I'm very pleased with this community. My mom loves it here - staff are consistently kind, patient, respectful and genuinely caring (Lauren is awesome). The building and grounds are clean and home-like, apartments are roomy, and the life-enrichment team keeps residents engaged with activities, live music and outings. Med techs and leadership are professional and responsive, and I feel my family member is in very good hands - peace of mind for us and a worthwhile place I'd recommend.
Loved one of resident
Jul 2026
Pricing
Prices shown are estimates and subject to change. Contact your senior living advisor for current pricing.
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Amenities
Healthcare services
Activities of daily living assistance
Assistance with bathing
Assistance with dressing
Assistance with transfers
Medication management
Mental wellness program
Healthcare staffing
24-hour call system
24-hour supervision
Meals and dining
Diabetes diet
Meal preparation and service
Restaurant-style dining
Special dietary restrictions
Room
Air-conditioning
Cable
Fully furnished
Housekeeping and linen services
Kitchenettes
Private bathrooms
Telephone
Wifi
Transportation
Community operated transportation
Transportation arrangement
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
3.58·(53)
Overall rating
5
4
3
2
1
Care
3.2
Staff
3.6
Meals
2.6
Amenities
3.4
Value
1.5
Pros
Caring, attentive direct-care staff
Supportive memory-care programming
Accepts Medicaid
Convenient location across from hospital
Clean, well-maintained grounds and common areas
Enclosed garden and outdoor seating
On-site beauty shop
Apartments allow personal furniture and decor
Robust life-enrichment program (music, outings)
Smooth transition support and admissions responsiveness
Compassionate end-of-life and bereavement support
Spacious apartments and ample closet space
Welcoming front-desk and warm atmosphere
Cons
Inconsistent staffing levels and high turnover
Variable quality of personal-care assistance
Gaps in housekeeping and laundry services
Inconsistent meal quality and delivery continuity
Weak management responsiveness and executive turnover
Communication gaps with families and limited care-plan inclusion
Insufficient staffing and engagement in memory-care wing
Safety oversight and transfer/fall-prevention weaknesses
Maintenance and equipment reliability issues
Inconsistent activity availability across units
Allegations of billing and financial-accountability issues
Summary of reviews
This collection of reviews paints a mixed but consistent picture: many families and residents praise the direct-care staff, life-enrichment team, and the facility’s physical environment, while others describe operational shortfalls that affect day-to-day quality of life.
Care quality and clinical oversight: Several reviewers described attentive, compassionate caregivers and improvements in residents’ clinical status after moving in (weight stabilization, fewer UTIs, improved engagement). At the same time, a substantial pattern of concerns centers on inconsistent personal-care delivery — especially bathing, dressing, and assistance with eating — and variability in how those needs are met across shifts and units. Memory-care residents are highlighted as particularly vulnerable to gaps in engagement and assistance when staffing is limited. There are also recurring notes about safety oversight: delayed attendances, transfer technique inconsistencies, and fall-risk management gaps.
Staff and culture: Many comments emphasize individual staff members who are kind, patient, and professional; life-enrichment staff and med techs receive repeated praise. However, high staff turnover, reports of thin staffing, and morale/compensation concerns are recurrent themes. Those operational pressures appear to contribute to inconsistent performance, uneven responsiveness to call lights, and occasional lapses in routine care tasks.
Dining and nutrition: Dining receives mixed evaluations. Positive reports note enjoyable meals and a pleasant dining room atmosphere in some units, while other families describe cold or overcooked entrées, missed meal deliveries, and menu limitations for residents with dietary restrictions. Some reviewers indicated that meal presentation and consistency vary by time and staffing.
Activities and social programming: The facility’s enrichment program is a clear strength when fully staffed: live music, outings, and varied activities are frequently mentioned as beneficial. However, there are also multiple accounts of limited engagement in certain wings or periods—particularly in memory care—where scheduled activities were not held or staff were unavailable to lead them.
Facilities and maintenance: Physical plant and grounds receive largely favorable comments — clean common areas, an enclosed garden, and rooms that can be personalized. Conversely, there are reports of maintenance and equipment reliability issues (inoperative washers/dryers, fireplace problems) and intermittent housekeeping gaps that families should verify during a visit.
Management, communication, and administration: Leadership turnover and variable responsiveness to family concerns are recurring issues. Reviewers cite inconsistent follow-through on care plans, limited family inclusion in care conferences, and some instances where complaints were not resolved to families’ satisfaction. A few reviews allege financial-accountability problems (unauthorized charges or money-handling concerns); these are serious claims that warrant direct inquiry during any assessment.
Notable patterns and guidance for families: The most consistent divide in these reviews is between positive experiences tied to stable, experienced staff and negative experiences tied to staffing shortages, especially in memory care and on off shifts. Prospective residents and families should ask targeted questions about current staffing ratios (day/evening/night), supervision in the memory-care unit, bathing and toileting schedules, complaint-resolution procedures, meal accommodations for dietary restrictions, and financial-billing policies. Visiting at different times, observing activity programming in the memory wing, and requesting documentation of care-plan meetings can help assess whether the facility’s strengths are present in the unit and shift where a loved one would reside.
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Location
Middlefield Oaks Assisted Living and Memory Care is located at 1500 Village Dr, Cottage Grove, OR, 97424.
About Middlefield Oaks Assisted Living and Memory Care
Middlefield Oaks Assisted Living and Memory Care sits at 1500 Village Dr in Cottage Grove, Oregon, and you'll find it has been through a big renovation in its memory care neighborhood, with over $300,000 put into things like new LVP and LVT floors, a refreshed kitchen with solid-surface counters and new appliances, bright paint, upgraded lights, window coverings, and more seating spots, all aiming to make things smoother for residents who deal with memory loss or dementia. The memory care wing stays calm and safe, and its open-concept layout lets residents see more and move around with as much independence as possible, while the secure design keeps folks with Alzheimer's or other forms of dementia from wandering off and helps them feel grounded in familiar routines, and the staff follows special training in dementia care best practices so everybody gets care that fits their needs.
This place has 62 beds, covering assisted living and memory care, and offers different room types like shared suites, private and deluxe studios, and larger private options, all under one price that covers meals and care. They keep the building clean, updated, and safe for seniors, with things like individual heating and cooling units and views of the garden. Seniors can count on help for daily activities like bathing, dressing, getting reminders for meals and medication, laundry, and housekeeping, and there's always someone around for emergencies, day or night, with hospitality and support staff known for being friendly and responsive. The dining room serves made-from-scratch meals using fresh, seasonal ingredients, with special diets handled as needed, and meals are set up so people can eat with others at their own speed.
The community includes spaces to host occasions like birthdays, anniversaries, or even a movie night, and activities such as exercise, brain games, book clubs, card games, puzzles, and crafts get scheduled and listed on a monthly brochure, and there are devotionals both onsite and offsite, plus a salon and barbershop for residents. Folks also get scheduled rides for medical visits and outings. The whole memory care setup aims to reduce stress and confusion, with features that keep the environment calm, bright, and easy to navigate, and life enrichment activities focus on helping residents feel engaged through music, social time, and routines familiar to them. Middlefield Oaks is, in the end, physician-owned and operated, and the staff works hard to create a home-like place for seniors who need help with daily tasks, memory care, or both, always making safety, comfort, and a sense of belonging a big part of life there.
People often ask...
Middlefield Oaks Assisted Living and Memory Care offers competitive pricing, with rates starting at a cost of $5,681 per month.
Middlefield Oaks Assisted Living and Memory Care offers assisted living and memory care.
There are 38 photos of Middlefield Oaks Assisted Living and Memory Care on Mirador.
The full address for this community is 1500 Village Dr, Cottage Grove, OR 97424.
No, Middlefield Oaks Assisted Living and Memory Care does not offer respite care.
Respite care in assisted living communities provides temporary, short-term relief for primary caregivers by offering professional care for their loved ones. It allows individuals to stay in an assisted living community for a limited time, giving caregivers a break while ensuring residents receive necessary support and assistance with daily activities.
Safety & Compliance
In Oregon, the Department of Human Services' Aging & People with Disabilities program licenses assisted living and residential care facilities, conducting inspections, complaint investigations, and renewals.
Identified extensive kitchen sanitation and equipment maintenance deficiencies that did not meet the food sanitation rule. Documented improper handling of dishes and hygiene practices.
Found multiple deficiencies in food sanitation and administration compliance, including unsanitary kitchen conditions, improper dishwashing practices, temperature concerns, and lack of ongoing monitoring.
Deficiency—Inspections and Investigation: Insp Interval
Deficiency—Administration Compliance
12 Aug 2025License Condition
12 Aug 2025License Condition
Found failure to staff as indicated by ABST and to fully implement and update an acuity-based staffing tool as required by the rule.
Regulatory Action—Failed to staff as indicated by ABST
07 Aug 2025License Condition
07 Aug 2025License Condition
Investigated an allegation that an acuity-based staffing tool was not used as required.
Regulatory Action—Failed to use an ABST
04 Aug 2025Inspection
04 Aug 2025Inspection
Investigated found that staff failed to notify the RN of changes in a resident's status as identified in the service plan.
Licensing—Failed to perform adequate screening or assessment
27 Jul 2025Inspection
27 Jul 2025Inspection
Investigated and found that monitoring requirements for a resident were not met, with missing monitoring plans for all shifts and documentation gaps.
Licensing—Failed to adequately plan discharge
09 May 2025Complaint
09 May 2025Complaint
Investigated the staffing complaint.
Deficiency—Staffing Requirements and Training: Staffing
16 Feb 2025Abuse: Neglect
16 Feb 2025Abuse: Neglect
Investigated an abuse/neglect case and concluded the environment was unsafe and care planning inadequate, with insufficient measures to protect residents from escalating sexual behaviors by another resident. A $375 fine was assessed.
Abuse—Failed to provide safe environment
02 Feb 2025Abuse: Neglect
02 Feb 2025Abuse: Neglect
Identified a safety deficiency where staff were not trained to use a required lift, resulting in an improper transfer and bruising; a $250 fine was assessed.
Abuse—Failed to provide safe environment
31 Aug 2024Abuse: Neglect
31 Aug 2024Abuse: Neglect
Found deficiencies in care planning for anxiety and in providing staff with written guidance, leading to neglect and abuse and resulting in an incident between residents.
Abuse—Failed to properly plan care
14 Aug 2024Licensure
14 Aug 2024Licensure
Identified sanitation and handling deficiencies in the kitchen during the August 14, 2024 visit; a follow-up on October 17, 2024 found substantial compliance.
Determined a failure to provide a safe environment led to a resident injury requiring emergency care, with a $250 fine assessed.
Abuse—Failed to provide safe environment
08 Dec 2023Inspection
08 Dec 2023Inspection
Determined that a staff member failed to follow the care plan, resulting in a resident fall and head injury. The actions were deemed neglect and abuse.
Licensing—Failed to follow care plan
27 Nov 2023Licensure
27 Nov 2023Licensure
Identified significant sanitation and storage deficiencies in kitchen areas during the initial visit; follow-up later found substantial compliance with applicable rules.
Determined substantial compliance with meal service and food sanitation requirements. No deficiencies were cited.
Deficiency—Comment
08 Nov 2023Inspection
08 Nov 2023Inspection
Determined that a failure to provide a safe environment led to a medication overdose and the resident's death, with neglect and abuse identified.
Licensing—Failed to provide safe environment
02 Nov 2023Abuse: Neglect
02 Nov 2023Abuse: Neglect
Found a failure to provide a safe environment that resulted in abuse and neglect; a $375 fine was assessed.
Abuse—Failed to provide safe environment
28 Sept 2023Abuse: Neglect
28 Sept 2023Abuse: Neglect
Found failure to provide a safe environment that led to an abuse/neglect finding.
Abuse—Failed to provide safe environment
16 Jun 2023License Condition
16 Jun 2023License Condition
Found that an Acuity Based Staffing Tool assessment was not completed for each resident before move-in and was not reviewed or amended when there was a significant change of condition or at least quarterly.
Regulatory Action—Failed to use an ABST
16 Jun 2023License Condition
16 Jun 2023License Condition
Determined that an acuity-based staffing tool was not used.
Regulatory Action—Failed to use an ABST
12 May 2023Abuse: Neglect
12 May 2023Abuse: Neglect
Found violations of resident rights due to the lack of PRN bowel medication, leading to unreasonable discomfort and abuse. A $250 fine was assessed.
Abuse—Failed to have medication available
12 May 2023Abuse: Neglect
12 May 2023Abuse: Neglect
Found failures to implement interventions and care plans for fall history, resulting in an unwitnessed fall and discomfort; a fine was assessed.
Abuse—Failed to properly plan care
21 Apr 2023Abuse: Neglect
21 Apr 2023Abuse: Neglect
Found neglect and abuse due to failure to implement fall interventions, resulting in bruises and knee pain from about seven falls over four months. A $375 fine was assessed.
Abuse—Failed to properly plan care
17 Apr 2023Validation
17 Apr 2023Validation
Identified numerous deficiencies across administration, resident care planning, health services, medications, staffing, training, and safety systems. Follow-up concluded substantial compliance.
Deficiency—Comment
Deficiency—Facility Administration: Operation
Deficiency—Resident Move-In and Eval: Res Evaluation
Deficiency—Service Plan: General
Deficiency—Service Plan: Service Planning Team
Deficiency—Change of Condition and Monitoring
Deficiency—Resident Health Services
Deficiency—Res Hlth Srvc: On- and Off-Site Health Srvc
Deficiency—Systems: Medications and Treatments
Deficiency—Systems: Treatment Orders
Deficiency—Systems: Medication and Treatment Review
Deficiency—Systems: Resident Right to Refuse
Deficiency—Systems: Medication Administration
Deficiency—Systems: Self-Administration of Meds
Deficiency—Acuity-Based Staffing Tool
Deficiency—Annual and Biennial Inservice For All Staff
Deficiency—Fire and Life Safety: Safety
Deficiency—Inspections and Investigation: Insp Interval
Inspected a re-licensure survey; identified extensive deficiencies across administration, resident care, health services, infection control, safety, and staff training.
Investigated and found failures to properly plan care and implement a safety plan and fall interventions, resulting in multiple falls with injuries and a violation of resident rights.
Abuse—Failed to properly plan care
31 Dec 2022Abuse: Neglect
31 Dec 2022Abuse: Neglect
Investigated an allegation of failing to plan care for fall history, which led to multiple falls, injuries, and hospice admission.
Abuse—Failed to properly plan care
19 Dec 2022Inspection
19 Dec 2022Inspection
Found failure to promptly investigate all reports of abuse and suspected abuse and to protect residents, with known incidents lacking corresponding incident reports or internal investigations.
Licensing—Failed to provide safe environment
19 Dec 2022Inspection
19 Dec 2022Inspection
Investigated the complaint and identified a deficiency for failing to immediately notify the local Department office or local AAA of abuse incidents.
Licensing—Failed to provide safe environment
05 Dec 2022Licensure
05 Dec 2022Licensure
Identified significant kitchen sanitation and food handling deficiencies, with repeated issues observed across visits.
Deficiency—Inspections and Investigation: Insp Interval
05 Dec 2022Licensure
05 Dec 2022Licensure
Identified ongoing kitchen sanitation and safety deficiencies across multiple visits, including dirty conditions, improper food handling, and incomplete corrective actions.
Deficiency—Inspections and Investigation: Insp Interval
Deficiency—Administration Compliance
30 Nov 2022Abuse: Neglect
30 Nov 2022Abuse: Neglect
Found violations for neglect and abuse due to failure to follow wound care and dressing instructions, which led to a surgical-site infection.
Abuse—Failed to provide medical treatment as ordered
02 Nov 2022License Condition
02 Nov 2022License Condition
Investigated the allegation that care plans were not updated quarterly; findings showed care plans were not updated in accordance with assessment and last revised about a year ago.
Regulatory Action—Failed to care plan in accordance with assessment
02 Nov 2022License Condition
02 Nov 2022License Condition
Investigated the allegation and found a failure to use an acuity-based staffing tool as required.
Regulatory Action—Failed to use an ABST
28 Oct 2022Abuse: Neglect
28 Oct 2022Abuse: Neglect
Investigated a complaint and found that an alleged victim relied on care, sustained approximately 10 falls with injuries, and care planning and interventions to mitigate fall risk were not implemented. A $250 fine was assessed.
Abuse—Failed to properly plan care
13 Oct 2022Abuse: Neglect
13 Oct 2022Abuse: Neglect
Investigated a complaint and found that a resident did not receive a safe environment, resulting in abuse and neglect.
Abuse—Failed to provide safe environment
05 Oct 2022Abuse: Neglect
05 Oct 2022Abuse: Neglect
Investigated the allegation of neglect related to failing to follow a care plan and found care plan requirements were not followed, resulting in a fine.
Abuse—Failed to follow care plan
04 Oct 2022Abuse: Neglect
04 Oct 2022Abuse: Neglect
Investigated a reported abuse and neglect; found a safety and care violation that harmed a resident. A fine was assessed.
Abuse—Failed to provide safe environment
30 Sept 2022Complaint
30 Sept 2022Complaint
Investigated and identified deficiencies in abuse reporting and quarterly service plan updates.
Investigated a wandering resident who reached for others' food and incidents occurred; found failure to properly plan care, leading to abuse/neglect with a $375 fine assessed.
Abuse—Failed to properly plan care
30 Sept 2022Complaint
30 Sept 2022Complaint
Identified deficiencies in quarterly updates of resident service plans and in the full implementation of an acuity-based staffing tool.
Deficiency—Licensing Complaint Investigation
Deficiency—Service Plan: General
Deficiency—Acuity-Based Staffing Tool
20 Sept 2022Inspection
20 Sept 2022Inspection
Found that quarterly service plans were not completed, violating Oregon Administrative Rules.
Licensing—Failed to properly plan care
16 Sept 2022Inspection
16 Sept 2022Inspection
Investigated a care-plan violation and found that a staff member failed to follow a two-person transfer plan, resulting in a resident fall and constituting neglect and abuse.
Licensing—Failed to follow care plan
16 Sept 2022Inspection
16 Sept 2022Inspection
Found failure to report potential or suspected abuse to the local Department, constituting a licensing violation.
Licensing—Failed to report potential or suspected abuse
03 Sept 2022Abuse: Neglect
03 Sept 2022Abuse: Neglect
Found that a resident was harmed due to a failure to provide a safe environment, constituting abuse and neglect.
Abuse—Failed to provide safe environment
01 Aug 2022Inspection
01 Aug 2022Inspection
Found a failure to submit timely weekly vaccination reporting to the proper authority for 30 days in July 2022.
Licensing—Failed to submit timely or adequate staffing documentation
01 Aug 2022Inspection
01 Aug 2022Inspection
Found a failure to submit timely or adequate weekly vaccination reporting for residents and staff to the proper authority during July 2022.
Licensing—Failed to submit timely or adequate staffing documentation
25 May 2022Abuse: Neglect
25 May 2022Abuse: Neglect
Investigated a complaint and found a failure to provide a safe environment, resulting in a resident-to-resident altercation and injuries.
Abuse—Failed to provide safe environment
25 May 2022Abuse: Neglect
25 May 2022Abuse: Neglect
Found neglect and abuse due to failure to update care plans reflecting known resident behaviors, with a 375 fine assessed.
Abuse—Failed to properly plan care
23 May 2022Inspection
23 May 2022Inspection
Identified deficiencies in infection prevention and control protocols that could compromise safety.
Licensing—Failed to provide safe environment
20 May 2022Inspection
20 May 2022Inspection
Investigated and found a failure to complete a resident's service plan before move-in.
Licensing—Failed to properly plan care
20 May 2022Inspection
20 May 2022Inspection
Found that residents were not treated with dignity and respect, indicating a violation of resident rights.
Licensing—Failed to assure resident rights
10 May 2022Abuse: Neglect
10 May 2022Abuse: Neglect
Investigated neglect allegations found the resident lacked a care plan and did not receive adequate personal care or timely toileting assistance.
Abuse—Failed to properly plan care
24 Apr 2022Abuse: Neglect
24 Apr 2022Abuse: Neglect
Found care planning deficiencies for swelling that led to a resident staying in a recliner overnight, risking harm; a $500 fine was assessed.
Abuse—Failed to properly plan care
17 Apr 2022Abuse: Neglect
17 Apr 2022Abuse: Neglect
Investigated abuse and neglect allegations and found that safety interventions were not in place to keep other residents safe. This resulted in risk of harm to residents.
Abuse—
11 Apr 2022Inspection
11 Apr 2022Inspection
Found that personal and other laundry services were not provided for two weeks.
Licensing—Failed to provide service
11 Apr 2022Inspection
11 Apr 2022Inspection
Investigated a complaint and found insufficient staff to meet scheduled and unscheduled resident needs, resulting in delayed response to call lights.
Licensing—Failed to answer call light in a timely manner
30 Mar 2022Abuse: Neglect
30 Mar 2022Abuse: Neglect
Investigated a resident-to-resident incident and found a failure to provide a safe environment that led to injury.
Abuse—Failed to provide safe environment
24 Mar 2022Abuse: Neglect
24 Mar 2022Abuse: Neglect
Investigated a failure to monitor a resident's change of condition, which resulted in neglect and potential harm.
Abuse—Failed to provide oversight and monitoring of change of condition
22 Mar 2022Abuse: Neglect
22 Mar 2022Abuse: Neglect
Found a failure to provide a safe medication administration system, resulting in missed medications and a $500 fine.
Abuse—Failed to provide a safe medication administration system
17 Mar 2022Inspection
17 Mar 2022Inspection
Investigated allegation that medication was not administered as ordered; found a failure to administer meds on time as required by the physician's order.
Licensing—Failed to administer medication as ordered
06 Mar 2022Abuse: Neglect
06 Mar 2022Abuse: Neglect
Investigated and found a failure to provide a safe environment for a resident, resulting in a fall and ER visit.
Abuse—Failed to provide safe environment
01 Feb 2022Abuse: Neglect
01 Feb 2022Abuse: Neglect
Found neglect of care and abuse for failing to monitor a change in condition, leading to infected leg wounds. A $1,500 fine was assessed.
Abuse—Failed to provide oversight and monitoring of change of condition
29 Jan 2022Abuse: Neglect
29 Jan 2022Abuse: Neglect
Investigated a complaint and found failure to plan care around a resident's known behaviors, constituting abuse and neglect, with a fine assessed.
Abuse—Failed to properly plan care
29 Jan 2022Abuse: Neglect
29 Jan 2022Abuse: Neglect
Investigated a resident care allegation and found abuse and neglect due to failure to provide a safe environment. A $375 fine was assessed.
Abuse—Failed to provide safe environment
17 Jan 2022Abuse: Neglect
17 Jan 2022Abuse: Neglect
Investigated a complaint about lacking a safe environment; found a resident-to-resident incident with injuries and a fine assessed.
Abuse—Failed to provide safe environment
17 Jan 2022Abuse: Neglect
17 Jan 2022Abuse: Neglect
Investigated and found a failure to provide a safe environment, resulting in abuse and neglect.
Abuse—Failed to provide safe environment
15 Dec 2021Abuse: Neglect
15 Dec 2021Abuse: Neglect
Found that a safe medication administration system was not provided, resulting in a resident's medications being unavailable for about 75 days; a $375 fine was assessed.
Abuse—Failed to provide a safe medication administration system
11 Dec 2021Abuse: Neglect
11 Dec 2021Abuse: Neglect
Investigated an abuse/neglect incident and found that care planning failed to prevent harm to residents, resulting in a fine.
Abuse—Failed to properly plan care
10 Dec 2021Abuse: Neglect
10 Dec 2021Abuse: Neglect
Investigated and substantiated a failure to provide a safe environment, leading to a $500 fine.
Abuse—Failed to provide safe environment
26 Nov 2021Abuse: Neglect
26 Nov 2021Abuse: Neglect
Found a failure to assess and properly care plan for a resident's behaviors, placing a resident at risk of serious harm.
Abuse—Failed to care plan in accordance with assessment
20 Oct 2021Abuse: Neglect
20 Oct 2021Abuse: Neglect
Investigated determined that a resident was not protected from rape, constituting abuse and neglect, and a $1500 fine was assessed.
Abuse—Failed to protect resident from rape
19 Oct 2021Abuse: Neglect
19 Oct 2021Abuse: Neglect
Investigated an alleged abuse/neglect incident and found a failure to provide a safe environment that harmed a resident; a fine was assessed.
Abuse—Failed to provide safe environment
05 Oct 2021Inspection
05 Oct 2021Inspection
Investigated an allegation that bathing assistance was not provided and verified the claim. Found that the requirement for bathing assistance was not met.
Licensing—Failed to provide or assist with hygiene
05 Oct 2021Inspection
05 Oct 2021Inspection
Investigated the complaint and found the allegation unable to be verified.
Licensing—Failed to provide or assist with hygiene
05 Oct 2021Inspection
05 Oct 2021Inspection
Investigated the complaint and found insufficient staff to meet residents' needs, causing delays in responding to call lights and assisting with bathing.
Licensing—Failed to answer call light in a timely manner
04 Oct 2021Abuse: Neglect
04 Oct 2021Abuse: Neglect
Found that the shower frequency in the care plan was not followed, resulting in missed showers for the resident due to staffing gaps. A $500 fine was assessed.
Abuse—Failed to follow care plan
04 Oct 2021Inspection
04 Oct 2021Inspection
Investigated a failure to follow treatment orders related to daily catheter flushing as prescribed by a doctor.
Licensing—Failed to follow care plan
29 Sept 2021Inspection
29 Sept 2021Inspection
Identified a deficiency that residents were not assisted with bathing and personal hygiene during the first week after move-in.
Licensing—Failed to provide or assist with hygiene
05 Sept 2021Abuse: Neglect
05 Sept 2021Abuse: Neglect
Found that the provider failed to provide a safe environment, constituting abuse and neglect. This action placed a resident at risk of harm.
Abuse—Failed to provide safe environment
03 Sept 2021Abuse: Neglect
03 Sept 2021Abuse: Neglect
Investigated and found a failure to provide a safe environment, resulting in abuse and neglect of a resident.
Abuse—Failed to provide safe environment
02 Aug 2021Abuse: Neglect
02 Aug 2021Abuse: Neglect
Found that a safe environment was not provided, resulting in abuse and neglect. A fine of $188.00 was assessed.
Abuse—Failed to provide safe environment
12 Jul 2021Abuse: Neglect
12 Jul 2021Abuse: Neglect
Found a failure to provide a safe environment that could have enabled elopement, due to weak door alarms and branches hanging over the fence.
Abuse—Failed to provide safe environment
08 Jul 2021Abuse: Neglect
08 Jul 2021Abuse: Neglect
Concluded that a resident experienced physical abuse and neglect, and protections to prevent abuse were not effective.
Abuse—Failed to protect resident from physical abuse
30 Jun 2021Abuse: Neglect
30 Jun 2021Abuse: Neglect
Investigated a complaint and found that staff did not follow the care plan, placing a resident at risk for serious harm; a $1,500 fine was assessed.
Abuse—Failed to follow care plan
30 Jun 2021Inspection
30 Jun 2021Inspection
Investigated an allegation that housekeeping services were not provided as required; the allegation was verified.
Licensing—Failed to provide appropriate housekeeping services
27 Jun 2021Abuse: Neglect
27 Jun 2021Abuse: Neglect
Investigated a failure to provide a safe environment after a resident eloped through an unlatched door, resulting in a cited violation and a fine of $188.
Abuse—Failed to provide safe environment
18 May 2021Inspection
18 May 2021Inspection
Found that visitation was not allowed, violating the applicable resident rights rule. The finding came from a complaint that a staff member from another facility was blocked from entering to evaluate a resident for a potential move.
Licensing—Failed to assure resident rights
15 May 2021Inspection
15 May 2021Inspection
Concluded that medication orders were not carried out as prescribed, risking resident safety.
Licensing—Failed to provide a safe medication administration system
12 May 2021Inspection
12 May 2021Inspection
Investigated the staffing allegation and found insufficient staff to meet scheduled and unscheduled resident needs.
Licensing—Failed to provide appropriate staffing
29 Apr 2021Abuse: Neglect
29 Apr 2021Abuse: Neglect
Investigated and found neglect due to not following the care plan for edema management and wound care, leading to maggot development in wounds; a $500 fine was assessed.
Abuse—Failed to follow care plan
29 Apr 2021Abuse: Neglect
29 Apr 2021Abuse: Neglect
Investigated an abuse/neglect allegation and identified a failure to administer medications as ordered, which contributed to a hospital visit; a $375 fine was assessed.
Abuse—Failed to administer medication as ordered
16 Apr 2021Inspection
16 Apr 2021Inspection
Found insufficient qualified awake direct care staff to meet 24-hour needs of residents.
Licensing—Failed to provide appropriate staffing
07 Feb 2021Abuse: Neglect
07 Feb 2021Abuse: Neglect
Found a violation for failure to administer medication as ordered, resulting in neglect and abuse; assessed a $250 fine.
Abuse—Failed to administer medication as ordered
19 Jan 2021Abuse: Neglect
19 Jan 2021Abuse: Neglect
Investigated a failure to provide timely medical treatment for a resident, found neglect and abuse, and assessed a fine.
Abuse—Failed to assure timely medical treatment
15 Jan 2021Inspection
15 Jan 2021Inspection
Found that essential housekeeping services based on the resident's needs were not provided.
Licensing—Failed to provide appropriate housekeeping services
15 Jan 2021Inspection
15 Jan 2021Inspection
Found a deficiency for not exercising reasonable precautions to protect residents' health, safety, or welfare.
Licensing—Failed to assure resident was safe
15 Jan 2021Inspection
15 Jan 2021Inspection
Investigated the staffing allegation and found insufficient qualified awake direct care staff to meet 24-hour needs.
Licensing—Failed to provide appropriate staffing
12 Jan 2021Inspection
12 Jan 2021Inspection
Found insufficient qualified awake direct care staffing to meet residents' 24-hour needs.
Licensing—Failed to provide appropriate staffing
12 Jan 2021Inspection
12 Jan 2021Inspection
Found that housekeeping services essential for residents' health and comfort were not provided.
Licensing—Failed to provide appropriate housekeeping services
07 Jan 2021Abuse: Neglect
07 Jan 2021Abuse: Neglect
Investigated allegations found that staff accepted money and gifts from a resident moving out, constituting neglect and financial abuse, and training gaps contributed.
Abuse—Failed to provide safe environment
08 Dec 2020Inspection
08 Dec 2020Inspection
Found deficiencies in cleanliness and repair of interior and exterior materials and surfaces.
Licensing—Failed to provide or maintain resident care equipment
18 Nov 2020Abuse: Neglect
18 Nov 2020Abuse: Neglect
Found failure to properly care plan for fall risk after unwitnessed falls, leading to injuries. A fine was assessed.
Abuse—Failed to properly plan care
29 Sept 2020Inspection
29 Sept 2020Inspection
Identified a violation for failing to protect a resident's belongings from theft by an employee.
Licensing—Failed to protect resident from financial exploitation
07 Aug 2020Inspection
07 Aug 2020Inspection
Identified a staffing deficiency: not enough qualified awake direct care staff to cover 24-hour needs of residents.
Licensing—Failed to provide appropriate staffing
01 May 2020Inspection
01 May 2020Inspection
Found insufficient staff to meet residents' scheduled and unscheduled needs.
Licensing—Failed to provide appropriate staffing
28 Apr 2020Abuse: Neglect
28 Apr 2020Abuse: Neglect
Investigated an allegation of neglect and abuse for failing to follow a resident's care plan, which led to an altercation; a $375 fine was assessed.
Abuse—Failed to follow care plan
22 Apr 2020Inspection
22 Apr 2020Inspection
Found a deficiency for failing to maintain a safe physical environment.
Licensing—Failed to maintain a safe physical environment
21 Apr 2020Abuse: Neglect
21 Apr 2020Abuse: Neglect
Investigated and found that staff failed to follow a resident's care plan by keeping the door locked, allowing entry and causing an injury to the resident.
Abuse—Failed to follow care plan
16 Apr 2020Inspection
16 Apr 2020Inspection
Found inadequate professional oversight of the medication administration system.
Licensing—Failed to provide a safe medication administration system
15 Apr 2020Abuse: Neglect
15 Apr 2020Abuse: Neglect
Investigated and found staff failed to supervise residents with aggressive behaviors and did not follow the care plan. This resulted in neglect and abuse.
Abuse—Failed to follow care plan
04 Apr 2020Abuse: Neglect
04 Apr 2020Abuse: Neglect
Identified neglect and abuse due to failure to provide a safe environment and inadequate care planning for behaviors, creating risk to residents; a fine was assessed.
Abuse—Failed to provide safe environment
29 Mar 2020Abuse: Neglect
29 Mar 2020Abuse: Neglect
Investigated allegations of neglect for failing to provide a safe environment, findings indicated abuse and neglect in the care of a resident, and a fine was assessed.
Abuse—Failed to provide safe environment
22 Mar 2020Abuse: Neglect
22 Mar 2020Abuse: Neglect
Found violations of care plan adherence and door security, violating resident rights and constituting neglect and abuse. A $375 fine was assessed.
Abuse—Failed to follow care plan
21 Mar 2020Abuse: Neglect
21 Mar 2020Abuse: Neglect
Identified violations for failing to secure medications and prevent theft; one employee admitted taking medications for a family member, constituting financial abuse and neglect, and a fine was assessed.
Abuse—Failure to provide a system that prevents theft or misuse of medication
16 Mar 2020Abuse: Neglect
16 Mar 2020Abuse: Neglect
Investigated and found neglect and abuse due to not following care plans, with a $375 fine assessed.
Abuse—Failed to follow care plan
12 Mar 2020Abuse: Neglect
12 Mar 2020Abuse: Neglect
Found that supervision and staff support failed for residents with known behaviors, resulting in an incident where one resident placed hands around another resident's neck, causing discomfort and risk of harm.
Abuse—Failed to provide safe environment
22 Feb 2020Inspection
22 Feb 2020Inspection
Confirmed the failure to immediately notify the local SPD office or the local AAA of any abuse or suspected abuse.
Licensing—Failed to report potential or suspected abuse
10 Feb 2020Abuse: Neglect
10 Feb 2020Abuse: Neglect
Investigated a complaint and found supervision failures that led to an incident causing redness and discomfort, constituting neglect and abuse.
Abuse—Failed to provide safe environment
08 Feb 2020Abuse: Neglect
08 Feb 2020Abuse: Neglect
Investigated and identified neglect and abuse due to inadequate supervision and staff support, resulting in an incident that caused discomfort to a resident.
Abuse—Failed to provide safe environment
02 Jan 2020Abuse: Neglect
02 Jan 2020Abuse: Neglect
Investigated a complaint and found a failure to provide a safe environment due to insufficient supervision; an incident involved a resident being hit and experiencing discomfort.
Abuse—Failed to provide safe environment
26 Dec 2019Inspection
26 Dec 2019Inspection
Investigated and found that the tab alarm was not attached to the resident's wheelchair during a transfer, leading to a fall and injury; the action violated resident rights and created an unsafe environment.
Licensing—Failed to provide safe environment
01 Dec 2019Abuse: Neglect
01 Dec 2019Abuse: Neglect
Found supervision and staff support inadequate regarding known behaviors, resulting in an incident causing a bruise and discomfort; a fine was assessed.
Abuse—Failed to provide safe environment
29 Nov 2019Abuse: Neglect
29 Nov 2019Abuse: Neglect
Found that supervision and staff support were inadequate regarding known behaviors, resulting in an incident where an arm was squeezed causing discomfort, constituting abuse.
Abuse—Failed to provide safe environment
11 Nov 2019Abuse: Neglect
11 Nov 2019Abuse: Neglect
Investigated a complaint and found supervision and staff support were inadequate, leading to an incident where a person grabbed another by the shoulder and squeezed, causing discomfort.
Abuse—Failed to provide safe environment
10 Nov 2019Abuse: Neglect
10 Nov 2019Abuse: Neglect
Investigated a complaint about supervision and fall risks and found neglect of care and abuse, violating resident rights. Found an incident where a resident grabbed and shook another.
Abuse—Failed to provide safe environment
08 Oct 2019Abuse: Physical Abuse
08 Oct 2019Abuse: Physical Abuse
Investigated an abuse allegation and found that a resident was subjected to rough treatment and neglected, which caused unreasonable discomfort.
Abuse—Failed to protect resident from rough treatment
25 Sept 2019Abuse: Neglect
25 Sept 2019Abuse: Neglect
Investigated and found neglect of basic resident care, creating risk of serious harm; a fine was assessed.
Abuse—Failed to provide safe environment
20 Sept 2019Abuse: Neglect
20 Sept 2019Abuse: Neglect
Investigated a neglect allegation and found failure to provide basic care, risking serious harm.
Abuse—Failed to provide safe environment
18 Sept 2019Abuse: Neglect
18 Sept 2019Abuse: Neglect
Determined neglect of a vulnerable adult by failing to provide basic care, creating a risk of serious harm. A $375 fine was assessed.
Abuse—Failed to provide safe environment
16 Sept 2019Abuse: Neglect
16 Sept 2019Abuse: Neglect
Found neglect due to inadequate supervision that caused unreasonable discomfort and assessed a $188 fine.
Abuse—Failed to provide safe environment
01 Sept 2019Abuse: Neglect
01 Sept 2019Abuse: Neglect
Found that resident rights were violated due to neglect and abuse, resulting in multiple falls and unsafe conditions by restricting indoor power chair use.
Abuse—Failed to assure resident rights
29 Aug 2019Abuse: Neglect
29 Aug 2019Abuse: Neglect
Identified failures to supervise and intervene, allowing unprovoked resident-to-resident altercations, with a fine assessed.
Abuse—Failed to provide safe environment
25 Jul 2019Inspection
25 Jul 2019Inspection
Found a failure to provide a safe medication administration system, resulting in a resident receiving twice the prescribed morphine dose.
Licensing—Failed to provide a safe medication administration system
18 Jun 2019Inspection
18 Jun 2019Inspection
Investigated a complaint and found neglect of care and an unsafe environment when a staff member did not supervise a resident during bathroom assistance, who then fell.
Licensing—Failed to provide safe environment
06 Jun 2019Abuse: Neglect
06 Jun 2019Abuse: Neglect
Found neglect of a resident by failing to provide basic care, creating risk of serious harm. A $375 fine was assessed.
Abuse—Failed to follow care plan
31 May 2019Abuse: Neglect
31 May 2019Abuse: Neglect
Investigated the neglect allegation and found inadequate supervision that created risk of serious harm; a fine was assessed.
Abuse—Failed to follow care plan
26 May 2019Abuse: Neglect
26 May 2019Abuse: Neglect
Investigated an abuse allegation and found neglect due to inadequate supervision, creating risk of serious harm.
Abuse—Failed to address resident's behavior
17 May 2019Abuse: Neglect
17 May 2019Abuse: Neglect
Investigated an allegation of neglect for failing to follow a care plan, which created a risk of serious harm to a resident.
Abuse—Failed to follow care plan
20 Apr 2019Abuse: Neglect
20 Apr 2019Abuse: Neglect
Investigated neglect allegation and found inadequate supervision that created risk of serious harm.
Abuse—Failed to properly plan care
16 Apr 2019Abuse: Neglect
16 Apr 2019Abuse: Neglect
Found neglect of a resident by failing to provide basic care, resulting in unreasonable discomfort; a fine was assessed.
Abuse—Failed to follow care plan
09 Apr 2019Abuse: Neglect
09 Apr 2019Abuse: Neglect
Investigated a medication administration neglect allegation; found failure to administer medications as ordered, creating risk of serious harm, and assessed a fine.
Abuse—Failed to provide a safe medication administration system
08 Apr 2019Inspection
08 Apr 2019Inspection
Found a deficiency involving an unsafe environment due to inadequate supervision that caused actual physical harm.
Licensing—Failed to provide safe environment
20 Feb 2019Abuse: Neglect
20 Feb 2019Abuse: Neglect
Found neglect for failing to answer a call light promptly, with moderate harm or potential for serious harm.
Abuse—Failed to answer call light in a timely manner
20 Feb 2019Inspection
20 Feb 2019Inspection
Determined that the allegation of failing to report potential or suspected abuse was substantiated and a $1,000 fine was assessed.
Licensing—Failed to report potential or suspected abuse
20 Feb 2019Inspection
20 Feb 2019Inspection
Investigated a report and found a failure to report suspected abuse; a $750 fine was assessed.
Licensing—Failed to report potential or suspected abuse
16 Jan 2019Abuse: Neglect
16 Jan 2019Abuse: Neglect
Investigated a neglect allegation and found inadequate supervision resulting in significant emotional harm. A fine of 188 dollars was assessed.
Abuse—Failed to provide safe environment
07 Jan 2019Abuse: Neglect
07 Jan 2019Abuse: Neglect
Found neglect due to failure to provide basic care related to falls, resulting in harm; a fine was assessed.
Abuse—Failed to adequately care plan related to falls
20 Dec 2018Abuse: Neglect
20 Dec 2018Abuse: Neglect
Investigated an allegation of neglect and found that basic care was not provided, resulting in a fungal rash.
Abuse—Failed to intervene when resident's condition changed
15 Dec 2018Abuse: Neglect
15 Dec 2018Abuse: Neglect
Found neglect due to inadequate supervision that resulted in actual physical harm and discomfort.
Abuse—Failed to provide safe environment
05 Nov 2018Abuse: Financial abuse
05 Nov 2018Abuse: Financial abuse
Determined that financial exploitation occurred, with property taken through theft resulting in a $250 loss. The allegation was substantiated.
Abuse—Failed to protect resident from financial exploitation
05 Jun 2018Abuse: Neglect
05 Jun 2018Abuse: Neglect
Found that basic care needed to maintain RV1's safety was not provided.
Abuse—Failed to follow care plan
26 Apr 2018Inspection
26 Apr 2018Inspection
Investigated an allegation of an unsafe environment and found lack of proper safety for residents. A fine of $375 was assessed.
Licensing—Failed to provide safe environment
24 Apr 2018Inspection
24 Apr 2018Inspection
Investigated the incident and found a failure to provide a safe environment that led to an assault.
Licensing—Failed to provide safe environment
09 Apr 2018Abuse: Neglect
09 Apr 2018Abuse: Neglect
Found failure to provide safe care, with potential for harm.
Abuse—Failed to provide safe environment
25 Mar 2018Inspection
25 Mar 2018Inspection
Identified safety deficiencies and violations.
Licensing—Failed to follow care plan
24 Jan 2018Abuse: Financial abuse
24 Jan 2018Abuse: Financial abuse
Found that a resident was financially exploited due to a lack of secure environment, resulting in theft.
Abuse—Failed to protect resident from financial exploitation
04 Jan 2018Inspection
04 Jan 2018Inspection
Investigated the allegation and identified a deficiency in providing a safe environment.
Licensing—Failed to provide safe environment
04 Dec 2017Abuse: Neglect
04 Dec 2017Abuse: Neglect
Investigated an allegation of failing to provide a safe environment and found failure to assess and intervene.
Abuse—Failed to provide safe environment
10 Oct 2017Inspection
10 Oct 2017Inspection
Investigated the allegation of failing to administer ordered medication and found an inadequate medication regimen.
Licensing—Failed to administer ordered medication
01 Oct 2017Abuse: Neglect
01 Oct 2017Abuse: Neglect
Found deficiencies related to failure to assess and intervene to provide a safe environment.
Abuse—Failed to provide safe environment
29 Sept 2017Abuse: Financial abuse
29 Sept 2017Abuse: Financial abuse
Investigated and substantiated that a resident was not protected from theft and financial exploitation.
Abuse—Failed to protect resident from financial exploitation
23 Sept 2017Abuse: Financial abuse
23 Sept 2017Abuse: Financial abuse
Determined that a resident was not protected from theft related to financial exploitation, and assessed a $250 fine.
Abuse—Failed to protect resident from financial exploitation
18 Sept 2017Abuse: Financial abuse
18 Sept 2017Abuse: Financial abuse
Investigated the financial exploitation allegation and substantiated a failure to protect a resident from theft.
Abuse—Failed to protect resident from financial exploitation
09 Sept 2017Inspection
09 Sept 2017Inspection
Concluded that a safe environment for residents was not provided.
Licensing—Failed to provide safe environment
23 Aug 2017Abuse: Financial abuse
23 Aug 2017Abuse: Financial abuse
Investigated the allegation of financial abuse and found a failure to protect a resident from theft.
Abuse—Failed to protect resident from financial exploitation
05 Jul 2017Abuse: Neglect
05 Jul 2017Abuse: Neglect
Investigated a neglect allegation and found a failure to provide a secure environment.
Abuse—Failed to provide safe environment
28 Jun 2017Abuse: Neglect
28 Jun 2017Abuse: Neglect
Found failure to assess and intervene after a neglect allegation.
Abuse—Failed to provide service
28 Jun 2017Inspection
28 Jun 2017Inspection
Investigated the allegation that prescribed care wasn't provided. Determined that prescribed care was not administered.
Licensing—Failed to provide service
17 Jun 2017Abuse: Neglect
17 Jun 2017Abuse: Neglect
Found a failure to provide a safe environment, resulting in a resident fall due to improper transfer.
Abuse—Failed to provide safe environment
15 May 2017Inspection
15 May 2017Inspection
Investigated the allegation and found a safety failure leading to a resident-to-resident altercation.
Licensing—Failed to provide safe environment
06 May 2017Abuse: Neglect
06 May 2017Abuse: Neglect
Investigated an allegation of neglect and found a deficiency for failing to provide a safe environment.
Abuse—Failed to provide safe environment
03 May 2017Inspection
03 May 2017Inspection
Investigated an allegation of failing to administer ordered medication and found that basic services were not provided, causing unreasonable discomfort.
Licensing—Failed to administer ordered medication
19 Apr 2017Inspection
19 Apr 2017Inspection
Found that a safe environment was not provided.
Licensing—Failed to provide safe environment
23 Jan 2017Abuse: Financial abuse
23 Jan 2017Abuse: Financial abuse
Found a failure to protect a resident from theft, indicating financial exploitation occurred.
Abuse—Failed to protect resident from financial exploitation
14 Nov 2016Inspection
14 Nov 2016Inspection
Determined the allegation of failing to provide a safe environment; identified a failure to assess and intervene.
Licensing—Failed to provide safe environment
01 Nov 2016Abuse: Financial abuse
01 Nov 2016Abuse: Financial abuse
Investigated a financial exploitation allegation and found that a resident's property was not adequately protected from theft.
Abuse—Failed to protect resident from financial exploitation
28 Oct 2016Inspection
28 Oct 2016Inspection
Found failure to protect residents from harm. Identified as a Level 2 licensing violation.
Licensing—Failed to provide safe environment
18 Oct 2016Abuse: Neglect
18 Oct 2016Abuse: Neglect
Investigated a medication safety issue and found the incorrect medication was administered.
Abuse—Failed to provide a safe medication administration system
19 Jul 2016Abuse: Neglect
19 Jul 2016Abuse: Neglect
Determined that the neglect allegation of failing to intervene when a resident's condition changed was supported.
Abuse—Failed to intervene when resident's condition changed
24 Jun 2016Abuse: Financial abuse
24 Jun 2016Abuse: Financial abuse
Investigated a financial exploitation allegation and found failures to protect residents from theft.
Abuse—Failed to protect resident from financial exploitation
13 Jun 2016Inspection
13 Jun 2016Inspection
Investigated a complaint and substantiated a licensing violation for failing to provide a safe environment by not protecting a resident from verbal/emotional wrongdoing.
Licensing—Failed to provide safe environment
04 Jun 2016Abuse: Financial abuse
04 Jun 2016Abuse: Financial abuse
Investigated an allegation of financial exploitation and found a resident was not protected from theft.
Abuse—Failed to protect resident from financial exploitation
12 May 2016Abuse: Neglect
12 May 2016Abuse: Neglect
Investigated the neglect allegation and found failures to provide a safe environment and to assess and intervene.
Abuse—Failed to provide safe environment
08 May 2016Abuse: Financial abuse
08 May 2016Abuse: Financial abuse
Found a failure to protect a resident from financial exploitation.
Abuse—Failed to protect resident from financial exploitation
28 Mar 2016Inspection
28 Mar 2016Inspection
Investigated an allegation of unsafe medication administration and found a failure to maintain a safe medication system that placed a resident at risk of serious harm.
Licensing—Failed to provide a safe medication administration system
28 Jan 2016Abuse: Neglect
28 Jan 2016Abuse: Neglect
Identified failure to provide a safe environment.
Abuse—Failed to provide safe environment
21 Jan 2016Inspection
21 Jan 2016Inspection
Identified a deficiency in medication management, finding no system for disposal of all unused medications and no approved process for tracking controlled substances.
Licensing—Failed to provide a safe medication administration system
21 Jan 2016Inspection
21 Jan 2016Inspection
Investigated an allegation of failing to provide appropriate housekeeping services. Found the interior not free of unpleasant odors in violation of the rule requiring an interior free of unpleasant odors.
Licensing—Failed to provide appropriate housekeeping services
13 Nov 2015Abuse: Neglect
13 Nov 2015Abuse: Neglect
Investigated a complaint about medication safety and found an inadequate medication regimen.
Abuse—Failed to provide a safe medication administration system
31 Jul 2015Inspection
31 Jul 2015Inspection
Investigated and determined the allegation to be substantiated that staff failed to assess and intervene when a resident's condition changed.
Licensing—Failed to intervene when resident's condition changed
31 Jul 2015Inspection
31 Jul 2015Inspection
Investigated a licensing allegation that a resident record was not kept current or accurate, and identified a failure to assess and intervene.
Licensing—Failed to keep resident record current or accurate
31 Jul 2015Abuse: Neglect
31 Jul 2015Abuse: Neglect
Found a failure to provide a safe environment.
Abuse—Failed to address resident's behavior
09 Jul 2015Abuse: Neglect
09 Jul 2015Abuse: Neglect
Investigated a neglect allegation and found failure to follow the care plan.
Abuse—Failed to follow care plan
29 Jun 2015Abuse: Neglect
29 Jun 2015Abuse: Neglect
Investigated and found a failure to follow the care plan, with potential for harm.
Abuse—Failed to follow care plan
15 Mar 2015Abuse: Neglect
15 Mar 2015Abuse: Neglect
Found a neglect-related deficiency due to not providing appropriate care. A $200 fine was assessed.
Abuse—Failed to address resident's behavior
07 Feb 2015Abuse: Neglect
07 Feb 2015Abuse: Neglect
Investigated a neglect allegation and found care not provided as per the care plan.
Abuse—Failed to follow care plan
01 Jan 2015Inspection
01 Jan 2015Inspection
Identified a deficiency for failing to follow the care plan, with potential for minor to moderate harm.
Licensing—Failed to follow care plan
12 Dec 2014Inspection
12 Dec 2014Inspection
Investigated an allegation that staff failed to address a resident's behavior and to provide a safe environment.
Licensing—Failed to address resident's behavior
20 Nov 2014Inspection
20 Nov 2014Inspection
Found the care plan was not followed. This is a licensing violation.
Licensing—Failed to follow care plan
09 Nov 2014Abuse: Neglect
09 Nov 2014Abuse: Neglect
Investigated and identified a failure to protect a resident from unwanted sexual contact. A $300 fine was assessed.
Abuse—Failed to protect resident from inappropriate sexual contact
06 Nov 2014Abuse: Neglect
06 Nov 2014Abuse: Neglect
Investigated an abuse/neglect allegation and identified a failure to provide a safe environment.
Abuse—Failed to address resident's behavior
15 Oct 2014Inspection
15 Oct 2014Inspection
Investigated a complaint and found failure to follow the care plan.
Licensing—Failed to follow care plan
14 Oct 2014Inspection
14 Oct 2014Inspection
Investigated the allegation and found a failure to follow the care plan.
Licensing—Failed to follow care plan
11 Oct 2014Inspection
11 Oct 2014Inspection
Investigated and found deficiencies related to safety and care for a resident.
Licensing—Failed to provide safe environment
30 Sept 2014Abuse: Financial abuse
30 Sept 2014Abuse: Financial abuse
Determined that a staff member used residents' resources for personal use, constituting financial abuse.
Abuse—Failed to provide safe environment
30 Sept 2014Abuse: Neglect
30 Sept 2014Abuse: Neglect
Investigated an abuse/neglect allegation and found failure to follow care plans, which led to an altercation between residents.
Abuse—Failed to follow care plan
30 Sept 2014Inspection
30 Sept 2014Inspection
Found that care plan was not followed, placing a resident at serious risk of harm.
Licensing—Failed to follow care plan
14 Sept 2014Abuse: Financial abuse
14 Sept 2014Abuse: Financial abuse
Identified a failure to protect a resident from theft. The finding indicated an unsafe environment.
Abuse—Failed to provide safe environment
30 Aug 2014Abuse: Financial abuse
30 Aug 2014Abuse: Financial abuse
Found that a resident's resources were wrongfully taken due to failure to protect them.
Abuse—Failed to provide safe environment
29 Aug 2014Abuse: Financial abuse
29 Aug 2014Abuse: Financial abuse
Investigated a financial abuse allegation and found a failure to protect a resident from wrongful taking, with a $400 fine assessed.
Abuse—Failed to provide safe environment
13 Aug 2014Abuse: Financial abuse
13 Aug 2014Abuse: Financial abuse
Investigated a financial abuse allegation and found the provider failed to protect a resident's property.
Abuse—Failed to provide safe environment
11 Aug 2014Abuse: Neglect
11 Aug 2014Abuse: Neglect
Found a failure to provide a safe environment.
Abuse—Failed to provide safe environment
05 Aug 2014Abuse: Neglect
05 Aug 2014Abuse: Neglect
Investigated and found neglect due to a failure to assess and intervene with a resident's behavior.
Abuse—Failed to address resident's behavior
21 Jul 2014Abuse: Financial abuse
21 Jul 2014Abuse: Financial abuse
Investigated a financial abuse allegation and found a secure environment was not provided.
Abuse—Failed to provide safe environment
06 Jul 2014Abuse: Financial abuse
06 Jul 2014Abuse: Financial abuse
Investigated and found the allegation of failing to provide a safe environment; residents were not protected from theft.
Abuse—Failed to provide safe environment
17 Jun 2014Inspection
17 Jun 2014Inspection
Identified deficiencies for failing to address a resident's behavior.
Licensing—Failed to address resident's behavior
05 May 2014Abuse: Financial abuse
05 May 2014Abuse: Financial abuse
Investigated and determined that a secure environment was not provided.
Abuse—Failed to provide safe environment
27 Mar 2014Abuse: Neglect
27 Mar 2014Abuse: Neglect
Found neglect due to failure to answer a call light promptly.
Abuse—Failed to answer call light in a timely manner
20 Feb 2014Abuse: Financial abuse
20 Feb 2014Abuse: Financial abuse
Identified a financial abuse allegation and found a failure to protect a resident's property from theft.
Abuse—Failed to provide safe environment
29 Dec 2013Abuse: Neglect
29 Dec 2013Abuse: Neglect
Investigated an allegation of neglect and determined there was a failure to oversee and monitor changes in condition. The finding noted a failure to assess and intervene.
Abuse—Failed to provide oversight and monitoring of change of condition
11 Oct 2013Abuse: Financial abuse
11 Oct 2013Abuse: Financial abuse
Determined a failure to protect funds from loss, creating financial risk for a resident.
Abuse—Failed to provide safe environment
23 May 2013Inspection
23 May 2013Inspection
Investigated a complaint and found a failure to answer a call light in a timely manner, risking resident care.
Licensing—Failed to answer call light in a timely manner
13 Feb 2013Abuse: Financial abuse
13 Feb 2013Abuse: Financial abuse
Investigated a financial abuse allegation and concluded there was a failure to protect a resident from theft. The finding shows a failure to provide a safe environment.
Abuse—Failed to provide safe environment
06 Jan 2013Abuse: Neglect
06 Jan 2013Abuse: Neglect
Investigated an abuse/neglect allegation and found that a safe environment was not provided.
Abuse—Failed to address resident's behavior
29 Dec 2012Abuse: Financial abuse
29 Dec 2012Abuse: Financial abuse
Investigated a financial abuse allegation and found a failure to protect a resident from loss of funds.
Abuse—Failed to provide safe environment
26 Dec 2012Inspection
26 Dec 2012Inspection
Investigated the allegation of an unsafe medication administration system and identified an inadequate medication system.
Licensing—Failed to provide a safe medication administration system
14 Sept 2012Inspection
14 Sept 2012Inspection
Investigated the allegation that a safe medication administration system was not provided and found an inadequate medication regime.
Licensing—Failed to provide a safe medication administration system
23 Jul 2012Abuse: Financial abuse
23 Jul 2012Abuse: Financial abuse
Investigated and found a failure to protect residents from theft.
Abuse—Failed to provide safe environment
15 Jul 2012Abuse: Financial abuse
15 Jul 2012Abuse: Financial abuse
Concluded that a safety deficiency occurred and found that a resident was not protected from the theft of her wedding ring.
Abuse—Failed to provide safe environment
08 Jul 2012Inspection
08 Jul 2012Inspection
Investigated an allegation of failing to administer medication as ordered and identified inadequate care.
Licensing—Failed to administer medication as ordered
30 Jun 2012Inspection
30 Jun 2012Inspection
Investigated and found a safety deficiency involving failure to provide a safe environment and to address resident behavior, creating potential for harm.
Licensing—Failed to address resident's behavior
31 May 2012Abuse: Neglect
31 May 2012Abuse: Neglect
Investigated the allegation of neglect and identified a failure to provide a safe environment.
Abuse—Failed to address resident's behavior
03 May 2012Abuse: Neglect
03 May 2012Abuse: Neglect
Investigated an allegation of failure to administer medication as ordered; found an inadequate medication regime.
Abuse—Failed to administer medication as ordered
09 Apr 2012Abuse: Financial abuse
09 Apr 2012Abuse: Financial abuse
Concluded that a resident was not protected from financial exploitation.
Abuse—Failed to provide safe environment
16 Mar 2012Inspection
16 Mar 2012Inspection
Found that RV were not protected from rough treatment, creating a safety risk.
Licensing—Failed to provide safe environment
27 Jan 2012Abuse: Financial abuse
27 Jan 2012Abuse: Financial abuse
Investigated a financial abuse allegation and found a failure to protect a resident from theft.
Abuse—Failed to provide safe environment
26 Dec 2011Abuse: Neglect
26 Dec 2011Abuse: Neglect
Investigated a neglect allegation and found a failure to provide a safe environment, resulting in a fine.
Abuse—Failed to address resident's behavior
12 Dec 2011Abuse: Financial abuse
12 Dec 2011Abuse: Financial abuse
Found a safety deficiency that left a resident at risk of theft.
Abuse—Failed to provide safe environment
08 Dec 2011Abuse: Financial abuse
08 Dec 2011Abuse: Financial abuse
Found a safety deficiency by not protecting a resident from theft. The financial abuse allegation was involved.
Abuse—Failed to provide safe environment
05 Nov 2011Abuse: Neglect
05 Nov 2011Abuse: Neglect
Fined $250 after finding a failure to provide a safe environment and to address a resident's behavior.
Abuse—Failed to address resident's behavior
05 Nov 2011Abuse: Physical Abuse
05 Nov 2011Abuse: Physical Abuse
Investigated a complaint and found that a resident was not protected from rough treatment.
Abuse—Failed to protect resident from rough treatment
28 Oct 2011Abuse: Neglect
28 Oct 2011Abuse: Neglect
Found failure to provide a secure environment.
Abuse—Failed to address resident's behavior
11 Oct 2011Abuse: Neglect
11 Oct 2011Abuse: Neglect
Investigated an abuse/neglect allegation and found failure to assess and intervene, resulting in a $250 fine.
Abuse—Failed to address resident's behavior
26 Aug 2011Abuse: Neglect
26 Aug 2011Abuse: Neglect
Investigated an abuse/neglect allegation and found failure to provide appropriate care.
Abuse—Failed to address resident's behavior
04 Aug 2011Abuse: Neglect
04 Aug 2011Abuse: Neglect
Investigated and found a failure to follow the care plan.
Abuse—Failed to follow care plan
23 Jul 2011Inspection
23 Jul 2011Inspection
Investigated and identified a failure to provide a safe environment.
Licensing—Failed to address resident's behavior
03 Jul 2011Abuse: Neglect
03 Jul 2011Abuse: Neglect
Investigated an allegation of neglect and found a failure to provide a safe environment.
Abuse—Failed to address resident's behavior
09 Apr 2011Inspection
09 Apr 2011Inspection
Investigated and found a failure to provide a safe environment.
Licensing—Failed to provide safe environment
13 Mar 2011Inspection
13 Mar 2011Inspection
Found a safety deficiency due to failure to follow the care plan, resulting in an unsafe environment.
Licensing—Failed to follow care plan
23 Feb 2011Abuse: Neglect
23 Feb 2011Abuse: Neglect
Identified deficiencies in care planning for two residents. The finding related to a substantiated allegation of failing to address resident behavior.
Abuse—Failed to address resident's behavior
01 Aug 2010Inspection
01 Aug 2010Inspection
Investigated the allegation of failing to provide a safe medication administration system and found that appropriate care was not provided. A safety issue was identified.
Licensing—Failed to provide a safe medication administration system
23 Jun 2010Abuse: Neglect
23 Jun 2010Abuse: Neglect
Identified a neglect violation resulting in a resident transfer to hospital; imposed a $400 fine.
Abuse—Failed to assure timely medical treatment
05 May 2010Abuse: Neglect
05 May 2010Abuse: Neglect
Investigated an allegation of neglect and identified a failure to administer medication as ordered.
Abuse—Failed to administer ordered medication
21 Apr 2010Abuse: Neglect
21 Apr 2010Abuse: Neglect
Found abuse/neglect occurred due to failure to intervene when a resident's condition changed. A repeat deficiency related to weight loss was noted, with a sanction of $300 assessed.
Abuse—Failed to intervene when resident's condition changed
17 Mar 2010Inspection
17 Mar 2010Inspection
Investigated a complaint and found a failure to follow the care plan that resulted in an unsafe, insecure environment.
Licensing—Failed to follow care plan
10 Mar 2010Abuse: Neglect
10 Mar 2010Abuse: Neglect
Investigated a neglect allegation and found failure to follow the care plan, with a $250 fine assessed.
Abuse—Failed to provide safe environment
24 Feb 2010Abuse: Neglect
24 Feb 2010Abuse: Neglect
Found a failure to provide a safe environment for residents.
Abuse—Failed to provide safe environment
10 Feb 2010Abuse: Neglect
10 Feb 2010Abuse: Neglect
Found a neglect violation for failing to intervene when a resident's condition changed, and assessed a $300 fine.
Abuse—Failed to intervene when resident's condition changed
09 Feb 2010Abuse: Neglect
09 Feb 2010Abuse: Neglect
Investigated an allegation of neglect and found a failure to provide a safe environment and to intervene when a resident's condition changed. A $2,500 fine was assessed.
Abuse—Failed to intervene when resident's condition changed
09 Feb 2010Abuse: Neglect
09 Feb 2010Abuse: Neglect
Investigated an allegation of neglect and found a failure to assess and intervene.
Abuse—Failed to provide appropriate skin care
07 Feb 2010Abuse: Neglect
07 Feb 2010Abuse: Neglect
Identified a deficiency for failing to maintain a safe environment.
Abuse—Failed to properly plan care
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