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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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
5
4
3
2
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
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.
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.
Concluded that actions by respondents created a risk of immediate jeopardy by failing to provide needed/necessary services.
Regulatory Action—Failed to provide safe environment
21 Aug 2025Inspection
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.
Licensing—Failed to provide safe environment
21 Aug 2025Abuse: Neglect
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.
Abuse—Failed to provide service
20 Mar 2025Licensure
20 Mar 2025Licensure
Identified multiple deficiencies across postings, resident rights and privacy, infection control, fire safety, building exterior, doors and memory care settings.
Investigated deficiencies in medication administration and staffing tool updates, identifying failures to follow orders and keep the acuity-based staffing tool current.
Deficiency—Licensing Complaint Investigation
Deficiency—Systems: Treatment Orders
Deficiency—Acuity Based Staffing Tool - Abst Time
Deficiency—Acuity Based Staffing Tool - Updates & Plan
21 Jan 2025Abuse: Neglect
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.
Abuse—Failed to provide safe environment
15 Jan 2025Kitchen
15 Jan 2025Kitchen
Investigated deficiencies in kitchen sanitation monitoring and in administration compliance with licensing rules.
Investigated a complaint and identified a failure to provide a safe medication administration system. No negative outcome occurred for the affected person.
Licensing—Failed to provide a safe medication administration system
03 Jan 2025Inspection
03 Jan 2025Inspection
Investigated and found a failure to provide a safe medication administration system, with no negative outcome for the resident.
Licensing—Failed to provide a safe medication administration system
12 Dec 2024Abuse: Neglect
12 Dec 2024Abuse: Neglect
Found neglect and abuse due to failure to provide services and maintain a safe environment, with a $500 fine assessed.
Abuse—Failed to provide service
08 Dec 2024Inspection
08 Dec 2024Inspection
Investigated the allegation that records were not provided upon request; found a violation of Oregon Administrative Rules.
Licensing—Failed to obtain appropriate consultation
06 Dec 2024Abuse: Neglect
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.
Abuse—Failed to provide service
02 Oct 2024Abuse: Neglect
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.
Abuse—Failed to provide safe environment
30 Sept 2024Abuse: Neglect
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.
Abuse—Failed to provide safe environment
09 Aug 2024Abuse: Neglect
09 Aug 2024Abuse: Neglect
Determined that staff failed to follow care plans, leading to unwitnessed falls and injuries. A $1125 fine was assessed.
Abuse—Failed to follow care plan
12 Jul 2024Inspection
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.
Licensing—Failed to protect resident from physical abuse
12 Jul 2024Inspection
12 Jul 2024Inspection
Found that a staff member made derogatory remarks during incontinence care in front of a resident, causing emotional distress.
Licensing—Failed to protect resident from verbal abuse
09 Jul 2024Inspection
09 Jul 2024Inspection
Found that medication and treatment orders were not carried out as prescribed, resulting in a violation of Oregon Administrative Rules.
Licensing—Failed to administer ordered medication
26 May 2024Abuse: Neglect
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.
Abuse—Failed to provide safe environment
23 May 2024Inspection
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.
Licensing—Failed to use an ABST
22 May 2024Inspection
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.
Licensing—Failed to protect resident from physical abuse
20 May 2024Inspection
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.
Licensing—Failed to use an ABST
07 May 2024Abuse: Neglect
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.
Abuse—Failed to properly plan care
28 Apr 2024Abuse: Neglect
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.
Abuse—Failed to provide service
27 Apr 2024Inspection
27 Apr 2024Inspection
Found that a staff member did not follow a resident's care plan, resulting in a skin tear and hospital visit.
Licensing—Failed to follow care plan
16 Apr 2024Inspection
16 Apr 2024Inspection
Found failure to administer ordered medication as prescribed.
Licensing—Failed to administer ordered medication
15 Apr 2024Inspection
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.
Licensing—Failed to protect resident from mental or emotional abuse
15 Apr 2024Inspection
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.
Licensing—Failed to assure resident rights
15 Apr 2024Inspection
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.
Licensing—Failed to protect resident from physical abuse
30 Mar 2024Abuse: Neglect
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.
Abuse—Failed to provide a safe medication administration system
26 Mar 2024Abuse: Neglect
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.
Abuse—Failed to provide service
22 Mar 2024Abuse: Neglect
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.
Abuse—Failed to communicate necessary information
17 Feb 2024Abuse: Neglect
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.
Abuse—Failed to follow care plan
12 Jan 2024Inspection
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.
Licensing—Failed to use an ABST
04 Jan 2024Inspection
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.
Licensing—Failed to provide safe environment
02 Jan 2024Complaint
02 Jan 2024Complaint
Found deficiencies in pre-service dementia training for direct care staff and unsecured chemical storage during a site visit.
Deficiency—Staffing Requirements and Training – Pre-Serv
Deficiency—Housekeeping and Laundry
02 Jan 2024Inspection
02 Jan 2024Inspection
Identified deficiencies in safe environment due to lack of a secured janitor closet and locked chemical storage.
Licensing—Failed to maintain a safe physical environment
15 Dec 2023Abuse: Neglect
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.
Abuse—Failed to provide a safe medication administration system
05 Dec 2023License Condition
05 Dec 2023License Condition
Found failure to implement an Acuity Based Staffing Tool as required.
Regulatory Action—Failed to use an ABST
13 Nov 2023Inspection
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.
Licensing—Failed to provide inservice
08 Nov 2023Abuse: Neglect
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.
Abuse—Failed to properly plan care
20 Oct 2023Abuse: Neglect
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.
Abuse—Failed to protect resident from verbal abuse
04 Oct 2023Abuse: Neglect
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.
Abuse—Failed to properly plan care
02 Oct 2023Licensure
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.
Deficiency—Inspections and Investigation: Insp Interval
Deficiency—Administration Compliance
21 Sept 2023Complaint
21 Sept 2023Complaint
Found deficiencies in implementing required services for residents, including toileting, bathing and dressing, and housekeeping; care plans were not consistently followed.
Deficiency—Licensing Complaint Investigation
Deficiency—Service Plan: General
Deficiency—Acuity-Based Staffing Tool
21 Sept 2023Inspection
21 Sept 2023Inspection
Investigated an allegation that hygiene assistance was not provided; found a failure to ensure the implementation of services.
Licensing—Failed to provide or assist with hygiene
21 Sept 2023Complaint
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.
Deficiency—Systems: Treatment Orders
05 Sept 2023Abuse: Neglect
05 Sept 2023Abuse: Neglect
Investigated found neglect and abuse due to failure to provide hygiene, resulting in a $250 fine.
Abuse—Failed to provide or assist with hygiene
01 Sept 2023Abuse: Neglect
01 Sept 2023Abuse: Neglect
Investigated and found failure to properly plan care to mitigate fall risk, resulting in a resident fall and head injury.
Abuse—Failed to properly plan care
29 Jul 2023Inspection
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.
Licensing—Failed to follow care plan
08 May 2023Abuse: Neglect
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.
Abuse—Failed to follow care plan
29 Apr 2023Inspection
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.
Licensing—Failed to protect resident from financial exploitation
29 Apr 2023Inspection
29 Apr 2023Inspection
Found that a resident's narcotic medication was tampered with and replaced with allergy medication, resulting in neglect and financial abuse.
Licensing—Failed to protect resident from financial exploitation
29 Apr 2023Inspection
29 Apr 2023Inspection
Found a violation for failing to protect residents from financial abuse.
Licensing—Failed to protect resident from financial exploitation
13 Apr 2023Inspection
13 Apr 2023Inspection
Found failure to ensure service implementation. This violated Oregon Administrative Rules.
Licensing—Failed to provide service
23 Mar 2023Abuse: Neglect
23 Mar 2023Abuse: Neglect
Investigated a complaint and found neglect and abuse due to failure to provide hygiene services, with a $750 fine assessed.
Abuse—Failed to provide or assist with hygiene
23 Mar 2023Abuse: Neglect
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.
Abuse—Failed to provide or assist with hygiene
22 Mar 2023Abuse: Neglect
22 Mar 2023Abuse: Neglect
Determined that a safety lapse allowed an elopement and injuries, constituting neglect and abuse; a $375 fine was assessed.
Abuse—Failed to provide safe environment
08 Mar 2023Abuse: Neglect
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.
Abuse—Failed to follow care plan
09 Jan 2023Abuse: Neglect
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.
Abuse—Failed to protect resident from financial exploitation
18 Nov 2022Inspection
18 Nov 2022Inspection
Found neglect and abuse due to failure to assess after a fall and inadequate oversight of change in condition.
Licensing—Failed to provide oversight and monitoring of change of condition
10 Nov 2022Abuse: Neglect
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.
Abuse—Failed to provide safe environment
01 Oct 2022Abuse: Neglect
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.
Abuse—Failed to provide safe environment
28 Sept 2022Inspection
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.
Licensing—Failed to protect resident from mental or emotional abuse
08 Aug 2022Licensure
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.
Found failure to follow a care plan led to uncovered legs and bleeding sores from picking, indicating neglect and abuse.
Abuse—Failed to follow care plan
09 May 2022Inspection
09 May 2022Inspection
Investigated and found that medication orders were not carried out as prescribed.
Licensing—Failed to have medication available
04 May 2022Abuse: Neglect
04 May 2022Abuse: Neglect
Investigated and found neglect of care resulting in serious skin injuries. A $1,500 fine was assessed.
Abuse—Failed to provide appropriate skin care
11 Apr 2022Abuse: Neglect
11 Apr 2022Abuse: Neglect
Found neglect and abuse due to failure to protect residents, resulting in sexual contact and a fine assessed.
Abuse—Failed to protect resident from inappropriate sexual contact
03 Dec 2021Inspection
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.
Licensing—Failed to assist with toileting
27 Oct 2021Validation
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.
Found a failure to provide a safe environment after a resident eloped and was found injured; a fine was assessed.
Abuse—Failed to provide safe environment
09 May 2021Abuse: Neglect
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.
Abuse—Failed to provide safe environment
29 Mar 2021Inspection
29 Mar 2021Inspection
Found a violation for failing to protect a resident from theft and financial exploitation.
Licensing—Failed to protect resident from financial exploitation
25 Nov 2020Inspection
25 Nov 2020Inspection
Investigated a missing resident money incident and found a failure to protect property from theft, constituting financial exploitation.
Licensing—Failed to protect resident from financial exploitation
25 Nov 2020Abuse: Neglect
25 Nov 2020Abuse: Neglect
Found deficiencies in catheter hygiene and leakage care resulting in a $250 fine.
Abuse—Failed to provide or assist with hygiene
31 Oct 2020Abuse: Neglect
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.
Abuse—Failed to provide safe environment
23 Oct 2020Inspection
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.
Licensing—Failed to protect resident from mental or emotional abuse
02 Sept 2020Inspection
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.
Licensing—Failed to assure resident was safe
02 Sept 2020Inspection
02 Sept 2020Inspection
Found that resident care equipment was not kept in good repair.
Licensing—Failed to provide or maintain resident care equipment
02 Sept 2020Inspection
02 Sept 2020Inspection
Found service plans did not reflect resident needs, were not updated at least quarterly, and failed to ensure implementation of services.
Licensing—Failed to follow care plan
02 Sept 2020Inspection
02 Sept 2020Inspection
Found a failure to properly post and maintain daily staffing documentation, including posting the manager on duty.
Licensing—Failed to properly post and maintain daily staffing documentation
02 Sept 2020Inspection
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.
Licensing—Failed to protect resident from verbal abuse
02 Sept 2020Inspection
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.
Licensing—Failed to provide safe environment
20 Aug 2020Inspection
20 Aug 2020Inspection
Found insufficient qualified awake direct care staffing to meet residents' 24-hour needs.
Licensing—Failed to provide appropriate staffing
20 Aug 2020Inspection
20 Aug 2020Inspection
Found failure to assess after a resident experienced a short-term change of condition.
Licensing—Failed to perform adequate screening or assessment
20 Aug 2020Inspection
20 Aug 2020Inspection
Found that the call system did not connect resident units to the care staff center or staff pager.
Licensing—Failed to answer call light in a timely manner
20 Aug 2020Inspection
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.
Licensing—Failed to provide service
21 Jul 2020Inspection
21 Jul 2020Inspection
Found that medication orders were not carried out as prescribed.
Licensing—Failed to administer medication as ordered
06 Jun 2020Inspection
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.
Licensing—Failed to provide safe environment
18 May 2020Inspection
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.
Licensing—Failed to control pests
11 May 2020Inspection
11 May 2020Inspection
Investigated the complaint alleging failure to assist with toileting and found a deficiency.
Licensing—Failed to assist with toileting
11 May 2020Inspection
11 May 2020Inspection
Found insufficient staffing to meet scheduled and unscheduled resident care needs.
Licensing—Failed to provide appropriate staffing
11 May 2020Inspection
11 May 2020Inspection
Investigated the allegation of inadequate meals and found that residents did not receive three daily nutritious, palatable meals.
Licensing—Failed to provide proper food/nutrition
11 May 2020Inspection
11 May 2020Inspection
Investigated and found inadequate hydration due to not providing water daily. Water was reportedly not given until lunchtime.
Licensing—Failed to assure proper hydration
06 May 2020Abuse: Neglect
06 May 2020Abuse: Neglect
Found failure to provide a safe environment, constituting neglect and abuse.
Abuse—Failed to provide safe environment
09 Apr 2020Inspection
09 Apr 2020Inspection
Found that a staff member verbally abused a resident and that the provider failed to protect the resident from verbal abuse.
Licensing—Failed to protect resident from verbal abuse
06 Apr 2020Abuse: Neglect
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.
Abuse—Failed to assure resident rights
05 Jan 2020Abuse: Neglect
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.
Abuse—Failed to provide safe environment
13 Jul 2019Abuse: Neglect
13 Jul 2019Abuse: Neglect
Investigated an abuse/neglect allegation and identified neglect in providing a safe medication administration system, risking serious harm.
Abuse—Failed to provide a safe medication administration system
29 Jun 2019Abuse: Neglect
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.
Abuse—Failed to provide service
10 Jan 2019Abuse: Neglect
10 Jan 2019Abuse: Neglect
Found neglect and abuse due to failure to provide necessary services to a resident. A fine was assessed.
Abuse—Failed to provide service
10 Nov 2018Abuse: Neglect
10 Nov 2018Abuse: Neglect
Concluded that neglect occurred by failing to provide a secure environment, creating risk of serious harm.
Abuse—Failed to provide safe environment
25 Oct 2018Abuse: Neglect
25 Oct 2018Abuse: Neglect
Found neglect due to not providing a safe environment, which resulted in physical injury. A fine of $188 was assessed.
Abuse—Failed to provide safe environment
17 Jul 2018Inspection
17 Jul 2018Inspection
Investigated a complaint alleging failure to report suspected abuse and found that reporting failed. A $1,000 fine was assessed.
Licensing—Failed to report potential or suspected abuse
17 Jul 2018Abuse: Neglect
17 Jul 2018Abuse: Neglect
Investigated a complaint and found failure to provide appropriate care, resulting in a $500 fine assessed.
Abuse—Failed to provide safe environment
30 Jun 2018Inspection
30 Jun 2018Inspection
Found that AV01 did not receive basic care, causing unreasonable discomfort.
Licensing—Failed to provide service
18 Jun 2018Inspection
18 Jun 2018Inspection
Investigated the allegation and found the medication was not administered as ordered.
Licensing—Failed to administer medication as ordered
18 May 2018Abuse: Neglect
18 May 2018Abuse: Neglect
Found failure to provide appropriate care when resident's condition changed. A $1,000 fine was assessed.
Abuse—Failed to intervene when resident's condition changed
18 May 2018Inspection
18 May 2018Inspection
Investigated the allegation of failing to report potential or suspected abuse and assessed a civil penalty for failure to self-report.
Licensing—Failed to report potential or suspected abuse
14 May 2018Inspection
14 May 2018Inspection
Investigated the staffing allegation and found a deficiency in administrator qualifications and availability.
Licensing—Failed to provide appropriate staffing
14 May 2018Inspection
14 May 2018Inspection
Found failure to maintain laundry facilities with locked storage for chemicals and equipment, in violation of state rule.
Licensing—Failed to provide safe environment
14 May 2018Inspection
14 May 2018Inspection
Investigated the staffing allegation and concluded that required staffing or staff training practices were not met.
Licensing—Failed to provide appropriate staffing
14 May 2018Inspection
14 May 2018Inspection
Determined that mandatory abuse reporting requirements were not followed, specifically failing to report potential or suspected abuse.
Licensing—Failed to report potential or suspected abuse
14 May 2018Inspection
14 May 2018Inspection
Found that door alarms were not monitored by staff. Some doors to the secure courtyard were propped open.
Licensing—Failed to provide service
14 May 2018Inspection
14 May 2018Inspection
Investigated the allegation of unsafe medication distribution and found a deficiency in safe medication administration practices.
Licensing—Failed to provide a safe medication administration system
07 May 2018Inspection
07 May 2018Inspection
Investigated an allegation of a failure to provide a safe environment and found a lack of substantial compliance.
Licensing—Failed to provide safe environment
29 Apr 2018Inspection
29 Apr 2018Inspection
Concluded that failure to self-report abuse occurred and assessed a $1000 fine.
Licensing—Failed to report potential or suspected abuse
29 Apr 2018Abuse: Neglect
29 Apr 2018Abuse: Neglect
Found an inadequate medication system that led to hospitalization; assessed a $2,500 fine.
Abuse—Failed to provide a safe medication administration system
28 Mar 2018Abuse: Neglect
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.
Abuse—Failed to follow care plan
28 Mar 2018Inspection
28 Mar 2018Inspection
Found failure to selfreport potential or suspected abuse and assessed a $1000 fine.
Licensing—Failed to report potential or suspected abuse
28 Mar 2018Abuse: Neglect
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.
Abuse—Failed to administer medication as ordered
21 Feb 2018Inspection
21 Feb 2018Inspection
Investigated an allegation that RN delegation and teaching were not provided; identified a deficiency in RN delegation and teaching.
Licensing—Failed to provide service
21 Feb 2018Inspection
21 Feb 2018Inspection
Found that service plans were not readily available to staff.
Licensing—Failed to provide service
20 Feb 2018Inspection
20 Feb 2018Inspection
Found insufficient staffing to meet residents' scheduled and unscheduled needs.
Licensing—Failed to provide appropriate staffing
08 Feb 2018Inspection
08 Feb 2018Inspection
Investigated the allegation of failing to administer medication as ordered and found a deficiency. A $500 fine was assessed.
Licensing—Failed to administer medication as ordered
08 Feb 2018Inspection
08 Feb 2018Inspection
Found failure to self-report potential or suspected abuse; $750 fine assessed.
Licensing—Failed to report potential or suspected abuse
19 Nov 2017Abuse: Neglect
19 Nov 2017Abuse: Neglect
Investigated an abuse/neglect allegation and found a lack of safe environment for four residents.
Abuse—Failed to provide safe environment
02 Aug 2017Abuse: Neglect
02 Aug 2017Abuse: Neglect
Found deficiencies in care planning that resulted in inappropriate care for a reported victim.
Abuse—Failed to properly plan care
30 Jul 2017Inspection
30 Jul 2017Inspection
Investigated the allegation and identified a deficiency related to failing to provide a safe environment for two victims.
Licensing—Failed to provide safe environment
19 May 2017Inspection
19 May 2017Inspection
Found failure to provide a safe environment.
Licensing—Failed to provide safe environment
17 Jan 2017Inspection
17 Jan 2017Inspection
Investigated an allegation of failing to provide a safe medication administration system and found medications were not administered as ordered.
Licensing—Failed to provide a safe medication administration system
03 Jan 2017Inspection
03 Jan 2017Inspection
Found a deficiency related to RN assessment under nursing delegation requirements.
Licensing—Failed to comply with nursing delegation requirement
11 Dec 2016Abuse: Financial abuse
11 Dec 2016Abuse: Financial abuse
Investigated an allegation of financial exploitation and found a failure to protect a resident from theft.
Abuse—Failed to protect resident from financial exploitation
17 Nov 2016Abuse: Neglect
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.
Abuse—Failed to intervene when resident's condition changed
17 Oct 2016Abuse: Physical Abuse
17 Oct 2016Abuse: Physical Abuse
Found that a resident was not protected from rough treatment.
Abuse—Failed to protect resident from rough treatment
17 Oct 2016Abuse: Verbal/Mental abuse
17 Oct 2016Abuse: Verbal/Mental abuse
Investigated the allegation of verbal abuse and found a resident was not protected from inappropriate verbal comments.
Abuse—Failed to protect resident from verbal abuse
23 Sept 2016Abuse: Neglect
23 Sept 2016Abuse: Neglect
Investigated and concluded that medication was not administered as ordered.
Abuse—Failed to administer medication as ordered
02 Jun 2016Abuse: Financial abuse
02 Jun 2016Abuse: Financial abuse
Found a failure to protect a resident from cash theft, indicating financial abuse.
Abuse—Failed to provide safe environment
16 Mar 2016Abuse: Neglect
16 Mar 2016Abuse: Neglect
Investigated and found that the care plan was not followed for the reported victim.
Abuse—Failed to follow care plan
01 Dec 2015Inspection
01 Dec 2015Inspection
Investigated and found failure to administer the prescribed medication as required.
Licensing—Failed to provide a safe medication administration system
19 Oct 2015Abuse: Neglect
19 Oct 2015Abuse: Neglect
Investigated and found failure to provide appropriate care, resulting in a $300 fine.
Abuse—Failed to provide service
13 Jun 2013Abuse: Neglect
13 Jun 2013Abuse: Neglect
Investigated a neglect allegation and determined oversight of change of condition was inadequate, resulting in an unsafe environment.
Abuse—Failed to provide oversight and monitoring of change of condition
13 Apr 2013Abuse: Neglect
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.
Abuse—Failed to perform adequate screening or assessment
29 Mar 2012Inspection
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.
Licensing—Failed to properly plan care
14 Sept 2011Abuse: Neglect
14 Sept 2011Abuse: Neglect
Investigated the neglect allegation and found a failure to provide a safe environment; a $300 fine was assessed.
Abuse—Failed to follow care plan
09 Nov 2010Inspection
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.
Licensing—Failed to provide medical treatment as ordered
09 Nov 2010Inspection
09 Nov 2010Inspection
Investigated an allegation that service was not provided and found the RV was not dressed appropriately.
Licensing—Failed to provide service
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