I'm very pleased with Pelican Pointe. The staff - especially Amber - treated my loved one like family: compassionate, responsive, and attentive, with excellent communication that gave me real peace of mind. Clean, homey facility with tasty meals, lots of engaging activities, and a caring atmosphere I gladly recommend.
Loved one of resident
Jul 2026
Pricing
Prices shown are estimates and subject to change. Contact your senior living advisor for current pricing.
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Amenities
Healthcare services
Activities of daily living assistance
Assistance with bathing
Assistance with dressing
Assistance with transfers
Coordination with health care providers
Hospice waiver
Medication management
Mental wellness program
Healthcare staffing
12-16 hour nursing
24-hour call system
24-hour supervision
Meals and dining
Diabetes diet
Meal preparation and service
Restaurant-style dining
Special dietary restrictions
Room
Air-conditioning
Cable
Fully furnished
Housekeeping and linen services
Kitchenettes
Private bathrooms
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
4.65·(113)
Overall rating
5
4
3
2
1
Care
4.6
Staff
4.7
Meals
3.8
Amenities
4.4
Value
4.0
Pros
Compassionate, personalized caregiving
Attentive and friendly direct-care staff
Strong staff–resident rapport and family orientation
Proactive move-in and transition support
Clean, well-maintained interior and grounds
Apartment-style units and studio/one-bedroom options
Engaging, varied activities calendar
Frequent social events and holiday programming
Regular religious services and worship opportunities
Music, exercise, and cognitive 'brain game' programming
Bingo and group social activities several times weekly
Weekly housekeeping and routine apartment services
Transportation for appointments and outings
Garden and outdoor access
Family education and support resources for dementia
Routine family communication and photo/updates
Pet-friendly policy and resident-centered decor
Competitive local pricing and perceived good value
Cons
Staffing variability and reduced night coverage
Delayed response times to resident calls
Inconsistent meal quality and nutritional balance
Unreliable meal-service continuity
Gaps in medication-management and clinical coordination
Gaps in emergency/alert response and monitoring processes
Inconsistent service-staff training and frontline performance
Limited visibility of administrative leadership
Poor communication and visibility of activity schedules
Sanitation inconsistencies and pet-policy enforcement issues
Limited capacity for higher-acuity memory-care needs
Allegations of serious staff conduct with perceived inadequate management response
Summary of reviews
Pelican Pointe by Cogir is largely described as a warm, activity-focused assisted living community with many families praising the caregiving staff and the community’s social environment. Reviewers consistently highlight compassionate, personalized attention from direct-care employees, frequent social programming (bingo, music, exercise, religious services, holiday events), and supportive transition services that make new residents feel welcome. Housekeeping, grounds maintenance, apartment-style unit layouts, and garden access are commonly noted as strengths that contribute to a home-like atmosphere.
Dining and activities are central to resident life. Many families compliment the variety of events, cognitive programming, and regular outings, as well as amenities such as transportation and weekly housekeeping. Several reviewers described the food as enjoyable and the dining staff as attentive, and there is a perception of good value relative to regional pricing. At the same time, food service shows variability: complaints about overcooked, overly salty, or less nutritious options and occasional missed or delayed meal delivery indicate opportunities to standardize menus and ensure consistent mealtime service.
Clinical and operational patterns are mixed. While many families report attentive, knowledgeable caregivers and responsive bedside support, there are repeated concerns about staffing variability—notably reduced coverage during night shifts—and consequent delays in attending to resident calls. Related operational weaknesses include gaps in medication-management coordination, uneven emergency/alert monitoring and response processes, and inconsistent training among service staff. Some families also found administrative leadership to be insufficiently visible, which can complicate follow-up on care concerns.
Communication about programming and incident handling is another theme. Families praise frequent outreach and photo updates in some cases, yet others report difficulty finding activity schedules or slow follow-up on requests. Sanitation and pet-policy enforcement have been raised as occasional issues and should be clarified during a tour. A small number of reviews describe situations serious enough that they invoked allegations of staff conduct and perceived inadequate management response; these comments merit direct inquiry with facility leadership and review of any regulatory history before a move.
Overall, Pelican Pointe appears well suited to prospective residents and families seeking an active, social assisted living environment with many staff who invest in personalized care and engagement. Prospective families should weigh these strengths against operational concerns by asking specific, concrete questions on tour: current staffing ratios (including night coverage), documented response-time performance, medication-management and clinical escalation protocols, meal menu planning and delivery reliability, sanitation and pet-policy enforcement, and the facility’s process for investigating and communicating about serious incidents. For residents with higher-acuity memory or medical needs, verify the community’s clinical scope and transfer protocols, as some families found those needs exceeded the community’s capabilities.
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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.
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 32 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.
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
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
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
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
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
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
26 Feb 2025License Condition
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
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
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
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
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
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.
Identified multiple deficiencies across administration, resident services, safety, staffing, and the physical environment. The findings show noncompliance with applicable rules.
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
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
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
02 Oct 2023Licensure
Determined substantial compliance with meal service requirements and food sanitation rules.
Deficiency—Comment
05 Sept 2023Abuse: Neglect
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
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
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
02 Aug 2023Abuse: Neglect
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
01 Apr 2023Abuse: Neglect
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
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
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
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
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
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
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
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
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
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
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
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
25 Jul 2022Inspection
Found failure to prevent entry of rodents, flies, mosquitoes, and other insects.
Licensing—Failed to control pests
05 Jul 2022Licensure
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.
Found insufficient staffing to meet scheduled and unscheduled resident needs.
Licensing—Failed to provide appropriate staffing
01 Jan 2022Abuse: Neglect
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
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
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
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
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
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
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
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
18 May 2021License Condition
Found that a safe environment was not provided.
Regulatory Action—Failed to provide safe environment
30 Apr 2021Inspection
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 2021Abuse: Neglect
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
11 Apr 2021Inspection
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
07 Apr 2021Abuse: Neglect
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
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
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
14 Feb 2021Abuse: Neglect
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
09 Feb 2021Abuse: Neglect
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
24 Mar 2020Inspection
Investigated an allegation of failing to follow the care plan and identified a licensing violation.
Licensing—Failed to follow care plan
24 Mar 2020Inspection
24 Mar 2020Inspection
Found that residents were not treated with dignity and respect.
Licensing—Failed to assure resident rights
03 Mar 2020Inspection
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
30 Sept 2019Abuse: Neglect
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
22 Sept 2019Abuse: Neglect
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
22 Sept 2019Abuse: Neglect
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
14 Sept 2019Abuse: Neglect
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
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
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
11 Sept 2019Abuse: Neglect
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
10 Sept 2019Abuse: Neglect
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
10 Sept 2019Abuse: Neglect
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
24 Aug 2019Abuse: Neglect
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
02 Aug 2019Abuse: Neglect
Identified neglect due to inadequate supervision that risked serious harm.
Abuse—Failed to follow care plan
28 Jul 2019Abuse: Neglect
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
28 Jul 2019Abuse: Neglect
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
28 Jul 2019Abuse: Neglect
Found neglect leading to health and safety harm due to inadequate staffing and care.
Abuse—Failed to provide appropriate staffing
23 Jul 2019Abuse: Neglect
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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 2019Inspection
20 Feb 2019Inspection
Determined that suspected abuse was not reported, resulting in a $1000 fine.
Licensing—Failed to report potential or suspected abuse
20 Feb 2019Abuse: Neglect
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
10 Dec 2018Inspection
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
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
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
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
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
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
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
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
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
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
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
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
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
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
11 May 2018Inspection
Found a deficiency in providing a secure environment.
Licensing—Failed to provide safe environment
07 May 2018Abuse: Verbal/Mental abuse
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
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
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
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
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
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
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 2018Abuse: Neglect
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
15 Mar 2018Inspection
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
10 Mar 2018Abuse: Neglect
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
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
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
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
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
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
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 2018Abuse: Neglect
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
26 Jan 2018Inspection
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
20 Jan 2018Inspection
20 Jan 2018Inspection
Determined the allegation to be supported by findings.
Licensing—Failed to report potential or suspected abuse
20 Jan 2018Abuse: Neglect
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
19 Jan 2018Inspection
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
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
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 2018Inspection
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
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 2018Abuse: Neglect
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
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
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
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
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
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
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
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 2017Inspection
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
22 Oct 2017Abuse: Neglect
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
12 Oct 2017Abuse: Neglect
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
08 Sept 2017Inspection
Investigated the allegation and found that a safe environment was not provided.
Licensing—Failed to provide safe environment
28 Aug 2017Condition
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
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
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
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
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
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
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
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
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
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 2017Inspection
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
05 Jan 2017Abuse: Neglect
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
26 Dec 2016Abuse: Neglect
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
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
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
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
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
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
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
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
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
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
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
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
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
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
28 Jan 2016Inspection
Found lack of orders for residents with restraints.
Licensing—Failed to properly use restraint
25 Jan 2016Abuse: Neglect
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
28 Oct 2014Abuse: Neglect
Found a failure to provide a safe environment.
Abuse—Failed to provide safe environment
07 Oct 2014Inspection
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
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
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
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
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
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
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
28 Nov 2013Inspection
Investigated an allegation of improper care planning and found a safety deficiency.
Licensing—Failed to properly plan care
18 Nov 2013Inspection
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
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
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
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
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
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
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
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
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
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
15 Sept 2011Inspection
Investigated and found a deficiency in protecting RV from injury.
Licensing—Failed to provide safe environment
31 Aug 2011Inspection
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
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
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
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
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
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
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
09 Jul 2010Abuse: Neglect
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
01 Jun 2010Inspection
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
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
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
26 Apr 2010Abuse: Neglect
Investigated and found a failure to provide appropriate care.
Abuse—Failed to provide service
20 Apr 2010Inspection
20 Apr 2010Inspection
Found that a resident did not receive appropriate care.
Licensing—Failed to provide service
26 Mar 2010Inspection
26 Mar 2010Inspection
Concluded that adequate care was not provided. Found the allegation of failing to provide service supported.
Licensing—Failed to provide service
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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.
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