Pricing ranges from
    $4,850 – 7,985/month

    Farmington Square at Gresham

    1655 NE 18th St, Gresham, OR 97030
    • Assisted Living
    • Memory Care

    Smooth move-in, caring staff, happy

    I moved my mom in and was impressed - the move-in was smooth, staff are caring and professional, and the community is clean, homey and cozy. Meals are appealing, activities keep residents engaged, and the wellness coordinator and administration communicate proactively with timely updates. My mother is happy and settling in; I recommend this place for compassionate, high-quality care and peace of mind.

    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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    Time Window
    Tour Type

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    Amenities

    Healthcare services

    • Activities of daily living assistance
    • Assistance with bathing
    • Assistance with dressing
    • Assistance with transfers
    • Coordination with health care providers
    • Hospice waiver
    • Medication management
    • Mental wellness program

    Healthcare staffing

    • 12-16 hour nursing
    • 24-hour call system
    • 24-hour supervision

    Meals and dining

    • Diabetes diet
    • Meal preparation and service
    • Restaurant-style dining
    • Special dietary restrictions

    Room

    • Air-conditioning
    • Cable
    • Fully furnished
    • Housekeeping and linen services
    • Kitchenettes
    • Private bathrooms
    • Telephone
    • Wifi

    Memory care community services

    • Dementia waiver
    • Mild cognitive impairment
    • Specialized memory care programming

    Transportation

    • Community operated transportation
    • Transportation arrangement
    • Transportation arrangement (medical)
    • Transportation arrangement (non-medical)
    • Transportation to doctors appointments

    Common areas

    • Beauty salon
    • Computer center
    • Dining room
    • Fitness room
    • Gaming room
    • Garden
    • Outdoor space
    • Pet friendly
    • 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

    4.02·(118)

    Overall rating

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

      4.0
    • Staff

      4.1
    • Meals

      3.1
    • Amenities

      3.4
    • Value

      1.9

    Pros

    • Compassionate, attentive caregiving staff
    • Knowledgeable nursing and clinical support
    • Clean, well-maintained facilities and grounds
    • Small, home-like cottage layout and courtyard
    • Rehabilitation and physical therapy services
    • Engaging cognitive programming (IN2L) and activities
    • Balanced, well-portioned meals with dessert options
    • Responsive admissions and move-in coordination
    • Consistent family communication and wellness coordination
    • Hospice and end-of-life support availability

    Cons

    • Inconsistent staffing levels and schedule instability
    • Delays in personal-assistance tasks (bathing, toileting)
    • Medication administration timing and coordination issues
    • Incontinence-supply and monitoring gaps
    • Personal-property, laundry, and belongings management issues
    • Variable food quality and meal-service consistency
    • Smaller-than-expected private-room dimensions
    • Maintenance responsiveness and HVAC/comfort problems
    • Management communication, billing, and policy inconsistencies
    • Memory-care design and placement limitations in older building sections
    • Weekend and night coverage shortages
    • High staff turnover and scheduling disruptions

    Summary of reviews

    Farmington Square at Gresham elicits a broadly mixed but coherent set of impressions. Strengths repeatedly cited include caring, personable frontline caregivers, competent nursing support, a generally clean and well-kept physical environment, and a small cottage-style layout with an attractive courtyard. Families frequently praise the admissions staff and wellness coordinators for smooth move-ins and ongoing communication; rehabilitation services and cognitive-engagement programming (IN2L) are also seen as meaningful supports for many residents.

    Care quality and staffing present a clear pattern of variability. Numerous families commend individual caregivers and nurses for compassion and attentiveness, and some describe successful transitions to higher levels of memory care. At the same time, a recurring operational concern is inconsistent staffing and schedule instability—particularly on nights and weekends—which reviewers link to delays in assistance with bathing, toileting and other personal-care tasks. Related patterns include incontinence-supply management gaps and inconsistent monitoring, which some families viewed as a significant area for improvement. Medication administration timing and coordination were also cited as uneven in a subset of accounts.

    Dining and activities receive similarly mixed feedback. Several reviewers appreciate balanced meal portions, dessert options, and a homelike dining environment; others note variability in food temperature and overall quality. Activity offerings and cognitive programs are present and valued by families who use them, though a number of reviewers said they would like to see expanded or more frequent programming tailored to individual interests.

    Facility condition and logistics are generally positive, with many comments about cleanliness and pleasant common areas. However, reviewers noted distinctions between newer and older sections—some older units lack memory-care design features, private rooms are often described as small, and there are occasional comfort issues such as noisy window units or delayed maintenance responses. Accessibility and wayfinding (entrance/parking) were identified as inconvenient in some reports.

    Management and administrative patterns are mixed: several staff in admissions and coordination receive high marks for responsiveness and support, while other families experienced inconsistent communication, unclear billing or payment policies, and scheduling changes that affected care delivery. Personal-property and laundry management is a recurrent operational weakness—loss and misplacement of belongings and inconsistent laundry turnaround were concerns. A few serious individual incidents, including concerns following a resident's death and disputes around payer-status transitions, highlight the importance of clarifying escalation and family-notification procedures prior to move-in.

    Overall, Farmington Square at Gresham appears to deliver strong interpersonal care from many frontline staff and offers a clean, small-community atmosphere with rehabilitative and cognitive supports. Prospective residents and families should plan a focused tour that includes: verifying staffing levels (especially night/weekend coverage), asking about bathing and incontinence-care protocols, reviewing medication administration procedures, confirming housekeeping and personal-property practices, inspecting room dimensions and HVAC options, and discussing billing, move-in fees, and Medicaid/private-pay transition policies. These targeted inquiries will help determine whether the facility’s operational consistency aligns with the prospective resident’s needs and expectations.

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    Location

    Map showing location of Farmington Square at Gresham

    Farmington Square at Gresham is located at 1655 NE 18th St, Gresham, OR, 97030.

    About Farmington Square at Gresham

    Farmington Square at Gresham sits just off N 18th Street in Gresham, Oregon, and belongs to the Radiant Senior Living family of communities, and honestly, when you walk in, the first thing you'll notice are the cozy living rooms, comfortable furnishings, and a homelike feeling throughout, which they say comes from designing every part of the place with residents in mind, so no matter if someone's looking for wider doorways, wheelchair accessible showers, or just an armchair to relax in, they've worked those little details in. The staff stays extra attentive, offering continuous support with a kind of care that's meant to feel both supportive and honest-residents get help with daily routines like bathing, dressing, and taking medicine, but also the freedom to do things for themselves if they can, which is a fine balance to strike, and they do it with care.

    They've got 102 total beds, and out of those, 64 are dedicated to memory care, which matters, because memory loss requires a different sort of environment and Farmington Square was actually the first senior care company in Oregon to create a memory care community, so they know about working with Alzheimer's and dementia, and their Memory Care Community stays secure to prevent wandering, but it's also got walking paths and an enclosed courtyard for safe outdoor time, giving folks the chance to get fresh air. The caregivers get specialized training, and the programming, with names like Transitions™, is aimed at changing care as needs change, always adjusting to how someone's memory care needs might shift, so routines, engagement activities, and social events are worked around what helps most, from brain-stimulating games to group meals in a dining room that offers menus their way.

    The whole place feels small and home-like, which makes it less intimidating for new residents, and there's a strong effort put into making everyone feel connected, so communal spaces, both indoors and outside, are set up for conversations, activities, and friendships to grow-things like the beauty salon on site, visiting chaplains, offsite devotional services, and a healthy living life-enrichment program. Residents' families or caregivers are encouraged to stay involved, which adds to the sense of support, and there's easy-to-understand personal service plans for those needing more help, while independent folks get a hassle-free, social place with housekeeping, meal services, and activities that make each day a little easier and brighter.

    The community stays pet-friendly and transportation, including complimentary rides, lets residents stay connected with the local area, while amenities like beautician services and on-site parking make daily living smoother. Everything's set up so residents can participate in things that keep body, mind, and spirit active through a schedule packed with social, educational, and entertainment options. Staff remains present 24 hours a day, always ready to assist, and private suites are available for those who need a little more personal space and support. At Farmington Square at Gresham, every bit of the environment points to giving each person comfort, care, and community all under one roof, with careful attention paid to the little things that help people feel at home, whether they need independent living, assisted care, or more specialized memory care.

    About Radiant Senior Living

    Farmington Square at Gresham is managed by Radiant Senior Living.

    A family-owned and operated group of residential communities dedicated to exceptional senior care, offering independent living, assisted living, memory care, respite stays, hospice care, and life enrichment programs across Oregon, Idaho, Nevada, and Montana.

    People often ask...

    Farmington Square at Gresham offers competitive pricing, with rates starting at a cost of $4,850 per month.

    Farmington Square at Gresham offers assisted living and memory care.

    There are 25 photos of Farmington Square at Gresham on Mirador.

    The full address for this community is 1655 NE 18th St, Gresham, OR 97030.

    No, Farmington Square at Gresham 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 number5MA031
    StatusActive
    Facility typeResidential Care Facility
    Capacity102 residents
    LicenseeRSL Gresham, LLC
    EffectiveJune 1st, 1992
    Special certificationMemory Care
    View the official license record

    Inspection Reports

    148

    Reports

    0

    Type A Citations

    0

    Type B Citations

    4

    Complaints

    16

    Years

    25 Aug 2025License Condition
    Concluded that actions by respondents created a risk of immediate jeopardy by failing to provide needed/necessary services.
    • Regulatory ActionFailed to provide safe environment
    21 Aug 2025Inspection
    Determined that a provider failed to provide a safe environment, finding a violation of Oregon Administrative Rules. The finding noted failure to exercise reasonable precautions that may threaten residents' health, safety, or welfare.
    • LicensingFailed to provide safe environment
    21 Aug 2025Abuse: Neglect
    Investigated and found neglect due to failure to provide appropriate care and resident safety, placing a resident at risk of harm.
    • AbuseFailed to provide service
    20 Mar 2025Licensure
    Identified multiple deficiencies across postings, resident rights and privacy, infection control, fire safety, building exterior, doors and memory care settings.
    • DeficiencyFacility Administration: Required Postings
    • DeficiencyResident Rights and Protection - General
    • DeficiencyInfection Prevention & Control
    • DeficiencyFire and Life Safety: Safety
    • DeficiencyFire and Life Safety: Training for Residents
    • DeficiencyGeneral Building Exterior
    • DeficiencyDoors, Walls, Elevators, Odors
    • DeficiencyIndividual Rights Settings: Privacy, Dignity
    • DeficiencyOptimize Settings: Independence, Activities
    • DeficiencyPhysical Setting: Individual Accessible
    • DeficiencyIndividual Privacy: Own Unit
    • DeficiencyIndividual Door Locks: Key Access
    • DeficiencyFacility Administration: Required Postings
    • DeficiencyAdministration Compliance
    • DeficiencyResident Rooms
    20 Feb 2025Complaint
    Investigated deficiencies in medication administration and staffing tool updates, identifying failures to follow orders and keep the acuity-based staffing tool current.
    • DeficiencyLicensing Complaint Investigation
    • DeficiencySystems: Treatment Orders
    • DeficiencyAcuity Based Staffing Tool - Abst Time
    • DeficiencyAcuity Based Staffing Tool - Updates & Plan
    21 Jan 2025Abuse: Neglect
    Investigated a safety concern and found failure to provide a safe environment, resulting in an unsupervised altercation and resident discomfort; neglect and abuse identified.
    • AbuseFailed to provide safe environment
    15 Jan 2025Kitchen
    Investigated deficiencies in kitchen sanitation monitoring and in administration compliance with licensing rules.
    • DeficiencyResident Services Meals, Food Sanitation Rule
    • DeficiencyAdministration Compliance
    03 Jan 2025Inspection
    Investigated a complaint and identified a failure to provide a safe medication administration system. No negative outcome occurred for the affected person.
    • LicensingFailed to provide a safe medication administration system
    03 Jan 2025Inspection
    Investigated and found a failure to provide a safe medication administration system, with no negative outcome for the resident.
    • LicensingFailed to provide a safe medication administration system
    12 Dec 2024Abuse: Neglect
    Found neglect and abuse due to failure to provide services and maintain a safe environment, with a $500 fine assessed.
    • AbuseFailed to provide service
    08 Dec 2024Inspection
    Investigated the allegation that records were not provided upon request; found a violation of Oregon Administrative Rules.
    • LicensingFailed to obtain appropriate consultation
    06 Dec 2024Abuse: Neglect
    Investigated an allegation of neglect after a resident with a fall risk sustained injuries from an unwitnessed fall; found failures in care planning and staff instruction related to walker placement and safety.
    • AbuseFailed to provide service
    02 Oct 2024Abuse: Neglect
    Investigated and found abuse/neglect due to failure to provide a safe environment after an incident involving two residents in their shared room.
    • AbuseFailed to provide safe environment
    30 Sept 2024Abuse: Neglect
    Identified abuse and neglect for failing to provide a safe environment after two residents in a shared room had altercations, causing injury.
    • AbuseFailed to provide safe environment
    09 Aug 2024Abuse: Neglect
    Determined that staff failed to follow care plans, leading to unwitnessed falls and injuries. A $1125 fine was assessed.
    • AbuseFailed to follow care plan
    12 Jul 2024Inspection
    Investigated an allegation of neglect and physical abuse and found that a caregiver's actions caused physical harm to a resident during incontinence care.
    • LicensingFailed to protect resident from physical abuse
    12 Jul 2024Inspection
    Found that a staff member made derogatory remarks during incontinence care in front of a resident, causing emotional distress.
    • LicensingFailed to protect resident from verbal abuse
    09 Jul 2024Inspection
    Found that medication and treatment orders were not carried out as prescribed, resulting in a violation of Oregon Administrative Rules.
    • LicensingFailed to administer ordered medication
    26 May 2024Abuse: Neglect
    Found neglect and abuse due to failure to provide a safe environment and follow the care plan, resulting in a resident's fall and facial injury; a fine was assessed.
    • AbuseFailed to provide safe environment
    23 May 2024Inspection
    Found deficiencies due to not maintaining an updated ABST reflecting residents' care needs, with inconsistencies between roster, care plans, and ABST data.
    • LicensingFailed to use an ABST
    22 May 2024Inspection
    Investigated a reported incident of physical abuse toward a resident; found that staff pushed the resident and the provider failed to protect the resident from abuse.
    • LicensingFailed to protect resident from physical abuse
    20 May 2024Inspection
    Determined that the ABST was not updated to reflect resident needs and discrepancies existed between the resident roster, care plans, and ABST data.
    • LicensingFailed to use an ABST
    07 May 2024Abuse: Neglect
    Investigated found a failure to properly plan shower-related care, contributing to a fall. The staff neglect allegation was not substantiated.
    • AbuseFailed to properly plan care
    28 Apr 2024Abuse: Neglect
    Investigated and identified neglect of care due to failure to implement fall-prevention interventions after falls, resulting in safety concerns and a fine.
    • AbuseFailed to provide service
    27 Apr 2024Inspection
    Found that a staff member did not follow a resident's care plan, resulting in a skin tear and hospital visit.
    • LicensingFailed to follow care plan
    16 Apr 2024Inspection
    Found failure to administer ordered medication as prescribed.
    • LicensingFailed to administer ordered medication
    15 Apr 2024Inspection
    Investigated and found emotional abuse and neglect of a resident during a shower, with staff actions violating resident rights and Oregon Administrative Rules.
    • LicensingFailed to protect resident from mental or emotional abuse
    15 Apr 2024Inspection
    Investigated an allegation of physical abuse during a shower; found that a staff member slapped the resident's hand, violating resident rights and constituting abuse and neglect, and that protections to prevent abuse were not upheld.
    • LicensingFailed to assure resident rights
    15 Apr 2024Inspection
    Found that a staff member slapped a resident's hand during a shower, constituting physical abuse, and that the provider failed to protect the resident from abuse.
    • LicensingFailed to protect resident from physical abuse
    30 Mar 2024Abuse: Neglect
    Found a failure to provide a safe medication administration system, resulting in an anti-convulsant medication being discontinued and the resident missing doses from March 27 to March 30, 2024.
    • AbuseFailed to provide a safe medication administration system
    26 Mar 2024Abuse: Neglect
    Investigated found that the provider failed to respond to a resident's call overnight and the call system was not functioning, leaving the resident uncomfortable and undignified.
    • AbuseFailed to provide service
    22 Mar 2024Abuse: Neglect
    Investigated a neglect case and found that the facility failed to follow the care plan and ensure staff training, resulting in a skin tear; a $500 fine was assessed.
    • AbuseFailed to communicate necessary information
    17 Feb 2024Abuse: Neglect
    Investigated a complaint and found the care plan was not followed, resulting in a resident fall and injury; a fine was assessed.
    • AbuseFailed to follow care plan
    12 Jan 2024Inspection
    Investigated the allegation that an Acuity-Based Staffing Tool was not used properly; found the ABST not updated to reflect resident needs and inconsistencies between the roster, care plans, and ABST data.
    • LicensingFailed to use an ABST
    04 Jan 2024Inspection
    Investigated a safety concern and found the environment unsafe after a staff member slept during a shift, resulting in a fall and alleged neglect.
    • LicensingFailed to provide safe environment
    02 Jan 2024Complaint
    Found deficiencies in pre-service dementia training for direct care staff and unsecured chemical storage during a site visit.
    • DeficiencyStaffing Requirements and Training – Pre-Serv
    • DeficiencyHousekeeping and Laundry
    02 Jan 2024Inspection
    Identified deficiencies in safe environment due to lack of a secured janitor closet and locked chemical storage.
    • LicensingFailed to maintain a safe physical environment
    15 Dec 2023Abuse: Neglect
    Identified a failure to provide a safe medication administration system, resulting in a resident not receiving prescribed narcotics for about two weeks and experiencing pain.
    • AbuseFailed to provide a safe medication administration system
    05 Dec 2023License Condition
    Found failure to implement an Acuity Based Staffing Tool as required.
    • Regulatory ActionFailed to use an ABST
    13 Nov 2023Inspection
    Investigated the allegation that inservice dementia training was not provided; found that direct care staff did not complete an approved pre-service dementia training before providing care.
    • LicensingFailed to provide inservice
    08 Nov 2023Abuse: Neglect
    Found that care planning and interventions for known fall risk were insufficient, resulting in substantiated neglect and abuse findings after multiple falls.
    • AbuseFailed to properly plan care
    20 Oct 2023Abuse: Neglect
    Investigated and found that a resident was verbally abused and not protected, constituting neglect and abuse. A $500 fine was assessed.
    • AbuseFailed to protect resident from verbal abuse
    04 Oct 2023Abuse: Neglect
    Found neglect for failure to plan and implement care addressing a known fall risk, leading to a fall with injury. A fine of $188 was assessed.
    • AbuseFailed to properly plan care
    02 Oct 2023Licensure
    Observed widespread deficiencies in food sanitation and kitchen practices across multiple kitchen areas, including improper storage, dirty surfaces, and gaps in staff hygiene.
    • DeficiencyComment
    • DeficiencyResident Services Meals, Food Sanitation Rule
    • DeficiencyInspections and Investigation: Insp Interval
    • DeficiencyAdministration Compliance
    21 Sept 2023Complaint
    Found deficiencies in implementing required services for residents, including toileting, bathing and dressing, and housekeeping; care plans were not consistently followed.
    • DeficiencyLicensing Complaint Investigation
    • DeficiencyService Plan: General
    • DeficiencyAcuity-Based Staffing Tool
    21 Sept 2023Inspection
    Investigated an allegation that hygiene assistance was not provided; found a failure to ensure the implementation of services.
    • LicensingFailed to provide or assist with hygiene
    21 Sept 2023Complaint
    Investigated and found that medication orders were not carried out as prescribed for two residents. This included unadministered medications and missing documentation.
    • DeficiencySystems: Treatment Orders
    05 Sept 2023Abuse: Neglect
    Investigated found neglect and abuse due to failure to provide hygiene, resulting in a $250 fine.
    • AbuseFailed to provide or assist with hygiene
    01 Sept 2023Abuse: Neglect
    Investigated and found failure to properly plan care to mitigate fall risk, resulting in a resident fall and head injury.
    • AbuseFailed to properly plan care
    29 Jul 2023Inspection
    Investigated and found neglect and abuse occurred when a caregiver transferred a resident alone and left them unattended on the toilet, causing a fall and head injury.
    • LicensingFailed to follow care plan
    08 May 2023Abuse: Neglect
    Investigated a complaint and found that the care plan was not followed, leading to multiple resident-to-resident altercations and injuries.
    • AbuseFailed to follow care plan
    29 Apr 2023Inspection
    Investigated found that a resident's narcotic medication was tampered with and replaced with allergy medication, with an unknown staff member involved, and protection against financial exploitation failed.
    • LicensingFailed to protect resident from financial exploitation
    29 Apr 2023Inspection
    Found that a resident's narcotic medication was tampered with and replaced with allergy medication, resulting in neglect and financial abuse.
    • LicensingFailed to protect resident from financial exploitation
    29 Apr 2023Inspection
    Found a violation for failing to protect residents from financial abuse.
    • LicensingFailed to protect resident from financial exploitation
    13 Apr 2023Inspection
    Found failure to ensure service implementation. This violated Oregon Administrative Rules.
    • LicensingFailed to provide service
    23 Mar 2023Abuse: Neglect
    Investigated a complaint and found neglect and abuse due to failure to provide hygiene services, with a $750 fine assessed.
    • AbuseFailed to provide or assist with hygiene
    23 Mar 2023Abuse: Neglect
    Investigated a hygiene and dental-care deficiency and found neglect and abuse due to not assisting with brushing and not scheduling a dental appointment.
    • AbuseFailed to provide or assist with hygiene
    22 Mar 2023Abuse: Neglect
    Determined that a safety lapse allowed an elopement and injuries, constituting neglect and abuse; a $375 fine was assessed.
    • AbuseFailed to provide safe environment
    08 Mar 2023Abuse: Neglect
    Found that failure to follow the care plan caused a resident to fall and fracture, resulting in ongoing mobility needs and a $2,500 fine for abuse and neglect.
    • AbuseFailed to follow care plan
    09 Jan 2023Abuse: Neglect
    Found violations involving neglect and financial exploitation, including a narcotic medication missing and not logged, with a failure to protect the resident from exploitation.
    • AbuseFailed to protect resident from financial exploitation
    18 Nov 2022Inspection
    Found neglect and abuse due to failure to assess after a fall and inadequate oversight of change in condition.
    • LicensingFailed to provide oversight and monitoring of change of condition
    10 Nov 2022Abuse: Neglect
    Investigated and found a failure to provide a safe environment, where a resident shoved another and staff could not redirect residents due to insufficient staffing. The findings indicate abuse and neglect.
    • AbuseFailed to provide safe environment
    01 Oct 2022Abuse: Neglect
    Found a failure to provide a safe environment, resulting in neglect and abuse. An Alleged Victim was found walking on the street after leaving unassisted.
    • AbuseFailed to provide safe environment
    28 Sept 2022Inspection
    Found that a staff member laughed at a resident on a video of vaping, constituting emotional abuse and neglect, and that a safe environment was not provided.
    • LicensingFailed to protect resident from mental or emotional abuse
    08 Aug 2022Licensure
    Found deficiencies in food sanitation and administration compliance, with multiple unsanitary conditions observed across several kitchens. The issues included unlabeled, undated foods, debris and labeling problems, and failure to follow licensing rules.
    • DeficiencyComment
    • DeficiencyResident Services Meals, Food Sanitation Rule
    • DeficiencyAdministration Compliance
    03 Aug 2022Abuse: Neglect
    Found failure to follow a care plan led to uncovered legs and bleeding sores from picking, indicating neglect and abuse.
    • AbuseFailed to follow care plan
    09 May 2022Inspection
    Investigated and found that medication orders were not carried out as prescribed.
    • LicensingFailed to have medication available
    04 May 2022Abuse: Neglect
    Investigated and found neglect of care resulting in serious skin injuries. A $1,500 fine was assessed.
    • AbuseFailed to provide appropriate skin care
    11 Apr 2022Abuse: Neglect
    Found neglect and abuse due to failure to protect residents, resulting in sexual contact and a fine assessed.
    • AbuseFailed to protect resident from inappropriate sexual contact
    03 Dec 2021Inspection
    Investigated a reported neglect and abuse; found that an overnight staff member did not check on a resident, leaving them in a cold room with a soiled brief and vomit on clothing.
    • LicensingFailed to assist with toileting
    27 Oct 2021Validation
    Identified multiple deficiencies across postings, incident investigations, service planning, change of condition monitoring, health services, medications, and nutrition; follow-up determined substantial compliance.
    • DeficiencyComment
    • DeficiencyFacility Administration: Required Postings
    • DeficiencyReporting & Investigating Abuse-Other Action
    • DeficiencyService Plan: General
    • DeficiencyChange of Condition and Monitoring
    • DeficiencyResident Health Services
    • DeficiencySystems: Treatment Orders
    • DeficiencySystems: Medication Administration
    • DeficiencySystems: Psychotropic Medication
    • DeficiencyGeneral Building Exterior
    • DeficiencyAdministration Compliance
    • DeficiencyCompliance With Rules Health Care
    • DeficiencyNutrition and Hydration
    24 Jul 2021Abuse: Neglect
    Found a failure to provide a safe environment after a resident eloped and was found injured; a fine was assessed.
    • AbuseFailed to provide safe environment
    09 May 2021Abuse: Neglect
    Identified a safety lapse when an Alleged Victim exited through an unsecured kitchen door and was found outside, crossing the street, placing them at risk of harm. A $375 fine was assessed.
    • AbuseFailed to provide safe environment
    29 Mar 2021Inspection
    Found a violation for failing to protect a resident from theft and financial exploitation.
    • LicensingFailed to protect resident from financial exploitation
    25 Nov 2020Inspection
    Investigated a missing resident money incident and found a failure to protect property from theft, constituting financial exploitation.
    • LicensingFailed to protect resident from financial exploitation
    25 Nov 2020Abuse: Neglect
    Found deficiencies in catheter hygiene and leakage care resulting in a $250 fine.
    • AbuseFailed to provide or assist with hygiene
    31 Oct 2020Abuse: Neglect
    Found a failure to provide a safe environment that placed a resident at risk of serious harm. A $375 fine was assessed.
    • AbuseFailed to provide safe environment
    23 Oct 2020Inspection
    Investigated and found that a caregiver made derogatory comments to a resident during care, constituting verbal/emotional abuse, and the provider failed to protect the resident.
    • LicensingFailed to protect resident from mental or emotional abuse
    02 Sept 2020Inspection
    Investigated and found that perimeter fencing did not meet a six-foot height and outdoor furniture was too light to prevent resident injury or elopement.
    • LicensingFailed to assure resident was safe
    02 Sept 2020Inspection
    Found that resident care equipment was not kept in good repair.
    • LicensingFailed to provide or maintain resident care equipment
    02 Sept 2020Inspection
    Found service plans did not reflect resident needs, were not updated at least quarterly, and failed to ensure implementation of services.
    • LicensingFailed to follow care plan
    02 Sept 2020Inspection
    Found a failure to properly post and maintain daily staffing documentation, including posting the manager on duty.
    • LicensingFailed to properly post and maintain daily staffing documentation
    02 Sept 2020Inspection
    Determined that the allegation of failing to protect a resident from verbal abuse was substantiated. Found that residents were not treated with dignity and respect, and not provided a safe, homelike environment.
    • LicensingFailed to protect resident from verbal abuse
    02 Sept 2020Inspection
    Investigated an allegation that a safe environment was not provided. Found that reasonable precautions to protect residents' health and safety were not exercised.
    • LicensingFailed to provide safe environment
    20 Aug 2020Inspection
    Found insufficient qualified awake direct care staffing to meet residents' 24-hour needs.
    • LicensingFailed to provide appropriate staffing
    20 Aug 2020Inspection
    Found failure to assess after a resident experienced a short-term change of condition.
    • LicensingFailed to perform adequate screening or assessment
    20 Aug 2020Inspection
    Found that the call system did not connect resident units to the care staff center or staff pager.
    • LicensingFailed to answer call light in a timely manner
    20 Aug 2020Inspection
    Investigated the allegation that services to assist residents with all activities of daily living were not provided on a 24-hour basis.
    • LicensingFailed to provide service
    21 Jul 2020Inspection
    Found that medication orders were not carried out as prescribed.
    • LicensingFailed to administer medication as ordered
    06 Jun 2020Inspection
    Found neglect of care and failure to protect a resident from elopement after a staff member exited a locked area, resulting in the resident being found outside in the rain.
    • LicensingFailed to provide safe environment
    18 May 2020Inspection
    Investigated the complaint and found pest-control deficiencies, including failure to prevent pest entry and ongoing bed bug issues with no extermination efforts pursued.
    • LicensingFailed to control pests
    11 May 2020Inspection
    Investigated the complaint alleging failure to assist with toileting and found a deficiency.
    • LicensingFailed to assist with toileting
    11 May 2020Inspection
    Found insufficient staffing to meet scheduled and unscheduled resident care needs.
    • LicensingFailed to provide appropriate staffing
    11 May 2020Inspection
    Investigated the allegation of inadequate meals and found that residents did not receive three daily nutritious, palatable meals.
    • LicensingFailed to provide proper food/nutrition
    11 May 2020Inspection
    Investigated and found inadequate hydration due to not providing water daily. Water was reportedly not given until lunchtime.
    • LicensingFailed to assure proper hydration
    06 May 2020Abuse: Neglect
    Found failure to provide a safe environment, constituting neglect and abuse.
    • AbuseFailed to provide safe environment
    09 Apr 2020Inspection
    Found that a staff member verbally abused a resident and that the provider failed to protect the resident from verbal abuse.
    • LicensingFailed to protect resident from verbal abuse
    06 Apr 2020Abuse: Neglect
    Investigated and found evidence of physical and verbal abuse and involuntary seclusion, and a failure to protect a resident from staff actions.
    • AbuseFailed to assure resident rights
    05 Jan 2020Abuse: Neglect
    Identified neglect and abuse due to failure to provide a safe environment, resulting in a resident knee injury after being pushed by another resident.
    • AbuseFailed to provide safe environment
    13 Jul 2019Abuse: Neglect
    Investigated an abuse/neglect allegation and identified neglect in providing a safe medication administration system, risking serious harm.
    • AbuseFailed to provide a safe medication administration system
    29 Jun 2019Abuse: Neglect
    Investigated a neglect allegation and found failure to provide basic care leading to a resident being hospitalized three times for falls. Violations were cited and a fine was assessed.
    • AbuseFailed to provide service
    10 Jan 2019Abuse: Neglect
    Found neglect and abuse due to failure to provide necessary services to a resident. A fine was assessed.
    • AbuseFailed to provide service
    10 Nov 2018Abuse: Neglect
    Concluded that neglect occurred by failing to provide a secure environment, creating risk of serious harm.
    • AbuseFailed to provide safe environment
    25 Oct 2018Abuse: Neglect
    Found neglect due to not providing a safe environment, which resulted in physical injury. A fine of $188 was assessed.
    • AbuseFailed to provide safe environment
    17 Jul 2018Inspection
    Investigated a complaint alleging failure to report suspected abuse and found that reporting failed. A $1,000 fine was assessed.
    • LicensingFailed to report potential or suspected abuse
    17 Jul 2018Abuse: Neglect
    Investigated a complaint and found failure to provide appropriate care, resulting in a $500 fine assessed.
    • AbuseFailed to provide safe environment
    30 Jun 2018Inspection
    Found that AV01 did not receive basic care, causing unreasonable discomfort.
    • LicensingFailed to provide service
    18 Jun 2018Inspection
    Investigated the allegation and found the medication was not administered as ordered.
    • LicensingFailed to administer medication as ordered
    18 May 2018Abuse: Neglect
    Found failure to provide appropriate care when resident's condition changed. A $1,000 fine was assessed.
    • AbuseFailed to intervene when resident's condition changed
    18 May 2018Inspection
    Investigated the allegation of failing to report potential or suspected abuse and assessed a civil penalty for failure to self-report.
    • LicensingFailed to report potential or suspected abuse
    14 May 2018Inspection
    Investigated the staffing allegation and found a deficiency in administrator qualifications and availability.
    • LicensingFailed to provide appropriate staffing
    14 May 2018Inspection
    Found failure to maintain laundry facilities with locked storage for chemicals and equipment, in violation of state rule.
    • LicensingFailed to provide safe environment
    14 May 2018Inspection
    Investigated the staffing allegation and concluded that required staffing or staff training practices were not met.
    • LicensingFailed to provide appropriate staffing
    14 May 2018Inspection
    Determined that mandatory abuse reporting requirements were not followed, specifically failing to report potential or suspected abuse.
    • LicensingFailed to report potential or suspected abuse
    14 May 2018Inspection
    Found that door alarms were not monitored by staff. Some doors to the secure courtyard were propped open.
    • LicensingFailed to provide service
    14 May 2018Inspection
    Investigated the allegation of unsafe medication distribution and found a deficiency in safe medication administration practices.
    • LicensingFailed to provide a safe medication administration system
    07 May 2018Inspection
    Investigated an allegation of a failure to provide a safe environment and found a lack of substantial compliance.
    • LicensingFailed to provide safe environment
    29 Apr 2018Inspection
    Concluded that failure to self-report abuse occurred and assessed a $1000 fine.
    • LicensingFailed to report potential or suspected abuse
    29 Apr 2018Abuse: Neglect
    Found an inadequate medication system that led to hospitalization; assessed a $2,500 fine.
    • AbuseFailed to provide a safe medication administration system
    28 Mar 2018Abuse: Neglect
    Found a neglect deficiency for failing to follow the care plan, including failing to assess and intervene, with an $8,500 fine assessed.
    • AbuseFailed to follow care plan
    28 Mar 2018Inspection
    Found failure to selfreport potential or suspected abuse and assessed a $1000 fine.
    • LicensingFailed to report potential or suspected abuse
    28 Mar 2018Abuse: Neglect
    Investigated an allegation of failure to administer medications as ordered; found that medications were not given as prescribed, and a $1,500 fine was assessed.
    • AbuseFailed to administer medication as ordered
    21 Feb 2018Inspection
    Investigated an allegation that RN delegation and teaching were not provided; identified a deficiency in RN delegation and teaching.
    • LicensingFailed to provide service
    21 Feb 2018Inspection
    Found that service plans were not readily available to staff.
    • LicensingFailed to provide service
    20 Feb 2018Inspection
    Found insufficient staffing to meet residents' scheduled and unscheduled needs.
    • LicensingFailed to provide appropriate staffing
    08 Feb 2018Inspection
    Investigated the allegation of failing to administer medication as ordered and found a deficiency. A $500 fine was assessed.
    • LicensingFailed to administer medication as ordered
    08 Feb 2018Inspection
    Found failure to self-report potential or suspected abuse; $750 fine assessed.
    • LicensingFailed to report potential or suspected abuse
    19 Nov 2017Abuse: Neglect
    Investigated an abuse/neglect allegation and found a lack of safe environment for four residents.
    • AbuseFailed to provide safe environment
    02 Aug 2017Abuse: Neglect
    Found deficiencies in care planning that resulted in inappropriate care for a reported victim.
    • AbuseFailed to properly plan care
    30 Jul 2017Inspection
    Investigated the allegation and identified a deficiency related to failing to provide a safe environment for two victims.
    • LicensingFailed to provide safe environment
    19 May 2017Inspection
    Found failure to provide a safe environment.
    • LicensingFailed to provide safe environment
    17 Jan 2017Inspection
    Investigated an allegation of failing to provide a safe medication administration system and found medications were not administered as ordered.
    • LicensingFailed to provide a safe medication administration system
    03 Jan 2017Inspection
    Found a deficiency related to RN assessment under nursing delegation requirements.
    • LicensingFailed to comply with nursing delegation requirement
    11 Dec 2016Abuse: Financial abuse
    Investigated an allegation of financial exploitation and found a failure to protect a resident from theft.
    • AbuseFailed to protect resident from financial exploitation
    17 Nov 2016Abuse: Neglect
    Found neglect due to failure to intervene when a resident's condition changed, leading to hospitalization. A $300 fine was assessed.
    • AbuseFailed to intervene when resident's condition changed
    17 Oct 2016Abuse: Physical Abuse
    Found that a resident was not protected from rough treatment.
    • AbuseFailed to protect resident from rough treatment
    17 Oct 2016Abuse: Verbal/Mental abuse
    Investigated the allegation of verbal abuse and found a resident was not protected from inappropriate verbal comments.
    • AbuseFailed to protect resident from verbal abuse
    23 Sept 2016Abuse: Neglect
    Investigated and concluded that medication was not administered as ordered.
    • AbuseFailed to administer medication as ordered
    02 Jun 2016Abuse: Financial abuse
    Found a failure to protect a resident from cash theft, indicating financial abuse.
    • AbuseFailed to provide safe environment
    16 Mar 2016Abuse: Neglect
    Investigated and found that the care plan was not followed for the reported victim.
    • AbuseFailed to follow care plan
    01 Dec 2015Inspection
    Investigated and found failure to administer the prescribed medication as required.
    • LicensingFailed to provide a safe medication administration system
    19 Oct 2015Abuse: Neglect
    Investigated and found failure to provide appropriate care, resulting in a $300 fine.
    • AbuseFailed to provide service
    13 Jun 2013Abuse: Neglect
    Investigated a neglect allegation and determined oversight of change of condition was inadequate, resulting in an unsafe environment.
    • AbuseFailed to provide oversight and monitoring of change of condition
    13 Apr 2013Abuse: Neglect
    Investigated and found a substantiated neglect case due to failure to perform adequate screening or assessment, risking moderate harm; a $350 fine was assessed.
    • AbuseFailed to perform adequate screening or assessment
    29 Mar 2012Inspection
    Investigated an allegation that care was not properly planned and found a failure to protect a resident from inappropriate actions during care.
    • LicensingFailed to properly plan care
    14 Sept 2011Abuse: Neglect
    Investigated the neglect allegation and found a failure to provide a safe environment; a $300 fine was assessed.
    • AbuseFailed to follow care plan
    09 Nov 2010Inspection
    Investigated the allegation that medical treatment was not provided as ordered. Found that orders from a physician and physical therapist were not followed for the resident's care.
    • LicensingFailed to provide medical treatment as ordered
    09 Nov 2010Inspection
    Investigated an allegation that service was not provided and found the RV was not dressed appropriately.
    • LicensingFailed to provide service

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