Pricing ranges from
    $7,372 – 9,583/month

    Jefferson Lodge Memory Care Community

    664 SE Jefferson St, Dallas, OR 97338
    • Assisted Living
    • Memory Care

    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

    Memory care community services

    • Mild cognitive impairment
    • Specialized memory care programming

    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

    3.73·(26)

    Overall rating

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

      3.7
    • Staff

      4.1
    • Meals

      3.7
    • Amenities

      4.3
    • Value

      2.0

    Pros

    • Clean, well-maintained environment
    • Home-like common areas and formal dining room
    • Spacious private rooms
    • Secure indoor and outdoor walking areas
    • Compassionate, welcoming staff
    • Color-coded staff role identification
    • Organized admissions and move-in process
    • Nutritious, varied meal options
    • Frequent staff check-ins and attentive bedside care
    • Strong hospice and end-of-life collaboration
    • Engaging activities program when staffed
    • Recently remodeled facility and pleasant outdoor spaces
    • Small, family-like community atmosphere
    • Convenient location for visitors

    Cons

    • Inconsistent staffing levels
    • Canceled or poorly organized activities due to staffing
    • Variable dementia-care consistency
    • Inconsistent personal-care assistance and bathing schedules
    • Incontinence-care concerns
    • High private-pay cost
    • Occasional unprofessional staff conduct and noisy common areas
    • Staff turnover and inexperienced management

    Summary of reviews

    Overall impression: Jefferson Lodge Memory Care Community is frequently described as a clean, inviting, and recently remodeled small community with home-like common areas, spacious private rooms, and accessible indoor and outdoor walking areas. Many families found the facility welcoming and appreciated visible safety protocols, color-coded staff identification, and an organized admissions and move-in process. The setting and some staff behaviors contributed to a sense of comfort for prospective residents and their relatives.

    Care quality: Several families praised compassionate, attentive caregiving, including regular check-ins, pain monitoring, and a collaborative approach with hospice for end-of-life support. Residents were often treated respectfully and addressed by name, and reviewers noted that staff could be reassuring during transitions. At the same time, accounts indicate variable consistency in personal-care tasks—examples include limited bathing frequency and gaps in hands-on assistance for residents with higher needs. There are also incontinence-care concerns that prospective families should clarify with management. In short, clinical and personal care is often strong but appears to vary by staffing and case complexity.

    Staff and management: Reviewers repeatedly described friendly, warm, and helpful staff members and highlighted specific strengths such as an engaged activities director and staff role identification. However, there are recurring operational concerns: inconsistent staffing levels, the presence of newer or inexperienced staff, and perceptions of inexperienced management. These staffing dynamics appear to affect service reliability and, in some accounts, contribute to occasional unprofessional conduct and a noisier environment in hallways. Prospective families should ask about current staffing ratios, staff turnover, and supervision when touring the community.

    Dining and activities: Meals are commonly characterized as nutritious, varied, and served in a pleasant dining environment with multiple choices. Many reviewers appreciated that meals were served with attention and kindness. Activities include bingo, exercise, hands-on tasks, and visiting artists; when activities are staffed and well organized they are described as engaging and meaningful. Several reviewers, however, reported activity cancellations or poor organization tied to staffing shortages, so scheduled programming can be inconsistent.

    Facilities and logistics: The physical environment scores well—recent remodeling, welcoming common rooms, two sizable outdoor areas, and a courtyard are consistently noted. The facility’s location and friendliness of other residents were also seen as positives for families who visit frequently. Admissions and move-in procedures were described as organized and supportive in many accounts.

    Notable patterns and considerations: The strongest and most consistent positives are cleanliness, a home-like atmosphere, compassionate individual staff, good meals, and strong hospice collaboration. The primary operational weaknesses are related to staffing and management stability, which contribute to variability in dementia-care consistency, personal-care assistance, activity programming, and occasional lapses in professionalism. Cost is another clear theme—care is described as private-pay and relatively expensive, which makes assessing reliability of services particularly important for decision-making. Prospective families should prioritize in-person observation of staffing levels, inquire about bathing and incontinence-care protocols, verify dementia-care capabilities for higher-dependency needs, and review current staffing/management plans before committing.

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    Location

    Jefferson Lodge Memory Care Community is located at 664 SE Jefferson St, Dallas, OR, 97338.

    About Jefferson Lodge Memory Care Community

    Jefferson Lodge Memory Care Community is nestled in a quiet Dallas, Oregon, neighborhood, surrounded by vineyards and rolling hills that set a tranquil atmosphere reminiscent of small-town charm. This intimate community has been thoughtfully designed to provide exceptional, personalized memory care for individuals living with Alzheimer’s disease and other types of dementia. Residents benefit from a warm and welcoming environment that radiates compassion, where they are made to feel valued, purposeful, and loved each day. Jefferson Lodge truly feels like home, thanks to its focus on meaningful connections between residents, their families, and care partners.

    The community features a fully renovated building with architecturally and operationally innovative spaces. Bright, oversized windows line the hallways, inviting natural light and scenic views into daily life. A welcoming lobby sets the tone for a home-like experience, while comfortable common areas, such as the living room with a grand piano, provide inviting spots for socialization and relaxation. Residents can also safely enjoy a secure outdoor courtyard, perfect for activities, special events, and visits with loved ones. At the heart of Jefferson Lodge is an open kitchen, serving as the hub of the community where activities and dining come together to provide both nourishment and opportunities for engagement.

    At Jefferson Lodge, care is guided by best-practices research and thoughtful consultations with families who have experienced Alzheimer’s and other dementias firsthand. The Mosaic Memory Care Program is at the heart of this approach, celebrating all the unique pieces that make up each resident’s life. Rooted in the Positive Approach to Care philosophy, Mosaic is thoughtfully designed to honor residents at every stage of their journey, supporting them with enriching, individualized programs and experiences. The small size of the community allows each care team member to form meaningful bonds with residents, ensuring a deep understanding of each person’s story, strengths, preferences, and changing abilities.

    Residents at Jefferson Lodge enjoy a variety of daily programs, events, and entertainment curated by wellness and life-enrichment teams. These offerings enhance each resident’s physical, social, emotional, and spiritual well-being, recognizing that purposeful engagement leads to a better quality of life for those living with memory challenges. Meaningful activities are woven into the fabric of daily life, offering opportunities to connect, reminisce, and find joy. Every memory care apartment is designed with safety and comfort in mind, catering to a wide range of needs and budgets, and placing residents just steps away from a world of supportive services and enrichment opportunities.

    Dining plays a significant role at Jefferson Lodge, creating both comfort and connection for residents. Meals are served family style from the open kitchen, letting residents enjoy the sights, sounds, and delicious aromas of food being prepared throughout the day. Table settings feature brightly colored linens and china to enhance visual perception, while frequent baking helps conjure memories of home and the joy of shared meals. The EverDine program offers flexibility and choice, allowing memory care residents to select what, when, and where they would like to eat, with the ongoing support and companionship of the respectful dining team.

    For caregivers seeking temporary support for their loved ones, Jefferson Lodge offers respite care or short-term stays. This program is designed to give caregivers a necessary break, whether for self-care or travel, while providing their loved ones with engaging experiences and a chance to benefit from the stimulating, supportive community environment. Respite stays are an important resource, ensuring both caregivers and their loved ones experience renewal and connection.

    The dedicated team at Jefferson Lodge Memory Care Community is passionate about enhancing the lives of residents and providing peace of mind for families. Every associate—whether part of the culinary, caregiving, or maintenance team—brings not only expertise in dementia care but also a deep sense of commitment and genuine compassion. Empowerment and collaboration are hallmarks of the community’s approach, ensuring that the needs and preferences of residents are always at the forefront of care and daily life. Jefferson Lodge stands out as a loving, caring, and connected community where every individual is recognized, embraced, and supported with the dignity they deserve.

    About Cascade Living Group

    Jefferson Lodge Memory Care Community is managed by Cascade Living Group.

    Founded by four experienced partners, Cascade Living Group is a privately-owned senior living provider headquartered in Bothell, Washington. Operating 31 communities across Oregon, Nevada, California, Washington, and Arizona, they offer assisted living, independent living, and memory care services.

    People often ask...

    Jefferson Lodge Memory Care Community offers competitive pricing, with rates starting at a cost of $7,372 per month.

    Jefferson Lodge Memory Care Community offers assisted living and memory care.

    There are 43 photos of Jefferson Lodge Memory Care Community on Mirador.

    The full address for this community is 664 SE Jefferson St, Dallas, OR 97338.

    No, Jefferson Lodge 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.

    License number50M065
    StatusActive
    Facility typeResidential Care Facility
    Capacity55 residents
    LicenseeVOP Jefferson Lodge, LLC
    EffectiveJuly 18th, 1994
    Special certificationMemory Care
    View the official license record

    Inspection Reports

    248

    Reports

    0

    Type A Citations

    0

    Type B Citations

    5

    Complaints

    15

    Years

    02 Jun 2026Inspection
    Investigated and found that a staff member restrained a resident during feeding by holding the resident's wrists, preventing movement. This violated resident rights and constituted wrongful restraint, and the program failed to protect the resident from such restraint.
    • Licensing—Failed to use restraint properly
    24 May 2026Inspection
    Found failure to staff according to the posted staffing plan for two of three shifts on one day.
    • Licensing—Failed to provide appropriate staffing
    20 Mar 2026Abuse: Neglect
    Found a safety-environment violation due to neglect, placing residents at risk when a resident pushed another and a walker was kicked away, and interventions were ineffective.
    • Abuse—Failed to provide safe environment
    31 Jan 2026Abuse: Neglect
    Found abuse by neglect involving failure to maintain a functioning pressure alarm during transfers, risking harm to the client.
    • Abuse—Failed to follow care plan
    28 Jan 2026Abuse: Neglect
    Found abuse by neglect for failing to provide a safe environment, with a $375 fine assessed.
    • Abuse—Failed to provide safe environment
    20 Jan 2026Inspection
    Concluded that a records access violation occurred and was substantiated.
    • Licensing—Failed to provide safe environment
    20 Jan 2026Inspection
    Found a violation due to failing to provide records to the Department upon request. The failure violated the records access rule.
    • Licensing—Failed to provide safe environment
    17 Jan 2026Abuse: Neglect
    Investigated a hallway incident and found a failure to ensure resident safety, with a $500 fine assessed.
    • Abuse—Failed to provide safe environment
    12 Jan 2026Abuse: Neglect
    Investigated and found abuse by neglect due to failure to provide a safe environment and adequate supervision. The finding notes that an altercation occurred resulting in injury.
    • Abuse—Failed to provide safe environment
    12 Jan 2026Abuse: Neglect
    Found abuse by neglect due to inadequate staff supervision, which placed a resident at risk of harm when an altercation occurred.
    • Abuse—Failed to provide safe environment
    12 Jan 2026Abuse: Neglect
    Investigated alleged neglect with a substantiated finding of abuse, resulting in a fine for the provider due to supervision failures that placed a resident at risk.
    • Abuse—Failed to provide safe environment
    15 Dec 2025Abuse: Neglect
    Investigated and found that a safe environment was not provided due to an aggression incident between residents; no injuries occurred, but a risk of harm existed.
    • Abuse—Failed to provide safe environment
    13 Dec 2025Inspection
    Found that direct care staffing did not meet the posted staffing plan for one of three shifts reviewed.
    • Licensing—Failed to provide appropriate staffing
    13 Dec 2025Abuse: Neglect
    Investigated identified abuse by neglect due to a failure to provide a safe environment; a $375 fine was assessed.
    • Abuse—Failed to provide safe environment
    16 Nov 2025Inspection
    Found staffing did not meet the posted staffing plan on 2 of 3 shifts.
    • Licensing—Failed to provide appropriate staffing
    12 Nov 2025Abuse: Neglect
    Identified a failure to provide a safe environment because the bed alarm was not on or functioning, creating a fall risk. This reflects a safety deficiency.
    • Abuse—Failed to provide safe environment
    16 Oct 2025Inspection
    Found neglect and abuse due to failure to take vitals after a fall, placing the resident at risk.
    • Licensing—Failed to provide safe environment
    04 Oct 2025Abuse: Neglect
    Investigated allegations of failing to provide a safe environment; a resident with known aggressive behavior endangered others, resulting in a substantiated abuse/neglect finding and a fine.
    • Abuse—Failed to provide safe environment
    03 Oct 2025Abuse: Neglect
    Found abuse by neglect due to staff failing to intervene when two residents were near each other, placing one resident at risk; a $500 fine was assessed.
    • Abuse—Failed to provide safe environment
    01 Oct 2025Inspection
    Found that staff left a resident alone during toileting, leading to a fall and tailbone injuries, violating resident rights and constituting abuse.
    • Licensing—Failed to follow care plan
    22 Sept 2025Inspection
    Found that the posted staffing plan was not followed on one shift for one day.
    • Licensing—Failed to provide appropriate staffing
    17 Aug 2025Abuse: Neglect
    Found a failure to provide a safe environment, including an incident where a resident attempted to stab another with a fork. A $375 fine was assessed.
    • Abuse—Failed to provide safe environment
    03 Aug 2025Abuse: Neglect
    Investigated found failure to follow the care plan, leaving a known fall risk resident on the floor and urine-soaked, with a fine assessed.
    • Abuse—Failed to follow care plan
    03 Aug 2025Inspection
    Investigated an allegation of improper restraint and found that staff sedated a resident for convenience, constituting neglect and abuse.
    • Licensing—Failed to use restraint properly
    03 Aug 2025Abuse: Neglect
    Found a failure to provide a safe environment that endangered a resident, and a $375 fine was assessed.
    • Abuse—Failed to provide safe environment
    31 Jul 2025Inspection
    Found a violation of safe medication administration practices after investigation into an allegation that residents did not receive PRNs when needed and that an unprescribed medication was given.
    • Licensing—Failed to provide a safe medication administration system
    24 Jul 2025Inspection
    Investigated the allegation of inadequate staffing and found insufficient awake direct care staff to meet residents' 24-hour needs.
    • Licensing—Failed to meet the scheduled and unscheduled needs of residents
    22 Jul 2025Abuse: Neglect
    Identified neglect and abuse due to restraining a resident and failing to provide proper care, with a fine assessed.
    • Abuse—Failed to provide safe environment
    21 Jul 2025Complaint
    Investigated a licensing complaint with potential for moderate harm. The available information does not specify any deficiencies.
    • Deficiency—Licensing Complaint Investigation
    19 Jul 2025Inspection
    Found insufficient qualified awake direct care staff to meet residents' 24-hour needs.
    • Licensing—Failed to meet the scheduled and unscheduled needs of residents
    18 Jul 2025Abuse: Neglect
    Investigated neglect due to failure to follow the care plan for hourly safety checks, creating risk of harm.
    • Abuse—Failed to follow care plan
    17 Jul 2025Inspection
    Found insufficient awake direct care staff to meet 24-hour scheduled and unscheduled resident needs.
    • Licensing—Failed to meet the scheduled and unscheduled needs of residents
    14 Jul 2025Inspection
    Found failure to complete or update and review the ABST evaluation for each resident quarterly.
    • Licensing—Failed to use an ABST
    07 Jul 2025Inspection
    Investigated and found staffing failures to meet 24-hour needs and ABST duties, including insufficient awake direct care staff and failure to update ABST-based plans.
    • Licensing—Failed to meet the scheduled and unscheduled needs of residents
    29 Jun 2025Inspection
    Found staffing deficiencies and failure to use ABST results to update the staffing plan and conduct quarterly ABST evaluations.
    • Licensing—Failed to meet the scheduled and unscheduled needs of residents
    29 Jun 2025Abuse: Neglect
    Found that the care plan was not followed, placing the resident at risk for harm; a fine was assessed.
    • Abuse—Failed to follow care plan
    19 Jun 2025Abuse: Neglect
    Investigated a fall-risk resident's care plan and found it wasn't followed during a transfer. The resident was found on the floor in the dining area, at risk for harm but not injured.
    • Abuse—Failed to follow care plan
    19 Jun 2025Inspection
    Identified staffing deficiencies and missing ABST evaluations to meet residents' 24-hour needs.
    • Licensing—Failed to meet the scheduled and unscheduled needs of residents
    13 Jun 2025Inspection
    Found failure to complete or update ABST evaluations quarterly for residents as required.
    • Licensing—Failed to update staffing plan based on ABST
    07 Jun 2025Inspection
    Found deficiencies in staffing and ABST use, resulting in insufficient qualified awake direct care staff to meet 24-hour needs.
    • Licensing—Failed to update staffing plan based on ABST
    24 May 2025Inspection
    Found that ABST results were not used to update the posted staffing plan and ABST evaluations for residents were not completed or updated quarterly.
    • Licensing—Failed to update staffing plan based on ABST
    16 May 2025Inspection
    Found staffing deficiencies—insufficient qualified awake direct care staff to meet 24-hour needs and failure to use ABST results to develop and routinely update the staffing plan and complete quarterly ABST evaluations.
    • Licensing—Failed to meet the scheduled and unscheduled needs of residents
    14 May 2025Inspection
    Identified staffing deficiencies and failure to use the ABST and update the posted staffing plan.
    • Licensing—Failed to meet the scheduled and unscheduled needs of residents
    14 May 2025Abuse: Neglect
    Identified violations for neglect and abuse due to failing to provide safety interventions for a fall-risk resident using a commode.
    • Abuse—Failed to properly plan care
    08 May 2025Inspection
    Found failure to use ABST results to develop and routinely update the posted staffing plan and to complete or update ABST evaluations quarterly.
    • Licensing—Failed to update staffing plan based on ABST
    08 May 2025Abuse: Neglect
    Found failure to follow the care plan, leading to a resident fall and skin injury.
    • Abuse—Failed to follow care plan
    08 May 2025Abuse: Neglect
    Identified that staff did not follow the care plan for a known fall-risk resident, resulting in a fall and potential harm.
    • Abuse—Failed to follow care plan
    05 May 2025Complaint
    Investigated the complaint and found no deficiencies.
    • Deficiency—Licensing Complaint Investigation
    05 May 2025Complaint
    Investigated the complaint and found no deficiencies.
    • Deficiency—Licensing Complaint Investigation
    05 May 2025Complaint
    Concluded that a licensing violation occurred due to failure to immediately notify the local Department office or local AAA about abuse incidents.
    • Deficiency—Licensing Complaint Investigation
    • Deficiency—Reporting & Investigating Abuse-Other Action
    04 May 2025Inspection
    Found that ABST results were not used to update the posted staffing plan and quarterly ABST evaluations were not completed or reviewed as required.
    • Licensing—Failed to update staffing plan based on ABST
    03 May 2025Inspection
    Investigated an allegation that staffing updates were not based on ABST results and quarterly ABST evaluations were not completed or reviewed. The investigation found these failures in violation of ABST-related staffing requirements.
    • Licensing—Failed to update staffing plan based on ABST
    18 Apr 2025Inspection
    Found staffing deficiencies related to providing qualified awake direct care staff around the clock and using ABST results to develop and routinely update the posted staffing plan; also found failures to complete or review ABST evaluations for each resident quarterly.
    • Licensing—Failed to meet the scheduled and unscheduled needs of residents
    13 Apr 2025Inspection
    Found staffing deficiencies due to insufficient qualified awake direct care staff and failure to use ABST to guide staffing planning and quarterly evaluations.
    • Licensing—Failed to meet the scheduled and unscheduled needs of residents
    07 Apr 2025Abuse: Neglect
    Found neglect due to failure to prevent a known fall risk from falling, which led to injury to a resident.
    • Abuse—Failed to properly plan care
    07 Apr 2025Inspection
    Found noncompliance with ABST quarterly evaluation requirements for residents.
    • Licensing—Failed to use an ABST
    03 Apr 2025Inspection
    Found insufficient awake direct care staff to meet 24-hour needs and ABST-based staffing processes were not completed or updated quarterly.
    • Licensing—Failed to meet the scheduled and unscheduled needs of residents
    30 Mar 2025Inspection
    Identified deficiency for failing to complete, update, and review quarterly ABST evaluations for each resident.
    • Licensing—Failed to use an ABST
    28 Mar 2025Inspection
    Found staffing deficiencies related to awake direct care and ABST use, with insufficient staff to meet 24-hour needs and ABST processes not completed or updated as required.
    • Licensing—Failed to meet the scheduled and unscheduled needs of residents
    23 Mar 2025Inspection
    Investigated and found that a semi-nude photo of the resident was taken and posted to social media, violating resident rights and constituting abuse and neglect, and a failure to protect the resident's safety.
    • Licensing—Failed to assure resident rights
    21 Mar 2025Inspection
    Identified that ABST evaluations for each resident were not completed, updated, or reviewed quarterly.
    • Licensing—Failed to use an ABST
    20 Mar 2025Inspection
    Identified failure to complete or update ABST evaluations for each resident quarterly.
    • Licensing—Failed to use an ABST
    15 Mar 2025Inspection
    Identified staffing deficiencies and failure to use ABST results to inform staffing plans, and incomplete quarterly ABST evaluations.
    • Licensing—Failed to use an ABST
    06 Mar 2025Abuse: Neglect
    Found that the provider failed to provide a safe environment, resulting in harm to a resident; a fine was assessed.
    • Abuse—Failed to provide safe environment
    03 Mar 2025Inspection
    Identified a deficiency in developing, maintaining, and implementing an Acuity Based Staffing Tool as required by the rule. This indicates non-compliance with the staffing tool requirements.
    • Licensing—Failed to use an ABST
    31 Jan 2025Inspection
    Found a deficiency in the development, maintenance, and implementation of an acuity-based staffing tool.
    • Licensing—Failed to use an ABST
    29 Jan 2025Inspection
    Found a deficiency for failing to develop, maintain, and implement an acuity-based staffing tool.
    • Licensing—Failed to use an ABST
    26 Jan 2025Inspection
    Found noncompliance with Acuity Based Staffing Tool requirements due to failure to develop, maintain, and implement the tool as required by OAR 411-054-0037(1-7).
    • Licensing—Failed to use an ABST
    23 Jan 2025Inspection
    Investigated a complaint and found substantiated violations involving verbal abuse toward a resident and neglect.
    • Licensing—Failed to cooperate with an investigation
    23 Jan 2025Inspection
    Found a deficiency in developing, maintaining, and implementing an Acuity Based Staffing Tool as required by rule.
    • Licensing—Failed to use an ABST
    23 Jan 2025Inspection
    Investigated and found violations of resident rights and abuse due to verbal insults, with a failure to protect the resident from verbal abuse.
    • Licensing—Failed to cooperate with an investigation
    03 Jan 2025Inspection
    Investigated and found that a fall-prevention device was turned off, causing a resident fall and injury, with violations of resident rights and neglect/abuse identified.
    • Licensing—Failed to follow care plan
    03 Jan 2025Inspection
    Investigated a staffing allegation and found a failure to develop, maintain, and implement an Acuity Based Staffing Tool per the applicable rule.
    • Licensing—Failed to provide appropriate staffing
    22 Dec 2024Inspection
    Found that a staff member physically abused a resident and failed to protect the resident from abuse, resulting in a skin tear.
    • Licensing—Failed to protect resident from physical abuse
    12 Dec 2024Abuse: Neglect
    Found a failure to provide a safe environment, resulting in a substantiated abuse/neglect finding.
    • Abuse—Failed to provide safe environment
    08 Nov 2024Abuse: Neglect
    Investigated and found that falls occurred and care planning to reduce falls was inadequate, indicating neglect and abuse; a fine was assessed.
    • Abuse—Failed to properly plan care
    08 Nov 2024Abuse: Neglect
    Found neglect and abuse due to failure to implement appropriate fall-prevention interventions, resulting in an injury; a $1500 fine assessed.
    • Abuse—Failed to properly plan care
    09 Aug 2024Inspection
    Investigated a report of unsafe supervision during ambulation; found that a staff member was not close enough to protect a resident from falling, resulting in a fractured wrist.
    • Licensing—Failed to provide safe environment
    30 Jul 2024Abuse: Neglect
    Determined neglect occurred due to failure to provide a safe environment and to follow a service plan, resulting in scratches from an altercation.
    • Abuse—Failed to properly plan care
    30 Jul 2024Abuse: Neglect
    Found a failure to provide a safe environment when a one-to-one staff was not near a resident during an altercation, resulting in neglect and abuse; a fine was assessed.
    • Abuse—Failed to properly plan care
    29 Jun 2024Abuse: Neglect
    Found a failure to provide a safe environment that resulted in substantiated abuse and neglect; a fine was assessed.
    • Abuse—Failed to provide safe environment
    29 Jun 2024Abuse: Neglect
    Found a failure to provide a safe environment, constituting neglect and abuse. A $375 fine was assessed.
    • Abuse—Failed to provide safe environment
    23 May 2024Abuse: Neglect
    Investigated a safety complaint and found a failure to provide a safe environment leading to neglect and abuse.
    • Abuse—Failed to provide safe environment
    11 May 2024Abuse: Neglect
    Investigated an incident where a resident was agitated; staff did not notify other staff and failed to ensure safety, resulting in neglect and abuse.
    • Abuse—Failed to provide safe environment
    10 May 2024Inspection
    Determined that a safe environment was not provided, resulting in an elopement without injury.
    • Licensing—Failed to provide safe environment
    02 May 2024Abuse: Neglect
    Found violations for failing to provide a safe environment, resulting in a $375 fine.
    • Abuse—Failed to provide safe environment
    25 Mar 2024Validation
    Identified multiple deficiencies in service planning, medication management, restraints, staff training, and life-safety compliance.
    • Deficiency—Comment
    • Deficiency—Service Plan: General
    • Deficiency—Service Plan: Service Planning Team
    • Deficiency—Systems: Treatment Orders
    • Deficiency—Systems: Medication Administration
    • Deficiency—Systems: Psychotropic Medication
    • Deficiency—Restraints and Supportive Devices
    • Deficiency—Annual and Biennial Inservice For All Staff
    • Deficiency—Fire and Life Safety: Safety
    • Deficiency—Administration Compliance
    • Deficiency—Staff Training Requirements
    • Deficiency—Compliance With Rules Health Care
    • Deficiency—Nutrition and Hydration
    • Deficiency—Activities
    18 Mar 2024Abuse: Neglect
    Found that monitoring failures allowed a resident to trigger aggression, resulting in a physical altercation and discomfort to another resident. A $375 fine was assessed.
    • Abuse—Failed to provide safe environment
    15 Mar 2024License Condition
    Found deficiencies showing failure to provide a safe environment, with several rule violations cited.
    • Regulatory Action—Failed to provide safe environment
    20 Feb 2024Abuse: Neglect
    Found that staff failed to follow the care plan by not keeping residents separated, resulting in harm to a resident.
    • Abuse—Failed to provide safe environment
    03 Feb 2024Abuse: Neglect
    Investigated a complaint and found neglect and abuse due to failure to properly plan care for a resident's behaviors. A $375 fine was assessed.
    • Abuse—Failed to properly plan care
    01 Feb 2024Licensure
    Determined substantial compliance with meal service and food sanitation requirements.
    • Deficiency—Comment
    26 Jan 2024Abuse: Neglect
    Found deficiencies in monitoring an aggressive resident and ensuring medical evaluation after a resident-to-resident incident, leading to preventable harm. The issue was classified as abuse and neglect and a fine was assessed.
    • Abuse—Failed to provide safe environment
    16 Jan 2024Abuse: Neglect
    Investigated a resident-to-resident incident where staff failed to monitor a resident with known aggression, risking harm to another resident and causing distress; a fine was assessed.
    • Abuse—Failed to provide safe environment
    29 Dec 2023Abuse: Neglect
    Determined that staff failed to provide a safe environment by not implementing interventions or monitoring known behavior, resulting in a physical altercation and harm to a resident; a fine was assessed.
    • Abuse—Failed to provide safe environment
    24 Dec 2023Abuse: Neglect
    Identified failure to monitor a resident and intervene, leading to an incident in which one resident harmed another; a fine was assessed.
    • Abuse—Failed to provide safe environment
    19 Dec 2023Abuse: Neglect
    Investigated a resident-to-resident incident and found neglect and abuse due to failure to implement interventions and obtain medical evaluation, causing unreasonable discomfort.
    • Abuse—Failed to provide safe environment
    14 Dec 2023Abuse: Neglect
    Found neglect and abuse due to failure to protect a resident from known aggressive behavior, resulting in harm.
    • Abuse—Failed to provide safe environment
    05 Dec 2023Abuse: Neglect
    Found failure to protect a resident from an aggressive peer, resulting in abuse and neglect with a $375 fine assessed.
    • Abuse—Failed to provide safe environment
    04 Dec 2023Abuse: Neglect
    Found deficiencies for failing to provide a safe environment and to monitor a known aggressive resident, resulting in a physical altercation and undue discomfort to the Alleged Victim.
    • Abuse—Failed to provide safe environment
    30 Nov 2023Abuse: Neglect
    Found inadequate supervision that allowed an elopement attempt and injury, and a fine was assessed.
    • Abuse—Failed to provide safe environment
    28 Nov 2023Abuse: Neglect
    Found failure to provide a safe environment that resulted in abuse and neglect; a $500 fine was assessed.
    • Abuse—Failed to provide safe environment
    23 Nov 2023Abuse: Neglect
    Investigated an allegation of abuse and neglect due to failure to provide a safe environment, leading to a resident altercation.
    • Abuse—Failed to provide safe environment
    22 Nov 2023Abuse: Neglect
    Found that staff failed to implement interventions and monitor behavior, leading to a physical altercation and abuse.
    • Abuse—Failed to provide safe environment
    19 Nov 2023Abuse: Neglect
    Found neglect and abuse due to failure to implement interventions and monitor a resident's known behavior, resulting in a physical altercation that caused discomfort to another resident; a fine was assessed.
    • Abuse—Failed to provide safe environment
    19 Nov 2023Abuse: Neglect
    Identified failures to provide a safe environment that led to a resident altercation and discomfort. Violations were cited with a fine assessed.
    • Abuse—Failed to provide safe environment
    18 Nov 2023Abuse: Neglect
    Investigated and found neglect and abuse due to failure to implement interventions and monitor known behavior, resulting in a resident being harmed during a physical altercation.
    • Abuse—Failed to provide safe environment
    17 Nov 2023License Condition
    Found that an acuity-based staffing tool was not fully implemented or updated as required.
    • Regulatory Action—Failed to use an ABST
    10 Nov 2023Abuse: Neglect
    Found abuse and neglect due to failure to monitor and intervene for a known behavior, resulting in a physical altercation.
    • Abuse—Failed to provide safe environment
    04 Nov 2023Abuse: Neglect
    Found a failure to provide a safe environment that led to a resident-to-resident altercation and abuse. The incident involved neglect of care and violation of resident rights.
    • Abuse—Failed to provide safe environment
    31 Oct 2023Inspection
    Investigated a resident care incident and found violations constituting physical abuse and neglect. The incident involved a staff member striking a resident after resistance and failure to follow the resident's care plan.
    • Licensing—Failed to protect resident from physical abuse
    30 Oct 2023Abuse: Neglect
    Investigated found abuse and neglect due to failures to provide a safe environment and monitor a resident's behavior, leading to a resident-on-resident altercation and harm.
    • Abuse—Failed to provide safe environment
    29 Oct 2023Abuse: Neglect
    Found neglect and abuse for failing to implement interventions and monitor known behavior, leading to a physical altercation and discomfort to a resident; a $375 fine was assessed.
    • Abuse—Failed to provide safe environment
    29 Oct 2023Abuse: Neglect
    Investigated and found a failure to provide a safe environment, which led to a physical altercation and discomfort to a resident.
    • Abuse—Failed to provide safe environment
    29 Oct 2023Abuse: Neglect
    Found abuse and neglect due to failure to follow the care plan, resulting in a resident altercation and injury.
    • Abuse—Failed to provide safe environment
    29 Oct 2023Abuse: Neglect
    Investigated an altercation linked to unsafe monitoring and failure to follow interventions, resulting in neglect and abuse.
    • Abuse—Failed to provide safe environment
    17 Oct 2023Inspection
    Investigated a complaint alleging failure to report abuse and resident falls. Determined a violation of reporting requirements.
    • Licensing—Failed to provide safe environment
    17 Oct 2023Abuse: Neglect
    Found a failure to provide a safe environment, constituting abuse and neglect. An altercation occurred in which a resident was hit and blankets were pulled off.
    • Abuse—Failed to provide safe environment
    16 Oct 2023Abuse: Neglect
    Found violations for abuse and neglect that placed a resident at risk, and assessed a $375 fine.
    • Abuse—Failed to provide safe environment
    03 Oct 2023Complaint
    Investigated found multiple deficiencies across abuse reporting, care planning, medication orders, staffing, acuity-based staffing, discharge readiness, and nutrition to ensure resident safety.
    • Deficiency—Licensing Complaint Investigation
    • Deficiency—Reporting & Investigating Abuse-Other Action
    • Deficiency—Service Plan: General
    • Deficiency—Systems: Treatment Orders
    • Deficiency—Staffing Requirements and Training: Staffing
    • Deficiency—Acuity-Based Staffing Tool
    • Deficiency—Involuntary Move-Out Criteria
    • Deficiency—Nutrition and Hydration
    02 Oct 2023Abuse: Neglect
    Found failures to properly address aggressive behavior in the care plan, resulting in neglect and abuse.
    • Abuse—Failed to properly plan care
    29 Sept 2023Abuse: Neglect
    Investigated a complaint and found failures to monitor residents according to known behavior, resulting in a physical altercation and unreasonable discomfort to a resident.
    • Abuse—Failed to provide safe environment
    28 Sept 2023Abuse: Neglect
    Investigated and substantiated neglect due to failure to plan care and provide supervision for a resident with a known history of falls, resulting in multiple falls and ongoing discomfort; a $1,500 fine was assessed.
    • Abuse—Failed to properly plan care
    28 Sept 2023Abuse: Neglect
    Investigated a fall-related care failure and found neglect and abuse due to inadequate care planning, which led to a resident's fall and injury. A fine of $1,500 was assessed.
    • Abuse—Failed to properly plan care
    21 Sept 2023Abuse: Neglect
    Found inadequate care planning led to multiple falls and injuries for the resident.
    • Abuse—Failed to properly plan care
    20 Sept 2023Inspection
    Found insufficient qualified awake direct care staffing to meet 24-hour scheduled and unscheduled resident needs.
    • Licensing—Failed to meet the scheduled and unscheduled needs of residents
    01 Sept 2023Inspection
    Investigated and found that medication orders were not carried out as prescribed.
    • Licensing—Failed to administer medication as ordered
    01 Sept 2023Abuse: Neglect
    Identified that a resident was not provided a safe environment and concerns about theft were not addressed, constituting neglect and abuse. A $375 fine was assessed.
    • Abuse—Failed to provide safe environment
    01 Sept 2023Inspection
    Investigated and confirmed a failure to immediately notify local authorities about an incident of abuse or suspected abuse.
    • Licensing—Failed to report potential or suspected abuse
    01 Sept 2023Abuse: Neglect
    Found a failure to provide a safe environment, constituting abuse. A $375 fine was assessed.
    • Abuse—Failed to provide safe environment
    01 Sept 2023Inspection
    Found that service plans did not reflect resident needs.
    • Licensing—Failed to properly plan care
    01 Sept 2023Inspection
    Found that a daily meal program for nutrition and hydration based on residents' preferences and needs was not provided.
    • Licensing—Failed to provide proper food/nutrition
    30 Jul 2023Abuse: Neglect
    Found that a resident did not receive required showers and appropriate care, leading to a toe infection and amputation. A fine of $1,125 was assessed.
    • Abuse—Failed to provide service
    24 Jul 2023Abuse: Neglect
    Investigated a complaint and found neglect and abuse due to multiple falls with injuries and inadequate safety measures.
    • Abuse—Failed to provide safe environment
    07 Jul 2023Inspection
    Investigated and found a deficiency for failing to meet the scheduled and unscheduled needs of residents. The violation was cited as a Level 2 minor harm risk.
    • Licensing—Failed to meet the scheduled and unscheduled needs of residents
    29 Jun 2023Abuse: Neglect
    Determined that the resident faced unsafe conditions and inadequate care; abuse and neglect were identified, and a $250 fine was assessed.
    • Abuse—Failed to provide service
    24 Jun 2023Abuse: Neglect
    Investigated and found neglect due to inadequate supervision that allowed a fall and a broken hand; a $500 fine was assessed.
    • Abuse—Failed to provide safe environment
    16 May 2023Inspection
    Investigated and determined that a resident's health and care needs were not evaluated within 24 hours after discharge readiness.
    • Licensing—Failed to perform adequate screening or assessment
    24 Apr 2023Abuse: Neglect
    Identified neglect and abuse due to failure to adjust care plans and provide interventions, which led to injuries; a fine was assessed.
    • Abuse—Failed to properly plan care
    24 Apr 2023Abuse: Neglect
    Investigated an incident of abuse and neglect involving two residents; found that care plans were not adjusted and appropriate interventions were not implemented, leading to injuries.
    • Abuse—Failed to properly plan care
    02 Apr 2023Abuse: Neglect
    Determined neglect and abuse occurred due to failing to provide a safe environment and to follow care plans, resulting in a fine.
    • Abuse—Failed to provide safe environment
    18 Mar 2023Abuse: Neglect
    Found neglect and abuse violations and assessed a fine.
    • Abuse—Failed to properly plan care
    15 Feb 2023Abuse: Neglect
    Investigated and found that a resident was not provided a safe environment, constituting abuse and neglect; a $450 fine was assessed.
    • Abuse—Failed to provide safe environment
    14 Feb 2023Abuse: Neglect
    Determined that care plan was not followed, placing a resident at risk and constituting abuse and neglect; a $500 fine was assessed.
    • Abuse—Failed to follow care plan
    11 Feb 2023Abuse: Neglect
    Investigated an abuse/neglect allegation and found a failure to properly plan care for an aggressive resident, which caused bruising.
    • Abuse—Failed to properly plan care
    09 Feb 2023Licensure
    Determined substantial compliance with meal service requirements and related food sanitation rules.
    • Deficiency—Comment
    06 Feb 2023Abuse: Neglect
    Investigated and found failures to properly plan care and address falls, resulting in injuries and indicating abuse and neglect.
    • Abuse—Failed to properly plan care
    18 Jan 2023Inspection
    Found a deficiency for failing to submit timely or adequate staffing documentation, including weekly vaccination reporting. A $7,500 fine was assessed.
    • Licensing—Failed to submit timely or adequate staffing documentation
    05 Jan 2023Abuse: Neglect
    Found that staff failed to properly plan care and apply reasonable interventions for a resident with aggressive behaviors, leading to an incident and a substantiated neglect/abuse finding.
    • Abuse—Failed to properly plan care
    19 Dec 2022Abuse: Neglect
    Determined that care planning failed to address ongoing aggression, resulting in abuse and neglect. A choking incident occurred when a resident grabbed another resident's throat, heightening safety concerns.
    • Abuse—Failed to properly plan care
    11 Dec 2022Abuse: Neglect
    Investigated a neglect allegation and found that care planning and interventions to address ongoing aggression were not properly implemented, leading to potential harm to a resident. A $500 fine was assessed.
    • Abuse—Failed to properly plan care
    01 Dec 2022Inspection
    Found failure to submit timely weekly vaccination reporting for residents and staff, ongoing for 30 days. A $7,500 fine was assessed.
    • Licensing—Failed to submit timely or adequate staffing documentation
    11 Nov 2022Abuse: Neglect
    Investigated allegations found failures to plan care and implement interventions addressing ongoing falls, resulting in injuries from multiple falls.
    • Abuse—Failed to properly plan care
    13 Oct 2022Abuse: Neglect
    Found neglect due to failure to properly care plan for falls for a known fall risk, with multiple falls and injuries reported.
    • Abuse—Failed to properly plan care
    10 Oct 2022Abuse: Neglect
    Found failures to properly plan care and provide safety checks every 15 minutes, leading to an altercation and injury.
    • Abuse—Failed to properly plan care
    02 Oct 2022Abuse: Neglect
    Investigated and found a failure to properly plan care for a resident's behavioral issues, constituting neglect and abuse with risk of harm.
    • Abuse—Failed to properly plan care
    02 Oct 2022Abuse: Neglect
    Found neglect and abuse due to failure to properly care plan for aggressive behavior, with a $375 fine assessed.
    • Abuse—Failed to properly plan care
    16 Sept 2022Abuse: Neglect
    Investigated a complaint alleging failure to properly plan care for a resident with aggressive behaviors; findings show the care plan and interventions were not adjusted, leading to an incident where a resident harmed another.
    • Abuse—Failed to properly plan care
    08 Sept 2022Abuse: Neglect
    Found violations for neglect and abuse due to failing to intervene when a resident's condition declined; a $500 fine was assessed.
    • Abuse—Failed to intervene when resident's condition changed
    02 Sept 2022Abuse: Neglect
    Found failure to follow the care plan that allowed a wandering resident to enter another resident’s room, leading to a physical altercation and injury; a $500 fine was assessed.
    • Abuse—Failed to follow care plan
    26 Aug 2022Abuse: Neglect
    Found that a care plan and its interventions were not followed, resulting in abuse and neglect; a $500 fine was assessed.
    • Abuse—Failed to follow care plan
    25 Aug 2022Abuse: Neglect
    Found abuse/neglect due to failure to follow the care plan, with a $500 fine assessed.
    • Abuse—Failed to follow care plan
    17 Aug 2022Abuse: Neglect
    Found that the care plan was not followed, leading to an incident where a resident slapped another and was not kept away from others, constituting neglect and abuse. A $500 fine was assessed.
    • Abuse—Failed to follow care plan
    16 Aug 2022Abuse: Neglect
    Investigated a resident-to-resident aggression case and found the care plan for an agitated resident was not properly adjusted, resulting in neglect and abuse, with a fine assessed.
    • Abuse—Failed to properly plan care
    03 Aug 2022Abuse: Neglect
    Investigated an allegation of neglect and found a failure to provide a safe environment, resulting in an aggressive incident toward a resident; a monetary penalty was assessed.
    • Abuse—Failed to provide safe environment
    01 Aug 2022Inspection
    Identified a licensing violation for failing to submit timely weekly vaccination reporting for residents and staff over a 30-day period.
    • Licensing—Failed to submit timely or adequate staffing documentation
    17 May 2022Abuse: Neglect
    Investigated an allegation of neglect and abuse and found that inadequate care planning and interventions addressed a resident's bed sliding, constituting abuse.
    • Abuse—Failed to properly plan care
    11 May 2022Abuse: Neglect
    Found violations for failing to follow the care plan, leading to a skin tear; a $500 fine was assessed.
    • Abuse—Failed to follow care plan
    17 Nov 2021Inspection
    Investigated a complaint and found that a resident's rights were violated and abuse and neglect occurred, with a failure to provide a safe environment.
    • Licensing—Failed to provide safe environment
    14 Nov 2021Abuse: Neglect
    Investigated allegations of unsafe medication handling; concluded there was excessive PRN narcotics administration and failures in the medication system. This included inadequate supervision and oversight by responsible personnel.
    • Abuse—Failed to provide a safe medication administration system
    14 Nov 2021Abuse: Neglect
    Determined that a staff member stole and over-administered PRN narcotics to a resident, causing financial exploitation, and that supervision of the medication administration system was inadequate.
    • Abuse—Failed to protect resident from financial exploitation
    14 Nov 2021Abuse: Neglect
    Investigated an allegation of financial exploitation and found that a staff member took a resident's medication, resulting in financial exploitation; also found failings in supervision and oversight of the medication administration system.
    • Abuse—Failed to protect resident from financial exploitation
    14 Nov 2021Inspection
    Investigated and found that a staff member exploited a resident by taking medications. Supervision over the medication administration process was inadequate.
    • Licensing—Failed to protect resident from financial exploitation
    17 Jul 2021Inspection
    Found that an individual was left alone in a wheelchair, attempted to stand, fell, and sustained injuries; neglect of care created an unsafe environment.
    • Licensing—Failed to provide safe environment
    30 Jun 2021Abuse: Neglect
    Found failure to follow the care plan, leaving a resident alone without proper footwear and resulting in neglect and abuse.
    • Abuse—Failed to follow care plan
    10 Jun 2021Abuse: Neglect
    Identified failure to properly plan for aggressive behaviors that affected residents. This resulted in neglect and abuse findings.
    • Abuse—Failed to properly plan care
    25 May 2021Inspection
    Identified neglect of care and an unsafe environment that resulted in a head injury during care.
    • Licensing—Failed to provide safe environment
    18 Apr 2021Inspection
    Investigated and found that a staff member grabbed a resident's left wrist and held them down during a combative episode, resulting in a bruise; a safe-environment deficiency was identified.
    • Licensing—Failed to provide safe environment
    11 Jan 2021Inspection
    Investigated the staffing allegation and found it substantiated.
    • Licensing—Failed to provide appropriate staffing
    11 Jan 2021Inspection
    Found failure to provide toileting assistance; the allegation was verified.
    • Licensing—Failed to assist with toileting
    06 Jan 2021Abuse: Neglect
    Found failures in fall risk care planning that led to seven falls and multiple hospital visits, with a fine assessed.
    • Abuse—Failed to properly plan care
    27 Dec 2020Abuse: Neglect
    Investigated an allegation of neglect regarding inadequate nutrition that led to harm and hospital visit; a $500 fine was assessed.
    • Abuse—Failed to provide oversight and monitoring of change of condition
    20 Dec 2020Inspection
    Investigated the allegation of failing to monitor residents' change of condition and found a deficiency in oversight and monitoring.
    • Licensing—Failed to provide oversight and monitoring of change of condition
    20 Dec 2020Inspection
    Found a deficiency for failing to report suspected abuse to the local APS office.
    • Licensing—Failed to provide safe environment
    16 Dec 2020Inspection
    Investigated a care plan violation and found that a staff member failed to follow the care plan, causing discomfort and neglect; the organization did not ensure plan adherence.
    • Licensing—Failed to follow care plan
    16 Dec 2020Inspection
    Investigated an allegation of not following the care plan and found inadequate staffing and failure to implement the plan.
    • Licensing—Failed to follow care plan
    16 Dec 2020Inspection
    Investigated allegations that a resident's care plan was not followed, leading to discomfort. Found violations of several care-related rules.
    • Licensing—Failed to follow care plan
    09 Nov 2020Abuse: Neglect
    Found failure to provide a safe environment that led to pain, constituting neglect and abuse; a $500 fine was assessed.
    • Abuse—Failed to provide safe environment
    12 Oct 2020Abuse: Neglect
    Found failure to provide a safe environment, resulting in abuse/neglect; a $375 fine was assessed.
    • Abuse—Failed to provide safe environment
    09 Oct 2020Abuse: Neglect
    Investigated and determined that a failure to provide a safe environment resulted in abuse and neglect. A fine was assessed.
    • Abuse—Failed to provide safe environment
    25 Sept 2020Inspection
    Investigated an allegation that residents were not provided laundry services; findings verified.
    • Licensing—Failed to provide appropriate housekeeping services
    25 Sept 2020Inspection
    Investigated the allegation that staff failed to assist with toileting and found a failure to provide activities of daily living support.
    • Licensing—Failed to assist with toileting
    25 Sept 2020Inspection
    Found insufficient awake qualified direct care staffing to meet scheduled and unscheduled resident needs.
    • Licensing—Failed to provide appropriate staffing
    13 Sept 2020Abuse: Neglect
    Found a failure to provide a safe environment that led to six non-injury falls and was deemed neglect and abuse.
    • Abuse—Failed to provide safe environment
    29 Jul 2020Abuse: Neglect
    Found that a safe environment was not provided, exposing a resident to risk of harm during a resident-to-resident altercation. A fine was assessed.
    • Abuse—Failed to provide safe environment
    26 Jul 2020Abuse: Neglect
    Found a failure to provide a safe environment, constituting neglect and abuse.
    • Abuse—Failed to provide safe environment
    26 Jun 2020Inspection
    Determined that a staff member restrained a resident and administered insulin after the resident declined, causing distress and a bruise, and that this reflected a failure to provide a safe environment.
    • Licensing—Failed to provide safe environment
    14 Jun 2020Inspection
    Concluded that inappropriate sexual contact occurred and protections for a resident from sexual abuse were insufficient.
    • Licensing—Failed to provide safe environment
    13 May 2020Abuse: Neglect
    Found a failure to provide a safe environment by not protecting a resident from non-consensual sexual touching.
    • Abuse—Failed to provide safe environment
    04 May 2020Abuse: Neglect
    Found that a resident was not protected from sexual encounters, resulting in serious emotional harm and risk of further harm. The findings indicate neglect and abuse.
    • Abuse—Failed to provide safe environment
    30 Apr 2020Abuse: Neglect
    Found neglect due to failure to plan care and protect residents, resulting in two sexual assaults.
    • Abuse—Failed to properly plan care
    03 Jan 2020Abuse: Neglect
    Found inadequate care planning for a resident's fall risk, placing the resident at risk for harm.
    • Abuse—Failed to properly plan care
    30 Sept 2019Inspection
    Found failure to provide appropriate activities. The finding carried a Level 1 designation indicating no harm or potential for minor harm.
    • Licensing—Failed to provide appropriate activities
    30 Sept 2019Inspection
    Investigated the allegation and identified a failure to provide a safe medication administration system.
    • Licensing—Failed to provide a safe medication administration system
    21 May 2019Abuse: Neglect
    Found violations for failing to provide a safe environment, resulting in abuse/neglect, with a fine assessed.
    • Abuse—Failed to provide safe environment
    14 Mar 2019Inspection
    Found failure to report suspected abuse and assessed a $1,000 fine.
    • Licensing—Failed to report potential or suspected abuse
    14 Mar 2019Abuse: Neglect
    Investigated a medication management failure and found neglect due to an inaccurate system that allowed a resident to go without tramadol, with increased behaviors. A $500 fine was assessed.
    • Abuse—Failed to provide a safe medication administration system
    28 Jan 2019Abuse: Neglect
    Found neglect due to inadequate supervision that caused pain to a person under care; assessed a $500 fine.
    • Abuse—Failed to properly plan care
    21 Jan 2019Abuse: Neglect
    Found a neglect violation that placed a resident at risk of harm, and a $375 fine was assessed.
    • Abuse—Failed to properly plan care
    30 Dec 2018Abuse: Neglect
    Determined neglect due to failure to provide supervision, creating a risk of serious harm. A $375 fine was assessed.
    • Abuse—Failed to properly plan care
    28 Dec 2018Abuse: Neglect
    Found neglect that failed to maintain the health and safety of a vulnerable adult, creating a risk of serious harm when the individual was hit.
    • Abuse—Failed to properly plan care
    12 Dec 2018Abuse: Neglect
    Investigated an abuse/neglect allegation and found health and safety were not maintained, resulting in harm. A $500 fine was assessed.
    • Abuse—Failed to properly plan care
    09 Dec 2018Abuse: Neglect
    Found neglect of a care recipient that resulted in physical harm; a $250 fine was assessed.
    • Abuse—Failed to properly plan care
    18 Nov 2018Abuse: Neglect
    Found neglect-related deficiencies resulting in a resident's falls and injuries; a $500 fine was assessed.
    • Abuse—Failed to adequately care plan related to falls
    18 Nov 2018Inspection
    Investigated an allegation of failing to report suspected abuse and found that suspected abuse was not reported.
    • Licensing—Failed to report potential or suspected abuse
    02 Nov 2018Abuse: Neglect
    Found neglect that failed to provide basic care, leaving a resident at risk of serious harm.
    • Abuse—Failed to provide safe environment
    02 Nov 2018Inspection
    Found failure to report suspected abuse. A $750 fine was assessed.
    • Licensing—Failed to report potential or suspected abuse
    05 May 2018Abuse: Sexual abuse
    Investigated a sexual abuse allegation, concluded there was a safety violation, and assessed a $375 fine.
    • Abuse—Failed to provide safe environment
    14 Nov 2017Abuse: Neglect
    Investigated the neglect allegation and found failure to assess and intervene to prevent a resident from falling and being injured.
    • Abuse—Failed to follow care plan
    25 Aug 2017Abuse: Neglect
    Investigated and found a failure to follow the care plan that led to a resident fall, resulting in a fractured finger and hospital stay; a fine was assessed.
    • Abuse—Failed to follow care plan
    20 Apr 2017Abuse: Neglect
    Investigated an allegation of neglect and found residents were not protected from a resident-to-resident altercation. This reflected a failure to provide a safe environment.
    • Abuse—Failed to provide safe environment
    25 Jan 2017Inspection
    Investigated and concluded that a safe environment was not provided, resulting in an altercation between residents.
    • Licensing—Failed to provide safe environment
    23 Jan 2017Abuse: Financial abuse
    Investigated a financial abuse allegation and found that residents' money was not protected from theft.
    • Abuse—Failed to protect resident from financial exploitation
    14 Dec 2016Inspection
    Concluded that a resident was not protected from verbal abuse.
    • Licensing—Failed to protect resident from verbal abuse
    13 Nov 2016Inspection
    Found a failure to provide a safe environment, resulting in risk of physical assault.
    • Licensing—Failed to provide safe environment
    16 Oct 2016Abuse: Neglect
    Found failure to assess and intervene when a resident's condition changed, resulting in an altercation between residents.
    • Abuse—Failed to intervene when resident's condition changed
    16 Oct 2016Abuse: Neglect
    Investigated an abuse/neglect allegation and found a failure to provide a safe environment that led to one resident punching another in the eye.
    • Abuse—Failed to provide safe environment
    02 Oct 2016Abuse: Neglect
    Investigated an allegation of neglect; found the care plan was not followed, resulting in a broken hip, and a $300 fine was assessed.
    • Abuse—Failed to follow care plan
    25 Sept 2016Abuse: Neglect
    Investigated and found a failure to provide a safe environment, resulting in residents at risk of physical assault.
    • Abuse—Failed to provide safe environment
    27 Aug 2016Abuse: Neglect
    Investigated a complaint and identified a failure to follow the care plan with minor harm potential.
    • Abuse—Failed to follow care plan
    18 Aug 2016Inspection
    Found a deficiency for failing to assist with dressing or grooming. The deficiency violated ADL assistance requirements.
    • Licensing—Failed to assist with dressing or grooming
    21 Jul 2016Inspection
    Investigated allegations of failure to provide a safe environment and found residents were not protected from physical assault.
    • Licensing—Failed to provide safe environment
    01 Jul 2016Inspection
    Found deficiencies in the medication management system.
    • Licensing—Failed to provide a safe medication administration system
    16 Jun 2016Abuse: Neglect
    Investigated an allegation of neglect and found that care after a resident's condition changed was not provided appropriately. The allegation was supported by findings.
    • Abuse—Failed to intervene when resident's condition changed
    07 Mar 2016Inspection
    Investigated and found that RV was not protected from inappropriate verbal comments. The finding indicates a rule violation.
    • Licensing—Failed to assure resident rights
    16 Dec 2015Abuse: Neglect
    Investigated an allegation of neglect and found a failure to provide a safe environment.
    • Abuse—Failed to provide safe environment
    31 Aug 2015Abuse: Neglect
    Investigated and found residents were not protected from physical aggression.
    • Abuse—Failed to provide safe environment
    09 Aug 2015Abuse: Neglect
    Found a failure to provide a safe environment and assessed a $300 fine.
    • Abuse—Failed to provide safe environment
    25 May 2015Inspection
    Investigated an allegation that resident records were not kept current or accurate and found that records were not kept current and the resident's needs were not properly assessed.
    • Licensing—Failed to keep resident record current or accurate
    27 Aug 2014Abuse: Neglect
    Investigated and found that a safe environment was not maintained.
    • Abuse—Failed to provide safe environment
    20 Sept 2013Abuse: Neglect
    Investigated and found a failure to provide appropriate care for a resident, with a substantiated abuse/neglect finding and a $250 fine assessed.
    • Abuse—Failed to address resident's behavior
    29 Aug 2013Inspection
    Investigated and found failure to provide a safe environment.
    • Licensing—Failed to provide safe environment
    11 Sept 2012Inspection
    Determined that a violation of resident rights occurred when the resident's family was not allowed to stay with the resident at the time of passing.
    • Licensing—Failed to assure resident rights
    29 Jun 2012Inspection
    Found failure to report an elder abuse allegation to designated authorities.
    • Licensing—Failed to report potential or suspected abuse
    30 Apr 2012Inspection
    Found a failure to provide a safe environment.
    • Licensing—Failed to provide safe environment
    08 Apr 2012Inspection
    Found that medication was not administered as ordered, resulting in inadequate care to a resident.
    • Licensing—Failed to administer medication as ordered
    22 Mar 2012Abuse: Neglect
    Determined neglect occurred when staff failed to protect a resident from rough handling, resulting in a bruise on the resident's upper left arm.
    • Abuse—Failed to investigate injury of unknown origin to rule out abuse
    16 May 2011Abuse: Neglect
    Found a failure to provide a safe and secure environment for a resident.
    • Abuse—Failed to provide safe environment

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