comment
    • Deficiency—Facility Administration: Operation
    • Deficiency—Reasonable Precautions
    • Deficiency—Resident Rights and Protection - General
    • Deficiency—Reporting & Investigating Abuse-Other Action
    • 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—Infection Prevention & Control
    • Deficiency—Systems: Medications and Treatments
    • Deficiency—Systems: Tracking Control Substances
    • Deficiency—Systems: Treatment Orders
    • Deficiency—Systems: Medication Administration
    • Deficiency—Systems: Psychotropic Medication
    • Deficiency—Restraints and Supportive Devices
    • Deficiency—Acuity-Based Staffing Tool
    • Deficiency—Fire and Life Safety: Safety
    • Deficiency—Fire and Life Safety: Training For Residents
    • Deficiency—Inspections and Investigation: Insp Interval
    • Deficiency—Physical Setting: Individual Accessible
    • Deficiency—Administration Compliance
    • Deficiency—Staff Training Requirements
    • Deficiency—Compliance With Rules Health Care
    03 Mar 2024Inspection
    Found that medication and treatment orders were not carried out as prescribed.
    • Licensing—Failed to administer medication as ordered
    27 Feb 2024Inspection
    Determined that a resident was financially exploited and that a safe medication administration system was not provided.
    • Licensing—Failed to protect resident from financial exploitation
    26 Feb 2024Inspection
    Investigated the allegation and found failure to administer medications as ordered.
    • Licensing—Failed to administer medication as ordered
    24 Feb 2024Inspection
    Found failure to provide a safe medication administration system, resulting in medication theft and potential financial exploitation.
    • Licensing—Failed to provide a safe medication administration system
    22 Feb 2024Inspection
    Investigated found an unsafe medication administration system that allowed morphine to be diverted by an unknown perpetrator.
    • Licensing—Failed to provide a safe medication administration system
    22 Feb 2024Inspection
    Investigated and determined that a resident's pain medication was stolen by an unknown person and protections against theft failed.
    • Licensing—Failed to protect resident from financial exploitation
    22 Feb 2024Inspection
    Investigated found that a safe medication administration system was not maintained, leading to narcotic discrepancies and diversion of prescribed Haldol by an unknown individual. The issues indicate breach of resident safety and rights.
    • Licensing—Failed to provide a safe medication administration system
    22 Feb 2024Inspection
    Substantiated that an unknown alleged perpetrator failed to protect a resident from financial exploitation.
    • Licensing—Failed to protect resident from financial exploitation
    14 Feb 2024Abuse: Wrongful Restraint
    Found a failure to provide a safe environment that led to an injury from wrongful restraint, and a $500 fine was assessed.
    • Abuse—Failed to provide safe environment
    25 Jan 2024Inspection
    Determined that medication orders were not carried out as prescribed, creating a risk of harm.
    • Licensing—Failed to administer medication as ordered
    22 Jan 2024Inspection
    Found a deficiency in timely notifying the local SPD office about abuse or suspected abuse.
    • Licensing—Failed to provide safe environment
    22 Dec 2023Abuse: Neglect
    Found a failure to provide a safe medication administration system that resulted in a resident not receiving morphine as ordered, causing unreasonable discomfort; a $1,500 fine was assessed.
    • Abuse—Failed to provide a safe medication administration system
    08 Dec 2023License Condition
    Found residents at risk of immediate jeopardy due to an unsafe environment. Cited violations against multiple safety rules.
    • Regulatory Action—Failed to provide safe environment
    06 Dec 2023Abuse: Neglect
    Found a failure to provide a safe medication administration system, resulting in the Alleged Victim going without medication and experiencing discomfort.
    • Abuse—Failed to provide a safe medication administration system
    05 Dec 2023Abuse: Neglect
    Found a violation for failing to administer the correct dosage of medication to a resident, causing discomfort. A $250 fine was assessed.
    • Abuse—Failed to administer medication as ordered
    04 Dec 2023Inspection
    Found a deficiency related to documenting the use of supportive devices with restraining qualities in the resident's service plan.
    • Licensing—Failed to provide safe environment
    04 Dec 2023Inspection
    Determined that there was a failure to maintain an accurate system for tracking controlled substances administered, based on issues with 9 of 9 sampled residents.
    • Licensing—Failed to provide a safe medication administration system
    04 Dec 2023Inspection
    Investigated and determined that the Acuity Based Staffing Tool was not fully implemented as required.
    • Licensing—Failed to use an ABST
    04 Dec 2023Inspection
    Identified a serious deficiency in medication administration oversight and MAR documentation. Affected 18 of 18 sampled residents.
    • Licensing—Failed to provide a safe medication administration system
    04 Dec 2023Inspection
    Found that an individualized nutrition plan was not developed for a resident.
    • Licensing—Failed to provide service
    04 Dec 2023Inspection
    Found deficiencies for failure to determine or document actions or interventions, communicate actions or interventions to staff, monitor a resident's condition, or evaluate the resident and refer to the RN for two sampled residents.
    • Licensing—Failed to provide oversight and monitoring of change of condition
    04 Dec 2023Complaint
    Identified deficiencies in reporting abuse, infection control, and staffing tool implementation.
    • Deficiency—Reporting & Investigating Abuse-Other Action
    • Deficiency—Infection Prevention & Control
    • Deficiency—Acuity-Based Staffing Tool
    04 Dec 2023Inspection
    Found that abuse incidents or suspected abuse were not immediately reported to authorities and were not promptly investigated, risking resident safety.
    • Licensing—Failed to provide safe environment
    04 Dec 2023Complaint
    Investigated the complaint and found extensive deficiencies across administration, monitoring, resident rights, medications, staffing, and nutrition that placed residents at risk.
    • Deficiency—Licensing Complaint Investigation
    • Deficiency—Facility Administration: Operation
    • Deficiency—Reasonable Precautions
    • Deficiency—Resident Rights and Protection - General
    • Deficiency—Change of Condition and Monitoring
    • Deficiency—Rn Delegation and Teaching
    • Deficiency—Systems: Medications and Treatments
    • Deficiency—Systems: Tracking Control Substances
    • Deficiency—Staffing Requirements and Training: Staffing
    • Deficiency—Training Within 30 Days: Direct Care Staff
    • Deficiency—Nutrition and Hydration
    04 Dec 2023Inspection
    Found a deficiency for inadequate administrative oversight of facility operations, including supervision and training of staff, which posed a risk to resident safety.
    • Licensing—Failed to provide safe environment
    04 Dec 2023Inspection
    Found that delegation and supervision of special nursing tasks were not completed in accordance with OSBN Division 47 Rules.
    • Licensing—Failed to assure a qualified caregiver was present
    04 Dec 2023Inspection
    Investigated and found insufficient staffing to meet residents' scheduled and unscheduled needs for all sampled residents.
    • Licensing—Failed to meet the scheduled and unscheduled needs of residents
    04 Dec 2023Inspection
    Investigated the allegation and found a violation related to a safe medication administration system. Found a failure to exercise reasonable precautions that could threaten residents' health, safety, or welfare.
    • Licensing—Failed to provide a safe medication administration system
    04 Dec 2023Inspection
    Found violations for failing to treat residents with dignity and respect and to provide a safe, homelike environment.
    • Licensing—Failed to provide peri care
    04 Dec 2023Inspection
    Found that direct care staff did not demonstrate satisfactory performance before performing duties independently for all sampled staff.
    • Licensing—Failed to assure a qualified caregiver was present
    04 Dec 2023Inspection
    Identified that infection prevention and control protocols were not established or maintained.
    • Licensing—Failed to provide safe environment
    04 Dec 2023Inspection
    Found failure to provide a safe medication administration system.
    • Licensing—Failed to provide a safe medication administration system
    04 Dec 2023Inspection
    Investigated allegations found infection prevention and control protocols lacking.
    • Licensing—Failed to provide safe environment
    03 Dec 2023Abuse: Neglect
    Concluded that a care plan wasn’t followed, resulting in neglect and abuse; a $250 fine was assessed.
    • Abuse—Failed to follow care plan
    30 Nov 2023Inspection
    Found a violation for failing to administer medications as ordered.
    • Licensing—Failed to administer medication as ordered
    29 Oct 2023Inspection
    Found insufficient qualified awake direct care staff to meet the 24-hour scheduled and unscheduled needs of residents.
    • Licensing—Failed to meet the scheduled and unscheduled needs of residents
    10 Oct 2023Abuse: Neglect
    Found inadequate care planning and interventions for the resident’s fall history, leading to an unwitnessed fall and a fractured rib. A fine was assessed.
    • Abuse—Failed to properly plan care
    14 Sept 2023Complaint
    Identified deficiencies in medication management, tracking controlled substances, treatment orders, restraints, and staff training.
    • Deficiency—Service Plan: General
    • Deficiency—Systems: Medications and Treatments
    • Deficiency—Systems: Tracking Control Substances
    • Deficiency—Systems: Treatment Orders
    • Deficiency—Restraints and Supportive Devices
    • Deficiency—Staffing Rqmt and Training: Training Rqmts
    • Deficiency—Training Within 30 Days: Direct Care Staff
    13 Sept 2023Inspection
    Investigated the allegation of failing to provide a safe environment and found treatment orders were not carried out as prescribed.
    • Licensing—Failed to provide safe environment
    08 Sept 2023Abuse: Neglect
    Determined that a prescribed daily blood thinner was not administered as ordered, risking serious harm to a resident. A $250 fine was assessed.
    • Abuse—Failed to administer medication as ordered
    06 Sept 2023Abuse: Neglect
    Concluded that neglect occurred due to failure to provide a safe environment, and assessed a fine.
    • Abuse—Failed to provide safe environment
    31 Aug 2023Inspection
    Identified failure to document the use of supportive devices with restraining qualities in the resident's service plan.
    • Licensing—Failed to provide safe environment
    31 Aug 2023Inspection
    Found that medication orders were not followed as prescribed, with potential for harm.
    • Licensing—Failed to administer ordered medication
    29 Aug 2023Inspection
    Identified inadequate professional oversight of the medication and treatment administration system. This indicates a deficiency in how medication administration was overseen.
    • Licensing—Failed to provide a safe medication administration system
    26 Aug 2023Inspection
    Investigated and found that written, signed orders for medications and treatments were not documented in resident records.
    • Licensing—Failed to provide a safe medication administration system
    22 Aug 2023Licensure
    Identified deficiencies in kitchen cleanliness and administration compliance; subsequent revisit found substantial compliance.
    • Deficiency—Comment
    • Deficiency—Resident Services Meals, Food Sanitation Rule
    • Deficiency—Administration Compliance
    20 Aug 2023Inspection
    Investigated the allegation and identified a failure to provide a safe environment.
    • Licensing—Failed to provide safe environment
    19 Aug 2023Inspection
    Found a deficiency in documenting observation and evaluation of an individual's ability to perform safe medication and treatment administration unsupervised.
    • Licensing—Failed to provide a safe medication administration system
    17 Aug 2023Abuse: Neglect
    Identified deficiencies in care planning for a history of repeated falls and assessed a $1500 fine.
    • Abuse—Failed to properly plan care
    14 Aug 2023Inspection
    Investigated a deficiency in tracking controlled substances and disposing of unused medications due to the absence of an approved system by a pharmacist consultant or registered nurse.
    • Licensing—Failed to provide safe environment
    14 Aug 2023Inspection
    Found that the training program for direct care staff did not include methods to determine competency through evaluation, observation, or written testing.
    • Licensing—Failed to provide safe environment
    03 Aug 2023Complaint
    Investigated the complaint and identified concerns in multiple program areas during the on-site visit.
    • Deficiency—Licensing Complaint Investigation
    • Deficiency—Reporting & Investigating Abuse-Other Action
    • Deficiency—Service Plan: General
    • Deficiency—Systems: Treatment Orders
    • Deficiency—Acuity-Based Staffing Tool
    • Deficiency—Training Within 30 Days: Direct Care Staff
    02 Aug 2023Abuse: Neglect
    Found neglect due to failure to properly plan and implement care, resulting in an unwitnessed fall and injury.
    • Abuse—Failed to properly plan care
    27 Jul 2023Inspection
    Investigated and identified a failure to establish and maintain infection prevention and control protocols to provide a safe environment.
    • Licensing—Failed to provide safe environment
    25 Jul 2023Inspection
    Investigated the allegation and found the service plan did not reflect the resident's needs identified in the evaluation.
    • Licensing—Failed to provide service
    24 Jul 2023Inspection
    Found that the allegation that a service was not provided was supported; an injury of unknown cause was not reported and an immediate investigation was not conducted as required.
    • Licensing—Failed to provide service
    22 Jul 2023Inspection
    Found violations for failing to immediately notify authorities about abuse and to promptly investigate abuse reports and protect residents.
    • Licensing—Failed to provide safe environment
    10 Jul 2023Inspection
    Found a deficiency in maintaining an accurate Medication Administration Record for all medications, including OTC medications ordered by a prescriber.
    • Licensing—Failed to keep medication record current or accurate
    12 Jun 2023Inspection
    Found failure to administer medication as ordered. This reflected noncompliance with medication administration requirements.
    • Licensing—Failed to administer medication as ordered
    07 Jun 2023Complaint
    Investigated a complaint and found deficiencies in infection prevention and control and in staffing requirements and training.
    • Deficiency—Infection Prevention & Control
    • Deficiency—Staffing Requirements and Training: Staffing
    • Deficiency—Staffing Requirements and Training – Pre-Serv
    • Deficiency—Training Within 30 Days: Direct Care Staff
    28 May 2023Abuse: Neglect
    Found that a safe medication administration system was not provided, resulting in missed insulin doses and a hospital visit.
    • Abuse—Failed to provide a safe medication administration system
    22 May 2023Inspection
    Found a lack of policies and procedures to assure prevention and appropriate response to incidents.
    • Licensing—Failed to provide safe environment
    17 May 2023Abuse: Neglect
    Found failure to plan and implement care for a resident's fall history, resulting in an unwitnessed fall and rib injury; a fine was assessed.
    • Abuse—Failed to properly plan care
    09 May 2023Abuse: Neglect
    Investigated a complaint and found a failure to provide a safe environment for a resident, involving inappropriate touching between residents; a $375 fine was assessed.
    • Abuse—Failed to provide safe environment
    24 Apr 2023Abuse: Neglect
    Investigated an allegation of abuse and neglect and found an unsecured door allowed elopement, creating a risk of serious harm; a fine was assessed.
    • Abuse—Failed to provide safe environment
    19 Mar 2023Abuse: Neglect
    Investigated the complaint and found a failure to provide a safe environment that caused injury and violated resident rights; a fine was assessed.
    • Abuse—Failed to provide safe environment
    19 Mar 2023Abuse: Neglect
    Found a failure to provide a safe environment that led to a resident's fall and injury. A $750 fine was assessed.
    • Abuse—Failed to provide safe environment
    12 Mar 2023Abuse: Neglect
    Found neglect and safety violations after multiple falls resulting in a head injury, with a $1500 fine assessed.
    • Abuse—Failed to provide safe environment
    28 Feb 2023Inspection
    Found that residents could be locked out of or inside their rooms at any time, compromising a safe environment.
    • Licensing—Failed to provide safe environment
    28 Feb 2023Inspection
    Found deficiencies in infection prevention and control protocols, resulting in a failure to provide a safe environment.
    • Licensing—Failed to provide safe environment
    28 Feb 2023Inspection
    Found insufficient awake direct care staff to meet 24-hour needs of residents.
    • Licensing—Failed to meet the scheduled and unscheduled needs of residents
    20 Feb 2023Abuse: Neglect
    Investigated a safety concern and found a resident in need of 24/7 care left the site and exposed to risk, resulting in a finding of abuse/neglect and a fine.
    • Abuse—Failed to provide safe environment
    15 Feb 2023Abuse: Neglect
    Found a deficiency for failing to provide a safe environment, which led to a resident sustaining a head injury; a $500 fine was assessed.
    • Abuse—Failed to provide safe environment
    14 Feb 2023Abuse: Neglect
    Investigated and found a failure to provide a safe environment, resulting in a fall with injuries.
    • Abuse—Failed to provide safe environment
    03 Jan 2023Inspection
    Found a failure to provide a safe medication administration system, resulting in a resident receiving double the daily warfarin dose and requiring ER care.
    • Licensing—Failed to provide a safe medication administration system
    18 Dec 2022Abuse: Neglect
    Investigated and found deficiencies related to fall risk planning and care for a resident; a fine was assessed.
    • Abuse—Failed to properly plan care
    02 Dec 2022Complaint
    Identified deficiencies related to treatment orders with potential for moderate harm.
    • Deficiency—Licensing Complaint Investigation
    • Deficiency—Systems: Treatment Orders
    02 Dec 2022Complaint
    Identified deficiencies in regulatory compliance during a complaint investigation.
    • Deficiency—Licensing Complaint Investigation
    • Deficiency—Acuity-Based Staffing Tool
    02 Dec 2022Complaint
    Identified deficiencies related to treatment orders.
    • Deficiency—Licensing Complaint Investigation
    • Deficiency—Systems: Treatment Orders
    30 Nov 2022Abuse: Neglect
    Investigated a resident with a known falls history and found insufficient care planning and fall prevention measures, risking harm.
    • Abuse—Failed to properly plan care
    19 Nov 2022Abuse: Neglect
    Found that a safe environment was not provided, resulting in neglect and abuse, and a $375 fine was assessed.
    • Abuse—Failed to provide safe environment
    17 Oct 2022Abuse: Neglect
    Found that a safe environment was not maintained, leading to several falls and injuries to a resident.
    • Abuse—Failed to provide safe environment
    13 Oct 2022Inspection
    Found a violation for failing to carry out medication and treatment orders as prescribed.
    • Licensing—Failed to cooperate with an investigation
    10 Oct 2022Abuse: Neglect
    Investigated a failure to properly plan care that led to repeated falls and injuries. Found ongoing risk due to inadequate interventions to mitigate fall risk.
    • Abuse—Failed to properly plan care
    10 Oct 2022Abuse: Neglect
    Found that a resident was not provided a safe environment, resulting in neglect and abuse findings; a $375 fine was assessed.
    • Abuse—Failed to provide safe environment
    09 Oct 2022Inspection
    Investigated an allegation that medication was not administered as ordered. Found a violation of medication administration rules.
    • Licensing—Failed to administer medication as ordered
    29 Sept 2022Complaint
    Investigated a complaint and identified a deficiency related to the call system, exit door alarm, and communication devices.
    • Deficiency—Licensing Complaint Investigation
    • Deficiency—Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable
    29 Sept 2022Complaint
    Identified deficiencies related to resident rights and protection.
    • Deficiency—Licensing Complaint Investigation
    • Deficiency—Resident Rights and Protection - General
    28 Sept 2022Inspection
    Investigated and found a violation involving restricted mail access that could affect a resident's safety.
    • Licensing—Failed to provide safe environment
    27 Sept 2022Inspection
    Found a deficiency in the call system connecting resident units to the care staff center or pagers. The deficiency was substantiated under state rules.
    • Licensing—Failed to provide service
    03 Sept 2022Abuse: Neglect
    Found the care plan for ambulation was not followed, resulting in falls and injuries; a fine was assessed.
    • Abuse—Failed to follow care plan
    31 Aug 2022Abuse: Neglect
    Found a violation for failing to provide a safe environment after a resident-to-resident incident; a $375 fine was assessed.
    • Abuse—Failed to provide safe environment
    24 Aug 2022Abuse: Neglect
    Found a violation of safe environment and resident rights due to a resident not receiving medication and a resident-to-resident incident causing harm.
    • Abuse—Failed to provide safe environment
    16 Aug 2022Abuse: Neglect
    Found a failure to provide a safe medication administration system, resulting in seven days without prescribed behavior medication and increased behaviors; violations of resident rights, constituting neglect and abuse, with a $375 fine assessed.
    • Abuse—Failed to administer medication as ordered
    12 Aug 2022Abuse: Neglect
    Identified deficient care planning for toileting that exposed an individual to urine and skin issues, constituting neglect and abuse. A $500 fine was assessed.
    • Abuse—Failed to properly plan care
    13 Jul 2022Abuse: Neglect
    Found a failure to provide a safe medication administration system, resulting in two incorrect dosages, and a $375 fine was assessed.
    • Abuse—Failed to provide a safe medication administration system
    14 Jun 2022Inspection
    Found that a staff member did not follow the care plan, leading to a fall and injuries, with neglect and abuse identified.
    • Licensing—Failed to follow care plan
    30 May 2022Abuse: Neglect
    Found to have failed to implement interventions and appropriately plan care for a resident with a history of falls, resulting in approximately five unwitnessed falls and discomfort.
    • Abuse—Failed to properly plan care
    07 May 2022Abuse: Neglect
    Found a safety deficiency due to neglect that allowed a resident with a history of elopement to leave the premises and be found at a bus stop. A fine was assessed.
    • Abuse—Failed to provide safe environment
    17 Apr 2022Abuse: Neglect
    Found a failure to provide a safe environment for a resident, and a $375 fine was assessed.
    • Abuse—Failed to provide safe environment
    12 Apr 2022Abuse: Neglect
    Found failure to provide a safe environment and proper care planning related to a resident's fall history. A resident suffered a fall resulting in a head injury and skin tear.
    • Abuse—Failed to provide safe environment
    11 Apr 2022Validation
    Identified multiple deficiencies during relicensure across administration, care planning, health services, medications, safety, and environment; later found to be in substantial compliance.
    • Deficiency—Comment
    • Deficiency—Facility Administration: Operation
    • Deficiency—Facility Administration: Required Postings
    • Deficiency—Facility Administration: Records
    • Deficiency—Reporting & Investigating Abuse-Other Action
    • Deficiency—Resident Services Meals, Food Sanitation Rule
    • 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: Medication Administration
    • Deficiency—Systems: Treatment Administration
    • Deficiency—Fire and Life Safety: Safety
    • Deficiency—Fire and Life Safety: Training For Residents
    • Deficiency—Inspections and Investigation: Insp Interval
    • Deficiency—General Building Exterior
    • Deficiency—Doors, Walls, Elevators, Odors
    • Deficiency—Administration Compliance
    • Deficiency—Staff Training Requirements
    • Deficiency—Compliance With Rules Health Care
    • Deficiency—Activities
    • Deficiency—Resident Rooms
    22 Mar 2022Abuse: Neglect
    Concluded that a safe medication administration system was not provided, leading to multiple occurrences of inappropriate medication administration that could cause serious harm.
    • Abuse—Failed to follow care plan
    17 Mar 2022Abuse: Neglect
    Investigated a complaint and found that required services were not provided to a resident, resulting in a toe injury and related discomfort.
    • Abuse—Failed to provide service
    01 Mar 2022Inspection
    Found that weekly reporting of vaccinated individuals, residents, and staff was not submitted timely for 27 days.
    • Licensing—Failed to submit timely or adequate staffing documentation
    23 Feb 2022Abuse: Neglect
    Found a failure to provide a safe medication administration system that could cause harm after a trainee handed another resident's medication to a second trainee who gave it to a resident, followed by adverse health symptoms.
    • Abuse—Failed to provide a safe medication administration system
    08 Feb 2022Complaint
    Investigated and found deficiencies in infection control due to improper masking and eye protection during care.
    • Deficiency—Reasonable Precautions
    07 Feb 2022Inspection
    Investigated an allegation that staff were not wearing masks and found a deficiency for failing to provide a safe environment.
    • Licensing—Failed to provide safe environment
    08 Dec 2021Inspection
    Investigated and found that staff were not wearing masks, creating a health and safety risk to residents.
    • Licensing—Failed to provide safe environment
    01 Dec 2021Abuse: Neglect
    Concluded that a safe medication administration system was not provided, leading to abuse/neglect. A $250 fine was assessed.
    • Abuse—Failed to provide a safe medication administration system
    12 Nov 2021Inspection
    Investigated and found that a staff member verbally abused a resident and that the entity failed to protect the resident from verbal abuse.
    • Licensing—Failed to protect resident from verbal abuse
    19 Oct 2021Abuse: Neglect
    Investigated and found neglect and abuse due to failing to complete toileting needs, leaving the resident at risk from prolonged moisture.
    • Abuse—Failed to assist with toileting
    21 Jun 2021Inspection
    Investigated an allegation of failure to provide or assist with hygiene for the Alleged Victim. Found a hygiene-related deficiency.
    • Licensing—Failed to provide or assist with hygiene
    21 Jun 2021Inspection
    Investigated a complaint alleging failure to ensure a qualified caregiver was present; the allegation was verified.
    • Licensing—Failed to assure a qualified caregiver was present
    21 Jun 2021Inspection
    Investigated an allegation that housekeeping services were not provided appropriately and verified the finding.
    • Licensing—Failed to provide appropriate housekeeping services
    21 Jun 2021Inspection
    Investigated the staffing allegation and found insufficient staffing.
    • Licensing—Failed to provide appropriate staffing
    21 Jun 2021Inspection
    Determined that the allegation concerning resident rights was substantiated.
    • Licensing—Failed to assure resident rights
    12 May 2021Abuse: Neglect
    Found deficiencies in care planning for falls, ambulation, and transfers that risked resident safety, indicating abuse and neglect related to resident rights.
    • Abuse—Failed to properly plan care
    19 Apr 2021Abuse: Neglect
    Determined that neglect and abuse occurred due to failure to properly plan care for a resident with aggression, which led to an assault.
    • Abuse—Failed to properly plan care
    06 Apr 2021Abuse: Neglect
    Found a violation for failing to provide a safe environment.
    • Abuse—Failed to provide safe environment
    03 Apr 2021Abuse: Neglect
    Investigated a complaint and found a failure to provide a safe environment, as an individual entered an unlocked, cluttered storage room and sustained abrasions. A $375 fine was assessed.
    • Abuse—Failed to provide safe environment
    23 Feb 2021Abuse: Neglect
    Found that care planning for a resident at risk of falls was incomplete and night checks were not performed, resulting in a fall with serious injury; a fine was assessed.
    • Abuse—Failed to properly plan care
    14 Feb 2021Inspection
    Identified deficiencies in medication recordkeeping due to an inaccurate MAR showing only an x for December 2020.
    • Licensing—Failed to keep medication record current or accurate
    14 Feb 2021Inspection
    Investigated a resident rights allegation and found a lack of policy guiding intra-facility moves, and that a resident was moved without notifying power of attorney.
    • Licensing—Failed to assure resident rights
    13 Feb 2021Abuse: Neglect
    Investigated a complaint and found a failure to provide a safe environment, resulting in neglect and abuse. An altercation between residents occurred due to inadequate safety planning and supervision.
    • Abuse—Failed to provide safe environment
    06 Feb 2021Abuse: Neglect
    Found a failure to provide a safe environment after a visitor wandered into a resident's room and swatted the resident, causing a skin tear; the actions constitute abuse and neglect.
    • Abuse—Failed to provide safe environment
    04 Jan 2021Inspection
    Investigated the allegation of an unsafe environment and found a deficiency in protecting residents' health and safety.
    • Licensing—Failed to provide safe environment
    16 Dec 2020Abuse: Neglect
    Investigated a complaint and found supervision failures related to known fall risks, resulting in multiple falls and a fracture. A fine was assessed.
    • Abuse—Failed to provide safe environment
    16 Nov 2020Inspection
    Investigated an allegation of failure to maintain a safe environment for residents and found evidence supporting the claim that reasonable precautions were not exercised.
    • Licensing—Failed to maintain a safe physical environment
    10 Nov 2020Inspection
    Investigated a feeding-related allegation and found that a staff member did not provide breakfast to a resident on time, violating resident rights and constituting neglect.
    • Licensing—Failed to provide proper food/nutrition
    28 Aug 2020Inspection
    Found neglect and abuse by staff during medication administration, resulting in an injury and a failure to provide a safe environment.
    • Licensing—Failed to provide safe environment
    23 Aug 2020Abuse: Neglect
    Identified a failure to provide a safe environment that constituted abuse and neglect, and a fine was assessed.
    • Abuse—Failed to provide safe environment
    04 Jul 2020Abuse: Neglect
    Found neglect and abuse due to failing to meet a resident's care needs and lacking planning for exit-seeking behaviors, resulting in an injury when a door was opened near the resident.
    • Abuse—Failed to provide safe environment
    22 Jun 2020Abuse: Neglect
    Investigated and found improper care planning and care delivery for a resident after admission, leading to weight loss and loss of dignity. A $500 fine was assessed.
    • Abuse—Failed to properly plan care
    08 Jun 2020Abuse: Neglect
    Determined neglect and abuse occurred after a resident was found outside unsupervised near a busy street, showing a failure to provide a safe environment.
    • Abuse—Failed to provide safe environment
    27 Nov 2019Inspection
    Found that a staff member slapped a resident and spoke inappropriately during an altercation, violating resident rights and constituting abuse. The actions included failure to protect the resident from staff misconduct.
    • Licensing—Failed to protect resident from physical abuse
    26 Nov 2019Abuse: Neglect
    Identified a failure to provide a safe environment that resulted in harm. A fine was assessed.
    • Abuse—Failed to provide safe environment
    05 Aug 2019Inspection
    Found a facility failure to ensure implementation of services on a resident's service plan; the complaint involved a resident needing a two-person transfer transferred incorrectly.
    • Licensing—Failed to provide service
    05 Aug 2019Abuse: Neglect
    Investigated a neglect allegation and found failure to provide a safe environment that led to a resident-to-resident altercation.
    • Abuse—Failed to provide safe environment
    30 Jul 2019Abuse: Neglect
    Found a deficiency for failing to provide a safe environment, risking serious harm. A $375 fine was assessed.
    • Abuse—Failed to provide safe environment
    14 Jul 2019Abuse: Neglect
    Investigated a neglect allegation found that a safe environment and an appropriate level of care were not provided, exposing a resident to risk of harm. A fine was assessed.
    • Abuse—Failed to provide safe environment
    14 May 2019Inspection
    Investigated the complaint and identified a violation involving failure to protect resident rights and disclosure of confidential information.
    • Licensing—Failed to assure resident rights
    26 Apr 2019Inspection
    Investigated found that restraining-type devices were not properly assessed and less restrictive alternatives were not documented.
    • Licensing—Failed to provide or maintain resident care equipment
    24 Apr 2019Inspection
    Found a failure to report suspected abuse. A $1000 fine was assessed.
    • Licensing—Failed to report potential or suspected abuse
    24 Apr 2019Abuse: Neglect
    Found neglect related to failing to provide a safe environment, resulting in repeated falls; a $500 fine was assessed.
    • Abuse—Failed to adequately care plan related to falls
    04 Apr 2019Inspection
    Found a deficiency in maintaining a safe physical environment.
    • Licensing—Failed to maintain a safe physical environment
    30 Mar 2019Abuse: Neglect
    Investigated an allegation of neglect and found failure to maintain a safe environment resulting in physical injury.
    • Abuse—Failed to provide safe environment
    20 Mar 2019Abuse: Neglect
    Found a neglect-related deficiency for failing to provide a safe environment, risking serious harm from falls.
    • Abuse—Failed to adequately care plan related to falls
    10 Mar 2019Abuse: Neglect
    Investigated an allegation of neglect related to falls care and found failure to reduce falls risk, leading to injury.
    • Abuse—Failed to adequately care plan related to falls
    10 Mar 2019Abuse: Neglect
    Found neglect due to failure to administer prescribed narcotic pain medication and an inadequate medication administration system; a $188 fine was assessed.
    • Abuse—Failed to administer ordered medication
    07 Mar 2019Inspection
    Found deficiencies in following resident safety policies and procedures, including razor and other personal care item procedures.
    • Licensing—Failed to provide safe environment
    20 Feb 2019Abuse: Neglect
    Found neglect by failing to provide a safe environment, creating risk of serious harm. A $375.00 fine was assessed.
    • Abuse—Failed to provide safe environment
    20 Feb 2019Abuse: Neglect
    Found deficiencies related to falls safety and care planning; a fine was assessed.
    • Abuse—Failed to adequately care plan related to falls
    06 Feb 2019Abuse: Neglect
    Investigated a complaint of neglect and found a failure to provide a safe environment. A $375 fine was assessed.
    • Abuse—Failed to provide safe environment
    18 Jan 2019Abuse: Neglect
    Investigated a neglect allegation; found failure to provide a safe environment, risking serious harm, and a $375 fine was assessed.
    • Abuse—Failed to provide safe environment
    20 Dec 2018Abuse: Neglect
    Investigated a neglect allegation and found inadequate care planning and supervision led to a resident's falls, injury, and fracture.
    • Abuse—Failed to adequately care plan related to falls
    30 Oct 2018Inspection
    Found a violation for failing to follow the care plan that caused physical harm to a resident.
    • Licensing—Failed to follow care plan
    26 Oct 2018Abuse: Neglect
    Investigated and determined that the plan of care was not followed.
    • Abuse—Failed to follow care plan
    22 Oct 2018Abuse: Neglect
    Investigated an allegation that potential or suspected abuse was not reported. Findings indicate a lack of substantial compliance.
    • Abuse—Failed to report potential or suspected abuse
    09 Oct 2018Inspection
    Investigated and substantiated a failure to provide a safe environment.
    • Licensing—Failed to provide safe environment
    03 Oct 2018Abuse: Neglect
    Found neglect of care due to failure to provide a safe environment, resulting in risk of serious harm. A fine was assessed.
    • Abuse—Failed to provide safe environment
    10 Sept 2018Inspection
    Determined a failure to report suspected abuse occurred and assessed a $1,000 fine.
    • Licensing—Failed to report potential or suspected abuse
    10 Sept 2018Abuse: Neglect
    Investigated the allegation of failing to provide a safe environment and found a safety violation resulting in a $1500 fine.
    • Abuse—Failed to provide safe environment
    04 Sept 2018Inspection
    Found a deficiency due to failure to provide a secure environment, with the allegation substantiated; a $375 fine was assessed.
    • Licensing—Failed to assure resident was safe
    20 Jul 2018Inspection
    Found deficiencies related to medication administration as ordered and to having medication on hand.
    • Licensing—Failed to administer ordered medication
    01 Jul 2018Inspection
    Investigated an allegation of failing to provide a safe environment and found a deficiency, resulting in a $375 fine.
    • Licensing—Failed to provide safe environment
    21 May 2018Inspection
    Found a failure to provide a secure environment.
    • Licensing—Failed to provide safe environment
    06 Apr 2018Abuse: Neglect
    Investigated an abuse/neglect allegation and determined a failure to provide a safe environment resulting in a fall with injury. A $500 fine was assessed.
    • Abuse—Failed to provide safe environment
    06 Apr 2018Inspection
    Fined for failing to self-report potential or suspected abuse; a civil penalty of $750 was assessed.
    • Licensing—Failed to report potential or suspected abuse
    28 Mar 2018Inspection
    Identified a failure to follow the care plan and a safety deficiency.
    • Licensing—Failed to follow care plan
    23 Mar 2018Inspection
    Found a failure to provide a safe environment, and a $375 fine was assessed.
    • Licensing—Failed to provide safe environment
    19 Mar 2018Inspection
    Found failure to provide a safe environment.
    • Licensing—Failed to provide safe environment
    14 Mar 2018Abuse: Neglect
    Found failure to provide adequate care related to falls; assessed a $2,500 fine.
    • Abuse—Failed to adequately care plan related to falls
    28 Feb 2018Inspection
    Found inadequate care and failure to provide a safe environment.
    • Licensing—Failed to provide safe environment
    22 Feb 2018Inspection
    Found that proper protocols were not followed before using a device with restraining quality, and the resident was locked in their unit with staff unable to access.
    • Licensing—Failed to protect resident from involuntary seclusion
    19 Jun 2017Inspection
    Investigated an allegation of an unsafe environment and found that a safe environment was not provided for the RVs. The finding identified a safety deficiency related to the RV area.
    • Licensing—Failed to provide safe environment
    17 Mar 2017Abuse: Neglect
    Investigated the neglect allegation and found a failure to provide appropriate care, with potential for minor to moderate harm.
    • Abuse—Failed to provide safe environment
    13 Mar 2017Inspection
    Found a deficiency in providing a safe environment.
    • Licensing—Failed to provide safe environment
    07 Nov 2016Inspection
    Found failure to provide a safe environment. The case was completed after the assigned investigator left state service.
    • Licensing—Failed to provide safe environment
    31 Oct 2016Abuse: Neglect
    Investigated the allegation of neglect related to safety and found a failure to provide a safe environment.
    • Abuse—Failed to provide safe environment
    15 Sept 2016Inspection
    Investigated allegation of failing to assure resident rights and concluded there was a violation.
    • Licensing—Failed to assure resident rights
    31 Aug 2016Inspection
    Investigated and found a deficiency for failing to provide a safe environment.
    • Licensing—Failed to provide safe environment
    30 Aug 2016Inspection
    Investigated a complaint alleging failure to provide service and found inadequate care.
    • Licensing—Failed to provide service
    29 May 2016Abuse: Neglect
    Found failure to provide a safe environment.
    • Abuse—Failed to provide safe environment

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