I'm very happy with this community - the staff are caring and professional, meals are excellent, the building and rooms are clean and well-kept, activities keep residents engaged, and management is responsive; I would happily recommend it to my grandmother.
Loved one of resident
Jul 2026
Pricing
Prices shown are estimates and subject to change. Contact your senior living advisor for current pricing.
Schedule a Tour
Amenities
Healthcare services
Activities of daily living assistance
Assistance with bathing
Assistance with dressing
Assistance with transfers
Medication management
Mental wellness program
Healthcare staffing
12-16 hour nursing
24-hour call system
24-hour supervision
Meals and dining
Diabetes diet
Meal preparation and service
Special dietary restrictions
Room
Air-conditioning
Cable
Fully furnished
Housekeeping and linen services
Kitchenettes
Private bathrooms
Telephone
Wifi
Transportation
Community operated transportation
Transportation arrangement
Common areas
Beauty salon
Computer center
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
4.65·(143)
Overall rating
5
4
3
2
1
Care
4.6
Staff
4.6
Meals
4.5
Amenities
4.5
Value
3.0
Pros
compassionate, resident-centered staff
friendly and reassuring front-desk team
engaging activities program (bingo, music, social events)
varied, restaurant-style dining with flexible menu options
spacious, well-furnished apartments and multiple floor plans
clean, well-maintained common areas and grounds
helpful move-in coordination and transition support
responsive maintenance and timely repairs
family-like community atmosphere and social opportunities
pet-friendly accommodations
assistance with Medicaid and financial coordination
convenient location near hospital and local services
24-hour staff availability
active activities director and concierge-style services
positive impressions of new leadership and marketing/ sales staff
Cons
Staff conduct and resident responsiveness
inconsistent clinical training and emergency-preparedness skills
variable housekeeping and sanitation practices
staffing shortages and high caregiver turnover
gaps in family communication and incident notification
inadequate safeguards for resident belongings and property security
management instability and leadership transition risk
inconsistent meal-service continuity during staffing strains
costly pricing structure and long-term contract terms
past regulatory/legal incidents and allegation resolution gaps
Summary of reviews
Overall impression: Reviews of Klamath Falls Senior Living present a mixed but actionable picture. Many residents and families describe a warm, family-like culture driven by compassionate caregivers, an attentive front desk, and an active life-enrichment program. At the same time, multiple reviews raise operational and clinical concerns that prospective residents and families should evaluate during a visit and pre-move discussions.
Care and clinical oversight: Numerous accounts praise individual caregivers and nursing staff for patience, attentiveness, and collaboration with families. However, there are repeated concerns about inconsistent care quality and responsiveness at times, including delays in attending to resident needs and gaps in basic clinical preparedness. Reviewers referenced a need for more consistent CPR and first-aid training and raised broader questions about clinical supervision. There are also mentions of external agency involvement and serious allegations that resulted in legal attention; prospective families should ask about the facility’s clinical oversight, training cadence, and the outcome of any regulatory or legal actions.
Staff, culture, and communication: Many reviewers emphasize staff kindness, an approachable executive/sales team, and strong move-in support. Activities personnel and certain administrators receive consistent praise. Counterbalancing this are comments about staffing shortages, frequent caregiver turnover, and instances of punitive responses to staff who raise concerns. Communication with families is uneven in some cases—positive when administrators are engaged, but delayed or insufficient around care incidents for other families. Ask about staff retention, whistleblower protections, and the routine methods the community uses to inform families about care issues.
Dining and activities: Dining is frequently called out as a strength: restaurant-style service, a varied menu, and flexible meal options are commonly noted. The activities program appears robust, with regular social events, games, and outings that contribute to resident engagement. Some reviewers reported interruptions to meal service or reduced variety during staffing strains; confirming current dining staffing and sample menus is advisable.
Facilities and operations: The physical plant, apartments, and common spaces receive largely positive comments—clean, well-kept, and spacious rooms with multiple floor-plan options. Maintenance responsiveness is a recurring plus. Operational weaknesses include inconsistent housekeeping in some areas, questions about safeguards for resident belongings, and an overall perception of higher-than-average cost with long-term contract terms. Ownership and management changes have been highlighted; some reviewers describe improvements under new leadership while others indicate lingering operational gaps.
Notable patterns and recommendations: The strongest patterns are the contrast between highly praised, compassionate staff and persistent operational risks tied to staffing, training, and management stability. Prospective residents and families should: tour at mealtime, meet nursing leadership, request current staffing ratios and training records (including emergency-response certification), ask about housekeeping schedules and property-security measures, review contract length and pricing, and inquire about the facility’s recent regulatory history and how any past incidents were addressed. Those who value an active social program, varied dining, and a close-knit community are likely to find many strengths here; those whose top priority is consistently high clinical oversight and rapidly responsive communication should pursue focused questions and documentation during the decision process.
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Location
Klamath Falls Senior Living is located at 2130 N Eldorado Ave, Klamath Falls, OR, 97601.
About Klamath Falls Senior Living
Klamath Falls Senior Living sits on an emerald hillside in Klamath Falls, surrounded by blossoming trees and garden views that just make people feel at home, and residents can choose from private or semi-private apartments in studio, one-bedroom, or two-bedroom layouts, with some ground-floor spaces offering patios that open into the garden. Apartments come with kitchenettes and private bathrooms, each fitted with walk-in, wheelchair-accessible showers, and all of them allow pets, so long as folks want to bring theirs along, and there's room service if anyone prefers a meal in their room. The building never feels stuffy since there's always someone in the restaurant-style dining room where chefs prepare meals each day, and there are housekeeping and laundry services, too, for anyone who'd rather spend time doing something else. People who like staying active can join in games, chair exercises, bingo, crafts, religious services, or garden socials, and the community calendar includes special events, like outings into town and holiday celebrations such as Easter with photos and goodie bags.
There are full-time Assisted Living and temporary Respite Care services for those needing more help, and Memory Care supports people living with Alzheimer's or other forms of dementia, with a medical and nursing staff that folks often find patient, skilled, and easy to talk to. Seniors can get help with walking or wheelchairs, and the in-house skilled nursing is meant for those who need it, with regular health assessments for everyone's peace of mind. The staff, concierge, and reception teams are known to be approachable and helpful, working hard to keep things running smoothly and keeping an eye on residents' dignity and enjoyment. The setting feels safe and clean, and people say the busy schedule keeps everyone engaged and social, but there's still plenty of privacy in each well-equipped apartment. Klamath Falls Senior Living welcomes adults 55 and over and accepts both independent folks and those who need a little more care, and being part of the Pacifica Senior Living family means it follows state licensing rules, under license number 1364036202, which many find reassuring. There's on-site parking, transportation for field trips, a salon and spa right in the building, and modern amenities like internet, landline, and TV to round out daily life, so it's the kind of place where people can settle in with support for many different needs and lifestyles.
Pacifica Senior Living, a division of Pacifica Companies (family-owned since 1978), was founded in 2008 and is headquartered in San Diego, California. Operating over 90 communities across 13-14 states with concentrations in California, Florida, and Arizona, Pacifica has grown to become the 13th largest overall senior care provider in the United States. The company ranks as the 5th largest memory care provider, 10th largest assisted living provider, and 21st largest independent living provider nationally, serving thousands of residents from coast to coast through their comprehensive care offerings.
Pacifica's mission centers on creating a lifestyle of independence, security, and peace of mind for each individual and their family. The company provides personalized, compassionate care services through their signature Heartland™ Assisted Living and Legacies™ Memory Care programs, which focus on the individual while offering customized care plans that respect each resident's needs, preferences, and privacy. Their philosophy emphasizes striking a balance between assistance and independence, providing dignified and compassionate retirement experiences in environments that feel like home. Each community is managed individually, allowing for tailored support of unique resident profiles and communal character, with everything from scheduling to dining menus designed around residents' preferences.
The company's specialized memory care programs demonstrate their expertise in dementia care. Their Legacies™ Memory Care program helps patients with Alzheimer's disease and other forms of memory loss feel safe and secure while providing memory-boosting activities. The innovative Amara Memory Support program creates welcoming and empowering environments that celebrate the essence of people rather than focusing on their diagnosis. Programming encompasses nine Focus Elements of Life: Recreation, Service, Spirituality, Movement, Sensory, Household Connection, Community, Exploration, and Creative Arts, delivered through stimulating activities including gardening, culinary adventures, musical experiences, creative artistic outlets, and mindfulness practices.
Pacifica offers a comprehensive continuum of care including independent living, assisted living, memory care, respite care, skilled nursing, and adult day care services. All communities focus on promoting well-being by meeting care needs while facilitating social interactions, activities, and wellness programs. Despite recent financial challenges leading to the bankruptcy of one management entity affecting approximately 20 California facilities, the majority of Pacifica's nearly 100 communities continue operating, maintaining their commitment to advancing senior living and providing peace of mind to residents and families through warm, family-like communities where each resident receives individualized attention while maintaining dignity and independence.
People often ask...
Klamath Falls Senior Living offers competitive pricing, with rates starting at a cost of $5,329 per month.
Klamath Falls Senior Living offers assisted living.
There are 32 photos of Klamath Falls Senior Living on Mirador.
The full address for this community is 2130 N Eldorado Ave, Klamath Falls, OR 97601.
No, Klamath Falls Senior Living 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.
Found a policy failure to refer residents who may be victims of acute sexual assault.
Licensing—Failed to assure resident rights
12 Feb 2026Inspection
12 Feb 2026Inspection
Investigated and found a failure to immediately report abuse or suspected abuse to the Department, AAA, or law enforcement and to promptly investigate all reports, violating Oregon administrative rules.
Licensing—Failed to report potential or suspected abuse
30 Jan 2026Inspection
30 Jan 2026Inspection
Identified that service plans were not reflective of resident preferences and not implemented.
Licensing—Failed to properly plan care
09 Jan 2026Inspection
09 Jan 2026Inspection
Investigated the allegation of failing to provide a safe environment and found a violation of Oregon Administrative Rules.
Licensing—Failed to provide safe environment
09 Jan 2026Inspection
09 Jan 2026Inspection
Investigated and found a failure to promptly report and investigate abuse, suspected abuse, and neglect.
Licensing—Failed to report potential or suspected abuse
09 Jan 2026Inspection
09 Jan 2026Inspection
Determined that service plans were not based on evaluations and reflective of residents' needs and preferences, and were not clearly directed, implemented, reviewed, updated, or readily available to staff.
Licensing—Failed to properly plan care
09 Jan 2026Inspection
09 Jan 2026Inspection
Investigated and found a failure to provide a safe environment.
Licensing—Failed to provide safe environment
09 Jan 2026Inspection
09 Jan 2026Inspection
Found that residents were not provided a safe and homelike environment.
Licensing—Failed to provide safe environment
09 Jan 2026License Condition
09 Jan 2026License Condition
Identified actions/omissions that created immediate jeopardy by failing to provide needed services and a safe environment.
Regulatory Action—Failed to provide safe environment
09 Jan 2026Inspection
09 Jan 2026Inspection
Investigated and found a violation for failing to identify, evaluate, monitor, and document significant change of condition requirements.
Licensing—Failed to provide service
09 Jan 2026Inspection
09 Jan 2026Inspection
Found a failure to develop and implement a policy for referring residents who may be victims of acute sexual assault.
Licensing—Failed to provide safe environment
05 Sept 2025Inspection
05 Sept 2025Inspection
Found that a staff member kissed and rubbed a person receiving care, creating an unsafe environment. This conduct constituted a licensing violation.
Licensing—Failed to provide safe environment
11 Aug 2025Abuse: Neglect
11 Aug 2025Abuse: Neglect
Investigated a complaint of abuse and neglect; concluded there was a failure to provide adequate services and a safe environment after an incident of inappropriate sexual touching by a resident.
Abuse—Failed to provide service
21 Jul 2025Inspection
21 Jul 2025Inspection
Investigated an allegation and found deficiencies in the medication administration system and documentation.
Licensing—Failed to keep medication record current or accurate
03 May 2025Abuse: Neglect
03 May 2025Abuse: Neglect
Investigated a complaint of neglect resulting in a resident fall and hip fracture; found failures in care planning and fall-prevention interventions, with a fine assessed.
Abuse—Failed to provide service
28 Jan 2025Abuse: Neglect
28 Jan 2025Abuse: Neglect
Investigated and found care planning failures and lack of fall-prevention interventions led to multiple falls and injuries, with a fine assessed.
Abuse—Failed to properly plan care
28 Jan 2025Abuse: Neglect
28 Jan 2025Abuse: Neglect
Found that the care plan was not followed, contributing to multiple falls and injuries, and assessed a $1125 fine.
Abuse—Failed to properly plan care
19 Dec 2024Abuse: Neglect
19 Dec 2024Abuse: Neglect
Investigated abuse/neglect findings identified failures in care and medication management, including missing oxygen orders, limited monitoring, and delayed nebulizer treatment, resulting in a monetary sanction.
Abuse—Failed to provide service
19 Dec 2024Abuse: Neglect
19 Dec 2024Abuse: Neglect
Found that safety interventions to prevent falls were not implemented after a resident at risk fell, creating a risk of harm. A $1,000 fine was assessed.
Abuse—Failed to provide service
17 Dec 2024Abuse: Neglect
17 Dec 2024Abuse: Neglect
Found neglect and abuse due to failure to follow the care plan and monitor, leading to a resident lying in urine and risk of infection and skin breakdown; a fine was assessed.
Abuse—Failed to provide service
20 Nov 2024Kitchen
20 Nov 2024Kitchen
Found multiple lapses in food storage and kitchen sanitation, and administration compliance concerns were identified. Violations were noted for food safety rules and for administration oversight.
Investigated neglect alleging failure to provide required safety checks and monitoring for a resident. A fall occurred after checks were not performed for about 13 hours, indicating insufficient care.
Abuse—Failed to provide service
30 Oct 2024Abuse: Neglect
30 Oct 2024Abuse: Neglect
Found neglect due to failure to properly plan care to address increasing seizure and fall risk, leading to multiple hospital visits for injuries between Sept 25 and Oct 30, 2024; a $1,500 fine was assessed.
Abuse—Failed to properly plan care
24 Oct 2024Licensure
24 Oct 2024Licensure
Identified widespread deficiencies across administration, resident rights, health services, staffing, and safety, indicating systemic failures in oversight and resident care.
Deficiency—Individual Rights Settings Right to Freedom
17 Oct 2024License Condition
17 Oct 2024License Condition
Found deficiencies for failing to meet residents' scheduled and unscheduled needs.
Regulatory Action—Failed to meet the scheduled and unscheduled needs of residents
16 Oct 2024Complaint
16 Oct 2024Complaint
Investigated a complaint about resident health services and found no deficiencies.
Deficiency—Resident Health Services
14 Oct 2024Abuse: Neglect
14 Oct 2024Abuse: Neglect
Found neglect and abuse due to failure to provide necessary care and services after unwitnessed falls, causing pain and discomfort.
Abuse—Failed to provide service
14 Oct 2024Inspection
14 Oct 2024Inspection
Found a staffing deficiency due to failure to provide an Oregon licensed nurse regularly scheduled onsite and available for phone consultation.
Licensing—Failed to provide appropriate staffing
14 Oct 2024Inspection
14 Oct 2024Inspection
Found a deficiency for failing to provide a safe environment because there was no working elevator.
Licensing—Failed to provide safe environment
14 Oct 2024Abuse: Neglect
14 Oct 2024Abuse: Neglect
Found neglect and abuse for failing to provide required care and planning for a resident, resulting in repeated UTIs and loss of dignity; a fine was assessed.
Abuse—Failed to provide service
12 Oct 2024Abuse: Neglect
12 Oct 2024Abuse: Neglect
Investigated allegations of neglect found the care plan wasn't followed, leaving the resident soaked in urine and at risk of serious harm; a $1,500 fine was assessed.
Abuse—Failed to follow care plan
12 Oct 2024Inspection
12 Oct 2024Inspection
Investigated staffing practices related to ABST. Found failure to fully implement and update ABST, violating Oregon Administrative Rules.
Licensing—Failed to update staffing plan based on ABST
11 Oct 2024Abuse: Neglect
11 Oct 2024Abuse: Neglect
Investigated found a resident did not receive timely call light responses and safety checks were not followed, leading to discomfort and loss of dignity.
Abuse—Failed to provide service
11 Oct 2024Abuse: Neglect
11 Oct 2024Abuse: Neglect
Investigated a neglect allegation and found care planning shortcomings and delayed responses to call lights, with a $500 fine assessed.
Abuse—Failed to provide service
10 Oct 2024Abuse: Neglect
10 Oct 2024Abuse: Neglect
Investigated the allegation of neglect and abuse and found failures in care planning and interventions that led to repeated injuries from falls, with a fine assessed.
Abuse—Failed to provide service
09 Oct 2024Abuse: Neglect
09 Oct 2024Abuse: Neglect
Identified neglect for failing to follow the care plan, resulting in AV sitting in soiled briefs daily with redness and skin injury; a $1,500 fine was assessed.
Abuse—Failed to follow care plan
07 Oct 2024Abuse: Neglect
07 Oct 2024Abuse: Neglect
Found neglect of care and abuse due to improper oxygen management that caused distress to a resident who depended on care. Staff repeatedly left portable oxygen canisters on and increased oxygen flow beyond orders, leading to distress and confinement until new canisters arrived.
Abuse—Failed to provide service
01 Oct 2024Abuse: Neglect
01 Oct 2024Abuse: Neglect
Investigated and found care planning failures led to repeated catheter removals and resulting discomfort, constituting neglect and abuse.
Abuse—Failed to properly plan care
01 Oct 2024Abuse: Neglect
01 Oct 2024Abuse: Neglect
Determined neglect and abuse occurred due to a caregiver's inaction after a catheter was pulled, leading to hospital care, and found training deficiencies with a $1500 fine assessed.
Abuse—Failed to provide service
30 Sept 2024Abuse: Neglect
30 Sept 2024Abuse: Neglect
Found neglect of care that left an individual in urine-soaked clothing for long periods, causing a rash and discomfort, with a fine assessed.
Abuse—Failed to provide service
30 Sept 2024Abuse: Neglect
30 Sept 2024Abuse: Neglect
Investigated a complaint and found deficiencies in care planning and fall prevention that led to unwitnessed falls and injuries; a fine was assessed.
Abuse—Failed to provide service
20 Sept 2024Abuse: Neglect
20 Sept 2024Abuse: Neglect
Investigated the allegation of abuse/neglect and found that inadequate care planning and interventions failed to mitigate falls and self-transfers, resulting in injuries; a $1,500 fine was assessed.
Abuse—Failed to provide service
15 Sept 2024Abuse: Neglect
15 Sept 2024Abuse: Neglect
Found neglect due to failure to follow the care plan, resulting in discomfort and risk to the resident. A $1,500 fine was assessed.
Abuse—Failed to follow care plan
11 Sept 2024Abuse: Neglect
11 Sept 2024Abuse: Neglect
Investigated and found neglect and abuse due to failure to provide needed services and care planning, resulting in a head injury; a $1,500 fine was assessed.
Abuse—Failed to provide service
26 Aug 2024Abuse: Neglect
26 Aug 2024Abuse: Neglect
Found neglect and abuse due to failures in care planning and following the care plan, with resulting injuries and a fine.
Abuse—Failed to provide service
26 Aug 2024Abuse: Neglect
26 Aug 2024Abuse: Neglect
Found that a resident did not receive care as planned, resulting in a severe health issue and neglect.
Abuse—Failed to provide service
17 Jul 2024Abuse: Neglect
17 Jul 2024Abuse: Neglect
Investigated a neglect allegation and found inadequate care planning and monitoring that led to a fall.
Abuse—Failed to provide service
11 Jul 2024Abuse: Neglect
11 Jul 2024Abuse: Neglect
Investigated and found substantiated neglect and abuse due to failure to provide services and to mitigate fall risk, resulting in an injury and a $1,500 fine assessed.
Abuse—Failed to provide service
01 Jul 2024Abuse: Neglect
01 Jul 2024Abuse: Neglect
Investigated deficiencies in care planning and staff training resulted in neglect, with a $500 fine assessed.
Abuse—Failed to provide service
26 Apr 2024Abuse: Neglect
26 Apr 2024Abuse: Neglect
Investigated and found neglect due to failure to plan care to mitigate fall risk; three falls occurred with skin tears and discomfort, and a fine was assessed.
Abuse—Failed to properly plan care
20 Feb 2024Abuse: Neglect
20 Feb 2024Abuse: Neglect
Identified a failure to obtain and administer medications as ordered after surgery, causing three ER visits; a $500 fine was assessed.
Abuse—Failed to provide a safe medication administration system
29 Nov 2023Inspection
29 Nov 2023Inspection
Investigated a staffing allegation and found failure to provide an Oregon-licensed nurse regularly on site and available for phone consultation.
Licensing—Failed to provide appropriate staffing
07 Nov 2023Abuse: Neglect
07 Nov 2023Abuse: Neglect
Found violations for failing to follow the care plan and administer PRN medication, resulting in severe pain and hospitalization. A $3,000 fine was assessed.
Abuse—Failed to follow care plan
07 Nov 2023Abuse: Neglect
07 Nov 2023Abuse: Neglect
Concluded neglect and abuse from failing to assess a resident’s changing skin condition and to provide a safe medication administration system, resulting in ongoing pain and a worsening infection; a $3,000 fine was assessed.
Abuse—Failed to provide service
03 Oct 2023Licensure
03 Oct 2023Licensure
Identified deficiencies in food storage and sanitation during the 10/03/2023 survey, with a 01/30/2024 revisit determining substantial compliance.
Found neglect and abuse due to failure to respond to AV's changing condition and skin breakdown, leading to ongoing licensed professional intervention.
Abuse—Failed to provide service
14 Sept 2023Abuse: Neglect
14 Sept 2023Abuse: Neglect
Investigated an allegation of unsafe environment and found staff were not monitored or following policy, risking resident safety. A $2,250 fine was assessed.
Abuse—Failed to provide safe environment
01 Sept 2023Abuse: Neglect
01 Sept 2023Abuse: Neglect
Investigated a complaint found failure to implement dietary-related interventions and care planning, risking serious harm to a resident. Substantiated abuse/neglect with a $500 fine assessed.
Abuse—Failed to properly plan care
25 Jul 2023License Condition
25 Jul 2023License Condition
Determined that an acuity-based staffing tool was not fully implemented. A deficiency was identified for not using an ABST.
Regulatory Action—Failed to use an ABST
25 Jul 2023License Condition
25 Jul 2023License Condition
Determined a failure to report potential or suspected abuse promptly, and found a deficiency related to resident rights.
Regulatory Action—Failed to report potential or suspected abuse
25 Jul 2023License Condition
25 Jul 2023License Condition
Investigated the allegation of failing to provide service; found the required transfer and two-person assist care planning were not implemented.
Regulatory Action—Failed to provide service
21 Jul 2023Inspection
21 Jul 2023Inspection
Investigated inconsistencies between the resident roster, care plans, and the Acuity-Based Staffing Tool. Determined this violates Oregon Administrative Rules.
Licensing—Failed to use an ABST
06 Jun 2023Abuse: Neglect
06 Jun 2023Abuse: Neglect
Investigated found neglect for failing to monitor a resident’s changing condition and follow the care plan, which contributed to a serious health decline and leg amputation.
Abuse—Failed to provide oversight and monitoring of change of condition
04 May 2023Complaint
04 May 2023Complaint
Investigated and found multiple deficiencies: failure to report incidents to SPD, inadequate service plan implementation, missed medication orders, and overdue service plan reviews in the ABST.
Concluded neglect occurred due to failure to monitor and respond to a resident's significant change in condition, resulting in serious harm. A fine was assessed.
Abuse—Failed to provide oversight and monitoring of change of condition
10 Apr 2023Abuse: Neglect
10 Apr 2023Abuse: Neglect
Investigated found a staff member coerced a resident to shower before an appointment after refusals, violating resident rights and constituting emotional abuse and neglect. A fine was assessed.
Abuse—Failed to assure resident rights
29 Mar 2023Abuse: Neglect
29 Mar 2023Abuse: Neglect
Found neglect for failing to provide two-person transfers per the care plan, resulting in a resident fall with injury.
Abuse—Failed to provide service
03 Mar 2023Abuse: Neglect
03 Mar 2023Abuse: Neglect
Found neglect and abuse due to failure to properly plan care, resulting in several injury falls and risk of serious harm. A $1,750 fine was assessed.
Abuse—Failed to properly plan care
03 Mar 2023Abuse: Neglect
03 Mar 2023Abuse: Neglect
Found neglect and abuse due to failure to provide CPAP care, risking infection.
Abuse—Failed to provide service
11 Jan 2023Abuse: Neglect
11 Jan 2023Abuse: Neglect
Investigated a medication safety complaint and found a safe administration system was not provided, resulting in about five days without medications and related discomfort.
Abuse—Failed to provide a safe medication administration system
02 Oct 2022Abuse: Neglect
02 Oct 2022Abuse: Neglect
Determined that verbal/emotional abuse and neglect occurred due to inadequate oversight of ambulation and hostile staff behavior. A $250 fine was assessed.
Abuse—Failed to protect resident from mental or emotional abuse
12 Jul 2022Inspection
12 Jul 2022Inspection
Found neglect and failure to follow the care plan, resulting in loss of personal dignity and risk of harm.
Licensing—Failed to provide service
05 Jun 2022Abuse: Neglect
05 Jun 2022Abuse: Neglect
Found that staff did not provide needed services to the resident, causing pain and emotional discomfort and constituting neglect and abuse; a $500 fine was assessed.
Abuse—Failed to provide service
10 May 2022License Condition
10 May 2022License Condition
Found that residents were at risk of immediate jeopardy due to failure to provide a safe environment, resulting in a license condition.
Regulatory Action—Failed to provide safe environment
02 May 2022Validation
02 May 2022Validation
Investigated a licensee's compliance during re-licensure; identified multiple deficiencies in oversight, care planning, medication management, infection control, staffing, and building safety, but reached substantial compliance.
Found abuse by neglect due to failure to monitor and respond to a significant change of condition, resulting in falls and ongoing pain.
Abuse—Failed to provide oversight and monitoring of change of condition
29 Apr 2022Abuse: Neglect
29 Apr 2022Abuse: Neglect
Identified neglect and abuse due to failure to properly plan for respiratory needs, leading to a significant medical event requiring an emergency room visit; a fine was assessed.
Abuse—Failed to properly plan care
24 Apr 2022Abuse: Neglect
24 Apr 2022Abuse: Neglect
Found neglect due to failure to plan care after a change in condition, leading to approximately four unwitnessed falls and risk of serious harm.
Abuse—Failed to properly plan care
21 Apr 2022Abuse: Neglect
21 Apr 2022Abuse: Neglect
Found violations related to failure to plan care for a resident, resulting in falls and risk of ongoing harm. A $500 fine was assessed.
Abuse—Failed to properly plan care
11 Apr 2022Inspection
11 Apr 2022Inspection
Investigated and found interior odors and interior materials and surfaces not kept clean, violating Oregon administrative rules.
Licensing—Failed to provide safe environment
31 Mar 2022Inspection
31 Mar 2022Inspection
Identified a staffing deficiency due to RN not assessing all residents when changes in condition occurred.
Licensing—Failed to provide appropriate staffing
30 Mar 2022Abuse: Neglect
30 Mar 2022Abuse: Neglect
Found substantiated neglect for failing to monitor and respond to a change in condition, resulting in hospitalization for stroke and sepsis.
Abuse—Failed to provide oversight and monitoring of change of condition
03 Jan 2022Abuse: Neglect
03 Jan 2022Abuse: Neglect
Investigated abuse by neglect; found failures to assess, monitor, and respond to a resident's change in condition and to honor a hospital transfer request, risking serious harm.
Abuse—Failed to provide oversight and monitoring of change of condition
29 Mar 2021Abuse: Neglect
29 Mar 2021Abuse: Neglect
Found abuse by neglect for failing to respond to a resident’s change of condition and oversee staff; a $188 fine was assessed.
Abuse—Failed to provide oversight and monitoring of change of condition
04 Jan 2021Abuse: Neglect
04 Jan 2021Abuse: Neglect
Investigated and found failure to provide a safe medication administration system, leading to missing medications and discomfort, constituting neglect and abuse; a $500 fine was assessed.
Abuse—Failed to provide a safe medication administration system
23 Dec 2020Abuse: Neglect
23 Dec 2020Abuse: Neglect
Identified a deficiency for failing to protect a resident from theft, resulting in missing personal items and constituting abuse.
Abuse—Failed to protect resident from financial exploitation
16 Dec 2020Inspection
16 Dec 2020Inspection
Identified a deficiency in assisting residents with activities of daily living around the clock.
Licensing—Failed to provide service
21 Nov 2020Inspection
21 Nov 2020Inspection
Investigated an allegation of verbal abuse toward a resident and found staff yelled during care and failed to protect the resident from abuse.
Licensing—Failed to protect resident from verbal abuse
16 Sept 2020Inspection
16 Sept 2020Inspection
Investigated and found a deficiency in safe medication administration; medication not given as prescribed.
Licensing—Failed to administer medication as ordered
14 Sept 2020Inspection
14 Sept 2020Inspection
Found a failure to provide a safe medication administration system that left a resident without medication on about September 13, 2020.
Licensing—Failed to provide a safe medication administration system
13 Sept 2020Inspection
13 Sept 2020Inspection
Determined that a safe medication administration system was not provided, resulting in a patient receiving a double dose and at risk of harm. This reflected neglect of care and abuse as identified in the findings.
Licensing—Failed to provide a safe medication administration system
03 Sept 2020Inspection
03 Sept 2020Inspection
Found failure to administer medications as ordered, resulting in 10 missed doses.
Licensing—Failed to administer medication as ordered
03 Sept 2020Abuse: Neglect
03 Sept 2020Abuse: Neglect
Investigated and found a failure to provide a safe medication administration system, resulting in missed doses and extreme pain for a resident.
Abuse—Failed to provide a safe medication administration system
01 Aug 2020Inspection
01 Aug 2020Inspection
Found violations related to failure to provide required services and protect a resident from neglect, resulting in a resident being left in a wet brief and experiencing loss of dignity.
Licensing—Failed to provide service
22 Jul 2020Inspection
22 Jul 2020Inspection
Investigated and found inappropriate verbal comments toward a resident by staff and a failure to protect the resident from verbal abuse.
Licensing—Failed to protect resident from verbal abuse
02 Jul 2020Abuse: Neglect
02 Jul 2020Abuse: Neglect
Found failures to plan and monitor care according to needs and fall history, resulting in an unwitnessed fall with injury.
Abuse—Failed to properly plan care
05 May 2020Inspection
05 May 2020Inspection
Investigated a complaint and found that medication orders were not followed as prescribed.
Licensing—Failed to administer medication as ordered
22 Apr 2020Inspection
22 Apr 2020Inspection
Found that resident privacy and dignity were not protected.
Licensing—Failed to assure resident rights
15 Feb 2020Inspection
15 Feb 2020Inspection
Found that a staff member wrongfully took medication from a resident after death and that the resident's belongings were not protected from theft.
Licensing—Failed to protect resident from financial exploitation
29 Dec 2019Inspection
29 Dec 2019Inspection
Investigated a financial exploitation allegation and found a staff member engaged in sexual contact with a resident, and protections against abuse were inadequate.
Licensing—Failed to protect resident from financial exploitation
30 Oct 2019Abuse: Neglect
30 Oct 2019Abuse: Neglect
Investigated and found failures to implement interventions and care planning, resulting in multiple falls, injuries of unknown origin, poor hygiene, and lack of behavioral support.
Abuse—Failed to provide service
30 Oct 2019Abuse: Neglect
30 Oct 2019Abuse: Neglect
Identified neglect due to failure to provide eating assistance, resulting in about 28 pounds of weight loss in two months. A $2,250 fine was assessed.
Abuse—Failed to provide service
30 Oct 2019Abuse: Involuntary Seclusion
30 Oct 2019Abuse: Involuntary Seclusion
Found a violation for involuntary seclusion constituting abuse and assessed a $2,250 fine.
Abuse—Failed to protect resident from involuntary seclusion
30 Oct 2019Abuse: Neglect
30 Oct 2019Abuse: Neglect
Investigated an allegation of physical abuse and neglect; found physical force used, causing fear and discomfort, and failure to protect or intervene for the resident, with a fine assessed.
Abuse—Failed to protect resident from physical abuse
14 Oct 2019Abuse: Neglect
14 Oct 2019Abuse: Neglect
Found that care planning failed to address a resident's change in condition, resulting in inadequate transfer support and a fall with fracture, constituting abuse and neglect.
Abuse—Failed to properly plan care
27 Sept 2019Inspection
27 Sept 2019Inspection
Found verbal abuse toward a resident and failure to protect the resident from abuse.
Licensing—Failed to protect resident from verbal abuse
22 Jul 2019Abuse: Neglect
22 Jul 2019Abuse: Neglect
Investigated an allegation of neglect that led to physical harm due to failure to provide basic care; a fine was assessed.
Abuse—Failed to assure resident was safe
03 Jun 2019Inspection
03 Jun 2019Inspection
Found a deficiency in safe medication administration due to delays in refilling medications. This resulted in residents not receiving medications as prescribed.
Licensing—Failed to provide a safe medication administration system
13 May 2017Abuse: Financial abuse
13 May 2017Abuse: Financial abuse
Investigated an allegation of financial abuse and found a failure to protect a resident from theft by another resident.
Abuse—Failed to provide safe environment
08 May 2017Condition
08 May 2017Condition
Investigated a neglect allegation of failed to provide service and found condition deficiencies at relicensure.
Regulatory Action—Failed to provide service
03 May 2017Abuse: Financial abuse
03 May 2017Abuse: Financial abuse
Investigated and found that a resident was not protected from theft.
Abuse—Failed to provide safe environment
19 Sept 2016Abuse: Neglect
19 Sept 2016Abuse: Neglect
Investigated the neglect allegation and identified a failure to obtain a medical order that led to serious injury, with a $400 fine assessed.
Abuse—Failed to obtain medical order
16 Sept 2016Abuse: Financial abuse
16 Sept 2016Abuse: Financial abuse
Found a failure to protect a resident from theft, resulting in monetary loss.
Abuse—Failed to provide safe environment
22 Apr 2016Inspection
22 Apr 2016Inspection
Found that residents did not receive palatable meals.
Licensing—Failed to provide proper food/nutrition
22 Apr 2016Inspection
22 Apr 2016Inspection
Found deficiencies in residents' meal choices and compliance with therapeutic diet requirements.
Licensing—Failed to provide a therapeutic diet
17 Mar 2015Abuse: Neglect
17 Mar 2015Abuse: Neglect
Found that staff failed to assess and intervene when a resident's condition changed, resulting in severe injury requiring surgery.
Abuse—Failed to intervene when resident's condition changed
04 Oct 2014Abuse: Neglect
04 Oct 2014Abuse: Neglect
Found a safety deficiency after substantiating neglect; a $300 fine was assessed.
Abuse—Failed to intervene when resident's condition changed
29 Aug 2014Abuse: Neglect
29 Aug 2014Abuse: Neglect
Investigated an allegation of neglect and found that staff failed to assess and intervene when a resident's condition changed; a $300 fine was assessed.
Abuse—Failed to intervene when resident's condition changed
13 Aug 2014Abuse: Neglect
13 Aug 2014Abuse: Neglect
Determined neglect occurred due to failure to assess and intervene after a resident's condition changed; a $200 fine was assessed.
Abuse—Failed to intervene when resident's condition changed
15 Jul 2014Abuse: Financial abuse
15 Jul 2014Abuse: Financial abuse
Determined financial abuse occurred and residents were not protected from it.
Abuse—Failed to provide safe environment
17 Jun 2014Abuse: Neglect
17 Jun 2014Abuse: Neglect
Found that care was not provided according to plan, resulting in injury, and a $300 fine was assessed.
Abuse—Failed to follow care plan
08 Apr 2014Abuse: Neglect
08 Apr 2014Abuse: Neglect
Determined a failure to properly plan care, with a $300 fine assessed.
Abuse—Failed to properly plan care
16 Nov 2013Abuse: Financial abuse
16 Nov 2013Abuse: Financial abuse
Found that a resident's funds were not protected, creating a risk of theft.
Abuse—Failed to provide safe environment
10 Jun 2013Abuse: Financial abuse
10 Jun 2013Abuse: Financial abuse
Found that protections against theft were inadequate, resulting in the loss of property.
Abuse—Failed to provide safe environment
28 Nov 2012Abuse: Neglect
28 Nov 2012Abuse: Neglect
Cited for failing to follow a care plan and provide appropriate care, with a $300 fine assessed.
Abuse—Failed to follow care plan
22 Dec 2011Inspection
22 Dec 2011Inspection
Found that a resident's pain medication was not administered as ordered.
Licensing—Failed to administer ordered medication
03 Mar 2010Inspection
03 Mar 2010Inspection
Investigated and found a violation of resident rights due to harassment of a resident.
Licensing—Failed to assure resident rights
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