I'm very pleased with Ocean Park - the warm, attentive staff provided excellent memory care for my mom, accommodated her medical needs, kept her clean and never left her unattended. The community is clean, homey and lively with strong activities, shuttle service and an engaged, compassionate team; I would recommend them to families.
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
24-hour call system
24-hour supervision
Meals and dining
Diabetes diet
Meal preparation and service
Special dietary restrictions
Room
Air-conditioning
Cable
Fully furnished
Housekeeping and linen services
Kitchenettes
Private bathrooms
Telephone
Wifi
Memory care community services
Mild cognitive impairment
Specialized memory care programming
Transportation
Community operated transportation
Transportation arrangement
Common areas
Beauty salon
Computer center
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
3.61·(28)
Overall rating
5
4
3
2
1
Care
3.4
Staff
4.0
Meals
1.8
Amenities
1.3
Value
1.0
Pros
Personalized hands-on dementia care
Compassionate, familiar staff interactions
Attentive assistance with feeding and mobility
Engaging life-enrichment and recreational programming
Warm and friendly front-line team
Management turnaround and leadership engagement
Remodeled, attractive interior environment
Secure, purpose-built memory-care unit
On-site shuttle/transportation service
Accommodation of medical equipment and higher-care needs
Comforting family-centered communication during staffed periods
Occasional high-quality dining experiences
Cons
Inconsistent medication-management controls
Variable staffing levels and high staff turnover
Gaps in family communication and administrative responsiveness
Inconsistent cleanliness and sanitation standards (odor and incontinence-care concerns)
Unreliable dining consistency and meal-temperature controls
Inconsistent activity programming and limited community outings
Inventory and property-control gaps (missing or damaged resident items)
Billing and accounts-reconciliation problems
History of oversight complaints and protective-services involvement
Summary of reviews
Reviews of Monarch Gardens Memory Care present a mixed picture with distinct positive themes alongside recurring operational concerns. Many families praise the facility's dementia-focused, hands-on approach: caregivers are frequently described as compassionate, attentive with feeding and mobility, and able to provide a reassuring, family-like environment. The memory-care unit itself is often viewed as secure and attractive after remodeling, and some reviewers highlight an engaged activities director, lively programming, shuttle transportation, and occasions of strong dining service. Several families also credit recent leadership changes with a noticeable improvement in staff engagement and responsiveness.
At the same time, a consistent set of operational weaknesses emerges. Medication-management and clinical oversight were flagged repeatedly; reviewers described missed or delayed medications and inconsistent medication administration controls. Staffing reliability is a second recurrent issue: reviewers reported variable staffing levels, resignations, and turnover that correlate with delays in attending to residents and gaps in incontinence care and room checks. Relatedly, cleanliness and sanitation standards were described as uneven, and some families raised concerns about odors and timeliness of personal-care assistance.
Dining and activities show similar variability. Multiple accounts note pleasant dining and active programming, while others describe cold meals, removed plates, limited outings, and a broken transport van that curtailed off-site activities. Inventory control and maintenance also appeared inconsistent: reviewers mentioned missing or damaged personal items and occasional equipment problems such as broken beds. Administrative processes — billing, communication between front-line staff and administration, and responsiveness to family complaints — were another area of divergence; some families experienced clear, helpful communication, while others reported billing disputes, poor responsiveness, and escalation to ombudsman or protective services.
In practice, the facility appears polarizing: many families find the staff caring and the environment appropriate for Alzheimer’s and dementia care, while a subset reports significant lapses in operational reliability and clinical controls. Prospective residents and families should plan an in-person visit focused on current staffing ratios, medication-administration protocols, sanitation practices, sample activity schedules and transportation availability, examples of recent management actions addressing complaints, and recent regulatory or oversight history. Asking for recent references from current residents’ families and documentation of corrective actions can help clarify whether positive trends cited by some reviewers are sustained across the community.
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Location
Monarch Gardens Memory Care is located at 984 Parkview Dr, Brookings, OR, 97415.
About Monarch Gardens Memory Care
Monarch Gardens Memory Care is a compassionate and dedicated memory care community located in the tranquil setting of Brookings, Oregon. The community embraces a person-centered approach, ensuring that the social, psychological, spiritual, and physical well-being of each resident is at the heart of every aspect of care. Monarch Gardens is committed to providing the highest quality of life for individuals living with dementia and related memory conditions, recognizing the unique challenges these conditions present to both residents and their families.
The community is designed to offer a safe, engaging, and loving environment where residents can feel at home. Staff at Monarch Gardens are carefully chosen for their passion and dedication to providing a truly incredible and supportive experience for both residents and their families. Emphasizing kindness and compassion, the team constantly strives to make a positive difference in every interaction while enhancing the value of togetherness and community. This "boutique-style" approach to senior living creates a warm and welcoming atmosphere where each resident receives individualized attention and support.
Respite care is also available at Monarch Gardens, giving primary caregivers the opportunity to rest, travel, or simply recharge while knowing their loved one is safe and well cared for. The respite services are flexible, catering to stays of a week or longer, and offer peace of mind for families seeking short-term support. Should the need arise for hospice care, Monarch Gardens has a highly trained nursing team that works closely with hospice providers to ensure residents experience comfort, dignity, and the highest quality of life possible during this stage.
Monarch Gardens takes pride in being a vital extension of the Brookings community, offering a peaceful setting along the beautiful southern Oregon coast. With its "banana belt" climate, this area is known for its milder air and scenic coastlines, providing an ideal backdrop for residents to enjoy both comfort and tranquility. The philosophy at Monarch Gardens is rooted in continuous improvement, with the staff aspiring to live and work by the "Optimist Creed"—creating an uplifting atmosphere for all who enter the community. Through every service and interaction, Monarch Gardens Memory Care remains steadfast in its mission to serve as a value-driven, resident-focused community where kindness, dignity, and proactive support are always prioritized.
People often ask...
Monarch Gardens Memory Care offers competitive pricing, with rates starting at a cost of $5,495 per month.
Monarch Gardens Memory Care offers assisted living and memory care.
There are 23 photos of Monarch Gardens Memory Care on Mirador.
The full address for this community is 984 Parkview Dr, Brookings, OR 97415.
No, Monarch Gardens 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.
Identified multiple deficiencies across several areas, including monitoring of short-term changes, PRN psychotropic use, ABST accuracy, interior odors, call system, resident privacy, administration compliance, staff training, and health care services.
Deficiency—Change of Condition and Monitoring
Deficiency—Systems: Psychotropic Medication
Deficiency—Acuity Based Staffing Tool - ABST Time
Deficiency—Doors, Walls, Elevators, Odors
Deficiency—Call Sys, Exit Dr Alarm, Phones, TV, or Cable
Deficiency—Individual Privacy: Own Unit
Deficiency—Administration Compliance
Deficiency—Staff Training Requirements
Deficiency—Compliance with Rules Health Care
24 Mar 2026Kitchen
24 Mar 2026Kitchen
Identified deficiencies in kitchen sanitation, menu availability, and food storage, and noncompliance with licensing rules.
Determined that records were not provided to the Department upon request, violating Oregon Administrative Rules. This reflected a deficiency in staffing documentation.
Licensing—Failed to submit timely or adequate staffing documentation
14 Jan 2025Inspection
14 Jan 2025Inspection
Investigated a staffing issue and found insufficient qualified awake direct care staff to meet residents' 24-hour needs.
Licensing—Failed to staff as indicated by ABST
14 Jan 2025Inspection
14 Jan 2025Inspection
Found a failure to submit timely or adequate staffing documentation. The records were not provided upon request.
Licensing—Failed to submit timely or adequate staffing documentation
27 Nov 2024Inspection
27 Nov 2024Inspection
Found that medication administration records were not kept current or accurate.
Licensing—Failed to keep resident record current or accurate
15 May 2024Licensure
15 May 2024Licensure
Identified significant kitchen cleanliness and sanitation issues during initial findings, with follow-up indicating substantial compliance for memory care requirements.
Deficiency—Inspections and Investigation: Insp Interval
Deficiency—Administration Compliance
12 May 2024Inspection
12 May 2024Inspection
Investigated a failure to follow the pureed-diet care plan, which led to choking after fruit chunks were given.
Licensing—Failed to follow care plan
08 May 2024Abuse: Neglect
08 May 2024Abuse: Neglect
Found that the resident was not monitored as required by the care plan, resulting in a fall when attempting to enter another resident's room; a $188 fine was assessed.
Abuse—Failed to follow care plan
07 Jan 2024Abuse: Neglect
07 Jan 2024Abuse: Neglect
Investigated found that a resident was struck after wandering into another resident's room, indicating a failure to provide a safe environment.
Abuse—Failed to provide safe environment
30 Nov 2023Abuse: Neglect
30 Nov 2023Abuse: Neglect
Investigated a complaint about medication administration and found that ordered medications were not given, potentially harming a resident. A fine was assessed.
Abuse—Failed to administer medication as ordered
28 Nov 2023Validation
28 Nov 2023Validation
Identified multiple deficiencies across resident care, safety, nutrition, activities, and administration. Failures included inadequate investigation of abuse, incomplete move-in evaluations and service plans, lapses in medication orders and refusals notifications, and safety issues such as fire drill compliance and outdoor access.
Deficiency—Resident Move-In and Eval: Res Evaluation
Deficiency—Service Plan: General
Deficiency—Change of Condition and Monitoring
Deficiency—Systems: Treatment Orders
Deficiency—Systems: Resident Right to Refuse
Deficiency—Systems: Psychotropic Medication
Deficiency—Fire and Life Safety: Safety
Deficiency—Fire and Life Safety: Training For Residents
Deficiency—Doors, Walls, Elevators, Odors
Deficiency—Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable
Deficiency—Administration Compliance
Deficiency—Staff Training Requirements
Deficiency—Compliance With Rules Health Care
Deficiency—Nutrition and Hydration
Deficiency—Activities
Deficiency—Outside Area
19 Nov 2023Abuse: Neglect
19 Nov 2023Abuse: Neglect
Investigated a resident-on-resident incident and found an unsafe environment that resulted in abuse and neglect.
Abuse—Failed to provide safe environment
18 Oct 2023Abuse: Neglect
18 Oct 2023Abuse: Neglect
Found that a resident-to-resident altercation occurred due to failure to provide a safe environment, constituting abuse and neglect. A $375 fine was assessed.
Abuse—Failed to provide safe environment
18 Sept 2023Inspection
18 Sept 2023Inspection
Investigated an incident where a staff member did not disengage from an agitated resident, leading to a physical confrontation; findings showed neglect, abuse, and an unsafe environment in violation of state rules.
Licensing—Failed to provide safe environment
29 Jul 2023Abuse: Neglect
29 Jul 2023Abuse: Neglect
Found that a resident was not provided a safe environment, exposing them to risk of harm; violations cited and a $375 fine assessed.
Abuse—Failed to provide safe environment
25 Jul 2023License Condition
25 Jul 2023License Condition
Found failure to use an Acuity Based Staffing Tool as required.
Regulatory Action—Failed to use an ABST
16 Jul 2023Abuse: Neglect
16 Jul 2023Abuse: Neglect
Investigated and found abuse and neglect related to failing to provide a safe environment, resulting in emotional harm to a resident. A $1000 fine was assessed.
Abuse—Failed to provide safe environment
16 Jul 2023Abuse: Neglect
16 Jul 2023Abuse: Neglect
Investigated and found that care planning for a resident with known aggressive behavior was not updated, linked to abuse and neglect; a $1,000 fine was assessed.
Abuse—Failed to properly plan care
23 Jun 2023Abuse: Neglect
23 Jun 2023Abuse: Neglect
Investigated and found a failure to provide a safe environment, constituting abuse and neglect.
Abuse—Failed to provide safe environment
31 May 2023Abuse: Neglect
31 May 2023Abuse: Neglect
Investigated a report of abuse and neglect and found that care planning did not address the resident's known behavioral history, creating risk of harm.
Abuse—Failed to properly plan care
11 May 2023Abuse: Neglect
11 May 2023Abuse: Neglect
Found violations for neglect and abuse due to failure to provide a safe environment, putting a resident at risk.
Abuse—Failed to provide safe environment
09 May 2023Abuse: Neglect
09 May 2023Abuse: Neglect
Found a failure to provide a safe environment that led to a resident-to-resident altercation and risk of harm; a $500 fine was assessed.
Abuse—Failed to provide safe environment
09 May 2023Abuse: Neglect
09 May 2023Abuse: Neglect
Investigated and found a failure to provide a safe environment and abuse; a fine was assessed.
Abuse—Failed to provide safe environment
06 May 2023Abuse: Neglect
06 May 2023Abuse: Neglect
Investigated abuse and neglect allegations and found a failure to provide a safe environment, risking serious harm to a resident. A $375 fine was assessed.
Abuse—Failed to provide safe environment
05 May 2023Inspection
05 May 2023Inspection
Identified a deficiency due to an outdated ABST that did not reflect residents' needs, with inconsistencies between the roster, care plans, and ABST data.
Licensing—Failed to use an ABST
25 Apr 2023Abuse: Neglect
25 Apr 2023Abuse: Neglect
Found that a safe environment was not provided, constituting abuse and neglect. A $500 fine was assessed.
Abuse—Failed to provide safe environment
25 Apr 2023Abuse: Neglect
25 Apr 2023Abuse: Neglect
Investigated an abuse/neglect allegation and found supervision failures that contributed to an altercation; a $500 fine was assessed.
Abuse—Failed to follow care plan
21 Apr 2023Abuse: Neglect
21 Apr 2023Abuse: Neglect
Found that a resident was not provided a safe environment, exposing them to risk of harm due to an aggressive resident's actions.
Abuse—Failed to provide safe environment
05 Apr 2023Licensure
05 Apr 2023Licensure
Identified deficiencies in kitchen cleanliness and repair, and administration compliance, across two visits.
Identified deficiencies in medication systems and monitoring during the investigation; no deficiencies were identified for the licensing complaint.
Deficiency—Licensing Complaint Investigation
Deficiency—Change of Condition and Monitoring
Deficiency—Systems: Medications and Treatments
Deficiency—Systems: Medication Administration
Deficiency—Systems: Treatment Orders
16 Mar 2023Abuse: Neglect
16 Mar 2023Abuse: Neglect
Found that a high fall risk resident's care plan was not followed, resulting in fall incidents and an abuse/neglect finding; a $500 fine was assessed.
Abuse—Failed to follow care plan
12 Mar 2023Abuse: Neglect
12 Mar 2023Abuse: Neglect
Found a failure to provide a safe environment that put a resident at risk of harm, constituting neglect and abuse; a fine was assessed.
Abuse—Failed to provide safe environment
12 Mar 2023Abuse: Neglect
12 Mar 2023Abuse: Neglect
Investigated and found that a safe environment was not provided, exposing a resident to risk during a resident-to-resident altercation. A fine of $375 was assessed.
Abuse—Failed to provide safe environment
12 Mar 2023Abuse: Neglect
12 Mar 2023Abuse: Neglect
Investigated and found a failure to provide a safe environment, resulting in an abuse/neglect finding. A $375 fine was assessed.
Abuse—Failed to provide safe environment
12 Mar 2023Abuse: Neglect
12 Mar 2023Abuse: Neglect
Found a violation for not providing a safe environment, constituting abuse and neglect; a $500 fine was assessed.
Abuse—Failed to provide safe environment
23 Feb 2023Abuse: Neglect
23 Feb 2023Abuse: Neglect
Investigated allegations found neglect and abuse due to not following the care plan and inadequate supervision, resulting in a $250 fine.
Abuse—Failed to follow care plan
23 Feb 2023Abuse: Neglect
23 Feb 2023Abuse: Neglect
Found failures to properly plan care for a resident's aggressive behavior, with a fine of $375 assessed.
Abuse—Failed to properly plan care
23 Feb 2023Abuse: Neglect
23 Feb 2023Abuse: Neglect
Found a failure to provide a safe environment, resulting in abuse and neglect toward a resident.
Abuse—Failed to provide safe environment
22 Feb 2023Abuse: Neglect
22 Feb 2023Abuse: Neglect
Concluded a safety violation occurred when a person slapped a resident, causing a fall and risk of harm due to failure to provide a safe environment.
Abuse—Failed to provide safe environment
15 Feb 2023Abuse: Neglect
15 Feb 2023Abuse: Neglect
Found that a safe environment was not provided, resulting in a resident-to-resident incident. A $375 fine was assessed.
Abuse—Failed to provide safe environment
31 Jan 2023Abuse: Neglect
31 Jan 2023Abuse: Neglect
Determined a violation for failure to plan care around a resident's known behaviors, contributing to a resident-to-resident altercation; a $500 fine was assessed.
Abuse—Failed to properly plan care
29 Jan 2023Abuse: Neglect
29 Jan 2023Abuse: Neglect
Determined that exits and gates were not properly secured, enabling a resident to elope and risk harm.
Abuse—Failed to provide safe environment
16 Jan 2023Abuse: Neglect
16 Jan 2023Abuse: Neglect
Found a failure to provide a safe environment that led to an injury, with violations of resident rights and abuse identified; a fine was assessed.
Abuse—Failed to provide safe environment
14 Jan 2023Abuse: Neglect
14 Jan 2023Abuse: Neglect
Investigated a complaint of abuse and neglect; found that a resident relied on care and experienced a harmful interaction, with the environment not providing a homelike setting and multiple prior resident-to-resident altercations.
Abuse—Failed to provide a homelike environment
09 Jan 2023Abuse: Neglect
09 Jan 2023Abuse: Neglect
Investigated and found care planning around a resident's known behaviors inadequate, constituting neglect and abuse.
Abuse—Failed to properly plan care
09 Jan 2023Abuse: Neglect
09 Jan 2023Abuse: Neglect
Determined that the facility failed to plan care for a resident with a known history of altercations, contributing to resident-to-resident aggression.
Abuse—Failed to properly plan care
07 Jan 2023Inspection
07 Jan 2023Inspection
Found a deficiency in providing a safe medication administration system and failure to carry out medication and treatment orders as prescribed.
Licensing—Failed to provide a safe medication administration system
07 Jan 2023Abuse: Neglect
07 Jan 2023Abuse: Neglect
Found a failure to provide a safe medication administration system, leading to missed medications and neglect/abuse; a $500 fine was assessed.
Abuse—Failed to provide a safe medication administration system
07 Jan 2023Inspection
07 Jan 2023Inspection
Investigated the allegation of an unsafe environment and found a failure to implement written policies to ensure a 24-hour resident monitoring and reporting system.
Licensing—Failed to provide safe environment
07 Jan 2023Inspection
07 Jan 2023Inspection
Investigated an allegation of unsafe medication administration and identified a deficiency in safe medication and treatment administration systems.
Licensing—Failed to provide a safe medication administration system
04 Jan 2023Abuse: Neglect
04 Jan 2023Abuse: Neglect
Found a failure to provide a safe environment that put a resident at risk of harm, constituting abuse and neglect.
Abuse—Failed to provide safe environment
28 Dec 2022Abuse: Neglect
28 Dec 2022Abuse: Neglect
Found abuse/neglect due to failing to provide a safe environment; a $500 fine assessed.
Abuse—Failed to provide safe environment
28 Dec 2022Abuse: Neglect
28 Dec 2022Abuse: Neglect
Investigated and found that care planning for known behaviors was incomplete, leading to abuse and neglect findings and a $500 fine.
Abuse—Failed to properly plan care
28 Dec 2022Abuse: Neglect
28 Dec 2022Abuse: Neglect
Found a failure to provide a safe environment resulting in a confirmed abuse/neglect finding and a $500 fine.
Abuse—Failed to provide safe environment
28 Dec 2022Abuse: Neglect
28 Dec 2022Abuse: Neglect
Found deficiencies in care planning for a resident's known behaviors, creating risk of harm and indicating abuse and neglect; a $375 fine was assessed.
Abuse—Failed to properly plan care
23 Dec 2022Abuse: Neglect
23 Dec 2022Abuse: Neglect
Investigated and found abuse/neglect from failure to provide a safe environment, resulting in a $500 fine.
Abuse—Failed to provide safe environment
18 Dec 2022Inspection
18 Dec 2022Inspection
Found failure to provide a safe medication administration system as prescribed.
Licensing—Failed to provide a safe medication administration system
16 Nov 2022Abuse: Neglect
16 Nov 2022Abuse: Neglect
Found a violation for failing to provide a safe environment that allowed an assault on a resident, with a fine assessed.
Abuse—Failed to provide safe environment
06 Nov 2022Abuse: Neglect
06 Nov 2022Abuse: Neglect
Investigated and found violations for failing to provide a safe environment and for an incident involving physical aggression, resulting in a $500 fine.
Abuse—Failed to provide safe environment
20 Sept 2022Abuse: Neglect
20 Sept 2022Abuse: Neglect
Found that a resident was not provided a safe environment, resulting in abuse and injuries. A $500 fine was assessed.
Abuse—Failed to provide safe environment
17 Sept 2022Abuse: Neglect
17 Sept 2022Abuse: Neglect
Investigated a complaint and found a failure to provide a safe environment, putting a resident at risk of harm.
Abuse—Failed to provide safe environment
15 Sept 2022Abuse: Neglect
15 Sept 2022Abuse: Neglect
Investigated a complaint and found violations for failing to provide a safe environment, resulting in minor harm to a resident.
Abuse—Failed to provide safe environment
28 Aug 2022Inspection
28 Aug 2022Inspection
Found violations for unsafe medication administration and failure to administer prescribed pain medication as ordered, with potential for harm.
Licensing—Failed to provide a safe medication administration system
28 Aug 2022Inspection
28 Aug 2022Inspection
Investigated and found that a staff member did not follow medication pass protocols, leaving a resident without prescribed medication and at risk of harm. This violated resident rights and safety rules.
Licensing—Failed to administer medication as ordered
24 Aug 2022Abuse: Neglect
24 Aug 2022Abuse: Neglect
Identified failure to adequately plan and implement fall-risk care for a resident, leading to multiple falls and related injuries over several weeks.
Abuse—Failed to properly plan care
22 Aug 2022Inspection
22 Aug 2022Inspection
Found failure to administer medication as ordered, putting a resident at risk of harm.
Licensing—Failed to administer medication as ordered
29 Jul 2022Abuse: Neglect
29 Jul 2022Abuse: Neglect
Found that a staff member administered two doses of pain medication instead of one and training/oversight for medication administration was lacking, indicating a failure to provide a safe system.
Abuse—Failed to provide a safe medication administration system
18 Jul 2022Abuse: Neglect
18 Jul 2022Abuse: Neglect
Found safety failures that led to an injury during an altercation; a $500 fine was assessed.
Abuse—Failed to provide safe environment
04 Jul 2022Abuse: Neglect
04 Jul 2022Abuse: Neglect
Investigated an allegation of neglect and abuse; found failure to provide a homelike environment and safety concerns after multiple falls, with a fine assessed.
Abuse—Failed to provide a homelike environment
01 Jul 2022Inspection
01 Jul 2022Inspection
Found a violation for failing to submit timely weekly vaccination reporting for vaccinated individuals, residents, and staff.
Licensing—Failed to submit timely or adequate staffing documentation
16 Jun 2022Abuse: Neglect
16 Jun 2022Abuse: Neglect
Investigated and identified a violation of resident rights due to abuse and neglect after an altercation placed a resident at risk for harm; a fine was assessed.
Abuse—Failed to provide safe environment
13 Apr 2022Abuse: Neglect
13 Apr 2022Abuse: Neglect
Investigated and found failures to address a resident's behavior and monitor known risk, which led to a physical altercation and risk of serious harm to another resident.
Abuse—Failed to address resident's behavior
13 Apr 2022Abuse: Neglect
13 Apr 2022Abuse: Neglect
Investigated a complaint and found violations of resident rights due to failure to address a resident's behavior and monitor him/her, which led to a physical altercation and unnecessary discomfort to another resident.
Abuse—Failed to address resident's behavior
03 Apr 2022Abuse: Neglect
03 Apr 2022Abuse: Neglect
Investigated an allegation of neglect and abuse and identified failures to address a resident's behavior, which led to a physical altercation and unreasonable discomfort.
Abuse—Failed to address resident's behavior
30 Mar 2022Abuse: Neglect
30 Mar 2022Abuse: Neglect
Found that staff failed to implement interventions and monitor a resident according to known behavior, leading to a physical altercation and undue discomfort, constituting abuse and neglect.
Abuse—Failed to address resident's behavior
29 Mar 2022Abuse: Neglect
29 Mar 2022Abuse: Neglect
Investigated a resident abuse and neglect case and found a failure to plan for a resident with known inappropriate behaviors, which allowed an inappropriate groping incident.
Abuse—Failed to protect resident from inappropriate sexual contact
11 Mar 2022Inspection
11 Mar 2022Inspection
Found a substantiated violation for failing to administer medication as ordered, including giving the wrong medication and neglect, with potential for moderate harm to a resident.
Licensing—Failed to administer medication as ordered
05 Jan 2022Abuse: Neglect
05 Jan 2022Abuse: Neglect
Investigated a complaint and found that staff failed to intervene and monitor a resident's known behavior, exposing the alleged victim to inappropriate sexual behaviors and causing discomfort, constituting neglect and abuse.
Abuse—Failed to address resident's behavior
04 Jan 2022Abuse: Neglect
04 Jan 2022Abuse: Neglect
Found a failure to supervise known behaviors that led to a physical altercation and risk of serious harm. This was considered neglect and abuse.
Abuse—Failed to address resident's behavior
04 Jan 2022Abuse: Neglect
04 Jan 2022Abuse: Neglect
Found that staff failed to follow the resident's care plan by supervising and redirecting behaviors, risking serious harm when the resident attempted to enter another resident's room.
Abuse—Failed to follow care plan
24 Dec 2021Abuse: Neglect
24 Dec 2021Abuse: Neglect
Investigated a safety complaint and found that a caregiver failed to provide a safe environment by leaving the resident unsupervised, resulting in a fall, with training deficiencies noted.
Abuse—Failed to provide safe environment
15 Dec 2021Abuse: Neglect
15 Dec 2021Abuse: Neglect
Identified a neglect violation due to inadequate care planning regarding a resident's falls that led to injury.
Abuse—Failed to properly plan care
04 Dec 2021Abuse: Neglect
04 Dec 2021Abuse: Neglect
Investigated a neglect allegation about falls and found a failure to properly plan care for falls, leading to injuries including an arm fracture.
Abuse—Failed to properly plan care
24 Nov 2021Abuse: Neglect
24 Nov 2021Abuse: Neglect
Investigated an allegation of abuse and neglect and found safety failures that violated resident rights and constituted abuse and neglect.
Abuse—Failed to provide safe environment
21 Nov 2021Abuse: Neglect
21 Nov 2021Abuse: Neglect
Identified abuse and neglect due to failing to follow the care plan, which led to an injury.
Abuse—Failed to provide safe environment
14 Nov 2021Abuse: Neglect
14 Nov 2021Abuse: Neglect
Found that staff failed to follow the care plans, leading to an altercation between residents; a $375 fine was assessed.
Abuse—Failed to provide safe environment
14 Nov 2021Abuse: Neglect
14 Nov 2021Abuse: Neglect
Investigated the complaint and found the care plan was not followed, resulting in neglect and abuse.
Abuse—Failed to provide safe environment
12 Nov 2021Abuse: Neglect
12 Nov 2021Abuse: Neglect
Found failures to properly care plan for wandering and escalating behaviors, resulting in abuse and neglect. A $500 fine was assessed.
Abuse—Failed to properly plan care
08 Nov 2021Abuse: Neglect
08 Nov 2021Abuse: Neglect
Found a failure to follow the care plan that led to an aggressive incident and injury, with a fine assessed.
Abuse—Failed to follow care plan
08 Nov 2021Abuse: Neglect
08 Nov 2021Abuse: Neglect
Found failure to follow a seating-care plan that kept residents from sitting in a preferred seat, leading to aggression and injury; a fine was assessed.
Abuse—Failed to provide safe environment
01 Nov 2021Abuse: Neglect
01 Nov 2021Abuse: Neglect
Investigated an abuse/neglect case involving failure to follow a care plan that led to a resident-to-resident altercation.
Abuse—Failed to follow care plan
01 Nov 2021Abuse: Neglect
01 Nov 2021Abuse: Neglect
Found that the care plan was not followed, leading to a resident-to-resident altercation and potential harm.
Abuse—Failed to follow care plan
01 Nov 2021Abuse: Neglect
01 Nov 2021Abuse: Neglect
Investigated and found that care plan requirements for resident safety were not followed, resulting in neglect and abuse due to a safety-related failure.
Abuse—Failed to follow care plan
21 Oct 2021Abuse: Neglect
21 Oct 2021Abuse: Neglect
Investigated deficiencies in care planning for wandering residents and managing escalating behavior; a fine was assessed.
Abuse—Failed to properly plan care
13 Oct 2021Abuse: Neglect
13 Oct 2021Abuse: Neglect
Investigated a complaint and found deficiencies in addressing a resident's behavior and implementing safety precautions after a prior altercation, which led to an assault and pain to a resident.
Abuse—Failed to address resident's behavior
09 Oct 2021Inspection
09 Oct 2021Inspection
Investigated and determined that a staff member did not follow the care plan, leading to distress and a resident-to-resident altercation, amounting to neglect and abuse.
Licensing—Failed to follow care plan
09 Oct 2021Inspection
09 Oct 2021Inspection
Found that a staff member did not follow the care plan by placing laundry on a bench in the common area, causing a resident to become upset and involved in a confrontation; identified violations of resident rights and neglect/abuse.
Licensing—Failed to follow care plan
29 Sept 2021Abuse: Neglect
29 Sept 2021Abuse: Neglect
Found violations for failure to properly plan care to prevent wandering and resident-to-resident altercations; a $375 fine was assessed.
Abuse—Failed to properly plan care
23 Sept 2021Abuse: Neglect
23 Sept 2021Abuse: Neglect
Identified neglect for failing to provide a safe environment due to a wandering resident entering other residents’ rooms; a fine was assessed.
Abuse—Failed to provide safe environment
23 Sept 2021Abuse: Neglect
23 Sept 2021Abuse: Neglect
Investigated found deficiencies related to providing a safe environment and neglect of care after a resident wandered into another resident's room with no staff nearby during lunch.
Abuse—Failed to provide safe environment
10 Sept 2021Abuse: Neglect
10 Sept 2021Abuse: Neglect
Investigated and found violations related to failing to address resident behaviors, which led to a physical altercation and injury.
Abuse—Failed to address resident's behavior
10 Sept 2021Abuse: Neglect
10 Sept 2021Abuse: Neglect
Found a failure to provide a safe environment, resulting in injuries from a resident-to-resident altercation.
Abuse—Failed to provide safe environment
10 Sept 2021Inspection
10 Sept 2021Inspection
Found that a staff member restrained a resident and pushed the resident against a wall while the resident attempted to enter the med room, constituting physical abuse and neglect. The resident was not protected from abuse.
Licensing—Failed to protect resident from physical abuse
09 Sept 2021Inspection
09 Sept 2021Inspection
Found safety and resident-rights deficiencies after an elopement occurred when a door wasn't shut and the care plan wasn't followed.
Licensing—Failed to provide safe environment
07 Sept 2021Abuse: Neglect
07 Sept 2021Abuse: Neglect
Investigated and found neglect and abuse where another resident sat at a resident's table at mealtime, violating resident rights. A sanction was assessed.
Abuse—Failed to provide safe environment
07 Sept 2021Abuse: Neglect
07 Sept 2021Abuse: Neglect
Investigated found the care plan did not prevent other residents from sitting at a table, leading to a resident-to-resident altercation and risk to the resident relying on care.
Abuse—Failed to provide safe environment
29 Aug 2021Abuse: Neglect
29 Aug 2021Abuse: Neglect
Investigated found that a resident wandered into another resident’s room and was not redirected as required by the care plan, resulting in a physical incident and abuse/neglect. A $500 fine was assessed.
Abuse—Failed to follow care plan
19 Aug 2021Abuse: Neglect
19 Aug 2021Abuse: Neglect
Investigated the complaint and found neglect of care and abuse due to failure to properly plan care and implement reasonable interventions; a $375 fine was assessed.
Abuse—Failed to properly plan care
17 Aug 2021Abuse: Neglect
17 Aug 2021Abuse: Neglect
Investigated and found that care planning and interventions to prevent wandering and intrusion into another resident's room were not properly implemented, resulting in abuse/neglect findings and a $500 fine.
Abuse—Failed to properly plan care
20 Jul 2021Abuse: Neglect
20 Jul 2021Abuse: Neglect
Investigated and found the provider failed to provide a safe environment and to properly care plan.
Abuse—Failed to provide safe environment
02 Jul 2021Abuse: Neglect
02 Jul 2021Abuse: Neglect
Investigated and found a failure to provide a safe environment due to missing safety plans and care planning for aggression, resulting in a $500 fine.
Abuse—Failed to provide safe environment
29 Jun 2021Abuse: Neglect
29 Jun 2021Abuse: Neglect
Investigated the allegation of abuse and neglect and found failure to plan care to protect a resident from resident-to-resident altercations, resulting in harm.
Abuse—Failed to properly plan care
29 Jun 2021Abuse: Neglect
29 Jun 2021Abuse: Neglect
Investigated a resident-on-resident incident and found that care planning to prevent resident-on-resident altercations was not implemented.
Abuse—Failed to properly plan care
22 Jun 2021Abuse: Neglect
22 Jun 2021Abuse: Neglect
Investigated a resident-to-resident incident and found failure to follow the care plan, constituting neglect and abuse. A $500 fine was assessed.
Abuse—Failed to follow care plan
15 Jun 2021Abuse: Neglect
15 Jun 2021Abuse: Neglect
Investigated and found that the care plan was not followed, resulting in neglect and abuse.
Abuse—Failed to follow care plan
15 Jun 2021Abuse: Neglect
15 Jun 2021Abuse: Neglect
Found neglect due to failure to follow the care plan and assessed a $500 fine.
Abuse—Failed to follow care plan
15 Jun 2021Abuse: Neglect
15 Jun 2021Abuse: Neglect
Found neglect and abuse due to failure to follow the care plan and monitoring requirements, with a fine assessed.
Abuse—Failed to follow care plan
12 Jun 2021Abuse: Neglect
12 Jun 2021Abuse: Neglect
Found failure to provide a safe environment resulting in neglect and abuse, with a $1,500 fine assessed.
Abuse—Failed to provide safe environment
12 Jun 2021Abuse: Neglect
12 Jun 2021Abuse: Neglect
Found neglect and abuse due to failure to provide a safe environment for residents. A $1500 fine was assessed.
Abuse—Failed to provide safe environment
09 Jun 2021Inspection
09 Jun 2021Inspection
Found violations for failing to keep medication records current and for not administering prescribed medication, indicating neglect of care.
Licensing—Failed to keep medication record current or accurate
07 Jun 2021Abuse: Neglect
07 Jun 2021Abuse: Neglect
Investigated a resident-to-resident incident and found supervision required by the care plan was not provided. This resulted in neglect and abuse, and a $500 fine was assessed.
Abuse—Failed to provide safe environment
03 Jun 2021Abuse: Neglect
03 Jun 2021Abuse: Neglect
Investigated and found a failure to provide a safe environment, resulting in abuse and neglect.
Abuse—Failed to provide safe environment
03 Jun 2021Abuse: Neglect
03 Jun 2021Abuse: Neglect
Investigated the allegation and found that a resident was left unsupervised, resulting in a resident-to-resident sexual altercation and indicating abuse and neglect.
Abuse—Failed to provide safe environment
01 Jun 2021Abuse: Neglect
01 Jun 2021Abuse: Neglect
Found neglect and abuse for failing to administer antibiotics as ordered. A $250 fine was assessed.
Abuse—Failed to administer medication as ordered
26 May 2021Abuse: Neglect
26 May 2021Abuse: Neglect
Investigated and found neglect and abuse due to failure to follow the care plan, resulting in several falls and a $1,500 fine assessed.
Abuse—Failed to follow care plan
12 May 2021Abuse: Neglect
12 May 2021Abuse: Neglect
Found a failure to meet resident care needs due to lack of planning for catheter care, monitoring, or follow-up after a Foley catheter was placed without a doctor's order, leading to deterioration and hospital transfer.
Abuse—Failed to obtain medical order
14 Apr 2021Abuse: Neglect
14 Apr 2021Abuse: Neglect
Investigated a resident-to-resident altercation and found neglect and abuse due to not following a care plan, which led to injuries.
Abuse—Failed to follow care plan
14 Apr 2021Abuse: Neglect
14 Apr 2021Abuse: Neglect
Investigated found neglect and abuse due to not following the care plan, leading to a resident injury; assessed a $1125 fine.
Abuse—Failed to follow care plan
01 Apr 2021Abuse: Neglect
01 Apr 2021Abuse: Neglect
Found two residents in the same bed with their pants off, indicating a failure to provide a safe environment and constituting abuse and neglect.
Abuse—Failed to provide safe environment
01 Apr 2021Abuse: Neglect
01 Apr 2021Abuse: Neglect
Found neglect and abuse due to failure to provide a safe environment by not protecting a resident from another resident's inappropriate sexual behavior. A $1500 fine was assessed.
Abuse—Failed to provide safe environment
24 Mar 2021Abuse: Neglect
24 Mar 2021Abuse: Neglect
Investigated allegations of abuse and neglect; found that a resident's safety was compromised when another resident touched them on the thigh, and safety measures were not adequate.
Abuse—Failed to provide safe environment
19 Mar 2021Abuse: Neglect
19 Mar 2021Abuse: Neglect
Determined that failure to follow a resident's care plan led to a resident-to-resident altercation with potential harm, constituting neglect and abuse.
Abuse—Failed to provide safe environment
19 Mar 2021Abuse: Neglect
19 Mar 2021Abuse: Neglect
Found a violation for failing to provide a safe environment, constituting neglect and abuse. A 375 fine was assessed.
Abuse—Failed to provide safe environment
17 Mar 2021Abuse: Neglect
17 Mar 2021Abuse: Neglect
Investigated a resident-to-resident altercation where a care plan was not followed, found neglect and abuse.
Abuse—Failed to follow care plan
17 Mar 2021Abuse: Neglect
17 Mar 2021Abuse: Neglect
Found that care plans were not followed, placing residents at risk and constituting neglect and abuse. A $375 fine was assessed.
Abuse—Failed to follow care plan
17 Mar 2021Abuse: Neglect
17 Mar 2021Abuse: Neglect
Investigated and determined that failing to follow the care plan caused harm and constitutes abuse and neglect.
Abuse—Failed to follow care plan
13 Mar 2021Abuse: Neglect
13 Mar 2021Abuse: Neglect
Found that the care plan for toileting was not followed, resulting in two falls and constituting neglect and abuse, with a $500 fine assessed.
Abuse—Failed to follow care plan
23 Feb 2021Abuse: Neglect
23 Feb 2021Abuse: Neglect
Investigated a resident-to-resident incident that injured a resident and found a failure to provide a safe environment, constituting abuse and neglect; a fine was assessed.
Abuse—Failed to provide safe environment
23 Feb 2021Abuse: Neglect
23 Feb 2021Abuse: Neglect
Concluded that a resident-to-resident incident occurred and a safe environment was not provided, constituting abuse and neglect.
Abuse—Failed to provide safe environment
23 Feb 2021Abuse: Neglect
23 Feb 2021Abuse: Neglect
Identified a resident-to-resident incident causing injury and found a failure to provide a safe environment.
Abuse—Failed to provide safe environment
15 Feb 2021Abuse: Neglect
15 Feb 2021Abuse: Neglect
Investigated and identified violations for failing to provide a safe environment, which led to a resident-to-resident altercation. A $375 fine was assessed.
Abuse—Failed to provide safe environment
15 Feb 2021Abuse: Neglect
15 Feb 2021Abuse: Neglect
Found neglect and abuse due to failure to properly plan care; a $500 fine assessed.
Abuse—Failed to properly plan care
12 Feb 2021Abuse: Neglect
12 Feb 2021Abuse: Neglect
Found abuse and neglect due to failure to provide a safe environment, resulting in a resident-to-resident altercation. A $375 fine was assessed.
Abuse—Failed to provide safe environment
11 Feb 2021Abuse: Neglect
11 Feb 2021Abuse: Neglect
Investigated and found inadequate supervision led to a resident fall and injury, constituting neglect and abuse.
Abuse—Failed to provide safe environment
30 Jan 2021Abuse: Neglect
30 Jan 2021Abuse: Neglect
Investigated neglect found a failure to provide a safe environment that led to an unwitnessed fall and head injury, with a fine assessed.
Abuse—Failed to provide safe environment
25 Dec 2020Abuse: Neglect
25 Dec 2020Abuse: Neglect
Found that the provider failed to follow the care plan, resulting in a resident-to-resident altercation and risk of serious harm; a fine was assessed.
Abuse—Failed to follow care plan
25 Dec 2020Abuse: Neglect
25 Dec 2020Abuse: Neglect
Investigated a complaint and found that a care plan was not followed, resulting in a resident-to-resident altercation and a fine was assessed.
Abuse—Failed to follow care plan
27 Nov 2020Inspection
27 Nov 2020Inspection
Investigated and found violations related to an unsafe environment and abusive conduct by a caregiver toward a resident.
Licensing—Failed to provide safe environment
20 Nov 2020Abuse: Neglect
20 Nov 2020Abuse: Neglect
Investigated the case and found neglect and abuse due to failure to implement interventions based on known behaviors, which led to a physical altercation and discomfort; a $500 fine was assessed.
Abuse—Failed to provide safe environment
06 Nov 2020Abuse: Neglect
06 Nov 2020Abuse: Neglect
Found a failure to follow the resident's care plan, resulting in risk of serious harm from inappropriate touching by another resident. This constitutes abuse and neglect.
Abuse—Failed to follow care plan
01 Nov 2020Abuse: Neglect
01 Nov 2020Abuse: Neglect
Found neglect and abuse due to failure to monitor a resident according to known behaviors, which led to a physical altercation and discomfort; a $375 fine was assessed.
Abuse—Failed to provide safe environment
24 Oct 2020Abuse: Neglect
24 Oct 2020Abuse: Neglect
Identified neglect and abuse from failure to implement interventions and care plans, resulting in a physical altercation and discomfort; a $375 fine was assessed.
Abuse—Failed to provide safe environment
05 Oct 2020Abuse: Neglect
05 Oct 2020Abuse: Neglect
Investigated and identified failures in supervision that led to a resident eloping outside the grounds and risking serious harm.
Abuse—Failed to provide safe environment
05 Oct 2020Abuse: Neglect
05 Oct 2020Abuse: Neglect
Investigated a complaint about safety and resident rights; found failures to monitor the alleged victim according to known behaviors, resulting in inappropriate contact with another person.
Abuse—Failed to provide safe environment
29 Sept 2020Inspection
29 Sept 2020Inspection
Investigated a complaint and found that resident services to assist with daily living activities were not provided adequately due to staffing levels.
Licensing—Failed to provide service
16 Sept 2020Abuse: Neglect
16 Sept 2020Abuse: Neglect
Found neglect and abuse due to inadequate supervision, resulting in inappropriate contact and risk of serious harm.
Abuse—Failed to provide safe environment
07 Sept 2020Abuse: Neglect
07 Sept 2020Abuse: Neglect
Investigated an allegation of abuse and neglect and found that interventions and the care plan were not properly implemented, resulting in a physical altercation and discomfort; a fine was assessed.
Abuse—Failed to provide safe environment
01 Sept 2020Abuse: Neglect
01 Sept 2020Abuse: Neglect
Found neglect and abuse due to failure to follow a resident care plan, leading to a physical altercation and discomfort.
Abuse—Failed to provide safe environment
01 Sept 2020Abuse: Neglect
01 Sept 2020Abuse: Neglect
Found neglect and abuse due to not following care plans for known behaviors, leading to a physical altercation and unreasonable discomfort; a fine was assessed.
Abuse—Failed to provide safe environment
14 Aug 2020Abuse: Neglect
14 Aug 2020Abuse: Neglect
Found that staff failed to provide a safe environment and adequate supervision based on known resident behaviors, leading to a physical altercation and nose bleed.
Abuse—Failed to provide safe environment
21 Jun 2020Abuse: Neglect
21 Jun 2020Abuse: Neglect
Investigated a complaint of abuse and neglect; found that interventions and care planning for a resident were not implemented, leading to a physical altercation and unnecessary discomfort.
Abuse—Failed to provide safe environment
21 Jun 2020Abuse: Neglect
21 Jun 2020Abuse: Neglect
Investigated and found violations of resident safety and abuse due to failure to implement interventions and care plans. This failure led to a physical altercation and unreasonable discomfort.
Abuse—Failed to provide safe environment
11 Jun 2020Abuse: Neglect
11 Jun 2020Abuse: Neglect
Investigated and found neglect and abuse due to failure to follow the incontinence care plan, causing discomfort and loss of dignity. A $500 fine was assessed.
Abuse—Failed to provide service
10 Jun 2020Inspection
10 Jun 2020Inspection
Investigated allegations of resident abuse and found that a staff member pinched a resident in the chest, causing bruising, and that protection from abuse was not provided.
Licensing—Failed to protect resident from physical abuse
23 May 2020Abuse: Neglect
23 May 2020Abuse: Neglect
Investigated an abuse and neglect allegation. Found a failure to monitor a resident according to known behaviors, which led to inappropriate touching and a neck hold with kissing, causing emotional distress and loss of dignity.
Abuse—Failed to provide safe environment
14 May 2020Abuse: Neglect
14 May 2020Abuse: Neglect
Found neglect and abuse due to failure to follow the care plan, resulting in an unsupervised wander into another resident's room and exposure to harm and loss of dignity.
Abuse—Failed to follow care plan
10 May 2020Inspection
10 May 2020Inspection
Found a failure to follow the resident's care plan for standby shower assistance, which led to an unwitnessed fall with injury and violations of resident rights and abuse.
Licensing—Failed to follow care plan
02 May 2020Abuse: Neglect
02 May 2020Abuse: Neglect
Identified a violation involving failure to provide a safe environment and appropriate care planning, which led to a resident being punched in the chest; a $375 fine was assessed.
Abuse—Failed to provide safe environment
15 Apr 2020Inspection
15 Apr 2020Inspection
Found that medical and other records were not kept confidential as required by the rule.
Licensing—Failed to assure resident rights
15 Mar 2020Inspection
15 Mar 2020Inspection
Found that care was not provided per the resident's plan requiring two-person assistance, leading to a wrist injury and indicating neglect and abuse; resident rights were violated.
Licensing—Failed to assure resident was safe
07 Mar 2020Abuse: Neglect
07 Mar 2020Abuse: Neglect
Found deficiencies related to neglect and abuse due to failure to monitor fall history and implement effective interventions, resulting in about 12 falls over two months with injuries. A fine was assessed.
Abuse—Failed to properly plan care
27 Feb 2020Inspection
27 Feb 2020Inspection
Found failure to administer medication as ordered.
Licensing—Failed to administer medication as ordered
12 Feb 2020Inspection
12 Feb 2020Inspection
Investigated the allegation and found medication orders were not followed, resulting in a dose not given to a resident.
Licensing—Failed to administer medication as ordered
12 Feb 2020Inspection
12 Feb 2020Inspection
Found that funds were spent from a resident's account without the resident's or family's consent, indicating a risk of financial exploitation.
Licensing—Failed to protect resident from financial exploitation
12 Feb 2020Inspection
12 Feb 2020Inspection
Found that residents' possessions were not kept safe. Investigated an allegation of failing to protect a resident from financial exploitation.
Licensing—Failed to protect resident from financial exploitation
26 Dec 2019Abuse: Neglect
26 Dec 2019Abuse: Neglect
Determined neglect and abuse occurred due to failure to follow the resident's care plan, leading to a physical altercation and unreasonable discomfort.
Abuse—Failed to provide safe environment
25 Dec 2019Abuse: Neglect
25 Dec 2019Abuse: Neglect
Investigated a complaint and found a failure to follow the care plan that led to an altercation and unreasonable discomfort, constituting abuse and neglect.
Abuse—Failed to provide safe environment
14 Nov 2019Abuse: Neglect
14 Nov 2019Abuse: Neglect
Determined that inadequate supervision led to a resident fall with injury, constituting neglect and abuse. A $500 fine was assessed.
Abuse—Failed to assure resident was safe
31 Oct 2019Abuse: Neglect
31 Oct 2019Abuse: Neglect
Found neglect and abuse due to failure to provide a safe environment, leading to several physical altercations and discomfort; a $500 fine was assessed.
Abuse—Failed to provide safe environment
25 Oct 2019Abuse: Neglect
25 Oct 2019Abuse: Neglect
Found that failure to follow the care plan caused a physical altercation and unreasonable discomfort, constituting abuse and neglect; a fine of $375 was assessed.
Abuse—Failed to provide safe environment
20 Oct 2019Abuse: Neglect
20 Oct 2019Abuse: Neglect
Identified neglect and abuse due to failure to implement interventions for known behaviors, which led to a physical altercation and discomfort, with a fine assessed.
Abuse—Failed to provide safe environment
04 Oct 2019Abuse: Neglect
04 Oct 2019Abuse: Neglect
Found a safety deficiency involving failure to keep a resident safe, resulting in risk of serious harm and indicating abuse through neglect.
Abuse—Failed to assure resident was safe
09 Sept 2019Abuse: Neglect
09 Sept 2019Abuse: Neglect
Investigated a complaint and found a failure to follow a resident's care plan, placing a resident at risk of serious harm due to being found in a shower with another resident.
Abuse—Failed to assure resident was safe
09 Sept 2019Abuse: Neglect
09 Sept 2019Abuse: Neglect
Identified neglect and abuse due to failure to follow a resident's care plan, which led to inappropriate contact with another resident and risk of serious harm; a $1500 fine was assessed.
Abuse—Failed to assure resident was safe
23 Aug 2019Abuse: Neglect
23 Aug 2019Abuse: Neglect
Found neglect of an individual by not protecting them from being slapped, creating risk of serious harm. A fine of 188 dollars was assessed.
Abuse—Failed to provide safe environment
28 Jul 2019Abuse: Neglect
28 Jul 2019Abuse: Neglect
Determined neglect in medication administration safety that caused harm or risk by administering a medication that should have been held due to low blood pressure.
Abuse—Failed to provide a safe medication administration system
03 Jul 2019Abuse: Neglect
03 Jul 2019Abuse: Neglect
Found neglect due to failure to provide proper supervision and services, leading to altercations and risk of serious harm.
Abuse—Failed to provide safe environment
22 Jun 2019Abuse: Neglect
22 Jun 2019Abuse: Neglect
Investigated the allegation and found that appropriate care and supervision were not provided, allowing a resident to elope and wander outside, creating a risk of serious harm.
Abuse—Failed to assure resident was safe
17 Jun 2019Inspection
17 Jun 2019Inspection
Investigated an allegation of failing to administer medication as ordered; a deficiency was found.
Licensing—Failed to administer medication as ordered
15 May 2019Inspection
15 May 2019Inspection
Investigated an allegation of failing to report suspected abuse and found it substantiated, with a $750 fine assessed.
Licensing—Failed to report potential or suspected abuse
15 May 2019Abuse: Neglect
15 May 2019Abuse: Neglect
Found that a resident was not protected from sexually inappropriate contact, resulting in significant emotional harm; a $375 fine was assessed.
Abuse—Failed to protect resident from inappropriate sexual contact
09 May 2019Abuse: Neglect
09 May 2019Abuse: Neglect
Found neglect due to failing to provide proper supervision and services to a resident, resulting in altercations and risk of serious harm.
Abuse—Failed to provide safe environment
09 Apr 2019Abuse: Neglect
09 Apr 2019Abuse: Neglect
Found neglect by allowing a resident to hit another, creating a risk of serious harm.
Abuse—Failed to provide safe environment
09 Apr 2019Abuse: Neglect
09 Apr 2019Abuse: Neglect
Found neglect by allowing a staff member to hit a resident in the chest, creating a risk of serious harm; a $281 fine was assessed.
Abuse—Failed to provide safe environment
02 Apr 2019Abuse: Neglect
02 Apr 2019Abuse: Neglect
Found neglect due to inadequate supervision that resulted in harm.
Abuse—Failed to provide safe environment
02 Apr 2019Abuse: Neglect
02 Apr 2019Abuse: Neglect
Investigated and found neglect due to inadequate supervision resulting in potential harm; a fine of $281 was assessed.
Abuse—Failed to provide safe environment
07 Mar 2019Inspection
07 Mar 2019Inspection
Investigated the complaint and found a violation involving failure to administer medication as ordered.
Licensing—Failed to administer medication as ordered
23 Jan 2019Inspection
23 Jan 2019Inspection
Investigated a complaint alleging failure to administer medication as ordered. Found a deficiency related to medication administration.
Licensing—Failed to administer medication as ordered
28 Dec 2018Abuse: Neglect
28 Dec 2018Abuse: Neglect
Investigated a neglect allegation and found a failure to provide a safe environment, resulting in harm from inappropriate physical contact. A fine was assessed.
Abuse—Failed to provide safe environment
28 Dec 2018Abuse: Neglect
28 Dec 2018Abuse: Neglect
Found neglect of a resident due to inadequate supervision and services, creating a risk of serious harm, and assessed a $375 fine.
Abuse—Failed to provide safe environment
15 Nov 2018Abuse: Neglect
15 Nov 2018Abuse: Neglect
Found neglect due to failure to properly plan care and supervise AV1, AV2, and AV3, leading to altercations and risk of serious harm.
Abuse—Failed to properly plan care
15 Nov 2018Abuse: Neglect
15 Nov 2018Abuse: Neglect
Investigated the allegation of neglect in planning care and found a failure to provide proper supervision and services, creating risk of serious harm to residents.
Abuse—Failed to properly plan care
18 Oct 2018Abuse: Neglect
18 Oct 2018Abuse: Neglect
Determined neglect occurred by failing to change bandages on a resident's coccyx/buttocks wounds, risking serious harm.
Abuse—Failed to follow care plan
06 Oct 2018Abuse: Neglect
06 Oct 2018Abuse: Neglect
Investigated and concluded a neglect incident by not dispensing medications as ordered, creating a risk of serious harm.
Abuse—Failed to administer medication as ordered
02 Oct 2018Abuse: Neglect
02 Oct 2018Abuse: Neglect
Found neglect and inadequate supervision related to falls that risked serious harm to a resident; a $375 fine was assessed.
Abuse—Failed to adequately care plan related to falls
24 Sept 2018Abuse: Neglect
24 Sept 2018Abuse: Neglect
Investigated a records complaint and determined neglect due to failing to properly plan care, resulting in physical harm and discomfort.
Abuse—Failed to properly plan care
20 Sept 2018Abuse: Neglect
20 Sept 2018Abuse: Neglect
Found deficiencies for failing to provide a safe medication administration system, resulting in an overdose and risk of serious harm. A $375 fine was assessed.
Abuse—Failed to provide a safe medication administration system
10 Sept 2018Abuse: Neglect
10 Sept 2018Abuse: Neglect
Found neglect of supervision and services leading to falls and risk of serious harm. A $375 fine was assessed.
Abuse—Failed to follow care plan
06 Sept 2018Abuse: Neglect
06 Sept 2018Abuse: Neglect
Found neglect due to failure to provide basic care necessary to maintain safety, resulting in physical harm; a $375 fine assessed.
Abuse—Failed to properly plan care
06 Sept 2018Abuse: Neglect
06 Sept 2018Abuse: Neglect
Found neglect of a resident due to failing to provide interventions to prevent falls, creating risk of serious harm.
Abuse—Failed to follow care plan
28 Aug 2018Abuse: Neglect
28 Aug 2018Abuse: Neglect
Found a violation for failing to protect a resident from involuntary seclusion; the resident was confined to a room, and a fine was assessed.
Abuse—Failed to protect resident from involuntary seclusion
23 Aug 2018Abuse: Neglect
23 Aug 2018Abuse: Neglect
Investigated a complaint and found neglect related to failing to provide a safe environment and failing to plan/intervene for falls, creating a risk of serious harm.
Abuse—Failed to provide safe environment
08 Aug 2018Abuse: Neglect
08 Aug 2018Abuse: Neglect
Determined that neglect occurred due to failure to adequately plan care for falls. A $750 fine was assessed.
Abuse—Failed to adequately care plan related to falls
08 Aug 2018Abuse: Neglect
08 Aug 2018Abuse: Neglect
Found a deficient medication administration system that created risk of serious harm by not dispensing insulin per doctor orders.
Abuse—Failed to provide a safe medication administration system
08 Aug 2018Abuse: Neglect
08 Aug 2018Abuse: Neglect
Investigated the allegation of failing to provide a safe environment; found that a resident suffered nasal injury during a physical altercation, and a $750 fine was assessed.
Abuse—Failed to provide safe environment
08 Aug 2018Abuse: Neglect
08 Aug 2018Abuse: Neglect
Found neglect due to not following a resident's care plan, which caused harm, and a fine was assessed.
Abuse—Failed to follow care plan
07 Aug 2018Abuse: Neglect
07 Aug 2018Abuse: Neglect
Investigated an allegation of neglect in care planning for several falls and identified neglect that posed a risk of serious harm, with a $188 fine assessed.
Abuse—Failed to follow care plan
17 Jul 2018Abuse: Neglect
17 Jul 2018Abuse: Neglect
Found failure to provide appropriate care to a resident.
Abuse—Failed to provide oversight and monitoring of change of condition
10 Jul 2018Inspection
10 Jul 2018Inspection
Identified lack of resident activities.
Licensing—Failed to provide appropriate activities
09 Jul 2018Abuse: Neglect
09 Jul 2018Abuse: Neglect
Found inadequate care planning related to falls, with a substantiated neglect finding and a $375 fine assessed.
Abuse—Failed to adequately care plan related to falls
03 Jul 2018Abuse: Neglect
03 Jul 2018Abuse: Neglect
Investigated an allegation of neglect related to falls care planning and supervision, leading to multiple falls and risk of serious harm.
Abuse—Failed to adequately care plan related to falls
03 Jul 2018Abuse: Neglect
03 Jul 2018Abuse: Neglect
Found neglect related to falls due to inadequate care, supervision, and services. A $375 fine was assessed.
Abuse—Failed to adequately care plan related to falls
22 Jun 2018Abuse: Financial abuse
22 Jun 2018Abuse: Financial abuse
Investigated a financial exploitation allegation and found that resident resources were not adequately protected.
Abuse—Failed to protect resident from financial exploitation
14 May 2018Inspection
14 May 2018Inspection
Investigated an allegation of inadequate staffing and found failure to meet staffing and training requirements.
Licensing—Failed to provide appropriate staffing
06 May 2018Inspection
06 May 2018Inspection
Investigated an allegation that a safe medication administration system was not provided.
Licensing—Failed to provide a safe medication administration system
23 Apr 2018Inspection
23 Apr 2018Inspection
Found a safety deficiency for failure to protect residents from a physical altercation.
Licensing—Failed to provide safe environment
23 Apr 2018Inspection
23 Apr 2018Inspection
Investigated a safety deficiency related to failing to protect residents from a physical altercation. Assessed a $750 fine.
Licensing—Failed to provide safe environment
22 Mar 2018Inspection
22 Mar 2018Inspection
Identified housekeeping and cleanliness deficiencies resulting in dirty conditions.
Licensing—Failed to provide appropriate housekeeping services
22 Mar 2018Inspection
22 Mar 2018Inspection
Investigated and found inadequate care planning related to falls.
Licensing—Failed to adequately care plan related to falls
27 Feb 2018Inspection
27 Feb 2018Inspection
Found that a safe environment for residents was not provided, posing risk of physical harm.
Licensing—Failed to provide safe environment
02 Feb 2018Abuse: Neglect
02 Feb 2018Abuse: Neglect
Found a failure to protect a resident from physical harm, resulting in a $500 fine.
Abuse—Failed to properly plan care
16 Nov 2017Abuse: Neglect
16 Nov 2017Abuse: Neglect
Found neglect due to failure to assure timely medical treatment and assessed a $300 fine.
Abuse—Failed to assure timely medical treatment
13 Nov 2017Abuse: Neglect
13 Nov 2017Abuse: Neglect
Investigated and found a violation involving failure to protect residents from inappropriate interaction.
Abuse—Failed to provide safe environment
07 Nov 2017Abuse: Neglect
07 Nov 2017Abuse: Neglect
Investigated and found that a resident was not protected from inappropriate verbal comments/interaction.
Abuse—Failed to protect resident from verbal abuse
20 Sept 2017Inspection
20 Sept 2017Inspection
Found substantiated an allegation that care was not properly planned and residents were not protected from inappropriate physical contact. A $300 fine was assessed.
Licensing—Failed to properly plan care
16 Sept 2017Inspection
16 Sept 2017Inspection
Found a failure to provide a safe environment for residents.
Licensing—Failed to provide safe environment
16 Sept 2017Inspection
16 Sept 2017Inspection
Investigated and found a failure to provide a safe environment for residents.
Licensing—Failed to provide safe environment
16 Sept 2017Inspection
16 Sept 2017Inspection
Found a safe environment deficiency affecting residents RV1 and RV3.
Licensing—Failed to provide safe environment
09 Sept 2017Inspection
09 Sept 2017Inspection
Investigated an allegation of failing to provide a safe environment and found a lack of proper supervision. This condition posed a potential for harm.
Licensing—Failed to provide safe environment
13 Jun 2017Inspection
13 Jun 2017Inspection
Investigated an allegation that medication was not administered as ordered and found a failure in the medication system that resulted in a resident receiving another resident's medications.
Licensing—Failed to administer medication as ordered
17 May 2017Inspection
17 May 2017Inspection
Determined that a safety deficiency existed due to failure to protect a resident from inappropriate physical contact.
Licensing—Failed to provide safe environment
16 May 2017Abuse: Neglect
16 May 2017Abuse: Neglect
Investigated the allegation and found failure to provide appropriate care, resulting in several falls and skin tears.
Abuse—Failed to provide safe environment
04 May 2017Condition
04 May 2017Condition
Concluded that the allegation of failing to provide a safe environment was supported.
Regulatory Action—Failed to provide safe environment
22 Mar 2017Inspection
22 Mar 2017Inspection
Found that equipment necessary for residents' health, safety, and comfort was not maintained in good repair.
Licensing—Failed to provide or maintain resident care equipment
21 Mar 2017Inspection
21 Mar 2017Inspection
Found that a resident was not allowed to use the phone when requested.
Licensing—Failed to provide service
03 Feb 2017Inspection
03 Feb 2017Inspection
Identified safety deficiencies due to inadequate screening or assessment and failure to provide a safe environment related to residents' unwanted sexual behavior.
Licensing—Failed to perform adequate screening or assessment
03 Feb 2017Inspection
03 Feb 2017Inspection
Investigated the allegation of a nonfunctional door alarm or call system and found safety deficiencies, resulting in an unsafe environment for residents.
Licensing—Failed to maintain functional door alarm or call system
02 Feb 2017Inspection
02 Feb 2017Inspection
Investigated the allegation of failing to properly plan care and found neglect of care.
Licensing—Failed to properly plan care
27 Jan 2017Abuse: Neglect
27 Jan 2017Abuse: Neglect
Investigated a neglect accusation and concluded that timely medical treatment for a right heel wound was not provided; a $300 fine was assessed.
Abuse—Failed to assure timely medical treatment
15 Dec 2016Abuse: Neglect
15 Dec 2016Abuse: Neglect
Investigated an allegation of neglect related to falls; identified a failure to provide a safe environment and assessed a $300 fine.
Abuse—Failed to adequately care plan related to falls
22 Nov 2016Inspection
22 Nov 2016Inspection
Investigated a complaint about medication safety and identified a deficiency in the safe medication administration system. The issue was classified as a licensing violation with minor harm or potential for moderate harm.
Licensing—Failed to provide a safe medication administration system
07 Apr 2016Abuse: Neglect
07 Apr 2016Abuse: Neglect
Determined that the allegation of failing to notify family was sustained. Moderate harm potential identified.
Abuse—Failed to notify family
07 Mar 2016Abuse: Neglect
07 Mar 2016Abuse: Neglect
Found violations of neglect related to skin breakdown and assessed a $2,400 fine.
Abuse—Failed to intervene when resident's condition changed
07 Mar 2016Abuse: Neglect
07 Mar 2016Abuse: Neglect
Determined neglect occurred due to failure to assess and intervene after multiple falls, and a $300 fine was assessed.
Abuse—Failed to adequately care plan related to falls
07 Mar 2016Abuse: Neglect
07 Mar 2016Abuse: Neglect
Found failures to provide adequate end-of-life pain management, with an allegation of abuse/neglect substantiated.
Abuse—Failed to provide appropriate pain control
07 Mar 2016Abuse: Neglect
07 Mar 2016Abuse: Neglect
Found neglect due to failure to assess and intervene when a resident's condition changed, resulting in a $400 fine.
Abuse—Failed to intervene when resident's condition changed
07 Mar 2016Abuse: Neglect
07 Mar 2016Abuse: Neglect
Identified deficiencies in assessing and intervening when a resident's skin condition changed; a fine was assessed.
Abuse—Failed to intervene when resident's condition changed
07 Mar 2016Inspection
07 Mar 2016Inspection
Determined a licensing violation occurred due to failure to monitor residents' blood sugar levels on time because of insufficient supplies.
Licensing—Failed to assure adequate supply or equipment
07 Mar 2016Abuse: Neglect
07 Mar 2016Abuse: Neglect
Found failure to obtain timely medical treatment for two residents with pneumonia.
Abuse—Failed to assure timely medical treatment
07 Mar 2016Abuse: Neglect
07 Mar 2016Abuse: Neglect
Investigated and found a failure to assess and intervene promptly when a resident's condition changed.
Abuse—Failed to intervene when resident's condition changed
07 Mar 2016Abuse: Neglect
07 Mar 2016Abuse: Neglect
Found that a resident's skin condition was not properly assessed or intervened. A $300 fine was assessed.
Abuse—Failed to properly plan care
17 Feb 2016Inspection
17 Feb 2016Inspection
Found deficiencies related to inadequate care planning for falls and an unsafe environment for residents.
Licensing—Failed to adequately care plan related to falls
28 Oct 2015Inspection
28 Oct 2015Inspection
Identified a deficiency for not maintaining at least three feet between beds.
Licensing—Failed to maintain a safe physical environment
20 Dec 2014Abuse: Neglect
20 Dec 2014Abuse: Neglect
Investigated a neglect of care related to falls and assessed a $300 fine.
Abuse—Failed to adequately care plan related to falls
23 Jun 2014Abuse: Physical Abuse
23 Jun 2014Abuse: Physical Abuse
Investigated an abuse allegation and identified a failure to provide a safe environment for residents.
Abuse—Failed to protect resident from rough treatment
27 May 2014Abuse: Involuntary Seclusion
27 May 2014Abuse: Involuntary Seclusion
Found that a resident was subjected to involuntary seclusion due to failure to protect.
Abuse—Failed to protect resident from involuntary seclusion
19 Mar 2014Abuse: Involuntary Seclusion
19 Mar 2014Abuse: Involuntary Seclusion
Determined that a resident was subjected to involuntary seclusion and protection from it was not ensured.
Abuse—Failed to protect resident from involuntary seclusion
24 Dec 2013Abuse: Neglect
24 Dec 2013Abuse: Neglect
Found unsafe environment for two residents.
Abuse—Failed to provide safe environment
16 Oct 2013Abuse: Neglect
16 Oct 2013Abuse: Neglect
Found failure to provide a safe environment for residents.
Abuse—Failed to provide safe environment
21 Feb 2013Abuse: Neglect
21 Feb 2013Abuse: Neglect
Found substantiated the neglect allegation that oversight and monitoring of change of condition were lacking.
Abuse—Failed to provide oversight and monitoring of change of condition
21 Mar 2011Abuse: Financial abuse
21 Mar 2011Abuse: Financial abuse
Found that medications were not kept secure, enabling theft; a $300 fine was assessed.
Abuse—Failure to provide a system that prevents theft or misuse of medication
21 Mar 2011Abuse: Neglect
21 Mar 2011Abuse: Neglect
Investigated an allegation of neglect related to medication administration and found that medication records were not adequately maintained.
Abuse—Failed to provide a safe medication administration system
16 Nov 2010Inspection
16 Nov 2010Inspection
Investigated and found a deficiency in documenting one medication correctly on the MAR.
Licensing—Failed to keep medication record current or accurate
22 Sept 2010Abuse: Verbal/Mental abuse
22 Sept 2010Abuse: Verbal/Mental abuse
Investigated and concluded residents were not protected from verbal/mental abuse.
Abuse—Failed to protect resident from mental or emotional abuse
04 Sept 2010Inspection
04 Sept 2010Inspection
Found a deficiency in care-plan documentation for a resident, with potential for minor harm.
Licensing—Failed to care plan in accordance with assessment
Disclaimer
Mirador Living is not affiliated with the owner or operator(s) of Monarch Gardens Memory Care. The information above has not been verified or approved by the owner or operator. For exact information, please contact Monarch Gardens Memory Care directly. There is no cost for this service. We are compensated by the community you select.
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