I moved my mom here and the transition was smooth. The executive director and caregiving team are professional, compassionate, and very involved; staff made her feel at home. The community is beautiful, clean, and welcoming with engaging activities and nice outdoor spaces. I felt she was well cared for and supported - I would recommend this memory-care community.
Loved one of resident
Jul 2026
Pricing
Prices shown are estimates and subject to change. Contact your senior living advisor for current pricing.
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Amenities
Healthcare services
Activities of daily living assistance
Assistance with bathing
Assistance with dressing
Assistance with transfers
Medication management
Mental wellness program
Healthcare staffing
12-16 hour nursing
24-hour call system
24-hour supervision
Meals and dining
Diabetes diet
Meal preparation and service
Restaurant-style dining
Special dietary restrictions
Room
Air-conditioning
Cable
Fully furnished
Housekeeping and linen services
Kitchenettes
Private bathrooms
Telephone
Wifi
Memory care community services
Mild cognitive impairment
Specialized memory care programming
Transportation
Community operated transportation
Transportation arrangement
Transportation arrangement (non-medical)
Common areas
Beauty salon
Computer center
Dining room
Fitness room
Gaming room
Garden
Outdoor space
Small library
Wellness center
Community services
Concierge services
Fitness programs
Move-in coordination
Activities
Community-sponsored activities
Planned day trips
Resident-run activities
Scheduled daily activities
Reviews
3.71·(34)
Overall rating
5
4
3
2
1
Care
2.7
Staff
3.8
Meals
2.8
Amenities
4.5
Value
1.7
Pros
Compassionate, engaged caregiving staff
Clean, well-maintained facility and interiors
Attractive outdoor garden, courtyards, and fountain
Robust activities program (music, arts, baking, outings)
Welcoming central common areas with kitchen and seating
Hands-on executive leadership and family engagement
Demonstrated hospice coordination and end-of-life support
Private, recently updated resident rooms available
Friendly, helpful service and support staff
Large facility offering varied social opportunities
Calm, nurturing atmosphere for many residents
Ongoing administrative and care-quality improvements
Cons
Inconsistent clinical care and wound-management practices
Erratic medication administration and clinical responsiveness
Chronic understaffing and high direct-care turnover
Weak family communication and care-coordination processes
Opaque pricing and tiered-billing structure with administrative fees
Administrative instability and frequent management turnover
Sanitation and incontinence-care concerns in some areas
Safety-management gaps for resident-to-resident interactions
Variable meal quality and dining satisfaction
Prior regulatory citations and documented compliance weaknesses
Large facility layout that can complicate supervision and continuity
Summary of reviews
Willamette Springs Memory Care Community presents a mixed picture in family and resident accounts. Many narratives emphasize a caring, warm environment with engaged direct-care staff, a clean physical plant, attractive outdoor areas and interior courtyards, and a broad activities program that includes music, arts, baking and day trips. Several families highlighted hands-on executive leadership, successful hospice coordination in end-of-life situations, and comfortable, recently updated private rooms. For prospective residents seeking a structured memory-care setting with plentiful social opportunities, these operational strengths are notable.
At the same time, a consistent set of operational concerns appears across experiences. Clinical care quality—including wound management, timely medication administration, and emergency responsiveness—was described as inconsistent. These care-process gaps are often connected to chronic understaffing and frequent turnover among nursing and direct-care staff, which reviewers linked to delays in assistance, missed care tasks (for example bathing or linen changes), and variable competency among caregivers. Safety-management issues were also raised, particularly regarding resident-to-resident incidents and how those are handled.
Management and administrative practices were another recurrent theme. Families cited frequent leadership changes, billing complexity tied to a tiered-care fee structure, an upfront community fee, and occasional billing errors or lack of pricing transparency. The facility has had regulatory citations in the past (2017–2018), and some reviewers described safety or conduct incidents that drew legal or regulatory attention. These points suggest prospective families should review licensing history, contract terms, and invoicing procedures carefully before committing.
Dining and housekeeping impressions were mixed. Several families praised cleanliness of common areas, friendly service staff, and planned meal programming; others described variable meal quality and sanitation/incontinence-care issues in parts of the building. The facility’s size and quadrant layout offer varied spaces and activity options but can also complicate supervision and continuity of care when staffing is limited.
Overall, experiences at Willamette Springs vary substantially. Many families reported excellent care, compassionate staff, and a supportive end-of-life experience; others reported care deficiencies that prompted relocation. Prospective residents and their decision-makers should directly assess clinical staffing levels and skill mix, ask for specific examples of how the community handles medication timing, wound care, and resident-aggression incidents, request recent licensing and inspection records, and review the contract and tiered-billing details before moving forward. Visiting during different times of day and speaking with current family members can help gauge whether the community’s strengths align with an individual’s care needs and expectations.
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Location
Willamette Springs Memory Care Community is located at 6000 SW Mosaic Dr, Corvallis, OR, 97333.
About Willamette Springs Memory Care Community
Willamette Springs Memory Care Community provides specialized memory care in Corvallis, Oregon, with a commitment to serving residents experiencing Alzheimer’s or other forms of dementia. The community is designed to evoke the atmosphere of a friendly, secure neighborhood, fostering a sense of comfort and belonging among residents. Emphasizing intentional, inspirational, and empathetic care, the team at Willamette Springs is devoted to supporting the social, spiritual, mental, and physical well-being of everyone in their care. The person-centered approach taken here is deeply rooted in recognizing and nurturing each individual’s abilities, strengths, and unique interests.
Life at Willamette Springs is enriched by a multifaceted program of life engagement activities tailored around each resident’s preferences and abilities. Daily participation in planned activities is encouraged, promoting the maintenance of cognitive, sensory, creative, and motor skills. This proactive approach supports residents’ independence while providing a safe environment where they can flourish. The enrichment of daily living is further supported by exceptional amenities and services, making it easier for residents to maintain a fulfilling and enhanced lifestyle.
The community is guided by a set of core values known as F.A.I.T.H.E., which shapes every aspect of care and interaction within the residence. These values are centered on joy, positivity, character, collaboration, honesty, and wholehearted living, fostering a culture of transparency, trust, and genuine connection. This focus on values ensures that every resident receives compassionate and respectful care from a team that embraces synergy and continuous improvement.
Residents at Willamette Springs have a choice of comfortable living options, including private suites measuring 343 square feet and companion suites at 464 square feet. Each accommodation is thoughtfully designed to provide both privacy and a homelike environment, with features such as well-lit, cozy bedrooms, accessible bathrooms equipped with safety grab bars, and open living areas. Common spaces include inviting lounges, a brightly lit lobby with contemporary design elements, a modern courtyard with landscaped gardens, and covered patios for outdoor relaxation and gatherings.
Residents and their families benefit from a flexible month-to-month residency model without the obligation of long-term contracts or buy-in fees. This arrangement offers peace of mind and adaptability should care needs change over time. The monthly fee covers a wide array of services and amenities, from dining, housekeeping, and utilities to Wi-Fi, cable, local transportation, community maintenance, and on-site entertainment. Thoughtful touches like landscaped courtyards, cozy sitting areas, and abundant natural light throughout the living spaces combine to create an uplifting, secure environment.
Located in scenic Corvallis, residents enjoy proximity to the natural beauty of the Oregon Coast, hiking trails, river activities, and a vibrant downtown with regular events, markets, parks, and coffee shops. The setting complements the nurturing and engaging environment cultivated within Willamette Springs Memory Care Community, where every detail is oriented around the comfort, safety, and holistic well-being of residents. Here, the philosophy is not just about providing care, but about enabling each person to experience an extraordinary quality of life, with dignity and purpose, every day.
People often ask...
Willamette Springs Memory Care Community offers competitive pricing, with rates starting at a cost of $5,838 per month.
Willamette Springs Memory Care Community offers assisted living and memory care.
There are 18 photos of Willamette Springs Memory Care Community on Mirador.
The full address for this community is 6000 SW Mosaic Dr, Corvallis, OR 97333.
No, Willamette Springs Memory Care Community 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.
Investigated the allegation and found care plan adherence violations; staff did not consistently check or change wet briefs, and required daily care was not completed.
Licensing—Failed to follow care plan
25 Jan 2026Inspection
25 Jan 2026Inspection
Found that services were not implemented as required, leaving footrests off a resident's wheelchair during escort and resulting in a fall from the chair.
Licensing—Failed to follow care plan
25 Jan 2026Inspection
25 Jan 2026Inspection
Found failure to document the use of a reclining wheelchair as a device with restraining qualities for one resident.
Licensing—Failed to use restraint properly
23 Jan 2026Inspection
23 Jan 2026Inspection
Identified a lapse in monitoring changes of condition because staff did not read and sign updated service plans. This resulted in inadequate oversight of residents' condition changes.
Licensing—Failed to provide oversight and monitoring of change of condition
16 Jan 2026License Condition
16 Jan 2026License Condition
Found that a safe environment was not provided, placing residents at risk of immediate jeopardy.
Regulatory Action—Failed to provide safe environment
11 Jan 2026Inspection
11 Jan 2026Inspection
Found that staff did not follow the care plan by not providing stand-by bathing assistance, resulting in a resident being found unresponsive in the shower.
Licensing—Failed to follow care plan
17 Nov 2025Inspection
17 Nov 2025Inspection
Investigated a failure to cooperate with an investigation and found a violation of Oregon Administrative Rules.
Licensing—Failed to cooperate with an investigation
17 Nov 2025Inspection
17 Nov 2025Inspection
Found a deficiency for failing to provide requested documentation.
Licensing—Failed to cooperate with an investigation
13 Nov 2025Inspection
13 Nov 2025Inspection
Investigated the allegation of failing to cooperate with an investigation and found that documentation was not provided upon request.
Licensing—Failed to cooperate with an investigation
13 Nov 2025Inspection
13 Nov 2025Inspection
Investigated a complaint and found a documentation deficiency.
Licensing—Failed to cooperate with an investigation
13 Nov 2025Inspection
13 Nov 2025Inspection
Investigated the allegation and identified a deficiency for failing to provide documentation upon request.
Licensing—Failed to cooperate with an investigation
12 Nov 2025Inspection
12 Nov 2025Inspection
Concluded that documentation was not provided as requested, resulting in a Level 2 licensing violation.
Licensing—Failed to cooperate with an investigation
12 Nov 2025Inspection
12 Nov 2025Inspection
Investigated an allegation of failing to cooperate and determined a violation for not providing requested documentation.
Licensing—Failed to cooperate with an investigation
12 Nov 2025Inspection
12 Nov 2025Inspection
Concluded a deficiency due to failure to provide requested documentation.
Licensing—Failed to cooperate with an investigation
12 Nov 2025Inspection
12 Nov 2025Inspection
Investigated the allegation of noncooperation and found a deficiency for failing to provide documentation upon request.
Licensing—Failed to cooperate with an investigation
12 Nov 2025Inspection
12 Nov 2025Inspection
Investigated the allegation of failing to cooperate; determined that documentation was not provided upon request and cited an Oregon Administrative Rule.
Licensing—Failed to cooperate with an investigation
12 Nov 2025Inspection
12 Nov 2025Inspection
Investigated the allegation and found a violation for failing to provide documentation when requested.
Licensing—Failed to cooperate with an investigation
12 Nov 2025Inspection
12 Nov 2025Inspection
Found a deficiency for failing to provide documentation upon request.
Licensing—Failed to cooperate with an investigation
12 Nov 2025Inspection
12 Nov 2025Inspection
Investigated an allegation and found that documentation was not provided upon request.
Licensing—Failed to cooperate with an investigation
12 Nov 2025Inspection
12 Nov 2025Inspection
Determined that a deficiency existed for failing to provide documentation upon request.
Licensing—Failed to cooperate with an investigation
12 Nov 2025Inspection
12 Nov 2025Inspection
Investigated the allegation of failing to cooperate and determined a violation for not providing requested documentation.
Licensing—Failed to cooperate with an investigation
12 Nov 2025Inspection
12 Nov 2025Inspection
Found that the licensee failed to provide documentation upon request, violating Oregon Administrative Rules.
Licensing—Failed to cooperate with an investigation
12 Nov 2025Inspection
12 Nov 2025Inspection
Investigated an allegation of failure to cooperate and found failure to provide documentation on request.
Licensing—Failed to cooperate with an investigation
12 Nov 2025Inspection
12 Nov 2025Inspection
Investigated allegation and determined that documentation was not provided upon request.
Licensing—Failed to cooperate with an investigation
02 Nov 2025Inspection
02 Nov 2025Inspection
Investigated the allegation and found a housekeeping-related deficiency: interior not free from unpleasant odors.
Licensing—Failed to provide appropriate housekeeping services
30 Oct 2025Abuse: Neglect
30 Oct 2025Abuse: Neglect
Found abuse by neglect due to failing to administer prescribed eye-drop medication to a resident for 15 days after hospital discharge; medication began on 10/30/2025.
Abuse—Failed to administer medication as ordered
30 Oct 2025Abuse: Neglect
30 Oct 2025Abuse: Neglect
Investigated abuse by neglect due to failure to provide skin checks and basic care after hospital discharge. The deficiencies contributed to deterioration in the resident's leg condition.
Abuse—Failed to follow care plan
11 Oct 2025Abuse: Neglect
11 Oct 2025Abuse: Neglect
Found abuse by neglect occurred due to staff failing to keep doors locked and perform required safety checks; a $500 fine was assessed.
Abuse—Failed to follow care plan
10 Oct 2025Abuse: Neglect
10 Oct 2025Abuse: Neglect
Determined that abuse by neglect occurred when staff failed to follow the 1:1 safety plan for an aggressive resident, placing a resident at risk. A $500 fine was assessed.
Abuse—Failed to follow care plan
09 Oct 2025Abuse: Neglect
09 Oct 2025Abuse: Neglect
Found that inadequate supervision and an unsafe environment during activities led to a resident injuring their finger with scissors. The incident indicated neglect of safety.
Abuse—Failed to provide safe environment
05 Oct 2025Abuse: Neglect
05 Oct 2025Abuse: Neglect
Investigated a neglect allegation and found failure to develop sufficient interventions to mitigate risk for a resident with mobility needs, leading to a fall.
Abuse—Failed to properly plan care
23 Sept 2025Abuse: Neglect
23 Sept 2025Abuse: Neglect
Found a failure to provide a safe environment that resulted in substantiated abuse by neglect. An ensuing incident required law enforcement involvement and resulted in a fine.
Abuse—Failed to provide safe environment
22 Sept 2025Inspection
22 Sept 2025Inspection
Found that behavioral symptoms were not evaluated or included in the service plan.
Licensing—Failed to address resident's behavior
18 Sept 2025Inspection
18 Sept 2025Inspection
Identified a failure to maintain a safe medication administration system and evidence of neglect and abuse when a staff member left two patches on a resident by not removing the old one; a $500 fine was assessed.
Licensing—Failed to provide a safe medication administration system
18 Sept 2025Abuse: Neglect
18 Sept 2025Abuse: Neglect
Found neglect and abuse due to failure to ensure timely medication availability, causing missed doses; a $500 fine was assessed.
Abuse—Failed to have medication available
14 Sept 2025Abuse: Neglect
14 Sept 2025Abuse: Neglect
Investigated and found abuse by neglect due to a failure to maintain a safe medication administration system, resulting in six missed doses of behavioral health medication.
Abuse—Failed to provide a safe medication administration system
11 Sept 2025Inspection
11 Sept 2025Inspection
Found insufficient qualified awake direct care staff to meet 24-hour needs. An investigation determined a licensing violation occurred.
Licensing—Failed to staff as indicated by ABST
11 Sept 2025Abuse: Neglect
11 Sept 2025Abuse: Neglect
Found neglect due to failure to follow the care plan, which led to missed skin checks, inadequate hygiene and repositioning, and improper cushion use. This contributed to new wounds and progression to a pressure ulcer.
Abuse—Failed to follow care plan
11 Sept 2025Abuse: Neglect
11 Sept 2025Abuse: Neglect
Identified abuse by neglect due to failure to follow the service plan, resulting in pressure injuries to a resident. A fine was assessed.
Abuse—Failed to follow care plan
11 Sept 2025Inspection
11 Sept 2025Inspection
Investigated the allegation and concluded a licensing violation occurred due to failure to implement services.
Licensing—Failed to follow care plan
26 Aug 2025Abuse: Neglect
26 Aug 2025Abuse: Neglect
Investigated an allegation of abuse by neglect and found that failures to plan care contributed to a resident-to-resident incident.
Abuse—Failed to properly plan care
22 Aug 2025Inspection
22 Aug 2025Inspection
Investigated and determined a violation of Oregon Administrative Rules for failing to provide requested documentation.
Licensing—Failed to cooperate with an investigation
21 Aug 2025Inspection
21 Aug 2025Inspection
Investigated an allegation that a staff member improperly restrained a resident; found that the staff member grabbed the resident's wrists and held them down against the chest, constituting abuse and neglect.
Licensing—Failed to use restraint properly
21 Aug 2025Inspection
21 Aug 2025Inspection
Found violations involving abuse and neglect during care, including forcefully moving a resident's legs and causing pain.
Licensing—Failed to protect resident from physical abuse
21 Aug 2025Inspection
21 Aug 2025Inspection
Investigated an allegation of verbal abuse toward a resident; found that a staff member mimicked and used derogatory language toward the resident and the facility failed to protect the resident, constituting abuse and neglect.
Licensing—Failed to protect resident from verbal abuse
20 Aug 2025Inspection
20 Aug 2025Inspection
Investigated and found a documentation deficiency due to failure to provide requested records.
Licensing—Failed to cooperate with an investigation
20 Aug 2025Inspection
20 Aug 2025Inspection
Investigated the allegation of noncooperation and found failure to provide requested documentation, violating Oregon Administrative Rules.
Licensing—Failed to cooperate with an investigation
18 Aug 2025Inspection
18 Aug 2025Inspection
Investigated and identified a violation for failing to provide documentation upon request.
Licensing—Failed to cooperate with an investigation
18 Aug 2025License Condition
18 Aug 2025License Condition
Found a failure to provide a safe environment that placed residents at risk of immediate jeopardy.
Regulatory Action—Failed to provide safe environment
14 Aug 2025Inspection
14 Aug 2025Inspection
Investigated the allegation of failing to cooperate and found a failure to provide documentation upon request.
Licensing—Failed to cooperate with an investigation
14 Aug 2025Inspection
14 Aug 2025Inspection
Investigated an allegation and found a violation for failing to provide documentation upon request.
Licensing—Failed to cooperate with an investigation
13 Aug 2025Abuse: Neglect
13 Aug 2025Abuse: Neglect
Found that known sexual behaviors were not adequately addressed, leading to abuse and neglect of a resident.
Abuse—Failed to address resident's behavior
13 Aug 2025Inspection
13 Aug 2025Inspection
Investigated a failure to monitor changes in condition due to incomplete service plans and staff not reading/signing the monitoring binder. Documentation showed missing staff read/signs and staff lacking time to review the TSP binder.
Licensing—Failed to provide oversight and monitoring of change of condition
13 Aug 2025Inspection
13 Aug 2025Inspection
Found staffing deficiencies based on ABST inaccuracies and inconsistencies between the roster, care plans, and ABST data, resulting in inadequate staffing to meet resident needs.
Licensing—Failed to staff as indicated by ABST
12 Aug 2025Abuse: Neglect
12 Aug 2025Abuse: Neglect
Found abuse by neglect due to failure to follow the service plan and ensure medications were available, leading to a resident missing blood pressure medication.
Abuse—Failed to follow care plan
11 Aug 2025Inspection
11 Aug 2025Inspection
Found a violation for failing to provide documentation upon request.
Licensing—Failed to cooperate with an investigation
09 Aug 2025Abuse: Neglect
09 Aug 2025Abuse: Neglect
Determined that inadequate supervision led to a resident-on-resident altercation, constituting neglect and abuse, with a $500 fine assessed.
Abuse—Failed to provide safe environment
08 Aug 2025Inspection
08 Aug 2025Inspection
Found a deficiency for failing to provide documentation upon request. The violation was classified as a level 2 minor-harm potential violation.
Licensing—Failed to cooperate with an investigation
08 Aug 2025Abuse: Neglect
08 Aug 2025Abuse: Neglect
Found abuse by neglect due to failure to plan care, with a $500 fine assessed.
Abuse—Failed to properly plan care
07 Aug 2025Inspection
07 Aug 2025Inspection
Found that documentation was not provided upon request, violating Oregon Administrative Rules.
Licensing—Failed to cooperate with an investigation
06 Aug 2025Abuse: Neglect
06 Aug 2025Abuse: Neglect
Found abuse by neglect due to failure to develop and implement suitable person-centered interventions; assessed a $375 fine.
Abuse—Failed to properly plan care
30 Jul 2025Inspection
30 Jul 2025Inspection
Investigated and found a records documentation violation for failing to provide requested documents.
Licensing—Failed to cooperate with an investigation
30 Jul 2025Inspection
30 Jul 2025Inspection
Investigated the allegation and found that the required documentation was not provided when requested.
Licensing—Failed to cooperate with an investigation
29 Jul 2025Inspection
29 Jul 2025Inspection
Investigated and determined that records were not provided upon request.
Licensing—Failed to cooperate with an investigation
29 Jul 2025Inspection
29 Jul 2025Inspection
Investigated and found a violation of Oregon Administrative Rules due to failure to provide documentation upon request.
Licensing—Failed to cooperate with an investigation
28 Jul 2025Inspection
28 Jul 2025Inspection
Investigated and found a failure to provide a safe medication administration system, resulting in an extra dose given without checking the MAR and hospital transport.
Licensing—Failed to provide a safe medication administration system
28 Jul 2025License Condition
28 Jul 2025License Condition
Determined that violations created risk to residents and issued a license condition.
Regulatory Action—Failed to provide safe environment
21 Jul 2025Abuse: Neglect
21 Jul 2025Abuse: Neglect
Found violations involving neglect and abuse that compromised resident safety, and assessed a fine.
Abuse—Failed to provide safe environment
16 Jul 2025Abuse: Neglect
16 Jul 2025Abuse: Neglect
Investigated the allegation of neglect and abuse and found failure to follow the care plan for one-on-one intervention and to provide clear written instructions on who would provide services and how often.
Abuse—Failed to follow care plan
14 Jul 2025Inspection
14 Jul 2025Inspection
Found insufficient staff to meet the scheduled and unscheduled needs of residents, resulting in unmet needs or extended wait times. This staffing deficiency was a violation of Oregon administrative rules.
Licensing—Failed to meet the scheduled and unscheduled needs of residents
14 Jul 2025Abuse: Neglect
14 Jul 2025Abuse: Neglect
Investigated an allegation of neglect and identified safety deficiencies, including an uncleared puddle and failure to ensure use of a required assistive device, which contributed to a resident fall with head injury.
Abuse—Failed to provide safe environment
12 Jul 2025Inspection
12 Jul 2025Inspection
Investigated staffing adequacy and determined insufficient staffing to meet residents' scheduled and unscheduled needs.
Licensing—Failed to meet the scheduled and unscheduled needs of residents
08 Jul 2025Inspection
08 Jul 2025Inspection
Found insufficient staffing to meet residents' scheduled and unscheduled needs, leading to delays in meeting those needs.
Licensing—Failed to meet the scheduled and unscheduled needs of residents
08 Jul 2025Abuse: Neglect
08 Jul 2025Abuse: Neglect
Found that a staff member did not follow the care plan's safety measures, leading to a preventable resident-to-resident altercation and injuries; a monetary penalty was assessed.
Abuse—Failed to follow care plan
07 Jul 2025Inspection
07 Jul 2025Inspection
Investigated and determined that records were not provided to the Department upon request. All requested documentation was not provided by the due date.
Licensing—Failed to cooperate with an investigation
27 Jun 2025Abuse: Neglect
27 Jun 2025Abuse: Neglect
Investigated an abuse by neglect allegation and found that a known allergen was served despite a documented plan, causing discomfort and risk of harm.
Abuse—Failed to follow care plan
27 Jun 2025Kitchen
27 Jun 2025Kitchen
Identified extensive deficiencies in kitchen sanitation, food safety, and meal service. Noted included were dirty preparation areas, improper temperatures, and failure to follow menus and dietary requirements.
Investigated found that staff failed to properly plan care and monitor weight loss, with no PCP notification or progress notes, leading to neglect and abuse; a fine was assessed.
Abuse—Failed to properly plan care
25 May 2025Abuse: Neglect
25 May 2025Abuse: Neglect
Determined abuse by neglect occurred due to failure to plan care and implement risk-reducing interventions, resulting in repeated falls and injuries.
Abuse—Failed to properly plan care
25 May 2025Abuse: Neglect
25 May 2025Abuse: Neglect
Investigated and found abuse by neglect due to failure to plan care, with a $500 fine assessed.
Abuse—Failed to properly plan care
09 May 2025License Condition
09 May 2025License Condition
Concluded that the acts or omissions created a risk of immediate jeopardy by failing to provide a safe environment for current and future residents.
Regulatory Action—Failed to provide safe environment
08 May 2025Inspection
08 May 2025Inspection
Found insufficient staff to meet residents' scheduled and unscheduled needs. This staffing shortfall violated Oregon Administrative Rules.
Licensing—Failed to meet the scheduled and unscheduled needs of residents
02 May 2025Abuse: Neglect
02 May 2025Abuse: Neglect
Investigated the complaint and found abuse and neglect occurred, with inadequate planning of care that led to harm of a resident.
Abuse—Failed to properly plan care
02 May 2025Inspection
02 May 2025Inspection
Investigated and found insufficient staff to meet residents' scheduled and unscheduled needs.
Licensing—Failed to meet the scheduled and unscheduled needs of residents
19 Apr 2025Abuse: Neglect
19 Apr 2025Abuse: Neglect
Found a failure to provide a safe medication system and four missed doses due to not having medication on site, constituting abuse by neglect.
Abuse—Failed to provide a safe medication administration system
10 Apr 2025Abuse: Neglect
10 Apr 2025Abuse: Neglect
Found deficiencies in fall risk care planning and interventions after a resident fell and sustained a head injury.
Abuse—Failed to properly plan care
10 Apr 2025Inspection
10 Apr 2025Inspection
Found insufficient staffing to meet residents' scheduled and unscheduled needs.
Licensing—Failed to meet the scheduled and unscheduled needs of residents
06 Apr 2025Abuse: Neglect
06 Apr 2025Abuse: Neglect
Investigated found that care plans were not followed and interventions were not effective, leading to a resident-to-resident altercation and abuse/neglect; a $500 fine was assessed.
Abuse—Failed to properly plan care
06 Apr 2025Inspection
06 Apr 2025Inspection
Found insufficient staff to meet residents' scheduled and unscheduled needs, leading to unmet or delayed care.
Licensing—Failed to meet the scheduled and unscheduled needs of residents
30 Mar 2025Abuse: Neglect
30 Mar 2025Abuse: Neglect
Investigated an allegation of neglect and abuse that resulted in a resident-to-resident altercation and injury; a fine was assessed.
Abuse—Failed to properly plan care
28 Mar 2025Abuse: Neglect
28 Mar 2025Abuse: Neglect
Found abuse by neglect due to failure to develop person-centered interventions, leading to a resident-to-resident altercation and injury; a $500 fine was assessed.
Abuse—Failed to properly plan care
21 Mar 2025Abuse: Neglect
21 Mar 2025Abuse: Neglect
Concluded neglect occurred due to failing to administer prescribed narcotic pain medication, leading to pain and an ER visit; a $500 fine was assessed.
Abuse—Failed to administer medication as ordered
06 Mar 2025Abuse: Neglect
06 Mar 2025Abuse: Neglect
Investigated and found neglect and abuse related to failure to plan care, resulting in increased pain and hospitalization.
Abuse—Failed to properly plan care
04 Mar 2025Inspection
04 Mar 2025Inspection
Investigated the allegation and found a failure to provide a manually operated emergency call system in bathrooms used by residents and visitors.
Licensing—Failed to provide or maintain resident care equipment
21 Feb 2025Abuse: Neglect
21 Feb 2025Abuse: Neglect
Investigated a resident-to-resident incident and found inadequate person-centered care planning that led to an altercation and an injury.
Abuse—Failed to properly plan care
05 Feb 2025Inspection
05 Feb 2025Inspection
Determined that records were not provided upon request.
Licensing—Failed to cooperate with an investigation
05 Feb 2025Inspection
05 Feb 2025Inspection
Determined that records were not provided to the Department upon request. The finding related to failing to cooperate with the investigation.
Licensing—Failed to cooperate with an investigation
05 Feb 2025Inspection
05 Feb 2025Inspection
Investigated a records request issue; found failure to provide required documents upon request.
Licensing—Failed to cooperate with an investigation
09 Jan 2025Inspection
09 Jan 2025Inspection
Investigated a records request and found that required documents were not provided to the Department by the due date.
Licensing—Failed to cooperate with an investigation
09 Jan 2025Abuse: Neglect
09 Jan 2025Abuse: Neglect
Investigated found that staff failed to follow interventions, leading to an altercation between residents and constituting abuse and neglect. A fine was assessed.
Abuse—Failed to follow care plan
19 Dec 2024Abuse: Neglect
19 Dec 2024Abuse: Neglect
Found neglect and abuse for failing to secure a resident's funds, resulting in theft. A reimbursement was provided and a fine was assessed.
Abuse—Failed to protect resident from financial exploitation
27 Nov 2024Abuse: Neglect
27 Nov 2024Abuse: Neglect
Investigated and found violations related to failing to follow care plans and supervise residents, resulting in neglect and abuse.
Abuse—Failed to follow care plan
10 Nov 2024Abuse: Neglect
10 Nov 2024Abuse: Neglect
Investigated a complaint alleging resident safety and rights concerns. Found failures to follow care plans and proper resident redirection that amounted to abuse and neglect, with a $500 fine assessed.
Abuse—Failed to provide safe environment
09 Oct 2024Inspection
09 Oct 2024Inspection
Investigated an allegation that staff failed to assist with toileting, leaving a resident in urine during a night shift; findings indicated neglect of care and abuse.
Licensing—Failed to assist with toileting
09 Oct 2024Inspection
09 Oct 2024Inspection
Investigated alleged care plan noncompliance and found that required checks and changing briefs for a resident were not consistently followed, resulting in neglect.
Licensing—Failed to follow care plan
09 Oct 2024Inspection
09 Oct 2024Inspection
Concluded that a staff member failed to assist with toileting, resulting in a resident being left in urine and discomfort. Found these actions violated resident rights and constituted neglect and abuse.
Licensing—Failed to assist with toileting
22 Sept 2024Abuse: Neglect
22 Sept 2024Abuse: Neglect
Investigated and found violations of resident rights due to neglect and abuse. A $500 fine was assessed.
Abuse—Failed to provide service
13 Sept 2024Inspection
13 Sept 2024Inspection
Found a substantiated licensing violation for failing to provide a safe environment and noted a long history of substantial non-compliance; no fine assessed.
Licensing—Failed to provide safe environment
10 Sept 2024Abuse: Neglect
10 Sept 2024Abuse: Neglect
Investigated and found abuse by neglect due to failure to develop and implement suitable interventions for a resident with transfer risks. A $500 fine was assessed.
Abuse—Failed to properly plan care
10 Sept 2024Abuse: Neglect
10 Sept 2024Abuse: Neglect
Investigated and found unsafe conditions and inadequate care planning that led to multiple falls and injuries.
Abuse—Failed to properly plan care
10 Sept 2024Abuse: Neglect
10 Sept 2024Abuse: Neglect
Investigated and found abuse by neglect due to failure to develop interventions addressing a resident's history of unassisted transfers, which led to a skin tear from self-transfer.
Abuse—Failed to properly plan care
10 Sept 2024Abuse: Neglect
10 Sept 2024Abuse: Neglect
Concluded that abuse by neglect occurred due to failure to plan care for a resident requiring transfers, which led to a fall; a $500 fine was assessed.
Abuse—Failed to properly plan care
06 Sept 2024Inspection
06 Sept 2024Inspection
Found that an up-to-date ABST reflecting resident needs was not maintained. Inconsistencies existed between the resident roster, care plans, and ABST data.
Licensing—Failed to use an ABST
06 Sept 2024Inspection
06 Sept 2024Inspection
Investigated an allegation of failing to use an Acuity-Based Staffing Tool (ABST). Found the ABST was not updated and inconsistencies existed between the resident roster, care plans, and ABST data.
Licensing—Failed to use an ABST
06 Sept 2024Inspection
06 Sept 2024Inspection
Identified a violation for not maintaining an updated ABST that accurately reflects resident needs, with inconsistencies among roster, care plans, and ABST data.
Licensing—Failed to use an ABST
06 Sept 2024Inspection
06 Sept 2024Inspection
Found deficiencies in ABST accuracy and its alignment with the resident roster and care plans.
Licensing—Failed to use an ABST
22 Aug 2024Inspection
22 Aug 2024Inspection
Investigated and determined that records were not provided to the Department upon request.
Licensing—Failed to cooperate with an investigation
22 Aug 2024Abuse: Neglect
22 Aug 2024Abuse: Neglect
Investigated the allegation of neglect and found failures to prevent unwitnessed falls, resulting in a substantiated finding and a fine.
Abuse—Failed to properly plan care
06 Aug 2024Abuse: Neglect
06 Aug 2024Abuse: Neglect
Found that the care plan was not followed and a safety alarm was not active during a fall, resulting in injury and constituting neglect and abuse.
Abuse—Failed to properly plan care
28 Jul 2024Abuse: Neglect
28 Jul 2024Abuse: Neglect
Found noncompliance with a resident service plan that led to a resident-to-resident altercation with harm; a $375 fine was assessed.
Abuse—Failed to follow care plan
09 Jul 2024Licensure
09 Jul 2024Licensure
Identified multiple deficiencies in kitchen sanitation, food handling, labeling, and temperature control, with a follow-up visit showing substantial compliance with meal service and sanitation requirements.
Investigated and found that care planning and diet updates were not properly managed, leading to choking incidents and risk of serious harm.
Abuse—Failed to properly plan care
07 Jun 2024Abuse: Neglect
07 Jun 2024Abuse: Neglect
Found that staff failed to follow the care plan and provide adequate supervision during dining, resulting in a resident being pushed and injured.
Abuse—Failed to follow care plan
01 Jun 2024Abuse: Neglect
01 Jun 2024Abuse: Neglect
Found that the care plans for residents were not followed, leading to a resident-to-resident altercation.
Abuse—Failed to address resident's behavior
01 Jun 2024Abuse: Neglect
01 Jun 2024Abuse: Neglect
Investigated and identified failure to follow a resident's care plan, leading to a resident-to-resident altercation. A fine was assessed.
Abuse—Failed to address resident's behavior
23 May 2024Abuse: Neglect
23 May 2024Abuse: Neglect
Found a failure to provide a safe environment and adequate interventions, which led to a resident-to-resident altercation.
Abuse—Failed to provide safe environment
22 May 2024Abuse: Neglect
22 May 2024Abuse: Neglect
Investigated and found that wandering by a resident was not adequately managed and led to a resident-to-resident altercation; care planning and interventions to prevent wandering were insufficient, constituting neglect and abuse. A fine was assessed.
Abuse—Failed to properly plan care
19 May 2024Abuse: Neglect
19 May 2024Abuse: Neglect
Investigated a resident-to-resident safety issue and found a failure to provide a safe environment that led to an altercation and injury.
Abuse—Failed to provide safe environment
14 May 2024Inspection
14 May 2024Inspection
Identified deficiencies in ABST accuracy reflecting resident care needs. Found inconsistencies between the resident roster, care plans, and the data entered into the ABST.
Licensing—Failed to use an ABST
11 May 2024Abuse: Neglect
11 May 2024Abuse: Neglect
Concluded that inadequate supervision and lack of person-centered interventions led to a resident-to-resident altercation and injury.
Abuse—Failed to provide safe environment
08 May 2024Complaint
08 May 2024Complaint
Investigated a complaint about records administration and resident rights; no specific findings are described.
Deficiency—Facility Administration: Records
Deficiency—Resident Rights and Protection - General
05 May 2024Abuse: Neglect
05 May 2024Abuse: Neglect
Found that care planning and interventions were insufficient, leading to harm during resident-to-resident interaction; a fine was assessed.
Abuse—Failed to properly plan care
25 Apr 2024License Condition
25 Apr 2024License Condition
Identified violations for failing to provide a safe environment. Multiple regulatory rules were cited.
Regulatory Action—Failed to provide safe environment
24 Apr 2024Abuse: Neglect
24 Apr 2024Abuse: Neglect
Investigated a report of abuse/neglect found a failure to provide a safe environment and adequate supervision, which allowed an inappropriate kiss without consent and harmed dignity.
Abuse—Failed to provide safe environment
23 Apr 2024Abuse: Neglect
23 Apr 2024Abuse: Neglect
Found that ongoing inappropriate sexual behaviors were not properly addressed and supervision was inadequate, leading to a kiss without consent.
Abuse—Failed to address resident's behavior
17 Apr 2024Abuse: Neglect
17 Apr 2024Abuse: Neglect
Investigated found that staff failed to implement behavior interventions after a prior resident-to-resident altercation, leading to another incident.
Abuse—Failed to address resident's behavior
10 Apr 2024Abuse: Neglect
10 Apr 2024Abuse: Neglect
Investigated an abuse/neglect allegation and found failure to properly plan care and implement interventions to prevent falls, resulting in injuries and a $500 fine.
Abuse—Failed to properly plan care
09 Apr 2024Abuse: Neglect
09 Apr 2024Abuse: Neglect
Identified failure to properly plan care and prevent falls, resulting in a hip fracture after a fall.
Abuse—Failed to properly plan care
08 Apr 2024Inspection
08 Apr 2024Inspection
Found deficiencies in keeping resident records current and accurate.
Licensing—Failed to keep resident record current or accurate
07 Apr 2024Abuse: Neglect
07 Apr 2024Abuse: Neglect
Investigated found care planning failed to address skin breakdown and wounds, leading to moisture-related injuries and a hospital concern.
Abuse—Failed to properly plan care
01 Apr 2024Abuse: Neglect
01 Apr 2024Abuse: Neglect
Investigated and found a failure to provide a safe environment that led to a resident-to-resident altercation and injury; a fine was assessed.
Abuse—Failed to provide safe environment
01 Apr 2024Inspection
01 Apr 2024Inspection
Investigated a staff member sat in a resident's recliner and used a cell phone while the resident slept, violating the resident's right to be treated with dignity and respect.
Licensing—Failed to assure resident rights
01 Apr 2024Abuse: Neglect
01 Apr 2024Abuse: Neglect
Found a failure to provide a safe environment due to inadequate supervision, resulting in a resident-to-resident incident and discomfort; a $375 fine was assessed.
Abuse—Failed to provide safe environment
26 Mar 2024Abuse: Neglect
26 Mar 2024Abuse: Neglect
Investigated a resident-to-resident incident and found failing to address known triggers with person-centered interventions, yielding a minor-injury altercation and a fine assessed.
Abuse—Failed to provide safe environment
18 Mar 2024Validation
18 Mar 2024Validation
The facility showed multiple deficiencies across administration, resident rights, care planning, health services, staffing, medication management, nutrition, and activity programming during the re-licensure process, with subsequent actions indicating partial compliance on one area.
Deficiency—Comment
Deficiency—Facility Administration: Operation
Deficiency—Resident Rights and Protection - General
Deficiency—Resident Services: Activities
Deficiency—Service Plan: General
Deficiency—Change of Condition and Monitoring
Deficiency—Resident Health Services
Deficiency—Systems: Medication Administration
Deficiency—Systems: Treatment Orders
Deficiency—Staffing Requirements and Training: Staffing
Deficiency—Acuity-Based Staffing Tool
Deficiency—Inspections and Investigation: Insp Interval
Deficiency—Doors, Walls, Elevators, Odors
Deficiency—Administration Compliance
Deficiency—Staff Training Requirements
Deficiency—Compliance With Rules Health Care
Deficiency—Nutrition and Hydration
Deficiency—Activities
18 Mar 2024Abuse: Neglect
18 Mar 2024Abuse: Neglect
Investigated the allegation of neglect and abuse and found failure to properly plan care and implement reasonable interventions for falls, with a $500 fine assessed.
Abuse—Failed to properly plan care
12 Mar 2024Complaint
12 Mar 2024Complaint
Investigated and found a failure to immediately notify the local Department or local Area Agency on Aging about abuse or suspected abuse.
Deficiency—Resident Rights and Protection - General
Investigated licensure complaint and identified deficiencies related to general building interior and safety systems with potential for moderate harm.
Deficiency—General Building Interior
Deficiency—Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable
12 Mar 2024Abuse: Neglect
12 Mar 2024Abuse: Neglect
Investigated and found safety-related neglect and abuse due to failure to provide a safe environment and inadequate care planning, with a fine assessed.
Abuse—Failed to provide safe environment
06 Mar 2024Inspection
06 Mar 2024Inspection
Investigated and determined a failure to immediately notify the local Department or AAA office of abuse or suspected abuse.
Licensing—Failed to report potential or suspected abuse
06 Mar 2024Inspection
06 Mar 2024Inspection
Investigated a records-keeping concern and found that medical and other records were not kept confidential. Two medication carts were left unattended with unlocked computers and residents medication administration records open.
Licensing—Failed to assure resident rights
04 Mar 2024Abuse: Neglect
04 Mar 2024Abuse: Neglect
Found abuse and neglect from resident-to-resident altercations due to inadequate interventions after prior incident, resulting in a $375 fine.
Abuse—Failed to provide safe environment
01 Mar 2024Abuse: Neglect
01 Mar 2024Abuse: Neglect
Found failures to implement fall prevention and behavior interventions, leading to repeated floor incidents and ongoing risk. The report noted insufficient interim planning and staffing to address these risks.
Abuse—Failed to address resident's behavior
01 Feb 2024Abuse: Neglect
01 Feb 2024Abuse: Neglect
Investigated an allegation of neglect and abuse and found failure to update care plans and implement reasonable interventions to address falls. A $500 fine was assessed.
Abuse—Failed to properly plan care
30 Jan 2024Abuse: Neglect
30 Jan 2024Abuse: Neglect
Identified violations for failure to plan care and implement behavior interventions, which led to a resident-to-resident altercation and bruising; a $500 fine was assessed.
Abuse—Failed to properly plan care
25 Jan 2024Abuse: Neglect
25 Jan 2024Abuse: Neglect
Investigated and found that interventions for a resident with aggression were not followed, resulting in a resident being struck; a $500 fine assessed.
Abuse—Failed to follow care plan
20 Jan 2024Abuse: Neglect
20 Jan 2024Abuse: Neglect
Investigated the allegation that care was not properly planned for a resident at risk of falls and found that no updated interventions were added after prior falls, contributing to two falls and injuries.
Abuse—Failed to properly plan care
19 Jan 2024Abuse: Neglect
19 Jan 2024Abuse: Neglect
Found neglect and abuse due to delayed call-light responses, and a $500 fine was assessed.
Abuse—Failed to answer call light in a timely manner
16 Jan 2024Abuse: Neglect
16 Jan 2024Abuse: Neglect
Identified neglect and abuse due to failure to properly plan care and provide appropriate behavior interventions for a resident with aggressive behavior, resulting in multiple resident-to-resident altercations.
Abuse—Failed to properly plan care
03 Jan 2024Abuse: Neglect
03 Jan 2024Abuse: Neglect
Investigated and identified neglect and abuse related to unsafe care practices during incontinence care that caused knee injuries, with a fine assessed.
Abuse—Failed to protect resident from physical abuse
28 Dec 2023Abuse: Neglect
28 Dec 2023Abuse: Neglect
Investigated and identified a failure to properly plan and implement care to address documented aggressive behaviors, resulting in a resident-to-resident altercation.
Abuse—Failed to properly plan care
27 Dec 2023Inspection
27 Dec 2023Inspection
Investigated and determined that staff failed to immediately report a potential abuse incident after a resident-to-resident altercation, with the December 28, 2023 incident reported late.
Licensing—Failed to report potential or suspected abuse
27 Dec 2023Inspection
27 Dec 2023Inspection
Investigated a failure to report a resident-to-resident altercation and potential abuse; findings showed the incident was not reported promptly and staff did not notify authorities as required.
Licensing—Failed to report potential or suspected abuse
26 Dec 2023Inspection
26 Dec 2023Inspection
Found that a staff member verbally abused a resident and failed to protect the resident from verbal/emotional abuse.
Licensing—Failed to protect resident from verbal abuse
19 Dec 2023Abuse: Neglect
19 Dec 2023Abuse: Neglect
Investigated found that inadequate care planning and interventions for falls led to injuries and a fine was assessed.
Abuse—Failed to properly plan care
19 Dec 2023Complaint
19 Dec 2023Complaint
Found deficiencies in notifying Central Office about an epidemic disease, disposing unused or outdated medications, and controlling interior odors.
Deficiency—Facility Administration: Notification
Deficiency—Systems: Tracking Control Substances
Deficiency—Doors, Walls, Elevators, Odors
19 Dec 2023Complaint
19 Dec 2023Complaint
Investigated the complaint and found no deficiencies.
Deficiency—Licensing Complaint Investigation
Deficiency—Service Plan: General
15 Dec 2023Abuse: Neglect
15 Dec 2023Abuse: Neglect
Investigated a resident-to-resident incident and found failure to plan care leading to ongoing aggression and wandering into other residents' rooms, constituting neglect and abuse. A $500 fine was assessed.
Abuse—Failed to address resident's behavior
15 Dec 2023Abuse: Neglect
15 Dec 2023Abuse: Neglect
Investigated and found violations related to neglect and abuse due to inadequate care planning and interventions. The deficiencies allowed aggressive behavior and wandering, resulting in injuries.
Abuse—Failed to address resident's behavior
12 Dec 2023Abuse: Neglect
12 Dec 2023Abuse: Neglect
Identified neglect and abuse due to failure to properly plan care and prevent falls, leading to a serious injury.
Abuse—Failed to properly plan care
09 Dec 2023Abuse: Neglect
09 Dec 2023Abuse: Neglect
Found abuse and neglect due to failure to address resident-to-resident aggression and to implement reasonable interventions; a $500 fine was assessed.
Abuse—Failed to address resident's behavior
09 Dec 2023Abuse: Neglect
09 Dec 2023Abuse: Neglect
Investigated and found that care did not provide a safe and homelike environment, constituting abuse and neglect.
Abuse—Failed to provide safe environment
04 Dec 2023Inspection
04 Dec 2023Inspection
Found a housekeeping deficiency with persistent urine odor and inadequate odor control. An unsampled guest entered with a pinched nose, and staff acknowledged a strong urine smell throughout interior common areas.
Licensing—Failed to provide appropriate housekeeping services
27 Nov 2023Abuse: Neglect
27 Nov 2023Abuse: Neglect
Investigated a complaint and found that clear care planning was lacking and the call system did not work, causing resident discomfort.
Abuse—Failed to properly plan care
23 Nov 2023Abuse: Neglect
23 Nov 2023Abuse: Neglect
Investigated a complaint and found failures to plan for balance issues and to mitigate fall risk, leading to a fall and injury.
Abuse—Failed to properly plan care
23 Nov 2023Abuse: Neglect
23 Nov 2023Abuse: Neglect
Investigated found neglect due to failure to properly plan care and address frequent falls, resulting in injuries.
Abuse—Failed to properly plan care
22 Nov 2023Abuse: Neglect
22 Nov 2023Abuse: Neglect
Found that a resident's balance issues and fall risk were not properly addressed in care planning. This failure contributed to a fall with head and back pain, and a $500 fine was assessed.
Abuse—Failed to properly plan care
22 Nov 2023Abuse: Neglect
22 Nov 2023Abuse: Neglect
Identified neglect for failing to plan care and address balance issues, which contributed to multiple falls and hospital transfer, with a $500 fine assessed.
Abuse—Failed to properly plan care
16 Nov 2023Abuse: Neglect
16 Nov 2023Abuse: Neglect
Identified failures to plan care and address aggressive behavior, resulting in resident-to-resident altercations and a monetary penalty.
Abuse—Failed to properly plan care
16 Nov 2023Abuse: Neglect
16 Nov 2023Abuse: Neglect
Investigated and found that the care plan lacked information about aggressive behaviors and related staff instructions. The deficiency contributed to an incident.
Abuse—Failed to properly plan care
15 Nov 2023Inspection
15 Nov 2023Inspection
Found a failure to dispose of all unused, outdated, or discontinued medications, with narcotics and other meds stored in the medication cart for two deceased residents and not destroyed.
Licensing—Failed to provide a safe medication administration system
06 Nov 2023Abuse: Neglect
06 Nov 2023Abuse: Neglect
Investigated and found that call lights were not answered promptly, leading to neglect and abuse; a fine was assessed.
Abuse—Failed to answer call light in a timely manner
01 Nov 2023Abuse: Neglect
01 Nov 2023Abuse: Neglect
Investigated found that staff failed to update the resident's care plan and to monitor for shortness of breath as instructed by hospice, resulting in an extended period without staff contact before death. A fine was assessed.
Abuse—Failed to properly plan care
20 Oct 2023Inspection
20 Oct 2023Inspection
Investigated a care-planning and call-light issue that showed the service plan contradicted itself and the call system was unreliable, with delayed toileting assistance documented.
Licensing—Failed to properly plan care
15 Oct 2023Abuse: Neglect
15 Oct 2023Abuse: Neglect
Investigated a resident-to-resident incident and found failures in care planning that contributed to aggression, constituting abuse and neglect.
Abuse—Failed to properly plan care
07 Oct 2023Abuse: Neglect
07 Oct 2023Abuse: Neglect
Found neglect and abuse due to inadequate care planning and supervision, and assessed a $1,500 fine.
Abuse—Failed to provide safe environment
04 Oct 2023Abuse: Neglect
04 Oct 2023Abuse: Neglect
Found that call lights were not functioning properly and were not answered promptly, causing discomfort to a resident; a $500 fine was assessed.
Abuse—Failed to answer call light in a timely manner
25 Sept 2023Abuse: Neglect
25 Sept 2023Abuse: Neglect
Investigated a resident-to-resident altercation and found abuse and neglect due to failing to address ongoing aggressive behavior and follow preventive interventions.
Abuse—Failed to address resident's behavior
25 Sept 2023Abuse: Neglect
25 Sept 2023Abuse: Neglect
Found violations related to resident rights and safety due to failure to redirect residents and address ongoing aggression, resulting in multiple incidents. A $500 fine was assessed.
Abuse—Failed to address resident's behavior
18 Sept 2023Abuse: Neglect
18 Sept 2023Abuse: Neglect
Investigated and found violations related to delaying a resident's call light response, resulting in neglect and abuse; a $1,500 fine was assessed.
Abuse—Failed to answer call light in a timely manner
17 Sept 2023Abuse: Neglect
17 Sept 2023Abuse: Neglect
Investigated the allegation and found neglect and abuse due to not following the care plan and inadequate staffing, resulting in an injury.
Abuse—Failed to provide appropriate staffing
15 Sept 2023Abuse: Neglect
15 Sept 2023Abuse: Neglect
Concluded that a resident-on-resident incident occurred due to failure to address an aggressive resident, constituting abuse and neglect. A $1,125 fine was assessed.
Abuse—Failed to address resident's behavior
15 Sept 2023Abuse: Neglect
15 Sept 2023Abuse: Neglect
Investigated a complaint and found neglect in care that led to a resident fall and injury, with a $500 fine assessed.
Abuse—Failed to follow care plan
06 Sept 2023Other
06 Sept 2023Other
Determined substantial compliance with applicable rules for residential care and memory care.
Deficiency—Comment
04 Sept 2023Abuse: Neglect
04 Sept 2023Abuse: Neglect
Investigated a fall incident and found that fall-prevention interventions were not included in the care plan for a resident with prior falls, resulting in injury and a $500 fine.
Abuse—Failed to properly plan care
28 Aug 2023Abuse: Neglect
28 Aug 2023Abuse: Neglect
Found violations for failing to provide a safe environment, resulting in neglect and abuse; a $1,125 fine was assessed.
Abuse—Failed to provide safe environment
14 Aug 2023Abuse: Neglect
14 Aug 2023Abuse: Neglect
Found that staff failed to follow a resident's care plan, resulting in a fall and injury; a $500 fine was assessed.
Abuse—Failed to follow care plan
08 Aug 2023Abuse: Neglect
08 Aug 2023Abuse: Neglect
Found that staff failed to provide a safe environment and follow the resident's care plan, resulting in a fall risk and unsafe conditions during a meal.
Abuse—Failed to provide safe environment
08 Aug 2023Abuse: Neglect
08 Aug 2023Abuse: Neglect
Investigated an allegation and found neglect for failing to provide a safe environment for a resident with a history of falls.
Abuse—Failed to provide safe environment
08 Aug 2023Abuse: Neglect
08 Aug 2023Abuse: Neglect
Investigated a complaint and found a failure to provide a safe environment, constituting neglect and abuse; a $500 fine was assessed.
Abuse—Failed to provide safe environment
08 Aug 2023Abuse: Neglect
08 Aug 2023Abuse: Neglect
Investigated a complaint and found failures to address increasing falls, resulting in abuse and neglect.
Abuse—Failed to provide safe environment
08 Aug 2023Abuse: Neglect
08 Aug 2023Abuse: Neglect
Investigated found unsafe fall risks and inadequate care planning after a resident fell and sustained a skin tear, with abuse and neglect identified and a $500 fine assessed.
Abuse—Failed to provide safe environment
04 Aug 2023Abuse: Neglect
04 Aug 2023Abuse: Neglect
Investigated a neglect allegation and found inadequate supervision that led to a resident injury after a fall; a $500 fine was assessed.
Abuse—Failed to provide service
04 Aug 2023Inspection
04 Aug 2023Inspection
Found that a service plan did not reflect the resident's needs identified in the evaluation.
Licensing—Failed to address resident's behavior
01 Aug 2023Abuse: Neglect
01 Aug 2023Abuse: Neglect
Investigated a complaint and found that a call light was not answered promptly, causing exhaustion and discomfort for a resident.
Abuse—Failed to answer call light in a timely manner
11 Jun 2023Abuse: Neglect
11 Jun 2023Abuse: Neglect
Investigated an allegation of abuse and neglect related to vision and mobility planning; found failures to plan care and provide appropriate interventions, resulting in injuries.
Abuse—Failed to properly plan care
31 May 2023Licensure
31 May 2023Licensure
Identified multiple deficiencies in kitchen sanitation and food handling during the initial visit, with partial improvement on follow-up.
Identified a violation for failing to notify the Department immediately about an epidemic disease outbreak.
Licensing—Failed to assure resident rights
06 Apr 2023Abuse: Neglect
06 Apr 2023Abuse: Neglect
Found neglect and abuse due to failure to properly plan care and address ongoing falls, resulting in a $1,500 fine.
Abuse—Failed to properly plan care
04 Apr 2023Abuse: Neglect
04 Apr 2023Abuse: Neglect
Identified failures to provide appropriate services and follow physician orders, resulting in significant weight loss.
Abuse—Failed to provide service
22 Mar 2023Inspection
22 Mar 2023Inspection
Investigated an allegation of failing to submit weekly vaccination status reports for residents, staff, and vaccinated individuals; found ongoing noncompliance for 30 days.
Licensing—Failed to submit timely or adequate staffing documentation
16 Feb 2023Abuse: Neglect
16 Feb 2023Abuse: Neglect
Investigated a safety concern and found a lack of alerting procedures for new residents and no clear way to distinguish residents from visitors. This contributed to a resident leaving the building.
Abuse—Failed to provide safe environment
30 Jan 2023License Condition
30 Jan 2023License Condition
Found that the Acuity Based Staffing Tool (ABST) was not used as required, violating the applicable rule.
Regulatory Action—Failed to use an ABST
24 Jan 2023Abuse: Neglect
24 Jan 2023Abuse: Neglect
Found a failure to provide a safe environment for a resident, resulting in a substantiated violation and a $375 fine.
Abuse—Failed to provide safe environment
23 Nov 2022Inspection
23 Nov 2022Inspection
Investigated a complaint and found safety deficiencies related to monitoring a fall-risk resident and performing safety checks; these actions were identified as neglect, abuse, and an unsafe environment.
Licensing—Failed to provide safe environment
10 Nov 2022Complaint
10 Nov 2022Complaint
Found deficiencies in the Acuity-Based Staffing Tool, with caregiving time for ADLs not entered for residents.
Deficiency—Licensing Complaint Investigation
Deficiency—Acuity-Based Staffing Tool
07 Nov 2022Abuse: Neglect
07 Nov 2022Abuse: Neglect
Identified a failure to properly plan care that allowed aggressive behavior by a resident, resulting in injury to the alleged victim; a fine was assessed.
Abuse—Failed to properly plan care
01 Nov 2022Inspection
01 Nov 2022Inspection
Identified a failure to submit timely or adequate staffing documentation and ongoing noncompliance with weekly vaccination reporting for about 30 days.
Licensing—Failed to submit timely or adequate staffing documentation
01 Nov 2022Abuse: Neglect
01 Nov 2022Abuse: Neglect
Investigated a complaint and found that a resident was not provided a safe environment or appropriate care planning, resulting in abuse/neglect and a fine.
Abuse—Failed to provide safe environment
24 Oct 2022Abuse: Neglect
24 Oct 2022Abuse: Neglect
Investigated and found that a safe environment was not provided and safety planning was inadequate, and a $500 fine was assessed.
Abuse—Failed to provide safe environment
01 Sept 2022Inspection
01 Sept 2022Inspection
Investigated the allegation of failing to submit timely or adequate staffing documentation and found ongoing failure to report weekly vaccination-related data to the proper authority during August 2022. This noncompliance occurred for 30 days.
Licensing—Failed to submit timely or adequate staffing documentation
22 Aug 2022Abuse: Neglect
22 Aug 2022Abuse: Neglect
Investigated a complaint of neglect and abuse; found staff failed to plan care to prevent wandering, leading to an altercation and injuries, with a $375 fine assessed.
Abuse—Failed to properly plan care
11 Aug 2022Abuse: Neglect
11 Aug 2022Abuse: Neglect
Found that a safe environment was not provided, leading to neglect and abuse.
Abuse—Failed to provide safe environment
07 Aug 2022Abuse: Neglect
07 Aug 2022Abuse: Neglect
Determined neglect due to failure to properly plan care, which contributed to multiple falls and injuries. A $1,500 fine was assessed.
Abuse—Failed to properly plan care
01 Jul 2022Inspection
01 Jul 2022Inspection
Found a deficiency for failing to submit timely weekly vaccination reporting for residents, staff, and vaccinated individuals for 30 days.
Licensing—Failed to submit timely or adequate staffing documentation
23 Jun 2022Abuse: Neglect
23 Jun 2022Abuse: Neglect
Found neglect and abuse due to failure to follow care plan and provide interventions, placing residents at risk and resulting in a $375 fine assessed.
Abuse—Failed to follow care plan
17 Jun 2022Abuse: Neglect
17 Jun 2022Abuse: Neglect
Found a failure to provide a safe medication administration system, placing a resident at risk of serious harm, and a $500 fine was assessed.
Abuse—Failed to provide a safe medication administration system
09 Jun 2022Abuse: Neglect
09 Jun 2022Abuse: Neglect
Investigated and found violations related to care planning and safety when a resident with a history of wandering was not properly mitigated, risking serious harm; a $500 fine was assessed.
Abuse—Failed to properly plan care
06 Jun 2022Abuse: Neglect
06 Jun 2022Abuse: Neglect
Concluded that deficiencies related to care planning and response to aggression occurred, constituting abuse. This involved inadequate planning and failure to intervene, leading to a physical incident between residents.
Abuse—Failed to properly plan care
02 May 2022Abuse: Neglect
02 May 2022Abuse: Neglect
Found a failure to provide a safe medication administration system, risking harm to a resident.
Abuse—Failed to provide a safe medication administration system
13 Apr 2022Abuse: Neglect
13 Apr 2022Abuse: Neglect
Identified neglect and abuse due to failure to provide services according to a resident's needs, resulting in weight loss, injuries, and missed medications.
Abuse—Failed to provide service
11 Apr 2022Validation
11 Apr 2022Validation
Investigated operational practices and found deficiencies in abuse reporting, move-in and quarterly evaluations, service plans, monitoring of changes in condition, and resident health services; subsequent follow-up showed substantial compliance.
Deficiency—Resident Move-In and Eval: Res Evaluation
Deficiency—Service Plan: General
Deficiency—Change of Condition and Monitoring
Deficiency—Resident Health Services
Deficiency—Administration Compliance
Deficiency—Compliance With Rules Health Care
28 Mar 2022Enhanced Oversight and Supervision
28 Mar 2022Enhanced Oversight and Supervision
Placed into the EOS program due to substantiated abuse findings, multiple citations, licensing violations, and failure to correct concerns.
Regulatory Action—Failed to provide safe environment
11 Mar 2022Abuse: Neglect
11 Mar 2022Abuse: Neglect
Found that a service plan addressing ongoing falls was not in place, resulting in abuse/neglect findings after a resident sustained a skin tear.
Abuse—Failed to properly plan care
18 Jan 2022Abuse: Neglect
18 Jan 2022Abuse: Neglect
Investigated a report of abuse and neglect and found violations of resident rights due to failure to intervene in significant condition changes and to treat pressure ulcers, causing pain; a $500 fine was assessed.
Abuse—Failed to intervene when resident's condition changed
22 Nov 2021Abuse: Neglect
22 Nov 2021Abuse: Neglect
Found neglect and abuse due to failure to properly plan care for falls, resulting in an injury and a $1,500 fine.
Abuse—Failed to properly plan care
02 Sept 2021Abuse: Neglect
02 Sept 2021Abuse: Neglect
Investigated and found failure to provide adequate staffing and isolating a resident during vocalizations caused distress and loss of dignity; a $1,000 fine was assessed.
Abuse—Failed to protect resident from involuntary seclusion
02 Sept 2021Abuse: Neglect
02 Sept 2021Abuse: Neglect
Found that a resident did not receive needed eating assistance due to insufficient staffing, leading to weight loss and loss of dignity.
Abuse—Failed to assist with eating
22 Aug 2021Abuse: Neglect
22 Aug 2021Abuse: Neglect
Found that care planning and interventions failed to address increasing resident behaviors, resulting in neglect and abuse during a resident-to-resident incident.
Abuse—Failed to properly plan care
24 Jul 2021Abuse: Neglect
24 Jul 2021Abuse: Neglect
Found neglect and abuse due to failure to properly plan care to address falls, leading to a resident’s hip fracture.
Abuse—Failed to properly plan care
22 Jul 2021Abuse: Neglect
22 Jul 2021Abuse: Neglect
Found neglect and abuse due to failure to properly plan care, leading to multiple falls and injuries; a fine was assessed.
Abuse—Failed to properly plan care
15 Jul 2021Abuse: Neglect
15 Jul 2021Abuse: Neglect
Investigated allegations of failing to properly plan care for a resident with aggressive behaviors. Findings support neglect and abuse, and a fine was assessed.
Abuse—Failed to properly plan care
13 Jul 2021Abuse: Neglect
13 Jul 2021Abuse: Neglect
Investigated alleged neglect and abuse involving inadequate care planning that allowed ongoing bruising; a $500 fine was assessed.
Abuse—Failed to properly plan care
05 Jul 2021Abuse: Neglect
05 Jul 2021Abuse: Neglect
Investigated a resident care complaint and found that staff failed to intervene when a resident's condition changed after a fall, leading to injuries. A 500-dollar fine was assessed.
Abuse—Failed to intervene when resident's condition changed
24 Jun 2021Abuse: Neglect
24 Jun 2021Abuse: Neglect
Found inadequate care planning and interventions for falls, constituting neglect and abuse; assessed a fine.
Abuse—Failed to properly plan care
19 Jun 2021Abuse: Neglect
19 Jun 2021Abuse: Neglect
Found deficiencies in care planning and interventions for frequent falls, resulting in neglect and abuse, and a $1,500 fine was assessed.
Abuse—Failed to properly plan care
16 Jun 2021Abuse: Neglect
16 Jun 2021Abuse: Neglect
Found that a safe medication administration system was not provided, resulting in an incorrect anticoagulant dose and a missed dose, placing a resident at risk for harm. A $500 fine was assessed.
Abuse—Failed to provide a safe medication administration system
15 Jun 2021Abuse: Neglect
15 Jun 2021Abuse: Neglect
Found neglect and abuse due to failure to properly plan care and intervene for aggressive behaviors, resulting in an altercation and injury, with a $500 fine assessed.
Abuse—Failed to properly plan care
13 Jun 2021Abuse: Neglect
13 Jun 2021Abuse: Neglect
Investigated a complaint and found neglect for failing to properly plan care and implement interventions to address frequent falls, constituting abuse.
Abuse—Failed to properly plan care
24 May 2021Abuse: Neglect
24 May 2021Abuse: Neglect
Investigated and identified a failure to provide a safe environment, constituting neglect and abuse, with a fine assessed.
Abuse—Failed to provide safe environment
21 May 2021Abuse: Neglect
21 May 2021Abuse: Neglect
Investigated a complaint and found multiple falls occurred within 90 days and care planning failed to address them, constituting neglect and abuse; a $500 fine was assessed.
Abuse—Failed to properly plan care
08 May 2021Abuse: Neglect
08 May 2021Abuse: Neglect
Investigated and found failure to implement reasonable interventions for ongoing resident falls, resulting in neglect and abuse.
Abuse—Failed to properly plan care
28 Apr 2021Abuse: Neglect
28 Apr 2021Abuse: Neglect
Investigated a neglect/abuse case found that the resident did not receive necessary care, leading to thrush, dehydration, a urinary tract infection, hospitalization, and a $500 fine was assessed.
Abuse—Failed to provide service
26 Apr 2021Abuse: Neglect
26 Apr 2021Abuse: Neglect
Investigated and concluded neglect due to delaying medical care after an injury and failing to address frequent falls.
Abuse—Failed to provide safe environment
20 Apr 2021Abuse: Neglect
20 Apr 2021Abuse: Neglect
Found neglect and abuse due to failure to properly plan care for a resident, resulting in weight loss and dehydration; a $500 fine was assessed.
Abuse—Failed to properly plan care
20 Apr 2021Abuse: Neglect
20 Apr 2021Abuse: Neglect
Investigated an allegation of neglect due to inadequate care planning for falls, resulting in a resident’s fall with injuries and a fine assessed.
Abuse—Failed to properly plan care
14 Apr 2021Abuse: Neglect
14 Apr 2021Abuse: Neglect
Identified violations of resident rights after discovering a chest bruise on a resident due to lack of safe care; a $375 fine was assessed.
Abuse—Failed to provide safe environment
03 Apr 2021Abuse: Neglect
03 Apr 2021Abuse: Neglect
Investigated the allegation of abuse/neglect and found a failure to provide a safe environment that led to a resident leaving unsafely and sustaining injuries.
Abuse—Failed to provide safe environment
24 Mar 2021Inspection
24 Mar 2021Inspection
Found a failure to provide a safe environment that led to a resident's fall and head injury.
Licensing—Failed to provide safe environment
09 Mar 2021Abuse: Neglect
09 Mar 2021Abuse: Neglect
Investigated a complaint alleging neglect and abuse; found failures to update a resident's service plan and provide fall-prevention interventions, and to adjust staff to resident care needs, resulting in harm; a fine was assessed.
Abuse—Failed to provide safe environment
15 Feb 2021Abuse: Neglect
15 Feb 2021Abuse: Neglect
Found deficiencies in staff oversight and response to a resident's changing condition, including increased care needs and potential need for timely medical intervention. This resulted in neglect and abuse.
Abuse—Failed to provide oversight and monitoring of change of condition
14 Feb 2021Abuse: Neglect
14 Feb 2021Abuse: Neglect
Investigated a complaint about fall-risk care and found failures to plan and implement interventions, resulting in an injury and an open pressure sore, constituting abuse and neglect. A $1500 fine was assessed.
Abuse—Failed to properly plan care
04 Feb 2021Abuse: Neglect
04 Feb 2021Abuse: Neglect
Found deficiencies in care planning and basic care delivery that led to significant weight loss. Nutrition planning and meal intake interventions were not adequate.
Abuse—Failed to properly plan care
22 Jan 2021Inspection
22 Jan 2021Inspection
Investigated and found violations involving physical and verbal abuse and wrongful restraint that compromised safety.
Licensing—Failed to provide safe environment
17 Jan 2021Abuse: Neglect
17 Jan 2021Abuse: Neglect
Found a failure to provide a safe environment that led to multiple falls and a head injury. Violations cited.
Abuse—Failed to provide safe environment
10 Jan 2021Abuse: Neglect
10 Jan 2021Abuse: Neglect
Investigated a neglect and abuse allegation; determined safety failures led to nine falls in eleven days with multiple injuries. A $2500 fine was assessed.
Abuse—Failed to provide safe environment
02 Jan 2021Inspection
02 Jan 2021Inspection
Found neglect of care and an unsafe environment related to a skin tear, caused by an untrained staff member attempting care and failing to notify a Medication Aide as required.
Licensing—Failed to provide safe environment
19 Dec 2020Abuse: Neglect
19 Dec 2020Abuse: Neglect
Found a violation for failing to provide a safe environment, which led to abuse and neglect, and a fine was assessed.
Abuse—Failed to provide safe environment
02 Dec 2020Abuse: Neglect
02 Dec 2020Abuse: Neglect
Found a failure to provide a safe environment that led to an unwitnessed fall with serious injuries. Repeated falls occurred and reasonable interventions to prevent them were not implemented.
Abuse—Failed to provide safe environment
26 Nov 2020Abuse: Neglect
26 Nov 2020Abuse: Neglect
Investigated and found neglect due to failure to provide basic care and safety, which led to multiple falls with injury.
Abuse—Failed to provide safe environment
24 Nov 2020Abuse: Neglect
24 Nov 2020Abuse: Neglect
Found that a safe environment was not provided, leading to nine falls and injuries to a resident, including a dislocated shoulder. A fine was assessed.
Abuse—Failed to provide safe environment
02 Nov 2020Abuse: Neglect
02 Nov 2020Abuse: Neglect
Concluded that failing to monitor a resident according to known behaviors led to a physical altercation and unreasonable discomfort, indicating abuse and neglect. A $375.00 fine was assessed.
Abuse—Failed to provide safe environment
09 Oct 2020Abuse: Neglect
09 Oct 2020Abuse: Neglect
Investigated and found neglect and abuse due to failing to address fall risk, which led to two unwitnessed falls and injuries; a $1,500 fine was assessed.
Abuse—Failed to properly plan care
04 Oct 2020Abuse: Neglect
04 Oct 2020Abuse: Neglect
Found failure to provide appropriate supervision, resulting in a physical altercation and harm.
Abuse—Failed to provide safe environment
22 Sept 2020Abuse: Neglect
22 Sept 2020Abuse: Neglect
Investigated found a failure to provide a safe medication administration system, leaving a medication unsecured and risking harm to a resident. A $375 fine was assessed.
Abuse—Failed to provide a safe medication administration system
02 Sept 2020Abuse: Neglect
02 Sept 2020Abuse: Neglect
Identified safety failures securing potentially harmful substances and supervising a resident, resulting in abuse and neglect findings.
Abuse—Failed to provide safe environment
31 Aug 2020Abuse: Neglect
31 Aug 2020Abuse: Neglect
Investigated and found that a provider failed to provide a safe environment, resulting in four falls and a fracture, constituting abuse and neglect.
Abuse—Failed to provide safe environment
26 Aug 2020Abuse: Neglect
26 Aug 2020Abuse: Neglect
Investigated a safety allegation and found a failure to provide a safe environment that led to six falls and a head injury. A total fine of $1,125 was assessed.
Abuse—Failed to provide safe environment
18 Jul 2020Abuse: Neglect
18 Jul 2020Abuse: Neglect
Investigated found that interventions weren't followed and the care plan wasn't implemented, leading to a physical altercation and injury that constitutes abuse and neglect.
Abuse—Failed to provide safe environment
18 Jul 2020Abuse: Neglect
18 Jul 2020Abuse: Neglect
Investigated a complaint and found neglect and abuse due to failure to provide a safe environment, resulting in a physical altercation and a $375 fine.
Abuse—Failed to provide safe environment
29 Jun 2020Abuse: Neglect
29 Jun 2020Abuse: Neglect
Investigated a complaint and found neglect and abuse for failing to monitor a change in condition and delaying medical care, including not providing all medications. A $1,500 fine was assessed.
Abuse—Failed to provide oversight and monitoring of change of condition
23 Jun 2020Abuse: Neglect
23 Jun 2020Abuse: Neglect
Found failures to implement interventions and care plans addressing a resident's behaviors, resulting in staff mishandling and resident discomfort. A $500 fine was assessed.
Abuse—Failed to provide safe environment
19 May 2020Abuse: Neglect
19 May 2020Abuse: Neglect
Found violations of resident rights, including neglect and abuse after investigation.
Abuse—Failed to provide safe environment
05 May 2020Abuse: Neglect
05 May 2020Abuse: Neglect
Found failure to implement interventions and care planning for a resident's known skin condition, leading to worsening condition and discomfort, constituting neglect and abuse. A $2,700 fine was assessed.
Abuse—Failed to properly plan care
05 May 2020Abuse: Neglect
05 May 2020Abuse: Neglect
Identified neglect and abuse due to failure to address the alleged victim's significant weight loss, resulting in approximately 19.47% body weight loss over about 71 days with a $2,700 fine assessed.
Abuse—Failed to properly plan care
02 May 2020Abuse: Neglect
02 May 2020Abuse: Neglect
Investigated allegations of neglect and abuse for failing to provide a safe environment. Found that interventions and care planning were not properly applied, leading to a physical altercation and risk of harm to the resident.
Abuse—Failed to provide safe environment
29 Apr 2020Abuse: Neglect
29 Apr 2020Abuse: Neglect
Investigated and found that a resident's care planning and interventions were not properly implemented after a fall history, leading to an unwitnessed fall and head injury, constituting neglect and abuse.
Abuse—Failed to properly plan care
08 Feb 2020Abuse: Neglect
08 Feb 2020Abuse: Neglect
Identified a failure to provide a safe environment that led to injuries when a cabinet door fell on a resident.
Abuse—Failed to follow care plan
16 Dec 2019Abuse: Neglect
16 Dec 2019Abuse: Neglect
Investigated and found inadequate supervision led to a physical altercation causing unreasonable discomfort, indicating abuse and neglect.
Abuse—Failed to provide safe environment
22 Nov 2019Abuse: Neglect
22 Nov 2019Abuse: Neglect
Investigated an abuse and neglect allegation and found that basic care was not provided as needed, causing discomfort and skin injury.
Abuse—Failed to provide service
15 Nov 2019Abuse: Neglect
15 Nov 2019Abuse: Neglect
Investigated the allegation and found that interventions were not implemented according to the resident's history of falls, resulting in an unwitnessed fall and discomfort.
Abuse—Failed to properly plan care
03 Nov 2019Abuse: Neglect
03 Nov 2019Abuse: Neglect
Cited a deficiency for inadequate care planning related to falls that led to harm, and assessed a $2,500 fine.
Abuse—Failed to adequately care plan related to falls
15 Oct 2019Abuse: Neglect
15 Oct 2019Abuse: Neglect
Identified a failure to provide a safe environment and adequate supervision, resulting in a physical altercation and discomfort; a fine was assessed.
Abuse—Failed to provide safe environment
12 Oct 2019Abuse: Neglect
12 Oct 2019Abuse: Neglect
Found inadequate monitoring led to a physical altercation causing unreasonable discomfort and violating resident rights, constituting neglect and abuse.
Abuse—Failed to provide safe environment
26 Sept 2019Abuse: Neglect
26 Sept 2019Abuse: Neglect
Identified neglect and abuse due to inadequate supervision that led to a physical altercation and unreasonable discomfort.
Abuse—Failed to provide safe environment
23 Aug 2019Abuse: Neglect
23 Aug 2019Abuse: Neglect
Found neglect of basic care that led to a resident fall with a head injury requiring sutures. A fine was assessed.
Abuse—Failed to adequately care plan related to falls
13 Aug 2019Abuse: Neglect
13 Aug 2019Abuse: Neglect
Investigated an allegation of neglect and found safety was not assured. Findings showed a lack of substantial compliance.
Abuse—Failed to assure resident was safe
19 Jul 2019Inspection
19 Jul 2019Inspection
Found failure to report suspected abuse; a $1,000 fine was assessed.
Licensing—Failed to report potential or suspected abuse
19 Jul 2019Abuse: Neglect
19 Jul 2019Abuse: Neglect
Investigated a neglect allegation and found that basic care was not provided, resulting in physical harm to a resident. A $500 fine was assessed.
Abuse—Failed to provide a safe medication administration system
30 May 2019Abuse: Neglect
30 May 2019Abuse: Neglect
Investigated the neglect allegation and found a failure to provide a safe environment, resulting in risk of serious harm. A fine was assessed.
Abuse—Failed to provide safe environment
30 May 2019Abuse: Neglect
30 May 2019Abuse: Neglect
Found neglect for failing to provide basic care and safety, creating risk of serious harm; a fine was assessed.
Abuse—Failed to provide safe environment
20 May 2019Abuse: Neglect
20 May 2019Abuse: Neglect
Investigated a neglect allegation and found failure to provide basic care, resulting in serious loss of personal dignity; a $1500 fine was assessed.
Abuse—Failed to provide service
20 May 2019Inspection
20 May 2019Inspection
Determined that suspected abuse was not reported. A $1,000 fine was assessed.
Licensing—Failed to report potential or suspected abuse
16 May 2019Inspection
16 May 2019Inspection
Found that staff did not administer medication as prescribed, indicating a safety issue with medication administration.
Licensing—Failed to provide a safe medication administration system
16 May 2019Inspection
16 May 2019Inspection
Found a privacy protection deficiency due to unattended med carts and unlocked computer screens, making resident information accessible.
Licensing—Failed to assure resident rights
09 May 2019Abuse: Neglect
09 May 2019Abuse: Neglect
Investigated a neglect allegation and found failure to provide a safe environment caused physical harm. A fine was assessed.
Abuse—Failed to provide safe environment
07 May 2019Abuse: Neglect
07 May 2019Abuse: Neglect
Investigated an abuse allegation of neglect and found neglect causing emotional harm; a $375 fine was assessed.
Abuse—Failed to follow care plan
04 May 2019Abuse: Physical Abuse
04 May 2019Abuse: Physical Abuse
Investigated an abuse allegation and found neglect that risked serious harm to a resident. A fine of $1,125 was assessed.
Abuse—Failed to follow care plan
25 Apr 2019Inspection
25 Apr 2019Inspection
Found failure to report potential or suspected abuse.
Licensing—Failed to report potential or suspected abuse
25 Apr 2019Abuse: Neglect
25 Apr 2019Abuse: Neglect
Found neglect of a resident that led to a 21-pound weight loss over six months; a $500 fine was assessed.
Abuse—Failed to assure resident was safe
10 Apr 2019Abuse: Neglect
10 Apr 2019Abuse: Neglect
Investigated a complaint and found neglect related to medication safety, risking serious harm.
Abuse—Failed to provide a safe medication administration system
10 Apr 2019Inspection
10 Apr 2019Inspection
Found failure to report suspected abuse and assessed a $1,000 fine.
Licensing—Failed to report potential or suspected abuse
30 Mar 2019Inspection
30 Mar 2019Inspection
Investigated and found failure to report suspected abuse.
Licensing—Failed to report potential or suspected abuse
30 Mar 2019Abuse: Neglect
30 Mar 2019Abuse: Neglect
Identified neglect that created a risk of serious harm and imposed a $1,500 fine.
Abuse—Failed to provide a safe medication administration system
30 Mar 2019Abuse: Neglect
30 Mar 2019Abuse: Neglect
Found neglect of basic care resulting in physical harm and assessed a $375 fine.
Abuse—Failed to follow care plan
17 Mar 2019Abuse: Neglect
17 Mar 2019Abuse: Neglect
Found neglect of a resident due to failing to provide safety, resulting in emotional harm, and a $375 fine was assessed.
Abuse—Failed to follow care plan
17 Mar 2019Abuse: Neglect
17 Mar 2019Abuse: Neglect
Found neglect causing emotional harm due to failure to provide safety, and a $375 fine was assessed.
Abuse—Failed to follow care plan
03 Mar 2019Abuse: Neglect
03 Mar 2019Abuse: Neglect
Found neglect of an adult in care that resulted in physical harm due to failure to provide basic care and safety.
Abuse—Failed to provide safe environment
03 Mar 2019Abuse: Neglect
03 Mar 2019Abuse: Neglect
Investigated the allegation of neglect and found neglect resulting in physical harm due to failure to provide basic care and safety. A $375.00 fine was assessed.
Abuse—Failed to provide safe environment
20 Feb 2019Inspection
20 Feb 2019Inspection
Investigated an allegation of resident safety concerns and found neglect by failing to provide basic care and safety, creating a risk of serious harm. The finding identifies neglect as the cause.
Licensing—Failed to assure resident was safe
02 Feb 2019Abuse: Neglect
02 Feb 2019Abuse: Neglect
Found neglect related to falls that caused physical harm, and a fine was assessed.
Abuse—Failed to adequately care plan related to falls
24 Jan 2019Abuse: Neglect
24 Jan 2019Abuse: Neglect
Investigated an allegation of neglect and found that basic care or safety was not provided, resulting in harm. A fine was assessed.
Abuse—Failed to provide safe environment
22 Jan 2019Abuse: Neglect
22 Jan 2019Abuse: Neglect
Identified neglect that failed to provide basic care and safety, creating risk of serious harm. A fine was assessed.
Abuse—Failed to provide safe environment
22 Jan 2019Abuse: Neglect
22 Jan 2019Abuse: Neglect
Found neglect of an adult in care due to failure to provide basic care and safety, creating risk of serious harm.
Abuse—Failed to provide safe environment
18 Jan 2019Abuse: Neglect
18 Jan 2019Abuse: Neglect
Investigated an abuse allegation and found neglect due to failure to provide basic care, causing discomfort and loss of dignity. A $1,500 fine was assessed.
Abuse—Failed to provide service
18 Jan 2019Inspection
18 Jan 2019Inspection
Investigated and sustained the allegation that failure to report suspected abuse occurred, and assessed a $1,000 fine.
Licensing—Failed to report potential or suspected abuse
10 Jan 2019Abuse: Neglect
10 Jan 2019Abuse: Neglect
Investigated the allegation and found neglect that created a risk of serious harm by failing to provide basic care and safety.
Abuse—Failed to properly plan care
30 Dec 2018Abuse: Neglect
30 Dec 2018Abuse: Neglect
Found neglect related to falls care planning and safety, resulting in physical harm; a $375 fine was assessed.
Abuse—Failed to adequately care plan related to falls
22 Dec 2018Abuse: Neglect
22 Dec 2018Abuse: Neglect
Investigated alleged neglect related to falls care planning and basic care, resulting in physical harm.
Abuse—Failed to adequately care plan related to falls
22 Dec 2018Abuse: Neglect
22 Dec 2018Abuse: Neglect
Found neglect by failing to provide for safety, which resulted in physical harm.
Abuse—Failed to follow care plan
18 Nov 2018Abuse: Neglect
18 Nov 2018Abuse: Neglect
Investigated and found a failure to provide a safe environment, resulting in the resident ingesting antiperspirant and constituting neglect and abuse. No civil penalty assessed.
Abuse—Failed to provide safe environment
18 Nov 2018Abuse: Neglect
18 Nov 2018Abuse: Neglect
Investigated a complaint and found neglect due to failure to properly plan care, creating a risk of serious harm; a $375 fine was assessed.
Abuse—Failed to properly plan care
13 Nov 2018Abuse: Neglect
13 Nov 2018Abuse: Neglect
Investigated a neglect allegation and found neglect due to failing to provide basic care and safety, creating risk of serious harm.
Abuse—Failed to provide peri care
13 Nov 2018Inspection
13 Nov 2018Inspection
Determined a failure to report suspected abuse and imposed a $1,000 fine. The finding indicated potential harm from the failure.
Licensing—Failed to report potential or suspected abuse
06 Nov 2018Inspection
06 Nov 2018Inspection
Concluded that the allegation of failing to report potential or suspected abuse. A $1,000 fine was assessed.
Licensing—Failed to report potential or suspected abuse
06 Nov 2018Abuse: Neglect
06 Nov 2018Abuse: Neglect
Investigated a neglect allegation and found neglect resulting in serious loss of personal dignity; assessed a $1,500 fine.
Abuse—Failed to assure resident was safe
31 Oct 2018Inspection
31 Oct 2018Inspection
Identified failure to report suspected abuse. A $1,000 fine was assessed.
Licensing—Failed to report potential or suspected abuse
31 Oct 2018Abuse: Neglect
31 Oct 2018Abuse: Neglect
Found neglect that caused harm and loss of dignity; a $2,500 fine was assessed.
Abuse—Failed to provide a safe medication administration system
29 Sept 2018Abuse: Neglect
29 Sept 2018Abuse: Neglect
Investigated an allegation of neglect for failing to follow the care plan, which led to physical harm. The case identified neglect in basic care and safety provisions.
Abuse—Failed to follow care plan
27 Sept 2018Abuse: Neglect
27 Sept 2018Abuse: Neglect
Found neglect due to failure to provide a safe environment, which risked serious harm.
Abuse—Failed to properly plan care
26 Aug 2018Abuse: Neglect
26 Aug 2018Abuse: Neglect
Found a failure to provide a safe environment, leading to a $2,500 fine.
Abuse—Failed to provide safe environment
22 Aug 2018Abuse: Neglect
22 Aug 2018Abuse: Neglect
Found a failure to assess a resident's condition in a timely manner and assessed a $2,500 fine.
Abuse—Failed to intervene when resident's condition changed
21 Aug 2018Abuse: Neglect
21 Aug 2018Abuse: Neglect
Investigated the allegation of neglect and found failure to follow the care plan.
Abuse—Failed to follow care plan
14 Aug 2018Abuse: Neglect
14 Aug 2018Abuse: Neglect
Investigated the neglect allegation and identified a risk to safety due to failing to properly plan care. A fine was assessed.
Abuse—Failed to properly plan care
13 Aug 2018Abuse: Neglect
13 Aug 2018Abuse: Neglect
Found violations for neglect and failure to follow a care plan, and a fine was assessed.
Abuse—Failed to follow care plan
07 Jul 2018Abuse: Neglect
07 Jul 2018Abuse: Neglect
Investigated an abuse/neglect allegation and found failure to provide a safe environment, resulting in a $1,500 fine.
Abuse—Failed to provide safe environment
07 Jul 2018Inspection
07 Jul 2018Inspection
Investigated a complaint and found failure to report suspected abuse, resulting in a $750 fine.
Licensing—Failed to report potential or suspected abuse
04 Jul 2018Abuse: Neglect
04 Jul 2018Abuse: Neglect
Investigated a neglect allegation involving removal of a resident's walker, which created a risk of serious harm. A fine was assessed.
Abuse—Failed to follow care plan
14 Apr 2018Abuse: Neglect
14 Apr 2018Abuse: Neglect
Investigated a complaint and found a failure to intervene when a resident's condition changed, resulting in a $2,500 fine.
Abuse—Failed to intervene when resident's condition changed
12 Mar 2018Inspection
12 Mar 2018Inspection
Found that an adequate medication system was not maintained. A $281 fine was assessed.
Licensing—Failed to provide a safe medication administration system
10 Mar 2018Abuse: Neglect
10 Mar 2018Abuse: Neglect
Investigated a complaint and found a deficiency for not following the care plan, resulting in a $375 fine.
Abuse—Failed to follow care plan
23 Feb 2018Inspection
23 Feb 2018Inspection
Investigated a complaint and found a deficiency in the medication administration system.
Licensing—Failed to provide a safe medication administration system
09 Feb 2018Condition
09 Feb 2018Condition
Investigated a complaint and found a failure to provide appropriate care and services, putting residents at risk of harm.
Regulatory Action—Failed to provide service
20 Jan 2018Abuse: Neglect
20 Jan 2018Abuse: Neglect
Investigated an allegation of failing to provide a secure environment and assessed a $1,500 fine.
Abuse—Failed to provide safe environment
13 Dec 2017Inspection
13 Dec 2017Inspection
Investigated the allegation of failing to administer medication as ordered and found a deficiency in maintaining an adequate medication system.
Licensing—Failed to administer medication as ordered
19 Nov 2017Abuse: Neglect
19 Nov 2017Abuse: Neglect
Investigated a neglect allegation of not following the care plan and found failures to assess and intervene.
Abuse—Failed to follow care plan
10 Nov 2017Abuse: Financial abuse
10 Nov 2017Abuse: Financial abuse
Found a failure to provide a secure medication system, resulting in missing medications.
Abuse—Failed to provide a safe medication administration system
24 Oct 2017Abuse: Neglect
24 Oct 2017Abuse: Neglect
Investigated a complaint and found a failure to provide appropriate care that could result in minor to moderate harm.
Abuse—Failed to provide service
17 Aug 2017Abuse: Neglect
17 Aug 2017Abuse: Neglect
Investigated an allegation of neglect related to an unsafe environment; deficiencies were cited and a $250 fine was assessed.
Abuse—Failed to provide safe environment
04 Aug 2017Abuse: Neglect
04 Aug 2017Abuse: Neglect
Found that a safe environment was not provided. A $300 fine was assessed.
Abuse—Failed to provide safe environment
22 Jul 2017Inspection
22 Jul 2017Inspection
Investigated and found failure to provide a safe environment.
Licensing—Failed to provide safe environment
26 Jun 2017Inspection
26 Jun 2017Inspection
Investigated the allegation of an unsafe environment and found a failure to provide a secure environment.
Licensing—Failed to provide safe environment
18 Jun 2017Inspection
18 Jun 2017Inspection
Investigated the allegation and found a failure to provide a safe environment.
Licensing—Failed to provide safe environment
13 Jun 2017Abuse: Neglect
13 Jun 2017Abuse: Neglect
Concluded there were failures to assess and intervene in recurring falls, leading to head injuries.
Abuse—Failed to intervene when resident's condition changed
16 May 2017Abuse: Neglect
16 May 2017Abuse: Neglect
Investigated a neglect allegation and found inadequate care provided to a resident.
Abuse—Failed to provide service
08 May 2017Inspection
08 May 2017Inspection
Investigated the staffing allegation and found inadequate staffing.
Licensing—Failed to provide appropriate staffing
08 May 2017Inspection
08 May 2017Inspection
Investigated and found failure to maintain a sanitary kitchen.
Licensing—Failed to provide sanitary food service conditions
04 May 2017Inspection
04 May 2017Inspection
Determined that a secure environment was not provided.
Licensing—Failed to provide safe environment
28 Apr 2017Abuse: Neglect
28 Apr 2017Abuse: Neglect
Investigated and found a failure to provide safe care during wheelchair transport.
Abuse—Failed to provide safe environment
15 Oct 2016Inspection
15 Oct 2016Inspection
Concluded that a safe environment was not provided.
Licensing—Failed to provide safe environment
Disclaimer
Mirador Living is not affiliated with the owner or operator(s) of Willamette Springs Memory Care Community. The information above has not been verified or approved by the owner or operator. For exact information, please contact Willamette Springs Memory Care Community directly. There is no cost for this service. We are compensated by the community you select.
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