Pricing ranges from
    $6,068 – 7,888/month

    Pelican Pointe by Cogir

    615 Washburn Way, Klamath Falls, OR 97603
    • Assisted Living

    Pricing

    Prices shown are estimates and subject to change. Contact your senior living advisor for current pricing.

    Request a Tour

    Date of Tour
    Time Window
    Tour Type

    You selected in-person tour on in the

    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
    • Spa
    • 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
    • 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

    4.67·(117)

    Overall rating

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

      4.6
    • Staff

      4.7
    • Meals

      3.8
    • Amenities

      4.4
    • Value

      4.0

    Pros

    • Compassionate, resident-centered caregiving staff
    • Strong individualized attention and resident rapport
    • Engaging, varied activity program (music, bingo, exercise, crafts)
    • Robust memory-care programming and family education support
    • Palatable dining and attentive dining service
    • Clean, well-maintained interior and attractive grounds
    • Apartment-style, home-like living units
    • Regular housekeeping and laundry services
    • Transportation and shuttle services for appointments and outings
    • Active seasonal and family-friendly community events
    • Consistent family communication and outreach with photos/updates
    • Supportive end-of-life and hospice coordination

    Cons

    • Inconsistent staffing levels and nighttime coverage
    • Slow response times to resident calls and requests
    • Variability in staff training and qualifications
    • Gaps in medication-management and clinical coordination
    • Inconsistent meal quality and occasional service interruptions
    • Gaps in fall-response and resident monitoring systems
    • Limited administrative visibility and front-desk accessibility
    • Underused or poorly promoted feedback and survey processes
    • Pet-policy enforcement issues leading to resident–family disputes

    Summary of reviews

    Overall impression: Reviews indicate a facility with strong strengths in caregiving culture, social programming, and a home-like environment. Families describe warm, attentive staff who build rapport with residents, an active calendar of activities that promote social engagement, and generally clean, well-maintained apartments and grounds. Memory-care supports, family education, transportation, weekly housekeeping, and hospice coordination are cited as meaningful supports that improve quality of life for many residents.

    Care and staff: The staff are consistently described as compassionate, attentive, and willing to provide personalized attention; a number of staff members are singled out for particularly positive interactions. Several families credit the team with helping residents regain social engagement and independence. At the same time, reviewers identify operational challenges: inconsistent staffing levels (especially overnight), variability in training and qualification across shifts, and slow response times to call buttons and requests. These patterns have led some families to assume a hands-on advocacy role to ensure consistent care. A few serious allegations concerning staff conduct and management response have appeared; these are isolated in the dataset but significant enough that prospective families should inquire directly about incident response protocols and staff training during a tour.

    Dining and clinical coordination: Dining receives mixed but generally favorable comments — many residents and families describe the food as tasty and the dining staff as attentive, while others note inconsistency in preparation (overcooking, high salt/fat levels) and occasional service lapses or missed meals. Clinical coordination is another area of mixed feedback: some families praise clinical attentiveness and medication plans, whereas others report gaps in medication management and handoffs that suggest room for more consistent clinical processes and communication with families and outside providers.

    Activities and community life: The facility’s activity program is a clear strength. Regular offerings such as bingo, music programs, exercise classes, church services, seasonal events, and family-friendly activities are highlighted repeatedly as contributing to residents’ social well-being. Families describe a welcoming atmosphere with frequent opportunities for engagement, outings via shuttle service, and responsiveness to resident input on programming.

    Facilities and amenities: Many reviewers describe the building as clean, remodeled in parts, and home-like with apartment-style units, attractive common areas, and a well-kept garden. Housekeeping and groundskeeping are commonly noted as strengths. A few comments reference small exterior space or smaller rooms in older sections, and isolated cleanliness or odor concerns are mentioned; these appear episodic rather than systemic based on the aggregated feedback.

    Management, communication, and family involvement: Communication practices receive generally positive remarks — families mention regular outreach, photos, and updates — but some reviewers raise concerns about administrative visibility, front-desk accessibility, and underutilized feedback mechanisms. Several reviewers encouraged the facility to promote survey participation and make leadership more available during visits. Staff turnover and occasional service-staff training gaps are also raised as operational weaknesses that can affect consistency of care.

    Recommendation for prospective families: Pelican Pointe by Cogir appears to be a strong option for families prioritizing an active, social assisted-living environment with a compassionate staff and robust activity programming. Prospective residents and families should, during a visit, ask specific questions about overnight staffing levels, incident-response and fall-monitoring protocols, medication-management procedures, staff training and turnover, and how family feedback is solicited and acted upon. Verifying current staffing patterns and reviewing recent clinical-incident handling procedures will help determine whether the facility’s operational practices meet the prospective resident’s clinical and safety needs.

    Reviews written on Mirador

    We have no reviews to show about Pelican Pointe by Cogir.

    Help other families by writing a review about your experience with this community.

    Location

    Pelican Pointe by Cogir is located at 615 Washburn Way, Klamath Falls, OR, 97603.

    About Pelican Pointe by Cogir

    Pelican Pointe by Cogir is a senior living community in Southern Oregon that's operated by Cogir and part of the Frontier Management network. The community offers assisted living, independent living, and memory care, along with short-term and respite stays for seniors who need temporary support. The staff at Pelican Pointe is known for being attentive and willing to go above and beyond for residents, available 24 hours a day with licensed nurses, LPNs, and caregivers who help with everything from bathing and dressing to medication management and diabetic care, even providing help for complex needs and memory care for Alzheimer's and dementia. There are sixty-four studio and one-bedroom apartments with private baths and kitchenettes, ranging from 359 to 437 square feet, air-conditioning, cable, and Wi-Fi, plus pet-friendly policies that let residents keep a dog or cat if they want, and wheelchair access throughout the building. Apartments are clean and thoughtfully organized, and shared areas include a dining room, game room, lounge with a fireplace, fitness center, gaming room, garden, computer center, beauty salon, small library, and spa, with outdoor patios furnished with tables, chairs, and umbrellas for relaxing with neighbors.

    Residents join a warm, welcoming environment that aims to feel comfortable and a bit like staying over at a relative's house, with a balance of privacy and community. There's always something to do with a busy calendar of onsite and off-site activities, including art classes through the Melody & Masterpiece Program, fitness through Forever Fit, wellness visits, pet programs, gardening, cards, trivia, outings, karaoke, and even virtual trips through Virtual Voyages, plus devotional services and community service projects. Meals are served restaurant-style, using fresh ingredients, and dietary needs like vegetarian, gluten-free, low sodium, and diabetic-friendly meals are accommodated. Residents can take trips to nearby parks, museums, shopping, restaurants, or medical appointments using the community bus or scheduled transportation. There's also on-site therapy with visiting nurses, physical therapy, and personal care services if needed. Specialized memory care programming helps residents feel safe and engaged, with secure areas to prevent wandering and activities to help memory.

    Pelican Pointe offers different levels of care, including standby or full help with moving, incontinence support, brain fitness classes, and options for those needing two-person transfers or mechanical lifts. The staff helps coordinate with doctors and provides reminders for grooming and medication. The goal is to create a connected, active place where seniors can age comfortably, get extra care as needs change, and still enjoy a social life with friends or quiet time in their own space. Amenities include housekeeping, linen service, transportation, resident parking, and room service, and the facility has won awards such as U.S. News Best Assisted Living (2024) and Pinnacle Customer Experience (2024). The dining team works closely with residents on meal options to make sure needs and tastes are met. Pelican Pointe emphasizes supportive, kind care and keeps residents connected with newsletters and life enrichment programs tied to their hobbies and past interests. Tours and consultations are available for families wanting to learn more about what the community offers.

    About Cogir Senior Living

    Pelican Pointe by Cogir is managed by Cogir Senior Living.

    Cogir Senior Living was founded in 1995 by Serge G. Duguay, a passionate real estate entrepreneur in Quebec, Canada. What began as a small family business has grown into one of North America's leading senior living operators. From humble beginnings with about a dozen U.S. communities in 2020, Cogir has experienced remarkable growth, approaching 100 communities across 11 states by 2025. The company's U.S. operations are headquartered in Sacramento, California, with additional offices in Scottsdale, Arizona, and Seattle, Washington, under the leadership of CEO David Eskenazy.

    People often ask...

    Pelican Pointe by Cogir offers competitive pricing, with rates starting at a cost of $6,068 per month.

    Pelican Pointe by Cogir offers assisted living.

    There are 46 photos of Pelican Pointe by Cogir on Mirador.

    The full address for this community is 615 Washburn Way, Klamath Falls, OR 97603.

    No, Pelican Pointe by Cogir 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 number5MA131
    StatusActive
    Facility typeResidential Care Facility
    Capacity48 residents
    LicenseeWelltower Tenant Group LLC
    EffectiveMarch 3rd, 2000
    View the official license record

    Inspection Reports

    273

    Reports

    0

    Type A Citations

    0

    Type B Citations

    1

    Complaints

    16

    Years

    27 Dec 2025Abuse: Neglect
    Found that a known fall risk was not properly managed. The care plan was not updated and safety protections were not implemented, contributing to a fall resulting in a skin tear and a bruise.
    • Abuse—Failed to properly plan care
    14 Dec 2025Abuse: Neglect
    Identified eight falls within 30 days with bruises, skin tears, head impact, and discomfort due to failure to plan care for fall risk and lack of interventions.
    • Abuse—Failed to properly plan care
    10 Dec 2025Abuse: Neglect
    Found abuse by neglect after a resident was left alone during toileting, resulting in a fall; service-plan and training deficiencies were cited and a fine assessed.
    • Abuse—Failed to provide inservice
    09 Dec 2025Abuse: Neglect
    Investigated abuse by neglect; found failure to plan care and protect a resident from inappropriate actions, resulting in a substantiated finding and a fine.
    • Abuse—Failed to properly plan care
    05 Sept 2025Abuse: Neglect
    Investigated and found abuse by neglect due to failure to properly plan care and implement fall-prevention interventions for a known fall risk.
    • Abuse—Failed to properly plan care
    25 Aug 2025Abuse: Neglect
    Substantiated that a staff member did not follow the care plan during a transfer, causing bruising, and training records were missing; a fine was assessed.
    • Abuse—Failed to follow care plan
    07 Jul 2025Abuse: Neglect
    Found neglect due to failure to plan and implement fall prevention, with eleven falls (four injuries) observed from May 13 to July 7, 2025; a $1500 fine was assessed.
    • Abuse—Failed to properly plan care
    16 May 2025Abuse: Neglect
    Investigated and found that staff failed to provide required personal care and catheter management, causing unnecessary discomfort; a fine was assessed.
    • Abuse—Failed to provide service
    26 Feb 2025License Condition
    Investigated an ABST-related allegation and found failure to have an updated ABST that reflected residents' needs and to use ABST.
    • Regulatory Action—Failed to use an ABST
    06 Oct 2024Abuse: Neglect
    Identified neglect and abuse due to failure to plan and communicate proper care after multiple falls, leading to injuries.
    • Abuse—Failed to properly plan care
    04 Sept 2024Abuse: Neglect
    Investigated a wandering and unsafe environment; found neglect and abuse due to insufficient protections against wandering.
    • Abuse—Failed to provide safe environment
    04 Sept 2024Abuse: Neglect
    Investigated and found neglect and abuse due to failure to plan care for a known fall risk, with eight falls in 30 days and a fine assessed.
    • Abuse—Failed to properly plan care
    26 Jun 2024Abuse: Neglect
    Found violations for failing to properly care plan for a resident at fall risk, leading to multiple unwitnessed falls and later injuries; a $1500 fine was assessed.
    • Abuse—Failed to properly plan care
    04 Jun 2024Licensure
    Identified deficiencies in kitchen cleanliness and maintenance, and infection control; follow-up found substantial compliance.
    • Deficiency—Comment
    • Deficiency—Resident Services Meals, Food Sanitation Rule
    04 Jun 2024Licensure
    Identified deficiencies in kitchen sanitation and food handling during the first visit; a follow-up visit found substantial compliance with the applicable food sanitation rules.
    • Deficiency—Comment
    • Deficiency—Resident Services Meals, Food Sanitation Rule
    03 Jun 2024Validation
    Identified multiple deficiencies across administration, resident services, safety, staffing, and the physical environment. The findings show noncompliance with applicable rules.
    • Deficiency—Comment
    • Deficiency—Facility Administration: Required Postings
    • Deficiency—Facility Administration: Policy & Procedure
    • Deficiency—Resident Services: Activities
    • Deficiency—Resident Move-In and Eval: Res Evaluation
    • Deficiency—Service Plan: General
    • Deficiency—Rn Delegation and Teaching
    • Deficiency—Acuity-Based Staffing Tool
    • Deficiency—Acuity Based Staffing Tool - Abst Time
    • Deficiency—Staffing Requirements and Training – Pre-Serv
    • Deficiency—Training Within 30 Days: Direct Care Staff
    • Deficiency—Fire and Life Safety: Safety
    • Deficiency—Fire and Life Safety: Training For Residents
    • Deficiency—Inspections and Investigation: Insp Interval
    • Deficiency—General Building Exterior
    • Deficiency—Doors, Walls, Elevators, Odors
    • Deficiency—Resident Units
    • Deficiency—Heating and Ventilation
    • Deficiency—Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable
    • Deficiency—Integrated Settings: Community Life
    • Deficiency—Optimize Settings: Independence, Activities
    • Deficiency—Physical Setting: Individual Accessible
    • Deficiency—Individual Privacy: Own Unit
    12 Feb 2024Change of Owner
    Identified multiple deficiencies across governance, resident rights, clinical services, infection control, staffing, training, safety, and exterior grounds; concluded with substantial compliance.
    • Deficiency—Comment
    • Deficiency—Facility Administration: Policy & Procedure
    • Deficiency—Resident Rights and Protection - General
    • Deficiency—Resident Move-In and Eval: Res Evaluation
    • Deficiency—Resident Health Services
    • Deficiency—Infection Prevention & Control
    • Deficiency—Systems: Treatment Orders
    • Deficiency—Systems: Psychotropic Medication
    • Deficiency—Restraints and Supportive Devices
    • Deficiency—Acuity-Based Staffing Tool
    • Deficiency—Acuity Based Staffing Tool - Abst Time
    • Deficiency—Staffing Requirements and Training – Pre-Serv
    • Deficiency—Annual and Biennial Inservice For All Staff
    • Deficiency—Fire and Life Safety: Safety
    • Deficiency—Inspections and Investigation: Insp Interval
    • Deficiency—General Building Exterior
    06 Dec 2023Abuse: Neglect
    Found failure to properly plan care for a resident with a falls history, resulting in neglect and abuse findings.
    • Abuse—Failed to properly plan care
    06 Dec 2023Abuse: Neglect
    Investigated a complaint and found neglect due to failure to properly plan care for a resident with a history of frequent falls, risking serious harm.
    • Abuse—Failed to properly plan care
    02 Oct 2023Licensure
    Determined substantial compliance with meal service requirements and food sanitation rules.
    • Deficiency—Comment
    05 Sept 2023Abuse: Neglect
    Determined that care planning for a known fall risk was inadequate, resulting in neglect and abuse. A $750 fine was assessed.
    • Abuse—Failed to properly plan care
    05 Sept 2023Abuse: Neglect
    Investigated and identified a failure to properly plan care for a known fall risk, resulting in neglect and abuse, with a $750 fine assessed.
    • Abuse—Failed to properly plan care
    02 Aug 2023Abuse: Neglect
    Identified failures to properly plan care for a resident's falls, contributing to injuries and risk of harm.
    • Abuse—Failed to properly plan care
    02 Aug 2023Abuse: Neglect
    Found neglect of care and abuse due to failure to properly plan care, leading to multiple falls and injury.
    • Abuse—Failed to properly plan care
    01 Apr 2023Abuse: Neglect
    Investigated an allegation of failing to assist with toileting, found repeated urine-soaked conditions and delayed incontinence care that led to discomfort and a urinary tract infection; a fine was assessed.
    • Abuse—Failed to assist with toileting
    29 Mar 2023Abuse: Neglect
    Investigated and found a failure to properly care plan after falls, constituting neglect and abuse.
    • Abuse—Failed to properly plan care
    05 Feb 2023Abuse: Neglect
    Investigated found staff did not follow the wound care plan, leaving dressings unchanged and wounds unmanaged; a $250 fine was assessed.
    • Abuse—Failed to follow care plan
    18 Dec 2022Abuse: Neglect
    Found violations involving unsafe medication administration and neglect that allowed narcotics to go missing and involved financial abuse by a staff member.
    • Abuse—Failed to provide a safe medication administration system
    21 Nov 2022Inspection
    Investigated a complaint and found a staff member yanked a resident's arm, causing pain, and protection against abuse failed.
    • Licensing—Failed to protect resident from physical abuse
    16 Nov 2022Abuse: Neglect
    Investigated found violations for inadequate assessments and care planning related to falls, resulting in unwitnessed falls, injury, and death.
    • Abuse—Failed to perform adequate screening or assessment
    16 Nov 2022Abuse: Neglect
    Found neglect and abuse for failing to properly plan care for a known fall risk, resulting in a $2,500 fine.
    • Abuse—Failed to properly plan care
    11 Nov 2022Abuse: Neglect
    Determined that improper oxygen management and insufficient training led to a resident's severe oxygen drop and hospital visit; violations cited and a fine assessed.
    • Abuse—Failed to provide safe environment
    26 Sept 2022Complaint
    Determined that no deficiencies were cited.
    • Deficiency—Licensing Complaint Investigation
    • Deficiency—Resident Services: Adls
    • Deficiency—General Building Exterior
    20 Aug 2022Abuse: Neglect
    Investigated the allegation and found violations involving neglect and financial abuse related to narcotic medication handling, with a fine assessed.
    • Abuse—Failed to protect resident from financial exploitation
    20 Aug 2022Abuse: Neglect
    Found abuse and neglect violations after a narcotic medication was diluted and not promptly investigated, with a fine assessed.
    • Abuse—Failed to provide a safe medication administration system
    25 Jul 2022Inspection
    Found a licensing violation for failing to provide intermittent intervention, supervision, and staff support for residents with behavioral symptoms. The finding noted a hoarder with piles of items, moldy food, and mice in a room.
    • Licensing—Failed to provide service
    25 Jul 2022Inspection
    Found failure to prevent entry of rodents, flies, mosquitoes, and other insects.
    • Licensing—Failed to control pests
    05 Jul 2022Licensure
    Found violations of food sanitation requirements, including dirty ceiling tiles above food prep areas, dented cans, unsanitary conditions under the dishwasher, improper glove changes, greasy stove surfaces, and an unsanitized thermometer. A later revisit found substantial compliance.
    • Deficiency—Comment
    • Deficiency—Resident Services Meals, Food Sanitation Rule
    24 Jan 2022Inspection
    Found insufficient staffing to meet scheduled and unscheduled resident needs.
    • Licensing—Failed to provide appropriate staffing
    01 Jan 2022Abuse: Neglect
    Investigated a reported abuse and neglect incident; found failure to provide a safe environment and timely response to call lights that contributed to a fall.
    • Abuse—Failed to provide safe environment
    13 Oct 2021Inspection
    Found that the failure to follow the care plan placed a resident at risk for serious harm, constituting neglect and abuse.
    • Licensing—Failed to follow care plan
    01 Oct 2021Abuse: Neglect
    Investigated and found violations for failing to follow the care plan, resulting in a resident not receiving planned showers; a $500 fine was assessed.
    • Abuse—Failed to follow care plan
    01 Sept 2021Inspection
    Found that resident service plans were not completed quarterly. The omission violated Oregon Administrative Rules.
    • Licensing—Failed to properly plan care
    16 Jul 2021Abuse: Neglect
    Investigated and found neglect and abuse due to failure to assist with toileting, leaving the resident soaked in urine. A $1,000 fine was assessed.
    • Abuse—Failed to assist with toileting
    16 Jul 2021Abuse: Neglect
    Found a failure to properly plan care around falls, resulting in neglect and abuse.
    • Abuse—Failed to properly plan care
    19 Jun 2021Abuse: Neglect
    Found a failure to provide a safe environment and separation between residents, resulting in an altercation and injury.
    • Abuse—Failed to provide safe environment
    14 Jun 2021Abuse: Neglect
    Investigated a complaint and found that proper hygiene assistance was not provided, leaving the resident in discomfort and indicating neglect and abuse; a fine was assessed.
    • Abuse—Failed to provide or assist with hygiene
    18 May 2021License Condition
    Found that a safe environment was not provided.
    • Regulatory Action—Failed to provide safe environment
    30 Apr 2021Inspection
    Investigated a complaint and determined that resident rights were violated and an unsafe environment occurred.
    • Licensing—Failed to provide safe environment
    11 Apr 2021Inspection
    Investigated the complaint and found violations of resident rights, neglect of care, and abuse due to failure to provide hygiene and care.
    • Licensing—Failed to provide or assist with hygiene
    11 Apr 2021Abuse: Neglect
    Investigated the allegation and found neglect of care due to a resident not being changed for about 12 hours, causing redness and discomfort. A $250 fine was assessed.
    • Abuse—Failed to assist with toileting
    07 Apr 2021Abuse: Neglect
    Found that a staff member pulled a resident down the hallway by both arms and dragged them after a doctor's appointment, constituting abuse and neglect; a fine was assessed.
    • Abuse—Failed to protect resident from physical abuse
    10 Mar 2021Inspection
    Found violations related to vaccination consent and the safety of the medication administration system.
    • Licensing—Failed to provide a safe medication administration system
    14 Feb 2021Abuse: Neglect
    Investigated found that a staff member neglected and abused a resident by rough transfer, causing bruising and belittling; the facility allowed the staff member to continue working, and a $500 fine was assessed.
    • Abuse—Failed to protect resident from physical abuse
    14 Feb 2021Abuse: Neglect
    Investigated a complaint and found that care planning for wheelchair safety was not done, resulting in a fall; a $500 fine was assessed.
    • Abuse—Failed to properly plan care
    09 Feb 2021Abuse: Neglect
    Found neglect and abuse for not following the care plan, including not wearing non-slip socks and not having water at the nightstand; a $500 fine was assessed.
    • Abuse—Failed to follow care plan
    02 Feb 2021Abuse: Neglect
    Investigated a care-related concern and found that staff training was insufficient, placing a resident at risk; a fine was assessed.
    • Abuse—Failed to assure a qualified caregiver was present
    30 Jan 2021Abuse: Neglect
    Investigated a failure to provide a safe environment that resulted in injuries; found neglect and abuse with a $500 fine assessed.
    • Abuse—Failed to provide safe environment
    14 Jan 2021License Condition
    Determined the respondent failed to implement adequate infection control practices to prevent the spread of COVID-19.
    • Regulatory Action—Failed to provide safe environment
    11 Jan 2021Abuse: Neglect
    Investigated and determined that neglect occurred from failing to intervene when a resident's condition changed, leading to a serious coccyx wound and hospital transfer; a 2500 fine was assessed.
    • Abuse—Failed to intervene when resident's condition changed
    09 Jan 2021Abuse: Neglect
    Investigated allegations of staff yelled at and hit a resident; findings identified neglect and physical abuse and a fine was assessed.
    • Abuse—Failed to protect resident from physical abuse
    05 Jan 2021Abuse: Neglect
    Investigated a complaint and found toileting assistance was not provided as planned, causing the resident discomfort.
    • Abuse—Failed to assist with toileting
    29 Dec 2020Inspection
    Identified infection control failures and delayed reporting of COVID-19 cases, resulting in a $1,000 fine.
    • Licensing—Failed to provide infection control
    23 Dec 2020Abuse: Neglect
    Investigated found a resident bruised after being pulled by the arm due to unsafe staffing and lack of safety measures.
    • Abuse—Failed to provide safe environment
    16 Dec 2020Abuse: Neglect
    Found inadequate care planning and supervision for residents with known behaviors, leading to a choking incident between two residents and risk of harm; a fine was assessed.
    • Abuse—Failed to properly plan care
    16 Dec 2020Abuse: Neglect
    Investigated an allegation of abuse and neglect and found a failure to provide a safe environment and to follow a one-to-one care plan, leaving a resident at risk for harm.
    • Abuse—Failed to provide safe environment
    16 Dec 2020Abuse: Neglect
    Investigated the incident and found a failure to provide a safe environment and one-to-one supervision, with the care plan not followed. This left a resident at risk for harm.
    • Abuse—Failed to provide safe environment
    02 Dec 2020Inspection
    Investigated the allegation and determined that a staff member forcefully pulled a resident from a chair, an action deemed neglect and physical abuse. This conduct violated Oregon Administrative Rules.
    • Licensing—Failed to protect resident from physical abuse
    27 Nov 2020Abuse: Neglect
    Investigated a non-injury altercation and found failure to provide a safe environment. This constitutes abuse and neglect, with a $450 fine assessed.
    • Abuse—Failed to provide safe environment
    27 Nov 2020Abuse: Neglect
    Investigated a complaint and found a failure to provide a safe environment, constituting abuse and neglect; a $500 fine was assessed.
    • Abuse—Failed to provide safe environment
    20 Nov 2020Abuse: Neglect
    Identified inadequate staffing and supervision for known fall risks, resulting in neglect and abuse findings. A fine was assessed.
    • Abuse—Failed to provide appropriate staffing
    26 Oct 2020Abuse: Neglect
    Investigated and found that falls occurred and care plans for falls were not properly developed, including a fall mat not being care planned for. This led to neglect and abuse findings and a $1,500 fine was assessed.
    • Abuse—Failed to properly plan care
    22 Oct 2020Abuse: Neglect
    Identified a failure to provide a safe medication administration system, resulting in an abuse/neglect finding and a $500 fine.
    • Abuse—Failed to provide a safe medication administration system
    16 Oct 2020Abuse: Neglect
    Found neglect and abuse due to insufficient supervision of known fall risks, resulting in a head injury requiring hospital treatment.
    • Abuse—Failed to provide service
    04 Oct 2020Abuse: Neglect
    Concluded neglect and abuse occurred due to failure to properly plan care for resident behaviors. A $338 fine was assessed.
    • Abuse—Failed to properly plan care
    02 Oct 2020Inspection
    Found that a staff member raised their voice at a resident, constituting verbal abuse, and protection from verbal abuse by staff was not ensured. This caused a licensing violation.
    • Licensing—Failed to protect resident from verbal abuse
    10 Sept 2020Abuse: Neglect
    Investigated found that a resident sustained skin tears after an altercation, and staff failed to implement interventions to keep residents safe, constituting abuse and neglect; a $338 fine assessed.
    • Abuse—Failed to provide safe environment
    23 Aug 2020Abuse: Neglect
    Identified a failure to provide a safe environment, with injuries observed on a resident.
    • Abuse—Failed to provide safe environment
    20 Aug 2020Abuse: Neglect
    Investigated a neglect allegation identified a failure to follow the care plan, leaving the resident at risk by not providing CPAP and oxygen at night; a $450 fine was assessed.
    • Abuse—Failed to follow care plan
    09 Aug 2020Abuse: Neglect
    Investigated a complaint about safety and found a failure to provide a safe environment, resulting in abuse and neglect with minor harm or potential for moderate harm; a fine was assessed.
    • Abuse—Failed to provide safe environment
    29 Jul 2020Abuse: Neglect
    Found failure to provide a safe environment, leading to an unwitnessed eye injury and head laceration.
    • Abuse—Failed to provide safe environment
    13 May 2020Abuse: Neglect
    Investigated a complaint and identified violations for failing to provide a safe environment and to follow the care plan, resulting in an incident.
    • Abuse—Failed to provide safe environment
    30 Mar 2020Abuse: Neglect
    Investigated found abuse and neglect violations related to failure to provide a safe environment, resulting in a fine.
    • Abuse—Failed to address resident's behavior
    24 Mar 2020Inspection
    Found that residents were not treated with dignity and respect.
    • Licensing—Failed to assure resident rights
    24 Mar 2020Inspection
    Investigated an allegation of failing to follow the care plan and identified a licensing violation.
    • Licensing—Failed to follow care plan
    03 Mar 2020Inspection
    Found neglect of care and an unsafe environment after a staff member did not check on a resident in time, leading to a fall and loss of dignity.
    • Licensing—Failed to provide safe environment
    01 Mar 2020Abuse: Neglect
    Investigated a reported incident and found failure to provide a safe environment and to follow the care plan, leading to neglect and abuse.
    • Abuse—Failed to provide safe environment
    23 Feb 2020Abuse: Neglect
    Investigated and found the resident was not using a walker as required by the care plan, resulting in a fall with head and eye injuries; a fine was assessed.
    • Abuse—Failed to properly plan care
    13 Feb 2020Abuse: Neglect
    Investigated and found that fall-risk care planning was not properly developed or followed, leading to a resident fall with a dislocated shoulder; a $450 fine was assessed.
    • Abuse—Failed to properly plan care
    23 Jan 2020Abuse: Neglect
    Investigated a failure to provide a safe environment, resulting in injuries to a resident during an altercation.
    • Abuse—Failed to provide safe environment
    19 Jan 2020Abuse: Neglect
    Investigated and found failures to provide a safe environment and to train staff on interventions. This constitutes neglect and abuse.
    • Abuse—Failed to provide safe environment
    05 Dec 2019Abuse: Neglect
    Found violations for neglect and abuse due to failing to provide a safe environment and failing to intervene during an aggressive incident.
    • Abuse—Failed to provide safe environment
    05 Dec 2019Abuse: Neglect
    Found a failure to provide a safe environment that could cause harm, constituting abuse and neglect.
    • Abuse—Failed to provide safe environment
    01 Dec 2019Abuse: Neglect
    Found a failure to provide a safe medication administration system, resulting in an insulin overdose to the resident.
    • Abuse—Failed to provide a safe medication administration system
    30 Nov 2019Abuse: Neglect
    Investigated and found a failure to provide a safe environment, resulting in abuse and neglect of a resident.
    • Abuse—Failed to provide safe environment
    23 Nov 2019Abuse: Neglect
    Determined that a staff member verbally abused a resident and retaliated against them, violating resident rights and constituting neglect and abuse. A $338 fine was assessed.
    • Abuse—Failed to protect resident from verbal abuse
    21 Nov 2019Abuse: Neglect
    Investigated found that a staff member threw water on the resident at the advice of a behavioral support specialist, causing loss of personal dignity and signaling failures to implement meaningful interventions, with a fine assessed for abuse and neglect.
    • Abuse—Failed to assure resident rights
    18 Nov 2019Abuse: Neglect
    Investigated and identified a safe-environment deficiency that posed a risk of harm, with a fine assessed.
    • Abuse—Failed to provide safe environment
    18 Nov 2019Abuse: Neglect
    Found a failure to provide a safe environment by not having staff present to supervise in the common area to redirect residents and prevent altercations, placing residents at risk. The finding involved known past conflicts and resulted in a substantiated determination with a fine.
    • Abuse—Failed to provide safe environment
    10 Nov 2019Abuse: Neglect
    Found a failure to provide a safe environment during a non-injury altercation due to staff not intervening with one-to-one care. This resulted in a violation of resident rights and is considered neglect and abuse.
    • Abuse—Failed to provide safe environment
    31 Oct 2019Abuse: Neglect
    Found abuse and neglect due to failure to follow the care plan, leading to a fall and a broken leg.
    • Abuse—Failed to follow care plan
    08 Oct 2019Condition
    Investigated a neglect allegation and found insufficient staffing that compromised safe environment.
    • Regulatory Action—Failed to provide safe environment
    04 Oct 2019Condition
    Investigated an allegation of neglect and found a failure to provide a safe environment.
    • Regulatory Action—Failed to provide safe environment
    03 Oct 2019Abuse: Neglect
    Found neglect due to inadequate supervision that led to serious harm to a resident; a fine of $1,125 was assessed.
    • Abuse—Failed to provide appropriate staffing
    01 Oct 2019Abuse: Neglect
    Found inadequate supervision leading to loss of personal dignity and risk of serious physical harm. A $375 fine was assessed.
    • Abuse—Failed to follow care plan
    30 Sept 2019Abuse: Neglect
    Investigated a neglect allegation and found inadequate supervision that risked serious harm to a resident.
    • Abuse—Failed to provide appropriate staffing
    30 Sept 2019Abuse: Neglect
    Found neglect due to inadequate supervision that resulted in physical harm; a fine was assessed.
    • Abuse—Failed to follow care plan
    30 Sept 2019Abuse: Neglect
    Investigated an allegation of inadequate staffing and found neglect due to insufficient supervision, risking serious harm to a resident; a $375 fine was assessed.
    • Abuse—Failed to provide appropriate staffing
    30 Sept 2019Abuse: Neglect
    Investigated and found neglect resulting in harm from failure to provide basic care, with a $375 fine assessed.
    • Abuse—Failed to provide appropriate staffing
    22 Sept 2019Abuse: Neglect
    Investigated an allegation of neglect and found failure to provide basic care resulting in physical harm; a $563 fine was assessed.
    • Abuse—Failed to provide safe environment
    22 Sept 2019Abuse: Neglect
    Investigated a neglect allegation about falls care and found a failure to adequately plan care for falls, resulting in harm and ongoing risk, with a fine assessed.
    • Abuse—Failed to adequately care plan related to falls
    14 Sept 2019Abuse: Neglect
    Concluded that neglect occurred due to inadequate supervision, resulting in physical harm to a resident.
    • Abuse—Failed to provide safe environment
    14 Sept 2019Abuse: Neglect
    Investigated a neglect allegation and found a failure to properly plan care that risked serious harm to the adult; a fine was assessed.
    • Abuse—Failed to properly plan care
    11 Sept 2019Abuse: Neglect
    Found inadequate staffing and supervision that resulted in physical harm, and assessed a $188 fine.
    • Abuse—Failed to provide appropriate staffing
    11 Sept 2019Abuse: Neglect
    Investigated a neglect allegation due to inadequate supervision that resulted in physical harm; a fine was assessed.
    • Abuse—Failed to provide safe environment
    10 Sept 2019Abuse: Neglect
    Investigated an allegation of neglect and found that basic services were not provided, resulting in harm to a resident. A $375 fine was assessed.
    • Abuse—Failed to provide appropriate staffing
    10 Sept 2019Abuse: Neglect
    Found neglect due to inadequate supervision that put a resident at risk of physical harm; a $375 fine was assessed.
    • Abuse—Failed to provide safe environment
    24 Aug 2019Abuse: Neglect
    Found neglect due to insufficient supervision, which risked serious harm to a resident. A $375 fine was assessed.
    • Abuse—Failed to follow care plan
    02 Aug 2019Abuse: Neglect
    Identified neglect due to inadequate supervision that risked serious harm.
    • Abuse—Failed to follow care plan
    28 Jul 2019Abuse: Neglect
    Found neglect leading to health and safety harm due to inadequate staffing and care.
    • Abuse—Failed to provide appropriate staffing
    28 Jul 2019Abuse: Neglect
    Investigated a neglect allegation and found that basic care or services were not provided, resulting in physical harm. A fine was assessed.
    • Abuse—Failed to provide safe environment
    28 Jul 2019Abuse: Neglect
    Identified neglect that harmed a resident by failing to provide basic care, and assessed a $375 fine.
    • Abuse—Failed to provide safe environment
    23 Jul 2019Abuse: Neglect
    Investigated and found neglect due to insufficient supervision that risked serious harm.
    • Abuse—Failed to provide safe environment
    23 Jul 2019Inspection
    Found that suspected abuse was not reported as required, and a $1,000 fine was assessed.
    • Licensing—Failed to report potential or suspected abuse
    21 Jul 2019Abuse: Neglect
    Investigated a complaint and found neglect due to insufficient supervision, creating risk of serious harm; a fine was assessed.
    • Abuse—Failed to follow care plan
    14 Jul 2019Abuse: Neglect
    Identified neglect due to failure to provide basic care and maintain resident safety, resulting in physical and significant emotional harm.
    • Abuse—Failed to provide safe environment
    23 Jun 2019Abuse: Neglect
    Found a failure to properly plan care that resulted in physical harm. A $188 fine was assessed.
    • Abuse—Failed to properly plan care
    17 Jun 2019Inspection
    Investigated and identified failure to report suspected abuse. A fine was assessed.
    • Licensing—Failed to report potential or suspected abuse
    17 Jun 2019Abuse: Neglect
    Found that basic care was not provided, causing harm and creating serious risk, and assessed a $500 fine.
    • Abuse—Failed to provide safe environment
    05 Jun 2019Abuse: Neglect
    Investigated the allegation of neglect and found that dentures were not in before breakfast, creating a choking risk.
    • Abuse—Failed to follow care plan
    23 May 2019Abuse: Neglect
    Found neglect due to inadequate supervision that led to a resident being harmed by another resident.
    • Abuse—Failed to follow care plan
    06 May 2019Abuse: Neglect
    Found neglect and abuse due to failure to provide a safe environment after a non-injury altercation.
    • Abuse—Failed to provide safe environment
    16 Apr 2019Abuse: Neglect
    Found neglect for failing to follow the care plan and provide basic care, creating risk of serious harm during an altercation.
    • Abuse—Failed to follow care plan
    23 Mar 2019Abuse: Neglect
    Investigated a neglect allegation and found the resident did not receive basic care, resulting in physical injury and a serious risk of harm.
    • Abuse—Failed to provide safe environment
    11 Mar 2019Abuse: Neglect
    Investigated and found a failure to supervise known behaviors and provide 1-to-1 care, resulting in abuse and neglect after an incident where one resident struck another across the face.
    • Abuse—Failed to follow care plan
    11 Mar 2019Abuse: Neglect
    Found inadequate supervision and staff support for known behaviors, leading to abuse and neglect of a resident.
    • Abuse—Failed to follow care plan
    08 Mar 2019Abuse: Neglect
    Investigated a complaint and found neglect of a resident that created a serious risk of harm.
    • Abuse—Failed to provide safe environment
    03 Mar 2019Abuse: Neglect
    Investigated a complaint alleging failure to properly plan care and found neglect resulting in physical harm.
    • Abuse—Failed to properly plan care
    20 Feb 2019Abuse: Neglect
    Investigated a complaint and found a failure to provide appropriate care under the care plan, resulting in unreasonable discomfort.
    • Abuse—Failed to follow care plan
    20 Feb 2019Inspection
    Determined that suspected abuse was not reported, resulting in a $1000 fine.
    • Licensing—Failed to report potential or suspected abuse
    10 Dec 2018Inspection
    Investigated and found a deficiency for failing to administer medication as ordered.
    • Licensing—Failed to administer medication as ordered
    11 Oct 2018Inspection
    Identified a licensing violation for failing to provide a secure environment, which created elopement risk. A $500 fine was assessed.
    • Licensing—Failed to provide safe environment
    06 Oct 2018Abuse: Neglect
    Found a failure to provide a safe environment that caused a resident to be struck and experience discomfort; a fine was assessed.
    • Abuse—Failed to provide safe environment
    04 Oct 2018Abuse: Neglect
    Found neglect resulting in an unsafe environment and assessed a fine.
    • Abuse—Failed to provide safe environment
    02 Oct 2018Abuse: Neglect
    Investigated allegation of abuse/neglect and found a substantiated failure to protect a resident from rough treatment, resulting in significant emotional harm.
    • Abuse—Failed to protect resident from rough treatment
    11 Sept 2018Abuse: Neglect
    Determined a medication administration error caused physical harm and assessed a $500 fine.
    • Abuse—Failed to administer medication as ordered
    06 Sept 2018Abuse: Neglect
    Investigated an allegation of neglect and found a failure to provide a safe environment that created a risk of serious harm.
    • Abuse—Failed to provide safe environment
    29 Aug 2018Inspection
    Found that the licensee failed to report suspected abuse; a $1,000 fine was assessed.
    • Licensing—Failed to report potential or suspected abuse
    29 Aug 2018Abuse: Neglect
    Found neglect related to falls due to an inadequate care plan and supervision, resulting in harm and discomfort. A $500 fine was assessed.
    • Abuse—Failed to adequately care plan related to falls
    17 Aug 2018Abuse: Neglect
    Investigated a complaint of abuse/neglect and found that a resident was not protected from rough treatment, causing pain.
    • Abuse—Failed to protect resident from rough treatment
    06 Aug 2018Abuse: Financial abuse
    Investigated an allegation of financial exploitation and documented improper safeguarding of a resident's funds, which resulted in loss.
    • Abuse—Failed to protect resident from financial exploitation
    26 Jul 2018Inspection
    Found a safety deficiency for failing to provide services to maintain safety, resulting in significant emotional harm and discomfort.
    • Licensing—Failed to provide safe environment
    14 Jun 2018Inspection
    Determined a licensing violation occurred, with failure to provide a safe environment leading to a physical altercation, and a fine was assessed.
    • Licensing—Failed to provide safe environment
    12 Jun 2018Inspection
    Found a failure to provide a safe environment, resulting in a resident-to-resident altercation.
    • Licensing—Failed to provide safe environment
    11 May 2018Inspection
    Found a deficiency in providing a secure environment.
    • Licensing—Failed to provide safe environment
    07 May 2018Abuse: Verbal/Mental abuse
    Investigated and found that verbal/mental abuse occurred and safe care was not provided.
    • Abuse—Failed to provide safe environment
    05 May 2018Inspection
    Investigated the allegation and found a failure to provide a safe environment that led to a physical altercation.
    • Licensing—Failed to provide safe environment
    03 May 2018Inspection
    Investigated a report of suspected abuse and found a failure to report suspected abuse, with a $1000 fine assessed.
    • Licensing—Failed to report potential or suspected abuse
    03 May 2018Abuse: Neglect
    Investigated an abuse/neglect allegation and found improper use of restraint leading to involuntary seclusion; a $250 fine was assessed.
    • Abuse—Failed to properly use restraint
    28 Apr 2018Abuse: Neglect
    Investigated a complaint and found a failure to provide a safe environment, resulting in injuries of unknown cause.
    • Abuse—Failed to provide safe environment
    21 Apr 2018Inspection
    Investigated an allegation of an unsafe environment and found failure to provide a safe environment, resulting in an altercation between residents.
    • Licensing—Failed to provide safe environment
    16 Mar 2018Abuse: Neglect
    Concluded a failure to provide a safe environment resulting in injury, with a $375 fine assessed.
    • Abuse—Failed to provide safe environment
    15 Mar 2018Inspection
    Investigated an allegation of failing to report potential or suspected abuse; the finding was substantiated and a fine was assessed.
    • Licensing—Failed to report potential or suspected abuse
    15 Mar 2018Abuse: Neglect
    Investigated medication management issues that led to pain due to an inadequate system; a $1,500 fine was assessed.
    • Abuse—Failed to administer medication as ordered
    10 Mar 2018Abuse: Neglect
    Found violations tied to failure to properly plan care that resulted in physical injury; a fine was assessed.
    • Abuse—Failed to properly plan care
    07 Mar 2018Inspection
    Found a failure to administer medication as ordered. The finding was classified as a level 1 licensing violation.
    • Licensing—Failed to administer medication as ordered
    03 Mar 2018Abuse: Neglect
    Found a failure to provide a safe environment resulting in minor injuries and a $250 fine was assessed.
    • Abuse—Failed to provide safe environment
    28 Feb 2018Abuse: Neglect
    Investigated a neglect allegation and determined unsafe care, resulting in a $375 fine.
    • Abuse—Failed to provide safe environment
    27 Feb 2018Inspection
    Found that medical treatment as ordered was not provided, putting a resident at risk of serious harm.
    • Licensing—Failed to provide medical treatment as ordered
    09 Feb 2018Abuse: Neglect
    Determined that a safe environment was not provided, resulting in a resident-to-resident physical altercation after failure to assess and intervene.
    • Abuse—Failed to provide safe environment
    08 Feb 2018Inspection
    Found a licensing violation for failing to provide a secure environment, with minor harm or potential for moderate harm and a $375 fine assessed.
    • Licensing—Failed to provide safe environment
    26 Jan 2018Inspection
    Found failure to report potential or suspected abuse, resulting in a civil penalty of $750.
    • Licensing—Failed to report potential or suspected abuse
    26 Jan 2018Abuse: Neglect
    Found that a resident did not receive appropriate care, resulting in pain and risk of harm. A $375 fine was assessed.
    • Abuse—Failed to provide or assist with hygiene
    20 Jan 2018Abuse: Neglect
    Found that the provider did not follow the care plan, resulting in injury, and a $500 fine was assessed.
    • Abuse—Failed to follow care plan
    20 Jan 2018Inspection
    Determined the allegation to be supported by findings.
    • Licensing—Failed to report potential or suspected abuse
    19 Jan 2018Inspection
    Found a deficiency in providing a safe environment and assessed a $375 fine.
    • Licensing—Failed to provide safe environment
    15 Jan 2018Inspection
    Concluded that the allegation of failing to report potential or suspected abuse was sustained.
    • Licensing—Failed to report potential or suspected abuse
    15 Jan 2018Abuse: Neglect
    Investigated a neglect allegation of failing to provide a safe environment and found a violation resulting in a $500 fine.
    • Abuse—Failed to provide safe environment
    12 Jan 2018Abuse: Neglect
    Determined that a safe environment was not provided. A $750 fine was assessed.
    • Abuse—Failed to provide safe environment
    12 Jan 2018Inspection
    Concluded that there was a failure to report potential or suspected abuse and assessed a civil penalty.
    • Licensing—Failed to report potential or suspected abuse
    12 Jan 2018Abuse: Neglect
    Found that a resident's rights were not assured and that a resident was confined to a bed.
    • Abuse—Failed to assure resident rights
    21 Dec 2017Abuse: Neglect
    Found a failure to assess and intervene, causing pain and injury in a resident. The finding involved neglect.
    • Abuse—Failed to intervene when resident's condition changed
    15 Dec 2017Inspection
    Determined inadequate supervision led to elopement and a possible risk of physical harm.
    • Licensing—Failed to provide safe environment
    12 Dec 2017Abuse: Neglect
    Investigated a neglect allegation and found a failure to assess and intervene, resulting in a resident injury; a $300 fine was assessed.
    • Abuse—Failed to intervene when resident's condition changed
    20 Nov 2017Abuse: Neglect
    Found deficiencies in administering medication as ordered and in maintaining an adequate medication system, with a $300 fine assessed.
    • Abuse—Failed to administer medication as ordered
    17 Nov 2017Abuse: Neglect
    Concluded that the allegation of failing to intervene when a resident's condition changed is substantiated, with care planning not ensuring safety.
    • Abuse—Failed to intervene when resident's condition changed
    23 Oct 2017Abuse: Neglect
    Found that staff failed to assess and intervene, resulting in a resident being sexually groped by another resident.
    • Abuse—Failed to properly plan care
    23 Oct 2017Abuse: Neglect
    Investigated an allegation of neglect involving failure to provide a safe environment and identified deficiencies related to safety and resident protection.
    • Abuse—Failed to provide safe environment
    22 Oct 2017Abuse: Neglect
    Found that a safe environment was not provided, resulting in injury, and assessed a $300 fine.
    • Abuse—Failed to follow care plan
    22 Oct 2017Inspection
    Found that there was a failure to provide a secure environment, resulting in elopement on two occasions.
    • Licensing—Failed to provide safe environment
    12 Oct 2017Abuse: Neglect
    Investigated an abuse/neglect allegation and concluded there was a failure to provide a safe environment, resulting in pain.
    • Abuse—Failed to provide safe environment
    08 Sept 2017Inspection
    Investigated the allegation and found that a safe environment was not provided.
    • Licensing—Failed to provide safe environment
    28 Aug 2017Condition
    Investigated an allegation of failing to provide a safe environment and identified safety-related deficiencies across multiple regulatory requirements.
    • Regulatory Action—Failed to provide safe environment
    09 Aug 2017Inspection
    Investigated the allegation that a safe medication administration system was not provided and found a deficiency.
    • Licensing—Failed to provide a safe medication administration system
    23 Jul 2017Abuse: Neglect
    Investigated and found that staff failed to assess and intervene when a resident's condition changed, resulting in physical injury.
    • Abuse—Failed to intervene when resident's condition changed
    17 Jul 2017Inspection
    Investigated and found a failure to have a licensed nurse as required.
    • Licensing—Failed to provide appropriate staffing
    30 Jun 2017Abuse: Neglect
    Investigated a neglect allegation and found the service plan was not followed, causing harm.
    • Abuse—Failed to follow care plan
    10 Jun 2017Abuse: Neglect
    Identified neglect that created an unsafe environment and resulted in hospitalization; a $250 fine was assessed.
    • Abuse—Failed to follow care plan
    29 May 2017Abuse: Neglect
    Found unsafe conditions that led to incorrect medications and an unwitnessed fall with serious injury.
    • Abuse—Failed to provide a safe medication administration system
    20 Apr 2017Abuse: Neglect
    Found a failure to properly plan care that resulted in a resident sustaining a physical injury.
    • Abuse—Failed to properly plan care
    24 Feb 2017Inspection
    Identified deficiencies in keeping equipment clean and in good repair, including motion alarms not working.
    • Licensing—Failed to provide or maintain resident care equipment
    09 Feb 2017Abuse: Neglect
    Investigated and found the care plan was not followed, resulting in injury; a $300 fine was assessed.
    • Abuse—Failed to follow care plan
    05 Jan 2017Abuse: Neglect
    Concluded that staff failed to assess and intervene when a resident's condition changed, resulting in hospital admission.
    • Abuse—Failed to intervene when resident's condition changed
    05 Jan 2017Inspection
    Found an inadequate medication administration system that put a resident at risk for harm. The issue involved unsafe practices affecting medication delivery.
    • Licensing—Failed to provide a safe medication administration system
    26 Dec 2016Abuse: Neglect
    Found neglect due to failure to assure timely medical treatment, resulting in hospitalization.
    • Abuse—Failed to assure timely medical treatment
    04 Dec 2016Abuse: Neglect
    Investigated a complaint alleging neglect. Findings showed the environment was not safe, resulting in injury, and a $400 fine was assessed.
    • Abuse—Failed to properly plan care
    20 Nov 2016Abuse: Neglect
    Investigation found a neglect allegation substantiated and that the facility failed to provide a safe environment, with a $300 fine assessed.
    • Abuse—Failed to follow care plan
    14 Oct 2016Abuse: Neglect
    Investigated and found failures to properly plan care that led to a resident's fall and pelvic fracture.
    • Abuse—Failed to properly plan care
    29 Sept 2016Abuse: Neglect
    Investigated a resident-to-resident altercation and found a failure to intervene, resulting in injury.
    • Abuse—Failed to address resident's behavior
    10 Jul 2016Abuse: Neglect
    Investigated an abuse/neglect allegation and found a failure to provide a safe environment.
    • Abuse—Failed to address resident's behavior
    09 Jul 2016Inspection
    Investigated the allegation and determined a failure to provide a safe environment.
    • Licensing—Failed to provide safe environment
    18 Jun 2016Abuse: Neglect
    Investigated a failure to maintain an adequate medication system that resulted in hospitalization.
    • Abuse—Failed to provide a safe medication administration system
    16 Jun 2016Abuse: Neglect
    Investigated a neglect allegation and found failure to assess and intervene regarding a resident's behavior.
    • Abuse—Failed to address resident's behavior
    10 Jun 2016Inspection
    Investigated and found a deficiency related to failing to assess and intervene for toenail care, letting toenails curl under toes.
    • Licensing—Failed to properly plan care
    03 Jun 2016Inspection
    Investigated the allegation and found failure to administer medication as ordered, violating safe medication administration requirements.
    • Licensing—Failed to administer medication as ordered
    28 May 2016Abuse: Neglect
    Found a failure to provide a safe environment that resulted in physical injury; a $300 fine was assessed.
    • Abuse—Failed to provide safe environment
    25 May 2016Inspection
    Found that medication was not administered as ordered. This reflects a failure to follow safe medication practices.
    • Licensing—Failed to administer medication as ordered
    15 Apr 2016Abuse: Neglect
    Found that appropriate care was not provided due to a failure to intervene when a resident's condition changed. A $300 fine was assessed.
    • Abuse—Failed to intervene when resident's condition changed
    28 Jan 2016Inspection
    Found lack of orders for residents with restraints.
    • Licensing—Failed to properly use restraint
    25 Jan 2016Abuse: Neglect
    Investigated an abuse/neglect allegation, found failure to follow the care plan resulting in serious injury, and assessed a $300 fine.
    • Abuse—Failed to follow care plan
    29 Dec 2015Inspection
    Investigated a complaint and found that residents were not protected from physical abuse.
    • Licensing—Failed to address resident's behavior
    28 Dec 2015Abuse: Neglect
    Determined that care was not provided as required, resulting in loss of personal dignity.
    • Abuse—Failed to provide service
    10 Dec 2015Abuse: Neglect
    Investigated the allegation of neglect related to falls and found a failure to assess and intervene, resulting in injury. A $300 fine was assessed.
    • Abuse—Failed to adequately care plan related to falls
    04 Dec 2015Inspection
    Found a violation for failing to administer the correct medications as ordered.
    • Licensing—Failed to administer medication as ordered
    23 Nov 2015Abuse: Neglect
    Found neglect related to falls that caused injury and assessed a $300 fine.
    • Abuse—Failed to adequately care plan related to falls
    21 Oct 2015Inspection
    Investigated an allegation of inadequate housekeeping and found a strong odor inside the building, indicating housekeeping issues.
    • Licensing—Failed to provide appropriate housekeeping services
    11 Aug 2015Abuse: Neglect
    Found neglect with moderate harm; failed to intervene when the resident's condition changed, resulting in injury.
    • Abuse—Failed to intervene when resident's condition changed
    21 Jul 2015Abuse: Neglect
    Investigated a neglect allegation and found care planning was deficient, resulting in physical injury and risk of serious harm.
    • Abuse—Failed to properly plan care
    12 Jul 2015Abuse: Neglect
    Found substantiated abuse/neglect due to failure to intervene when a resident's condition changed. A $300 fine was assessed.
    • Abuse—Failed to intervene when resident's condition changed
    21 Apr 2015Inspection
    Identified inadequate care that created a risk of physical harm to a resident.
    • Licensing—Failed to provide service
    12 Feb 2015Abuse: Neglect
    Investigated abuse/neglect allegation and found insufficient oversight of changes in condition, resulting in hospitalization.
    • Abuse—Failed to provide oversight and monitoring of change of condition
    10 Feb 2015Abuse: Neglect
    Investigated an abuse/neglect allegation and found that one resident pushed another, causing injury.
    • Abuse—Failed to address resident's behavior
    05 Feb 2015Abuse: Neglect
    Found a failure to implement and follow a smoking policy. A $600 fine was assessed.
    • Abuse—Failed to provide safe environment
    05 Feb 2015Abuse: Neglect
    Found a failure to assess and intervene for falls that led to injury; a $300 fine was assessed.
    • Abuse—Failed to adequately care plan related to falls
    30 Jan 2015Abuse: Neglect
    Identified substantiated neglect related to falls care planning that resulted in injury.
    • Abuse—Failed to adequately care plan related to falls
    13 Dec 2014Abuse: Neglect
    Investigated the allegation and found a failure to provide a safe environment, resulting in injury.
    • Abuse—Failed to provide safe environment
    09 Dec 2014Abuse: Neglect
    Found a failure to provide a safe environment resulting in serious injury, pain and anxiety.
    • Abuse—Failed to provide safe environment
    28 Nov 2014Abuse: Neglect
    Found neglect due to failure to provide a safe environment, resulting in pain and anxiety.
    • Abuse—Failed to adequately care plan related to falls
    16 Nov 2014Inspection
    Investigated an allegation of not following the care plan and identified unsafe conditions.
    • Licensing—Failed to follow care plan
    28 Oct 2014Abuse: Neglect
    Found a failure to provide a safe environment.
    • Abuse—Failed to provide safe environment
    07 Oct 2014Inspection
    Concluded that there was an unsafe environment and inadequate supervision occurred.
    • Licensing—Failed to provide safe environment
    10 Sept 2014Abuse: Sexual abuse
    Investigated a sexual abuse allegation and found a resident was not protected from inappropriate sexual contact; a $2,500 fine was assessed.
    • Abuse—Failed to protect resident from inappropriate sexual contact
    24 Aug 2014Inspection
    Investigated and substantiated failures to prevent theft or misuse of medication and to protect a resident from financial abuse.
    • Licensing—Failure to provide a system that prevents theft or misuse of medication
    10 Jul 2014Abuse: Verbal/Mental abuse
    Investigated an allegation of verbal/mental abuse and found a failure to protect a resident from threats of punishment, deprivation, humiliation or harassment.
    • Abuse—Failed to protect resident from verbal abuse
    07 Jun 2014Abuse: Neglect
    Investigated an allegation of neglect related to falls and found failures to access and intervene, with a $300 fine assessed.
    • Abuse—Failed to adequately care plan related to falls
    03 May 2014Inspection
    Investigated an allegation of improper care planning and found that a resident was not kept in a protected environment.
    • Licensing—Failed to properly plan care
    08 Feb 2014Abuse: Neglect
    Investigated an allegation of neglect related to falls and found inadequate care planning related to falls, resulting in injury.
    • Abuse—Failed to adequately care plan related to falls
    28 Nov 2013Inspection
    Investigated an allegation of improper care planning and found a safety deficiency.
    • Licensing—Failed to properly plan care
    18 Nov 2013Inspection
    Determined a safety deficiency where a resident was not protected from physical harm.
    • Licensing—Failed to provide safe environment
    29 Aug 2013Abuse: Neglect
    Found failure to properly plan care that resulted in harm; a $300 fine was assessed.
    • Abuse—Failed to properly plan care
    18 Jul 2013Inspection
    Investigated and found failures to adequately assess and intervene when a resident's condition changed, creating potential for harm.
    • Licensing—Failed to intervene when resident's condition changed
    16 Apr 2013Inspection
    Found neglect and substantiated a failure to provide a safe medication administration system, resulting in further medical issues.
    • Licensing—Failed to provide a safe medication administration system
    18 Mar 2013Inspection
    Investigated a complaint found a failure to follow the care plan that led to an injury from a fall due to a missing fall pad.
    • Licensing—Failed to follow care plan
    11 Jul 2012Inspection
    Investigated the allegation of inadequate fall-related care planning and found a failure to provide a safe environment.
    • Licensing—Failed to adequately care plan related to falls
    05 Feb 2012Abuse: Neglect
    Investigated an abuse/neglect allegation and found that residents were not protected from a physical altercation, resulting in harm to a resident.
    • Abuse—Failed to address resident's behavior
    28 Dec 2011Abuse: Neglect
    Investigated and identified neglect related to failing to address a resident's behavior and to protect a resident from physical abuse.
    • Abuse—Failed to address resident's behavior
    28 Oct 2011Abuse: Neglect
    Investigated an allegation of neglect and found the care plan wasn't followed, resulting in an infection in the groin area.
    • Abuse—Failed to follow care plan
    03 Oct 2011Abuse: Neglect
    Investigated an abuse/neglect allegation and found that timely medical attention was not sought. A $300 fine was assessed.
    • Abuse—Failed to assure timely medical treatment
    15 Sept 2011Inspection
    Investigated and found a deficiency in protecting RV from injury.
    • Licensing—Failed to provide safe environment
    31 Aug 2011Inspection
    Found that medication was not administered as ordered, resulting in a negative outcome.
    • Licensing—Failed to administer medication as ordered
    16 Jun 2011Abuse: Financial abuse
    Found failure to protect residents from theft of money. The finding indicated financial abuse with minor harm potential.
    • Abuse—Failed to provide safe environment
    21 May 2011Abuse: Neglect
    Investigated the allegation and found failure to seek medical attention in a timely manner.
    • Abuse—Failed to provide service
    25 Dec 2010Abuse: Neglect
    Investigated an allegation of neglect related to safety. Found a safe and secure environment was not provided.
    • Abuse—Failed to provide safe environment
    30 Oct 2010Abuse: Physical Abuse
    Investigated and found a failure to provide a safe environment.
    • Abuse—Failed to provide safe environment
    26 Oct 2010Abuse: Neglect
    Investigated the neglect allegation and found a failure to provide a safe environment, resulting in injury.
    • Abuse—Failed to follow care plan
    09 Jul 2010Abuse: Neglect
    Determined neglect occurred due to failure to follow care plans and to provide a safe environment.
    • Abuse—Failed to follow care plan
    09 Jul 2010Abuse: Neglect
    Determined that an allegation of neglect was substantiated and that residents were not protected from inappropriate sexual contact; assessed a $2,500 fine.
    • Abuse—Failed to perform adequate screening or assessment
    01 Jun 2010Inspection
    Investigated a discharge-planning allegation and found an inadequate medication system that led to a resident being discharged without medications.
    • Licensing—Failed to adequately plan discharge
    29 May 2010Abuse: Neglect
    Investigated a report and identified failures 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 May 2010Abuse: Neglect
    Investigated a neglect allegation and found care was not provided as required. The finding notes a failure to follow the care plan.
    • Abuse—Failed to follow care plan
    26 Apr 2010Abuse: Neglect
    Investigated and found a failure to provide appropriate care.
    • Abuse—Failed to provide service
    20 Apr 2010Inspection
    Found that a resident did not receive appropriate care.
    • Licensing—Failed to provide service
    26 Mar 2010Inspection
    Concluded that adequate care was not provided. Found the allegation of failing to provide service supported.
    • Licensing—Failed to provide service

    Disclaimer

    Mirador Living is not affiliated with the owner or operator(s) of Pelican Pointe by Cogir. The information above has not been verified or approved by the owner or operator. For exact information, please contact Pelican Pointe by Cogir directly. There is no cost for this service. We are compensated by the community you select.

    Are you an owner or operator of Pelican Pointe by Cogir?

    Claim this listing to receive messages from prospective customers and manage your community page.

    Nearby Communities

    Assisted Living in Nearby Cities

    1. 21 facilities$5,450/mo
    2. 5 facilities$4,414/mo
    3. 10 facilities$5,422/mo
    4. 18 facilities$5,102/mo
    5. 40 facilities$5,479/mo
    6. 10 facilities$4,153/mo
    7. 84 facilities$5,412/mo
    8. 4 facilities$4,095/mo
    9. 10 facilities$4,153/mo
    10. 2 facilities
    11. 94 facilities$5,324/mo
    12. 39 facilities$4,910/mo
    © 2026 Mirador Living