I moved my mom into the memory-care wing and was impressed by the caring, attentive staff - Shakira and the caregivers kept her calm, engaged and peaceful, and even let me stay by her side overnight. The modern, clean facility has restaurant-like dining, plenty of activities, 24-hour support, laundry and housekeeping, and staff stayed responsive and informative through a smooth transition. Overall I'm very pleased and would recommend this warm, well-run community.
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
24-hour call system
24-hour supervision
Meals and dining
Diabetes diet
Meal preparation and service
Restaurant-style dining
Special dietary restrictions
Room
Cable
Fully furnished
Housekeeping and linen services
Kitchenettes
Telephone
Wifi
Memory care community services
Dementia waiver
Mild cognitive impairment
Specialized memory care programming
Transportation
Transportation arrangement (medical)
Transportation to doctors appointments
Common areas
Beauty salon
Dining room
Garden
Outdoor space
Small library
Community services
Move-in coordination
Activities
Community-sponsored activities
Resident-run activities
Scheduled daily activities
Reviews
3.49·(45)
Overall rating
5
4
3
2
1
Care
2.6
Staff
3.5
Meals
3.2
Amenities
4.2
Value
2.8
Pros
Compassionate and affectionate caregiving staff
Friendly, patient frontline aides
Attentive, restaurant-style dining service
Nutritious and varied meal options
Clean, modern facility with bright, airy rooms
Quiet environment with courtyard and natural light
Multiple dining areas and private family meeting spaces
One-bedroom apartment availability and sensible floor plans
Housekeeping and laundry services
24-hour staff presence and medication assistance
Engaging activities and bus outings
Memory-care programming and dedicated memory wing
Smooth move-in support and responsive admissions staff
Convenient central location and access to nearby services
Positive social atmosphere and resident rapport
Cons
Inconsistent clinical care planning and documentation
Gaps in night staffing coverage, especially in memory care
Delays in staff responsiveness to resident requests
Inconsistent hygiene and incontinence-care practices
Variable medication-management and after-hours clinical response
High staff turnover and uneven staff training/engagement
Weak family communication and slow management follow-up
Property-control and personal-belonging management weaknesses
Fall-prevention and transfer-safety process gaps
Inconsistent activity frequency and engagement in memory care
Sanitation and cleanliness inconsistencies
Perceived cost-to-value mismatch for some residents
Summary of reviews
Reviews for Wildflower Lodge Senior Living present a mixed portrait: many families praise the facility's compassionate staff, pleasant dining, and well-maintained physical environment, while other accounts raise operational concerns that affect clinical reliability and family confidence. Strengths consistently mentioned include attentive, affectionate frontline caregivers, restaurant-style meal service with varied menus, a modern bright facility with a courtyard, and active social programming for assisted-living residents. Admissions and transition experiences are often described as smooth, with helpful sales staff and useful move-in support.
Care quality is an area of clear divergence. Positive accounts describe gentle, reassuring care that helped residents feel calmer and supported. However, several statements point to inconsistent care planning and documentation, gaps in medication oversight, and instances where clinical follow-through was inadequate. There are also recurring indications of fall-risk and transfer-safety weaknesses. Families should verify individualized care plans, medication protocols, and fall-prevention measures during a tour.
Staffing and staff conduct receive both significant praise and notable criticism. Many reviewers highlight kind, joyful staff who engage with residents and provide compassionate day-to-day support. At the same time, concerns include high staff turnover, variability in training and engagement, delays in responding to resident requests, and specific gaps in night coverage—particularly within the memory-care unit. These operational patterns appear to produce uneven experiences depending on unit, shift, and staffing levels.
Dining and activities are generally described positively for assisted-living residents: meals are characterized as nutritious, varied, and served in a pleasant dining environment, and the community offers activities and off-site trips. Memory-care programming is available and has praised staff leadership in some accounts, but other reviewers describe infrequent activities and lower engagement levels in the memory wing. Prospective residents and families may wish to review activity schedules and staffing ratios for memory care specifically.
The facility’s physical environment and services are frequently singled out as strengths: clean, modern interiors, private meeting rooms, multiple dining venues, and apartment-style units. Conversely, a subset of reviews notes sanitation and cleanliness inconsistencies and references to past infection-control events; these comments suggest it is prudent to ask about current infection-control practices and housekeeping protocols.
Management and communication are additional areas of variability. Positive interactions with admissions and floor staff are common, but several families reported slow management callbacks, difficulty obtaining timely answers after incidents, and dissatisfaction with administrative follow-through. There are also concerns about property-control processes after move-in (missing personal items) and perceptions of cost versus value for certain residents.
Overall, Wildflower Lodge may offer a warm, well-appointed environment with strong dining and many compassionate caregivers; however, prospective residents and families should conduct targeted inquiries prior to commitment. Key topics to review on a visit include individualized care plans, night and memory-care staffing levels, medication-administration procedures, fall-prevention practices, property-inventory controls, and the frequency and staffing of memory-care activities. These checks can help determine whether the facility’s strengths align with a given resident’s clinical and social needs.
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Location
Wildflower Lodge Senior Living is located at 508 16th St, La Grande, OR, 97850.
About Wildflower Lodge Senior Living
Wildflower Lodge is nestled in the scenic Grande Ronde Valley in Eastern Oregon, surrounded by the breathtaking vistas of the Blue Mountains, Elkhorn Mountains, Eagle Cap Wilderness, and the Grande Ronde River. The natural beauty and abundant wildlife of the region create a tranquil and inspiring setting for residents. La Grande itself offers a unique fusion of country-casual charm and urban culture, made vibrant by attractions such as historical museums, interpretive parks, and a thriving local arts scene. Life at Wildflower Lodge is closely connected to the spirit of the community and the wonders of the surrounding environment.
Designed to meet the needs of individuals requiring assistance with daily living activities, Wildflower Lodge provides a secure and comfortable home with a focus on holistic, person-centered care. This approach involves thorough assessments crafted in partnership with family members and care providers, ensuring that each resident’s needs, preferences, and desires are respected and met. Whether someone is just beginning to experience memory challenges or has lived with Alzheimer’s or dementia for some time, the experienced and dedicated team at Wildflower Lodge offers round-the-clock care, providing peace of mind for residents and their loved ones.
The environment at Wildflower Lodge is both warm and thoughtfully designed, offering spaces that cater specifically to adults living with Alzheimer’s, dementia, or other forms of memory loss. Spacious, efficient apartments provide comfort and privacy, while shared common areas such as a resident lounge with sofas and armchairs, a dining room for gatherings and meals, sitting rooms with large windows offering natural light, and cozy sitting areas complemented by fireplaces invite residents to relax and socialize. The large tables in common areas are ideal for games, dining, and group activities, fostering a strong sense of community.
True North Programs are a highlight of life at Wildflower Lodge, reflecting the philosophy of person-directed care that adapts to the unique patterns of each individual. Wellness services and life enrichment opportunities are central to the lodge’s mission to maintain or improve each resident’s capabilities, empowering them to enjoy life as independently as possible. The empathetic Care Partners are available 24 hours a day to support residents, always guided by values of goodness, loyalty, faith, and fun. The team at Wildflower Lodge is committed to doing the right thing, showing care, and making a meaningful impact in the lives of residents.
Above all, Wildflower Lodge strives to be a supportive home where dignity, choice, and positive well-being are at the heart of every day. Family and community play a vital role, serving as sources of comfort, inspiration, and joy. The atmosphere is welcoming, the care is compassionate, and the lodge’s underlying philosophy is grounded in the belief that choices made from a place of kindness and integrity create a nurturing and uplifting community for all.
Senior Lifestyle, founded in 1985 as a family-owned business headquartered in Chicago, Illinois, has grown from its first lakefront community to become one of the nation's leading senior living providers. Operating more than 130 communities across 20+ states from coast to coast, Senior Lifestyle serves nearly 10,000 residents as the 10th largest senior living provider in the United States, with annual revenues reaching $1 billion. The company functions as an owner, operator, and developer of senior living communities, offering services across all market segments from luxury to affordable.
The company provides a comprehensive continuum of care including independent living, assisted living, memory care, and skilled nursing services. Their award-winning "embrace" Memory Care program stands as a cornerstone of their offerings, built on five key principles: Wellness, Enrichment, Challenge, Connection, and Creativity. This research-driven program features specialized initiatives such as Bookmarks (reading support), Essence (multi-sensory experiences), Snapshots (emotional wellness for residents and families), Spark (cognitive stimulation and social engagement), and Thymeless (a garden-to-table dining program). Each component is designed to provide person-centered care that focuses on the individual rather than the disease, ensuring dignity and overall well-being in a supportive environment.
Senior Lifestyle's operational philosophy is guided by their HEART values: Hospitality, Excellence, Appreciation, Respect, and Teamwork. These core values shape every aspect of their approach to serving residents and supporting team members. The company's commitment extends beyond traditional care models, emphasizing connection and inclusion throughout their communities. Their person-centered approach ensures that daily life is filled with joy and serenity, with personalized experiences tailored to each resident's unique needs, preferences, and abilities.
As a pioneer in the senior living industry for nearly four decades, Senior Lifestyle continues to innovate and expand while maintaining its family-owned heritage and commitment to quality care. Their comprehensive wellness approach addresses mind, body, and soul through coordinated programs that promote cognitive stimulation, social engagement, and meaningful moments. This dedication to excellence across luxury, moderate, and affordable segments demonstrates Senior Lifestyle's mission to provide exceptional senior living experiences that enhance quality of life for all residents, regardless of their care needs or economic circumstances.
People often ask...
Wildflower Lodge Senior Living offers competitive pricing, with rates starting at a cost of $5,534 per month.
Wildflower Lodge Senior Living offers assisted living and memory care.
There are 25 photos of Wildflower Lodge Senior Living on Mirador.
The full address for this community is 508 16th St, La Grande, OR 97850.
No, Wildflower Lodge Senior Living does not offer respite care.
Respite care in assisted living communities provides temporary, short-term relief for primary caregivers by offering professional care for their loved ones. It allows individuals to stay in an assisted living community for a limited time, giving caregivers a break while ensuring residents receive necessary support and assistance with daily activities.
Safety & Compliance
In Oregon, the Department of Human Services' Aging & People with Disabilities program licenses assisted living and residential care facilities, conducting inspections, complaint investigations, and renewals.
Determined that a staff member verbally abused a resident and that the provider failed to protect the resident from staff verbal abuse.
Licensing—Failed to protect resident from verbal abuse
14 Nov 2025License Condition
14 Nov 2025License Condition
Investigated the allegation of failing to provide a safe environment and identified deficiencies related to census cap, service plan audits, RN and administrator training, staff training, and reporting requirements.
Regulatory Action—Failed to provide safe environment
11 Sept 2025FEOS
11 Sept 2025FEOS
Found deficiencies in reporting and investigating injuries of unknown cause, ensuring treatment orders were followed, and maintaining accurate MARs, indicating health care rule noncompliance.
Investigated an allegation of neglect for not administering medication as ordered; found failure to follow orders and a fine was assessed.
Abuse—Failed to administer medication as ordered
02 Sept 2025Abuse: Neglect
02 Sept 2025Abuse: Neglect
Investigated a medication management allegation and found the resident did not receive their medication, resulting in seizure activity due to an unsafe medication management system.
Abuse—Failed to provide a safe medication administration system
01 Sept 2025Abuse: Neglect
01 Sept 2025Abuse: Neglect
Investigated and found that the resident's medication levels were not monitored or documented, placing the resident at risk due to failure to follow the care plan and medication orders.
Abuse—Failed to provide service
28 Aug 2025Abuse: Neglect
28 Aug 2025Abuse: Neglect
Found failures to follow the care plan for catheter care that placed a resident at risk of harm.
Abuse—Failed to follow care plan
24 Jul 2025Abuse: Neglect
24 Jul 2025Abuse: Neglect
Found that timely response to a resident's call light was not provided, leading to soiling and risk of harm; a $500 fine was assessed.
Abuse—Failed to provide service
27 Jun 2025Abuse: Neglect
27 Jun 2025Abuse: Neglect
Investigated an allegation of abuse and neglect and found that a safe environment was not provided, resulting in distress to a resident; a $450 fine was assessed.
Abuse—Failed to provide safe environment
27 Jun 2025Abuse: Neglect
27 Jun 2025Abuse: Neglect
Found a failure to provide a safe environment, resulting in abuse and neglect, with a $1,500 fine assessed.
Abuse—Failed to provide safe environment
27 Jun 2025License Condition
27 Jun 2025License Condition
Investigated the allegation of failing to provide a safe environment. Found that actions or omissions created a risk of immediate jeopardy to current and future residents.
Regulatory Action—Failed to provide safe environment
26 Jun 2025Abuse: Neglect
26 Jun 2025Abuse: Neglect
Investigated a complaint and found a failure to provide a safe environment, indicating abuse and neglect.
Abuse—Failed to provide safe environment
25 Jun 2025Abuse: Neglect
25 Jun 2025Abuse: Neglect
Investigated and found a violation for failing to provide a safe environment after an incident involving an attempted kiss between residents; a fine was assessed.
Abuse—Failed to provide safe environment
07 May 2025Complaint
07 May 2025Complaint
Identified deficiencies in updating and implementing an acuity-based staffing tool, with mismatches between service plans and ABST profiles for two residents.
Deficiency—Acuity Based Staffing Tool - Abst Time
06 May 2025Complaint
06 May 2025Complaint
Identified deficiencies in updating and using an acuity-based staffing tool and documenting care time for residents.
Deficiency—Acuity Based Staffing Tool - Abst Time
Deficiency—Acuity Based Staffing Tool - Updates & Plan
01 May 2025Abuse: Neglect
01 May 2025Abuse: Neglect
Investigated a report of abuse and neglect; found the resident was not provided a safe environment and was placed at risk.
Abuse—Failed to provide safe environment
23 Apr 2025FEOS
23 Apr 2025FEOS
Identified deficiencies in training and administration compliance, including incomplete abdominal thrust training for a newly hired direct care staff and missing pre-service dementia and infectious disease trainings.
Deficiency—Training Within 30 Days of Hire – Direct Care Staff
Deficiency—Administration Compliance
Deficiency—Staff Training Requirements
23 Apr 2025FEOS
23 Apr 2025FEOS
Investigated multiple deficiencies including service plans not reflecting current resident needs, medication order issues, ABST inaccuracies, inadequate new-hire competency documentation, and pervasive facility odors.
Deficiency—Service Plan: General
Deficiency—Systems: Treatment Orders
Deficiency—Acuity Based Staffing Tool - ABST Time
Deficiency—Training Within 30 Days of Hire – Direct Care Staff
Investigated a medication administration complaint and found that medication orders were not carried out, resulting in about 11 days of anticoagulant medication missing.
Licensing—Failed to administer medication as ordered
07 Mar 2025Inspection
07 Mar 2025Inspection
Found staffing levels did not align with ABST guidance and did not meet residents' scheduled and unscheduled needs.
Licensing—Failed to staff as indicated by ABST
20 Nov 2024Inspection
20 Nov 2024Inspection
Investigated found that a staff member shoved a resident, causing loss of balance and distress, and protection from physical abuse was not maintained.
Licensing—Failed to protect resident from physical abuse
19 Nov 2024Abuse: Neglect
19 Nov 2024Abuse: Neglect
Investigated a complaint about unsafe medication management that led to missing pain medication; found failures in ensuring timely availability of medications.
Abuse—Failed to provide a safe medication administration system
09 Sept 2024Abuse: Neglect
09 Sept 2024Abuse: Neglect
Found that a resident's call light was not answered for about 29 minutes due to staffing, creating a serious risk of harm; a $250 fine was assessed.
Abuse—Failed to meet the scheduled and unscheduled needs of residents
06 Jun 2024License Condition
06 Jun 2024License Condition
Investigated the allegation of failure to provide a safe environment and found deficiencies.
Regulatory Action—Failed to provide safe environment
29 May 2024License Condition
29 May 2024License Condition
Found deficiencies related to providing a safe environment.
Regulatory Action—Failed to provide safe environment
23 May 2024Abuse: Neglect
23 May 2024Abuse: Neglect
Investigated a neglect allegation and found failure to follow the resident's care plan, risking harm. A $250 fine was assessed.
Abuse—Failed to follow care plan
13 May 2024Revisit
13 May 2024Revisit
Investigated multiple deficiencies across licensing rules, including resident privacy, abuse reporting, wellness planning, staffing, training, and safety, with numerous findings of noncompliance observed during the on-site reviews and follow-up visit.
Deficiency—Resident Move-In and Eval: Res Evaluation
Deficiency—Change of Condition and Monitoring
Deficiency—Resident Health Services
Deficiency—Infection Prevention & Control
Deficiency—Systems: Medication Administration
Deficiency—Systems: Psychotropic Medication
Deficiency—Administrator Qualification and Requirements
Deficiency—Acuity-Based Staffing Tool
Deficiency—Staffing Rqmt and Training: Training Rqmts
Deficiency—Training Within 30 Days: Direct Care Staff
Deficiency—Fire and Life Safety: Safety
Deficiency—General Building Exterior
Deficiency—Doors, Walls, Elevators, Odors
Deficiency—Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable
Deficiency—Individual Privacy: Own Unit
Deficiency—Individual Door Locks: Key Access
Deficiency—Limitations: Threats to Health and Safety
Deficiency—Administration Compliance
Deficiency—Staff Training Requirements
Deficiency—Compliance With Rules Health Care
Deficiency—Activities
Deficiency—Behavior
Deficiency—Resident Rooms
13 May 2024Revisit
13 May 2024Revisit
Investigated numerous deficiencies across administration, resident rights, care planning, infection control, medications, staffing, fire safety, and building maintenance, resulting in multiple citations.
Investigated care planning and service delivery, found neglect and risk due to inadequate care and unsanitary conditions.
Abuse—Failed to provide service
15 Apr 2024Inspection
15 Apr 2024Inspection
Investigated a complaint and found a staff member verbally abused a resident and protections against abuse were lacking.
Licensing—Failed to provide safe environment
10 Mar 2024Inspection
10 Mar 2024Inspection
Investigated and found violations of resident rights, neglect of care, and verbal abuse, including failure to provide a safe environment.
Licensing—Failed to provide safe environment
15 Dec 2023Inspection
15 Dec 2023Inspection
Investigated and found deficiencies in staffing levels per the Acuity-Based Staffing Tool. Inconsistencies between the staffing schedule and ABST data left the levels not meeting resident needs.
Licensing—Failed to staff as indicated by ABST
07 Dec 2023Abuse: Neglect
07 Dec 2023Abuse: Neglect
Investigated and determined that failure to provide services resulted in neglect and abuse.
Abuse—Failed to provide service
30 Nov 2023Inspection
30 Nov 2023Inspection
Identified deficiencies due to an outdated Acuity-Based Staffing Tool that did not reflect residents' care needs. Inconsistencies were found between the roster, care plans, and ABST data.
Licensing—Failed to use an ABST
19 Sept 2023Complaint
19 Sept 2023Complaint
Investigated and found that the ABST was not updated to include a new resident.
Deficiency—Licensing Complaint Investigation
Deficiency—Acuity-Based Staffing Tool
19 Sept 2023Complaint
19 Sept 2023Complaint
Found deficiencies in staff background checks and in updating the ABST for a resident.
Deficiency—Licensing Complaint Investigation
Deficiency—Facility Administration: Operation
Deficiency—Acuity-Based Staffing Tool
29 Aug 2023Licensure
29 Aug 2023Licensure
Found no deficiencies.
Deficiency—Comment
29 Aug 2023Licensure
29 Aug 2023Licensure
Determined substantial compliance with meals and food sanitation requirements.
Deficiency—Comment
13 Dec 2022Inspection
13 Dec 2022Inspection
Investigated and found a failure to provide a safe medication administration system, resulting in a resident receiving a double dosage of nerve medication and risking serious harm.
Licensing—Failed to provide a safe medication administration system
07 Dec 2022Inspection
07 Dec 2022Inspection
Found that background checks for all subject individuals were not completed as required, resulting in a licensing violation.
Licensing—Failed to provide service
05 Dec 2022Abuse: Neglect
05 Dec 2022Abuse: Neglect
Found a failure to provide a safe medication administration system, resulting in missed injectable blood sugar medication and risk of serious harm, with a $500 fine assessed.
Abuse—Failed to provide a safe medication administration system
22 Nov 2022Abuse: Neglect
22 Nov 2022Abuse: Neglect
Found a failure to provide a safe medication administration system that resulted in under-dosing prescribed pain medication and significant pain for the resident. A $500 fine was assessed.
Abuse—Failed to provide a safe medication administration system
17 Nov 2022Inspection
17 Nov 2022Inspection
Investigated found that a resident's soap disappeared and was taken by an unknown individual, constituting financial exploitation; the environment failed to protect the resident from exploitation.
Licensing—Failed to protect resident from financial exploitation
02 Nov 2022Complaint
02 Nov 2022Complaint
Identified deficiencies in care planning, infection prevention/control, medication management, and staffing levels.
Deficiency—Licensing Complaint Investigation
Deficiency—Service Plan: General
Deficiency—Infection Prevention & Control
Deficiency—Systems: Treatment Orders
Deficiency—Staffing Requirements and Training: Staffing
Deficiency—Acuity-Based Staffing Tool
01 Nov 2022Complaint
01 Nov 2022Complaint
Found deficiencies in safety precautions, infection control, medication management, staffing, and training at the licensed care setting.
Deficiency—Licensing Complaint Investigation
Deficiency—Reasonable Precautions
Deficiency—Infection Prevention & Control
Deficiency—Systems: Medications and Treatments
Deficiency—Systems: Treatment Orders
Deficiency—Staffing Requirements and Training: Staffing
Deficiency—Acuity-Based Staffing Tool
Deficiency—Staffing Rqmt and Training: Training Rqmts
Deficiency—Doors, Walls, Elevators, Odors
28 Oct 2022License Condition
28 Oct 2022License Condition
Investigated an allegation of unsafe conditions that could place residents at risk and found not in substantial compliance.
Regulatory Action—Failed to provide safe environment
28 Oct 2022License Condition
28 Oct 2022License Condition
Found violations related to providing a safe environment and noncompliance with multiple rules, placing residents at risk.
Regulatory Action—Failed to provide safe environment
26 Oct 2022Inspection
26 Oct 2022Inspection
Investigated and found the interior not free from unpleasant odors, violating the odor-free interior requirement.
Licensing—Failed to provide appropriate housekeeping services
26 Oct 2022Inspection
26 Oct 2022Inspection
Investigated an allegation that direct care staffing was insufficient to meet residents' scheduled and unscheduled needs; found staffing levels insufficient to meet those needs.
Licensing—Failed to meet the scheduled and unscheduled needs of residents
26 Oct 2022Inspection
26 Oct 2022Inspection
Investigated a complaint about a medication administration system and found a deficiency in carrying out prescribed medication and treatment orders.
Licensing—Failed to provide a safe medication administration system
26 Oct 2022Inspection
26 Oct 2022Inspection
Investigated an allegation of unsafe medication administration and concluded that safe medication and treatment administration systems approved by a pharmacist consultant were not implemented.
Licensing—Failed to provide a safe medication administration system
26 Oct 2022Inspection
26 Oct 2022Inspection
Found masking requirements not followed during an infection control investigation.
Licensing—Failed to provide infection control
26 Oct 2022Abuse: Neglect
26 Oct 2022Abuse: Neglect
Found a violation for failing to provide a safe medication administration system, which led to missed diabetes doses.
Abuse—Failed to provide a safe medication administration system
26 Oct 2022Inspection
26 Oct 2022Inspection
Found failure to establish and maintain infection prevention and control protocols to prevent transmission of communicable diseases, constituting a licensing violation.
Licensing—Failed to provide infection control
26 Oct 2022Inspection
26 Oct 2022Inspection
Investigated the allegation and found a deficiency for not updating care plans quarterly.
Licensing—Failed to properly plan care
26 Oct 2022Inspection
26 Oct 2022Inspection
Investigated and found a failure to fully implement and update an Acuity Based Staffing Tool.
Licensing—Failed to use an ABST
26 Oct 2022Inspection
26 Oct 2022Inspection
Investigated the allegation and found a violation related to not carrying out medication orders.
Licensing—Failed to administer medication as ordered
26 Oct 2022Inspection
26 Oct 2022Inspection
Investigated the allegation of failing to provide a safe environment and identified a violation.
Licensing—Failed to provide safe environment
13 Oct 2022Abuse: Neglect
13 Oct 2022Abuse: Neglect
Found a failure to provide a safe medication administration system, risking harm by not administering prescribed diabetes and cholesterol medications; a $500 fine was assessed.
Abuse—Failed to provide a safe medication administration system
04 Oct 2022License Condition
04 Oct 2022License Condition
Found that care planning was improper and non-pharmacological interventions were not offered before PRN psychotropic medications.
Regulatory Action—Failed to properly plan care
04 Oct 2022License Condition
04 Oct 2022License Condition
Found staffing levels did not meet residents' scheduled and unscheduled needs.
Regulatory Action—Failed to meet the scheduled and unscheduled needs of residents
04 Oct 2022License Condition
04 Oct 2022License Condition
Investigated ABST-based staffing issues and found failures to adopt the tool and to update the staffing plan accordingly.
Regulatory Action—Failed to staff as indicated by ABST
04 Oct 2022License Condition
04 Oct 2022License Condition
Found insufficient staffing to meet residents' scheduled and unscheduled needs.
Regulatory Action—Failed to meet the scheduled and unscheduled needs of residents
04 Oct 2022License Condition
04 Oct 2022License Condition
Identified a deficiency in maintaining an accurate Medication Administration Record (MAR) in accordance with the rule.
Regulatory Action—Failed to provide a safe medication administration system
04 Oct 2022License Condition
04 Oct 2022License Condition
Found deficiencies in providing a safe medication administration system and failing to carry out prescribed medication and treatment orders.
Regulatory Action—Failed to provide a safe medication administration system
04 Oct 2022License Condition
04 Oct 2022License Condition
Found that an acuity-based staffing tool was not adopted to determine appropriate staffing levels as required.
Regulatory Action—Failed to staff as indicated by ABST
04 Oct 2022License Condition
04 Oct 2022License Condition
Found deficiencies in care planning for residents with behavioral symptoms, including lack of interventions, supervision, and staff support.
Regulatory Action—Failed to properly plan care
26 Sept 2022Inspection
26 Sept 2022Inspection
Investigated and determined that qualified awake direct care staff were not provided in sufficient numbers to meet residents' 24-hour needs.
Licensing—Failed to meet the scheduled and unscheduled needs of residents
26 Sept 2022Inspection
26 Sept 2022Inspection
Determined that ABST was not adopted or implemented to determine appropriate staffing levels.
Licensing—Failed to use an ABST
07 Sept 2022Complaint
07 Sept 2022Complaint
Investigated a complaint and identified multiple deficiencies involving staffing, medication management, service planning, and assistance with daily activities, risking resident health and safety.
Deficiency—Licensing Complaint Investigation
Deficiency—Reasonable Precautions
Deficiency—Resident Services: Adls
Deficiency—Service Plan: General
Deficiency—Service Plan: Service Planning Team
Deficiency—Systems: Medications and Treatments
Deficiency—Systems: Treatment Orders
Deficiency—Staffing Requirements and Training: Staffing
Deficiency—Acuity-Based Staffing Tool
Deficiency—Staffing Rqmt and Training: Training Rqmts
Deficiency—Staffing Requirements and Training – Pre-Serv
07 Sept 2022Complaint
07 Sept 2022Complaint
Investigated found multiple deficiencies related to resident ADL support, service planning, medication management, staffing adequacy, and equipment maintenance.
Deficiency—Licensing Complaint Investigation
Deficiency—Reasonable Precautions
Deficiency—Resident Services: Adls
Deficiency—Service Plan: General
Deficiency—Systems: Treatment Orders
Deficiency—Systems: Medication Administration
Deficiency—Systems: Psychotropic Medication
Deficiency—Staffing Requirements and Training: Staffing
Investigated a complaint and found a violation related to failing to carry out medication and treatment orders as prescribed.
Licensing—Failed to provide a safe medication administration system
06 Sept 2022Inspection
06 Sept 2022Inspection
Investigated the allegation and determined a safe medication administration system approved by a pharmacist consultant, registered nurse, or physician was not provided.
Licensing—Failed to provide a safe medication administration system
01 Sept 2022Inspection
01 Sept 2022Inspection
Found a violation for failing to submit timely weekly vaccination reporting for residents and staff, with a 30-day lapse in August 2022, and assessed a $7,500 fine.
Licensing—Failed to submit timely or adequate staffing documentation
30 Aug 2022Abuse: Neglect
30 Aug 2022Abuse: Neglect
Found violations due to delayed response to call lights that caused abuse and neglect. A $1500 fine was assessed.
Abuse—Failed to answer call light in a timely manner
28 Aug 2022Abuse: Neglect
28 Aug 2022Abuse: Neglect
Found neglect and abuse due to not following the care plan for incontinence care, causing discomfort. A $500 fine was assessed.
Abuse—Failed to follow care plan
24 Aug 2022Abuse: Neglect
24 Aug 2022Abuse: Neglect
Identified a failure to provide a safe medication administration system, resulting in missed insulin doses and improper signing for out-of-stock vitamins; a fine was assessed.
Abuse—Failed to provide a safe medication administration system
24 Aug 2022Inspection
24 Aug 2022Inspection
Found that the acuity-based staffing tool was not fully updated, resulting in insufficient day-shift coverage.
Licensing—Failed to update staffing plan based on ABST
24 Aug 2022Inspection
24 Aug 2022Inspection
Found inadequate oversight of the medication administration system, resulting in residents missing doses due to stockouts and pharmacy delivery failures.
Licensing—Failed to provide a safe medication administration system
24 Aug 2022Inspection
24 Aug 2022Inspection
Found that resident care equipment was not kept in good repair. A scale was dismantled and nonfunctional.
Licensing—Failed to provide or maintain resident care equipment
24 Aug 2022Abuse: Neglect
24 Aug 2022Abuse: Neglect
Found a failure to provide a safe medication administration system, resulting in neglect and abuse, with about seven missed doses and a $500 fine assessed.
Abuse—Failed to provide a safe medication administration system
23 Aug 2022Abuse: Neglect
23 Aug 2022Abuse: Neglect
Found violations for failing to provide a safe environment and neglect of care, with a $375 fine assessed.
Abuse—Failed to properly plan care
23 Aug 2022Abuse: Neglect
23 Aug 2022Abuse: Neglect
Found a failure to provide a safe medication administration system, leaving a resident in pain for an extended period.
Abuse—Failed to provide a safe medication administration system
23 Aug 2022Abuse: Neglect
23 Aug 2022Abuse: Neglect
Found a failure to provide a safe environment that resulted in abuse and neglect against a resident around August 23, 2022.
Abuse—Failed to provide safe environment
23 Aug 2022Abuse: Neglect
23 Aug 2022Abuse: Neglect
Found a failure to follow the care plan for showers, resulting in neglect and abuse, with a $500 fine assessed.
Abuse—Failed to follow care plan
19 Aug 2022Abuse: Neglect
19 Aug 2022Abuse: Neglect
Found abuse and neglect due to failure to properly plan care, with a fine assessed.
Abuse—Failed to properly plan care
19 Aug 2022Inspection
19 Aug 2022Inspection
Found failure to update an acuity-based staffing tool to reflect current staffing needs, resulting in day-shift understaffing.
Licensing—Failed to update staffing plan based on ABST
19 Aug 2022Inspection
19 Aug 2022Inspection
Found that the service plan was not readily available, did not provide clear direction for service delivery, and did not identify who would provide the services.
Licensing—Failed to properly plan care
19 Aug 2022Abuse: Neglect
19 Aug 2022Abuse: Neglect
Investigated a complaint and found neglect of care due to failure to provide required services, resulting in loss of dignity and unclean conditions. A $1000 fine was assessed.
Abuse—Failed to provide service
19 Aug 2022Inspection
19 Aug 2022Inspection
Identified insufficient staff to meet scheduled and unscheduled resident needs, with reports of delayed showers, long call-light wait times, and records showing understaffing on the day reviewed.
Licensing—Failed to meet the scheduled and unscheduled needs of residents
19 Aug 2022Abuse: Neglect
19 Aug 2022Abuse: Neglect
Found a failure to provide a safe medication administration system and to obtain medication orders, leading to an injectable medication not being placed on the eMAR or administered; a $1,000 fine was assessed.
Abuse—Failed to provide a safe medication administration system
17 Aug 2022Abuse: Neglect
17 Aug 2022Abuse: Neglect
Found a failure to provide a safe medication administration system, resulting in neglect and abuse.
Abuse—Failed to provide a safe medication administration system
16 Aug 2022Abuse: Neglect
16 Aug 2022Abuse: Neglect
Investigated a neglect allegation and found a failure to provide a safe medication administration system, resulting in residents not receiving prescribed medications as scheduled.
Abuse—Failed to provide a safe medication administration system
16 Aug 2022Abuse: Neglect
16 Aug 2022Abuse: Neglect
Investigated an allegation of neglect due to failure to provide a safe medication administration system, which led to a resident not receiving medication as ordered and caused discomfort. A $500 fine was assessed.
Abuse—Failed to provide a safe medication administration system
15 Aug 2022Abuse: Neglect
15 Aug 2022Abuse: Neglect
Found violations for neglect and abuse due to failure to properly plan care and mitigate aggressive behaviors.
Abuse—Failed to properly plan care
09 Aug 2022Inspection
09 Aug 2022Inspection
Found failure to implement services per the care plan and to document weekly weights.
Licensing—Failed to follow care plan
09 Aug 2022Inspection
09 Aug 2022Inspection
Found that a piece of resident care equipment was not kept in good repair; a scale was dismantled and not functioning during a site visit.
Licensing—Failed to provide or maintain resident care equipment
01 Aug 2022Inspection
01 Aug 2022Inspection
Found a violation for failing to submit timely weekly vaccination reporting for residents and staff to the proper authority for July 2022, resulting in a $7,500 fine.
Licensing—Failed to submit timely or adequate staffing documentation
28 Jul 2022Inspection
28 Jul 2022Inspection
Found deficiencies in staff competency training, including no competency checks before staff worked independently and delays in documenting competencies.
Licensing—Failed to provide safe environment
26 Jul 2022Abuse: Neglect
26 Jul 2022Abuse: Neglect
Investigated allegations of abuse and neglect found that a resident was not provided a safe environment, with an incident where one resident struck another and caused facial scratches.
Abuse—Failed to provide safe environment
26 Jul 2022Abuse: Neglect
26 Jul 2022Abuse: Neglect
Investigated a medication administration safety issue and found a failure to provide a safe system, constituting neglect and abuse; a $500 fine was assessed.
Abuse—Failed to provide a safe medication administration system
18 Jul 2022Abuse: Neglect
18 Jul 2022Abuse: Neglect
Found failure to follow the care plan for twice-weekly showers and skin checks, with skin breakdown not documented or reported.
Abuse—Failed to follow care plan
15 Jul 2022Abuse: Neglect
15 Jul 2022Abuse: Neglect
Identified a failure to provide a safe medication administration system, risking harm to a resident, with a $500 fine assessed.
Abuse—Failed to provide a safe medication administration system
14 Jul 2022Abuse: Neglect
14 Jul 2022Abuse: Neglect
Investigated and found neglect and abuse due to failure to properly plan care to address wandering and aggressive behavior, which led to an injury; a fine was assessed.
Abuse—Failed to properly plan care
12 Jul 2022Inspection
12 Jul 2022Inspection
Found deficiencies in service planning due to failure to form a proper Service Planning Team and ensure service plans exist for all residents.
Licensing—Failed to properly plan care
12 Jul 2022Inspection
12 Jul 2022Inspection
Found deficiencies in medication administration that resulted in late or omitted doses when medications were not available.
Licensing—Failed to provide a safe medication administration system
12 Jul 2022Inspection
12 Jul 2022Inspection
Found staff not properly oriented to residents’ service plans, with many plans unreviewed or unsigned and some residents lacking a service plan, plus rare shift-change meetings.
Licensing—Failed to properly plan care
12 Jul 2022Inspection
12 Jul 2022Inspection
Found failure to maintain an accurate MAR, resulting in a medication being out and doses missed for a resident.
Licensing—Failed to provide a safe medication administration system
12 Jul 2022Inspection
12 Jul 2022Inspection
Found insufficient staffing to meet residents' scheduled and unscheduled needs.
Licensing—Failed to meet the scheduled and unscheduled needs of residents
11 Jul 2022Licensure
11 Jul 2022Licensure
Found deficiencies in food sanitation during the first visit, including dirty kitchen surfaces and improper food storage, with a follow-up showing substantial compliance.
Identified deficiencies in food safety practices and infection prevention across multiple visits, including improper storage and handling of food and inconsistent mask use.
Found a violation of safe medication administration practices due to missed medications and a resident-to-resident altercation risk. This constitutes neglect and abuse.
Abuse—Failed to provide a safe medication administration system
08 Jul 2022Abuse: Neglect
08 Jul 2022Abuse: Neglect
Found failures to plan care and provide appropriate interventions, contributing to an injury, with a $1,000 fine assessed.
Abuse—Failed to properly plan care
08 Jul 2022Abuse: Neglect
08 Jul 2022Abuse: Neglect
Investigated a medication-safety allegation and found a failure to provide a safe medication administration system, risking harm to residents; a $500 fine was assessed.
Abuse—Failed to provide a safe medication administration system
08 Jul 2022Abuse: Neglect
08 Jul 2022Abuse: Neglect
Investigated a complaint and found improper care planning and resident-to-resident aggression that created risk of harm; a fine was assessed.
Abuse—Failed to properly plan care
07 Jul 2022Inspection
07 Jul 2022Inspection
Found a safety deficiency due to failure to exercise reasonable precautions. Staff were observed not wearing masks properly during an unannounced visit.
Licensing—Failed to provide safe environment
07 Jul 2022Inspection
07 Jul 2022Inspection
Found that housekeeping standards were not met, with dirty interior surfaces observed including a black film on the shower floor and a spill at a recliner base.
Licensing—Failed to provide appropriate housekeeping services
07 Jul 2022Inspection
07 Jul 2022Inspection
Found that staff failed to provide resident services to assist with daily living, including missed showers for a resident over a period in late August to September 2022.
Licensing—Failed to provide service
07 Jul 2022Inspection
07 Jul 2022Inspection
Investigated found deficiencies in providing 24-hour daily living assistance and inadequate daytime staffing.
Licensing—Failed to protect resident from financial exploitation
07 Jul 2022Inspection
07 Jul 2022Inspection
Investigated found that residents were not adequately assisted with daily living activities, including toileting and hygiene, on a 24-hour basis due to staffing constraints.
Licensing—Failed to meet the scheduled and unscheduled needs of residents
05 Jul 2022Abuse: Neglect
05 Jul 2022Abuse: Neglect
Investigated violations for failing to answer call lights promptly, causing residents to wait over 45 minutes on multiple occasions and lose dignity. A $500 fine was assessed.
Abuse—Failed to answer call light in a timely manner
26 Jun 2022Abuse: Neglect
26 Jun 2022Abuse: Neglect
Investigated a resident-to-resident altercation and found inadequate care planning and interventions for escalating behaviors, resulting in abuse/neglect and a fine.
Abuse—Failed to properly plan care
22 Jun 2022Inspection
22 Jun 2022Inspection
Found a failure to provide a safe environment due to staff not wearing masks during an unannounced site visit.
Licensing—Failed to provide safe environment
17 Jun 2022Inspection
17 Jun 2022Inspection
Found failure to provide 24-hour toileting assistance, risking inadequate daily living support.
Licensing—Failed to assist with toileting
17 Jun 2022Inspection
17 Jun 2022Inspection
Found insufficient direct care staff to meet residents' scheduled and unscheduled needs, with observed care gaps and a licensing violation cited.
Licensing—Failed to meet the scheduled and unscheduled needs of residents
13 Jun 2022Inspection
13 Jun 2022Inspection
Found a deficiency for failing to provide a safe environment by not exercising reasonable precautions against conditions that may threaten residents' health, safety, or welfare.
Licensing—Failed to provide safe environment
13 Jun 2022Inspection
13 Jun 2022Inspection
Investigated and verified the allegation that the provider did not license, maintain, and operate as a separate and distinct entity under the applicable rule.
Licensing—Failed to obtain a facility license
13 Jun 2022Complaint
13 Jun 2022Complaint
Identified deficiencies across several regulatory areas, indicating potential for moderate harm. Findings covered licensing standards, resident rights, service planning, staffing, and building conditions.
Deficiency—Licensing Complaint Investigation
Deficiency—Licensing Standard
Deficiency—Reasonable Precautions
Deficiency—Resident Rights and Protection - General
Deficiency—Service Plan: General
Deficiency—Staffing Requirements and Training: Staffing
Found neglect of care resulting in pressure ulcers and missed meals. A $500 fine was assessed.
Abuse—Failed to provide service
08 Jun 2022Abuse: Neglect
08 Jun 2022Abuse: Neglect
Found neglect and abuse due to a failed safe medication administration system that left a resident without needed medications for about two days.
Abuse—Failed to have medication available
07 Jun 2022Abuse: Neglect
07 Jun 2022Abuse: Neglect
Found neglect and abuse due to failure to assist with toileting, causing the resident to be soiled and uncomfortable. A fine was assessed.
Abuse—Failed to assist with toileting
06 Jun 2022Abuse: Neglect
06 Jun 2022Abuse: Neglect
Investigated a medication-availability issue. Found prescribed medications were not stocked, causing residents not to receive them as ordered and to experience pain.
Abuse—Failed to have medication available
31 May 2022Abuse: Neglect
31 May 2022Abuse: Neglect
Found that call lights were not answered promptly, leading to an incontinence episode and loss of dignity for a resident.
Abuse—Failed to answer call light in a timely manner
28 May 2022Inspection
28 May 2022Inspection
Investigated a staffing complaint and found insufficient direct care staff to meet residents' scheduled and unscheduled needs, especially after hours, weekends, and holidays.
Licensing—Failed to assure a qualified caregiver was present
28 May 2022Inspection
28 May 2022Inspection
Investigated a complaint and found a cleanliness deficiency due to garbage and food on the floor.
Licensing—Failed to provide appropriate housekeeping services
28 May 2022Inspection
28 May 2022Inspection
Verified the allegation that a resident's service plan did not include how often toileting assistance is provided and who shall provide the services.
Licensing—Failed to properly plan care
28 May 2022Inspection
28 May 2022Inspection
Found a deficiency in treating residents with dignity and respect after a resident was found with spilled food and debris on clothes and shoes.
Licensing—Failed to assure resident rights
21 May 2022Abuse: Neglect
21 May 2022Abuse: Neglect
Identified neglect and abuse due to failure to provide adequate services in medications, timely call pendant response, activities of daily living, and odor control, with a $500 fine assessed.
Abuse—Failed to provide service
17 May 2022Inspection
17 May 2022Inspection
Investigated a complaint and found that a caregiver did not dress the resident properly, resulting in wearing the wrong shoe and causing discomfort.
Licensing—Failed to assist with dressing or grooming
15 May 2022Inspection
15 May 2022Inspection
Found insufficient staffing to meet residents' scheduled and unscheduled needs.
Licensing—Failed to meet the scheduled and unscheduled needs of residents
15 May 2022Inspection
15 May 2022Inspection
Found failure to adopt and fully implement an acuity-based staffing tool (ABST).
Licensing—Failed to use an ABST
07 May 2022Abuse: Neglect
07 May 2022Abuse: Neglect
Identified a failure to provide a safe medication administration system, with medications given daily instead of the prescribed M-W-F schedule, resulting in neglect and abuse findings and a $500 fine assessed.
Abuse—Failed to provide a safe medication administration system
05 May 2022Abuse: Neglect
05 May 2022Abuse: Neglect
Investigated an allegation of neglect related to monitoring a resident's change of condition; found oversight was lacking and medical attention was delayed, causing discomfort.
Abuse—Failed to provide oversight and monitoring of change of condition
04 May 2022Abuse: Neglect
04 May 2022Abuse: Neglect
Investigated a medication safety failure where a staff member discontinued a medication without a doctor's order, leading to missed medications and safety concerns.
Abuse—Failed to provide a safe medication administration system
03 May 2022Abuse: Neglect
03 May 2022Abuse: Neglect
Found that hygiene assistance was not provided, leaving the resident without a shower and experiencing discomfort.
Abuse—Failed to provide or assist with hygiene
02 May 2022Inspection
02 May 2022Inspection
Found that a training program to determine direct care staff competency was missing.
Licensing—Failed to provide safe environment
25 Apr 2022Abuse: Neglect
25 Apr 2022Abuse: Neglect
Investigated a neglect allegation and found failures to properly plan and implement incontinence care, resulting in increased incontinence and discomfort for the resident. A $500 fine was assessed.
Abuse—Failed to properly plan care
18 Apr 2022Abuse: Neglect
18 Apr 2022Abuse: Neglect
Investigated and found neglect and abuse due to delayed response to a call light, resulting in discomfort; a $1500 fine assessed.
Abuse—Failed to answer call light in a timely manner
15 Apr 2022Abuse: Neglect
15 Apr 2022Abuse: Neglect
Found violations for unsafe medication administration. A $500 fine was assessed.
Abuse—Failed to provide a safe medication administration system
12 Apr 2022Abuse: Neglect
12 Apr 2022Abuse: Neglect
Investigated and found a failure to provide a safe medication administration system, resulting in missed medications and potential harm; a $500 fine was assessed.
Abuse—Failed to provide a safe medication administration system
10 Apr 2022Abuse: Neglect
10 Apr 2022Abuse: Neglect
Found that a staff member assaulted a resident and care planning was inadequate, constituting abuse and neglect.
Abuse—Failed to properly plan care
09 Apr 2022Abuse: Neglect
09 Apr 2022Abuse: Neglect
Found a failure to provide a safe medication administration system, resulting in missed medications and a period without the prescribed meds onsite. A $500 fine was assessed.
Abuse—Failed to provide a safe medication administration system
06 Apr 2022Abuse: Neglect
06 Apr 2022Abuse: Neglect
Found that staff did not follow the care plan by not providing required compression socks, leading to leg discoloration and swelling; a $500 fine was assessed.
Abuse—Failed to follow care plan
24 Mar 2022Abuse: Neglect
24 Mar 2022Abuse: Neglect
Identified neglect and abuse due to improper transfer planning and inadequate staff training with a Hoyer lift, resulting in bruising; a $500 fine was assessed.
Abuse—Failed to properly plan care
24 Mar 2022Abuse: Neglect
24 Mar 2022Abuse: Neglect
Found failure to reassess and update a resident's care plan for toileting needs, indicating neglect and abuse; a $500 fine was assessed.
Abuse—Failed to properly plan care
22 Mar 2022Abuse: Neglect
22 Mar 2022Abuse: Neglect
Investigated a complaint and found neglect and abuse due to failing to monitor a resident's changing condition, resulting in dehydration, pressure injuries, and hospitalization; a fine was assessed.
Abuse—Failed to intervene when resident's condition changed
11 Mar 2022Abuse: Neglect
11 Mar 2022Abuse: Neglect
Found that a safe medication administration system was not provided and medications were found in a resident's room, indicating abuse and neglect. A $500 fine was assessed.
Abuse—Failed to provide a safe medication administration system
04 Mar 2022Abuse: Neglect
04 Mar 2022Abuse: Neglect
Found neglect and abuse for failing to follow the care plan by not providing compression socks as ordered, resulting in swelling; a $500 fine was assessed.
Abuse—Failed to follow care plan
18 Feb 2022Abuse: Neglect
18 Feb 2022Abuse: Neglect
Investigated the complaint and found failures to provide a safe medication administration system and to verify doctor-ordered discontinuations, resulting in neglect and abuse findings.
Abuse—Failed to provide a safe medication administration system
14 Feb 2022Abuse: Neglect
14 Feb 2022Abuse: Neglect
Found failures in the medication administration system leading to incorrect dosing and missed doses, causing pain and discomfort and constituting abuse and neglect; assessed a fine of $1,125.
Abuse—Failed to provide a safe medication administration system
30 Jan 2022Abuse: Neglect
30 Jan 2022Abuse: Neglect
Found that call lights were not answered promptly, indicating neglect and abuse, and a $500 fine was assessed.
Abuse—Failed to answer call light in a timely manner
07 Jan 2022Abuse: Neglect
07 Jan 2022Abuse: Neglect
Investigated and found that staff did not respond promptly to a resident's call light, resulting in neglect and abuse; a $1,500 fine was assessed.
Abuse—Failed to answer call light in a timely manner
03 Jan 2022Abuse: Neglect
03 Jan 2022Abuse: Neglect
Found violations of the care plan related to assistive-device use and a resident-to-resident conflict causing head injury. A $500 fine was assessed.
Abuse—Failed to follow care plan
22 Dec 2021Abuse: Neglect
22 Dec 2021Abuse: Neglect
Found neglect and abuse for failing to follow the care plan, resulting in a $500 fine.
Abuse—Failed to follow care plan
22 Dec 2021Abuse: Neglect
22 Dec 2021Abuse: Neglect
Investigated and found that the care plan for compression socks was not followed, leaving the individual with swollen feet and without the prescribed socks or wraps, and with reports that staff did not assist.
Abuse—Failed to follow care plan
22 Dec 2021Abuse: Neglect
22 Dec 2021Abuse: Neglect
Found that the care plan was not followed for daily compression sock assistance, leading to swelling and discoloration; a $500 fine was assessed.
Abuse—Failed to follow care plan
10 Dec 2021Abuse: Neglect
10 Dec 2021Abuse: Neglect
Investigated a complaint about delayed call-light responses and found repeated failures to respond promptly, resulting in neglect and abuse with a $1,500 fine assessed.
Abuse—Failed to answer call light in a timely manner
09 Dec 2021Abuse: Neglect
09 Dec 2021Abuse: Neglect
Found a failure to provide a safe environment that resulted in harm to a resident. The finding cited violations of safety and resident rights.
Abuse—Failed to provide safe environment
30 Nov 2021Abuse: Neglect
30 Nov 2021Abuse: Neglect
Investigated and found a failure to provide a safe medication administration system, resulting in missed medications and patient discomfort; a $1,500 fine was assessed.
Abuse—Failed to provide a safe medication administration system
20 Nov 2021Abuse: Neglect
20 Nov 2021Abuse: Neglect
Investigated a resident-to-resident altercation resulting in a minor injury and found a failure to provide a safe environment.
Abuse—Failed to provide safe environment
12 Nov 2021Abuse: Neglect
12 Nov 2021Abuse: Neglect
Found violations for failing to plan care around frequent incontinence refusals, leading to a pressure injury and unsanitary conditions; a $500 fine was assessed.
Abuse—Failed to properly plan care
05 Nov 2021Abuse: Neglect
05 Nov 2021Abuse: Neglect
Found violations related to unsafe medication administration and neglect; assessed a $500 fine.
Abuse—Failed to provide a safe medication administration system
04 Nov 2021Abuse: Neglect
04 Nov 2021Abuse: Neglect
Found a safety deficiency involving neglect and abuse toward a resident who relied on care.
Abuse—Failed to provide safe environment
03 Nov 2021Abuse: Neglect
03 Nov 2021Abuse: Neglect
Found a failure to provide a safe medication administration system, risking harm from narcotic medications; a $500 fine was assessed.
Abuse—Failed to provide a safe medication administration system
20 Oct 2021License Condition
20 Oct 2021License Condition
Investigated the allegation and found deficiencies related to failing to provide needed/necessary services due to insufficient administrative oversight.
Regulatory Action—Failed to provide service
20 Oct 2021License Condition
20 Oct 2021License Condition
Found inadequate administrative oversight resulting in gaps in quality care and failure to provide needed services.
Regulatory Action—Failed to provide service
15 Oct 2021Abuse: Neglect
15 Oct 2021Abuse: Neglect
Found a failure to provide a safe environment that led to injury and constituted abuse and neglect.
Abuse—Failed to provide safe environment
06 Oct 2021Abuse: Neglect
06 Oct 2021Abuse: Neglect
Found failure to administer medications and to provide needed services, constituting neglect and abuse. The actions resulted in falls and lack of required incident reports.
Abuse—Failed to provide service
04 Oct 2021Validation
04 Oct 2021Validation
Investigated multiple deficiencies across medication management, care planning, infection control, abuse reporting, staffing, and safety, indicating ongoing safety and quality concerns.
Deficiency—Resident Move-In and Eval: Res Evaluation
Deficiency—Service Plan: General
Deficiency—Change of Condition and Monitoring
Deficiency—Resident Health Services
Deficiency—Res Hlth Srvc: On- and Off-Site Health Srvc
Deficiency—Systems: Medications and Treatments
Deficiency—Systems: Treatment Orders
Deficiency—Systems: Medication and Treatment Review
Deficiency—Systems: Medication Administration
Deficiency—Staffing Requirements and Training: Staffing
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—Doors, Walls, Elevators, Odors
Deficiency—Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable
Deficiency—Administration Responsibilities
Deficiency—Administration Compliance
Deficiency—Staff Training Requirements
Deficiency—Compliance With Rules Health Care
17 Sept 2021Abuse: Neglect
17 Sept 2021Abuse: Neglect
Found neglect and abuse in the care setting, including failure to provide two weekly showers and slow responses to call lights, resulting in a $500 fine.
Abuse—Failed to provide service
13 Sept 2021Validation
13 Sept 2021Validation
Identified numerous deficiencies across administration, resident care, health services, infection control, and staff training; improvements were implemented and substantial compliance was achieved on follow-up.
Found that a staff member failed to follow a resident's care plan, resulting in abuse and neglect, and a $500 fine was assessed.
Abuse—Failed to follow care plan
31 Aug 2021Abuse: Neglect
31 Aug 2021Abuse: Neglect
Found violations related to care planning that failed to address fall risk, resulting in multiple falls; a fine was assessed.
Abuse—Failed to properly plan care
31 Aug 2021Abuse: Neglect
31 Aug 2021Abuse: Neglect
Investigated a medication administration incident and found a failure to provide a safe medication administration system, resulting in delayed treatment for a resident and potential harm. A $2,000 fine was assessed.
Abuse—Failed to provide a safe medication administration system
06 Aug 2021Abuse: Neglect
06 Aug 2021Abuse: Neglect
Found improper care planning that led to neglect and abuse, with a $500 fine assessed.
Abuse—Failed to properly plan care
29 Jul 2021Abuse: Neglect
29 Jul 2021Abuse: Neglect
Found that the care plan was not followed and the resident did not wear prescribed stockings, resulting in neglect and abuse.
Abuse—Failed to follow care plan
25 Jul 2021Abuse: Neglect
25 Jul 2021Abuse: Neglect
Investigated a complaint and found a failure to answer a resident's call light promptly, resulting in minor harm and abuse; a $500 fine was assessed.
Abuse—Failed to answer call light in a timely manner
22 Jul 2021Abuse: Neglect
22 Jul 2021Abuse: Neglect
Investigated a complaint about delayed responses to a resident’s call light and found repeated long delays plus an incident causing embarrassment, with a fine assessed.
Abuse—Failed to answer call light in a timely manner
08 Jul 2021Abuse: Neglect
08 Jul 2021Abuse: Neglect
Found that a resident sustained serious injuries after an attempted entry into their room and that the care setting failed to provide a safe environment, constituting abuse and neglect; a fine was assessed.
Abuse—Failed to provide safe environment
08 Jul 2021Abuse: Neglect
08 Jul 2021Abuse: Neglect
Investigated and found neglect due to failure to provide a safe environment and improper care planning, leading to a resident sustaining head injuries requiring hospital care.
Abuse—Failed to provide safe environment
23 Jun 2021Inspection
23 Jun 2021Inspection
Found lack of appropriate staffing. Verified the staffing deficiency.
Licensing—Failed to provide appropriate staffing
23 Jun 2021Inspection
23 Jun 2021Inspection
Investigated the allegation of failing to assure resident rights and verified it.
Licensing—Failed to assure resident rights
21 Jun 2021Inspection
21 Jun 2021Inspection
Investigated the allegation that ordered medication was not administered and identified a deficiency.
Licensing—Failed to administer ordered medication
14 Jun 2021Abuse: Neglect
14 Jun 2021Abuse: Neglect
Investigated and found a failure to provide a safe medication administration system, leading to six months of incorrect psychotropic dosing and increased behaviors, constituting neglect and abuse. A $500 fine was assessed.
Abuse—Failed to administer medication as ordered
13 Jun 2021Abuse: Neglect
13 Jun 2021Abuse: Neglect
Found that a prescribed muscle relaxant was not administered as ordered, causing pain.
Abuse—Failed to administer ordered medication
03 Jun 2021Abuse: Neglect
03 Jun 2021Abuse: Neglect
Found a violation for failing to investigate an injury of unknown origin to rule out abuse, resulting in a $500 fine.
Abuse—Failed to investigate injury of unknown origin to rule out abuse
01 Jun 2021Inspection
01 Jun 2021Inspection
Found a deficiency in housekeeping services.
Licensing—Failed to provide appropriate housekeeping services
01 Jun 2021Abuse: Neglect
01 Jun 2021Abuse: Neglect
Found neglect of care and abuse due to failure to provide essential services to a resident, including grooming, toileting assistance, sanitation, and room cleanliness.
Abuse—Failed to provide service
27 May 2021Abuse: Neglect
27 May 2021Abuse: Neglect
Investigated a complaint about delayed response to a resident's call light and found multiple instances of delayed responses in May 2021, indicating neglect and abuse with a fine assessed.
Abuse—Failed to answer call light in a timely manner
27 May 2021Inspection
27 May 2021Inspection
Found a deficiency in housekeeping services.
Licensing—Failed to provide appropriate housekeeping services
26 Apr 2021Abuse: Neglect
26 Apr 2021Abuse: Neglect
Found that a safe medication administration system was not provided, leading to multiple medication errors and related documentation issues; a $500 fine was assessed.
Abuse—Failed to provide a safe medication administration system
09 Apr 2021Inspection
09 Apr 2021Inspection
Investigated and verified failure to administer ordered medication.
Licensing—Failed to administer ordered medication
09 Apr 2021Inspection
09 Apr 2021Inspection
Found that a safe physical environment was not maintained.
Licensing—Failed to maintain a safe physical environment
09 Apr 2021Inspection
09 Apr 2021Inspection
Investigated a staffing allegation and determined staffing was insufficient.
Licensing—Failed to provide appropriate staffing
04 Mar 2021Inspection
04 Mar 2021Inspection
Found a violation for failing to provide appropriate housekeeping services.
Licensing—Failed to provide appropriate housekeeping services
02 Mar 2021Inspection
02 Mar 2021Inspection
Found a failure to provide a safe medication administration system, resulting in a second dosage being given without MAR entry and the resident reporting dizziness.
Licensing—Failed to provide a safe medication administration system
25 Feb 2021Inspection
25 Feb 2021Inspection
Investigated a complaint alleging failure to maintain a safe physical environment; found the allegation to be supported.
Licensing—Failed to maintain a safe physical environment
19 Feb 2021Abuse: Neglect
19 Feb 2021Abuse: Neglect
Investigated an allegation that a resident's care plan was not followed, resulting in abuse and neglect; a fine was assessed.
Abuse—Failed to follow care plan
09 Feb 2021Abuse: Neglect
09 Feb 2021Abuse: Neglect
Identified a violation for failing to provide a safe environment after a resident-to-resident hair-pulling incident, resulting in a $375 fine.
Abuse—Failed to provide safe environment
03 Feb 2021Abuse: Neglect
03 Feb 2021Abuse: Neglect
Investigated found neglect for failing to follow the care plan, leaving a resident without required one-on-one supervision during a resident-to-resident altercation.
Abuse—Failed to follow care plan
03 Feb 2021Abuse: Neglect
03 Feb 2021Abuse: Neglect
Found that one-on-one supervision required by the care plan was not provided, exposing a resident to potential harm and constituting neglect and abuse.
Abuse—Failed to follow care plan
05 Jan 2021Inspection
05 Jan 2021Inspection
Found violations of care plan adherence that led to a fall due to improper footwear.
Licensing—Failed to follow care plan
28 Dec 2020Abuse: Neglect
28 Dec 2020Abuse: Neglect
Investigated a complaint about medication administration safety and found a failure to provide a safe medication administration system, resulting in missed and late medications and a $500 fine.
Abuse—Failed to provide a safe medication administration system
13 Dec 2020Abuse: Neglect
13 Dec 2020Abuse: Neglect
Found violations for failure to properly plan care and for resident-to-resident abuse, with a $375 fine assessed.
Abuse—Failed to properly plan care
25 Nov 2020Abuse: Neglect
25 Nov 2020Abuse: Neglect
Investigated a failure to provide a safe medication administration system, resulting in neglect and abuse findings.
Abuse—Failed to provide a safe medication administration system
25 Nov 2020Abuse: Neglect
25 Nov 2020Abuse: Neglect
Investigated a complaint alleging neglect and abuse related to hydration and peri-care; found the resident did not receive proper hydration, leading to dehydration and acute renal insufficiency. A $250 fine was assessed.
Abuse—Failed to assure proper hydration
19 Nov 2020Abuse: Neglect
19 Nov 2020Abuse: Neglect
Investigated the allegation of neglect found that a resident's meals and hydration were not adequately tracked, contributing to dehydration and failure to follow the care plan.
Abuse—Failed to follow care plan
19 Nov 2020Abuse: Neglect
19 Nov 2020Abuse: Neglect
Investigated and found neglect and abuse resulting in injuries to a resident. A $1,500 fine was assessed.
Abuse—Failed to provide service
18 Nov 2020License Condition
18 Nov 2020License Condition
Determined that infection control practices were inadequate to prevent the spread of COVID-19.
Regulatory Action—Failed to provide infection control
18 Nov 2020License Condition
18 Nov 2020License Condition
Investigated the allegation of infection control failures and found deficiencies in practices to prevent the spread of COVID-19.
Regulatory Action—Failed to provide infection control
12 Nov 2020Abuse: Neglect
12 Nov 2020Abuse: Neglect
Determined neglect due to inadequate staffing that failed to provide dressing/undressing assistance, resulting in an unsafe environment; a $500 fine was assessed.
Abuse—Failed to provide safe environment
01 Sept 2020Abuse: Neglect
01 Sept 2020Abuse: Neglect
Investigated and determined that medications and/or supplements were not provided as ordered, constituting neglect and abuse; a $500 fine was assessed.
Abuse—Failed to provide a safe medication administration system
26 Aug 2020Abuse: Neglect
26 Aug 2020Abuse: Neglect
Investigated found violations for failing to follow a resident's care plan and provide adequate supervision, resulting in neglect and abuse.
Abuse—Failed to properly plan care
01 Aug 2020Abuse: Neglect
01 Aug 2020Abuse: Neglect
Determined a failure to provide a safe medication administration system, resulting in neglect and abuse, and assessed a $500 fine.
Abuse—Failed to provide a safe medication administration system
11 Jul 2020Abuse: Neglect
11 Jul 2020Abuse: Neglect
Investigated a complaint alleging medication safety failures. Found a failure to provide a safe medication administration system that led to multiple missed doses.
Abuse—Failed to provide a safe medication administration system
26 May 2020Abuse: Neglect
26 May 2020Abuse: Neglect
Found that the facility failed to develop or maintain a comprehensive falls risk care plan, contributing to multiple falls.
Abuse—Failed to properly plan care
24 May 2020Abuse: Neglect
24 May 2020Abuse: Neglect
Determined that a safe environment was not provided, resulting in a resident-to-resident altercation and constituting neglect and abuse.
Abuse—Failed to provide safe environment
08 Apr 2020Inspection
08 Apr 2020Inspection
Found that a risk agreement was not used when a resident's actions posed a potential risk to health or well-being.
Licensing—Failed to assure resident was safe
25 Feb 2020Inspection
25 Feb 2020Inspection
Found neglect of care due to administering the wrong medication, constituting abuse, and a failure to supervise staff in violation of rules.
Licensing—Failed to administer medication as ordered
20 Feb 2020Abuse: Neglect
20 Feb 2020Abuse: Neglect
Investigated and found a violation related to safe medication administration, resulting in a $500 fine.
Abuse—Failed to provide a safe medication administration system
30 Jan 2020Abuse: Neglect
30 Jan 2020Abuse: Neglect
Investigated found that a resident's weight loss was not monitored and dietary guidelines were not followed, constituting neglect and abuse, with a fine assessed.
Abuse—Failed to provide oversight and monitoring of change of condition
26 Jan 2020Abuse: Neglect
26 Jan 2020Abuse: Neglect
Investigated a neglect and abuse allegation and found a failure to follow a care plan led to a fall with injury.
Abuse—Failed to follow care plan
25 Jan 2020Abuse: Neglect
25 Jan 2020Abuse: Neglect
Identified failure to provide a safe environment, resulting in abuse/neglect findings and a $250 fine.
Abuse—Failed to provide safe environment
14 Jan 2020Abuse: Neglect
14 Jan 2020Abuse: Neglect
Found neglect of care and abuse for failing to follow the wound-care plan, resulting in worsening wounds. A $1500 fine was assessed.
Abuse—Failed to follow care plan
06 Jan 2020Abuse: Neglect
06 Jan 2020Abuse: Neglect
Found that the facility failed to properly plan care for a resident's oral hygiene, resulting in pain and not eating or drinking; a $1,500 fine was assessed.
Abuse—Failed to properly plan care
07 Dec 2019Abuse: Neglect
07 Dec 2019Abuse: Neglect
Investigated found failures to administer doctor-ordered medications and modify care plan interventions, resulting in an unsafe environment and resident-to-resident altercations; a $500 fine was assessed.
Abuse—Failed to provide safe environment
24 Nov 2019Abuse: Neglect
24 Nov 2019Abuse: Neglect
Found neglect and abuse due to failure to plan for aggressive behavior and protect others from aggression.
Abuse—Failed to properly plan care
18 Nov 2019Inspection
18 Nov 2019Inspection
Confirmed the allegation that three daily nutritious meals were not provided and not prepared in accordance with Food Sanitation Rules.
Licensing—Failed to assure food safety
13 Nov 2019Abuse: Neglect
13 Nov 2019Abuse: Neglect
Investigated and concluded neglect occurred by failing to shower the individual, resulting in loss of personal dignity; a $500 fine was assessed.
Abuse—Failed to follow care plan
13 Nov 2019Inspection
13 Nov 2019Inspection
Found a violation of reporting requirements for failing to report suspected abuse. A $1000 fine was assessed.
Licensing—Failed to report potential or suspected abuse
04 Nov 2019Abuse: Neglect
04 Nov 2019Abuse: Neglect
Investigated a neglect allegation and found failure to provide basic care, resulting in a $500 fine.
Abuse—Failed to properly plan care
04 Nov 2019Inspection
04 Nov 2019Inspection
Found failure to report suspected abuse; a $1,000 fine was assessed.
Licensing—Failed to report potential or suspected abuse
28 Oct 2019Abuse: Neglect
28 Oct 2019Abuse: Neglect
Investigated an allegation of neglect and found failure to follow service plans, which resulted in physical harm.
Abuse—Failed to properly plan care
13 Oct 2019Abuse: Neglect
13 Oct 2019Abuse: Neglect
Investigated and concluded that staff failed to provide a safe environment during transfers, constituting abuse and neglect.
Abuse—Failed to provide safe environment
02 Oct 2019Abuse: Neglect
02 Oct 2019Abuse: Neglect
Determined that failing to follow the care plan during ambulation caused a fall and hip fracture, constituting abuse and neglect. A fine was assessed.
Abuse—Failed to follow care plan
20 Sept 2019Abuse: Neglect
20 Sept 2019Abuse: Neglect
Investigated and found neglect due to failure to supervise, resulting in physical harm.
Abuse—Failed to follow care plan
06 Sept 2019Abuse: Neglect
06 Sept 2019Abuse: Neglect
Investigated a neglect allegation and found that basic care was not provided, resulting in unreasonable discomfort. A $500 fine was assessed.
Abuse—Failed to properly plan care
06 Sept 2019Inspection
06 Sept 2019Inspection
Found failure to report suspected abuse. A fine was assessed.
Licensing—Failed to report potential or suspected abuse
04 Aug 2019Abuse: Neglect
04 Aug 2019Abuse: Neglect
Investigated a neglect allegation and found failure to provide basic care and a safe medication administration system, resulting in unreasonable discomfort and a fine was assessed.
Abuse—Failed to provide a safe medication administration system
04 Aug 2019Inspection
04 Aug 2019Inspection
Determined that suspected abuse was not reported. A $1,000.00 fine was assessed.
Licensing—Failed to report potential or suspected abuse
19 Jul 2019Inspection
19 Jul 2019Inspection
Found failure to report suspected abuse and assessed a $750 fine.
Licensing—Failed to report potential or suspected abuse
19 Jul 2019Abuse: Neglect
19 Jul 2019Abuse: Neglect
Found neglect that resulted in significant physical harm to a resident.
Abuse—Failed to assure resident was safe
10 Jun 2019Abuse: Physical Abuse
10 Jun 2019Abuse: Physical Abuse
Investigated a complaint and found neglect for failing to protect a resident from physical abuse.
Abuse—Failed to protect resident from rough treatment
04 Jun 2019Abuse: Neglect
04 Jun 2019Abuse: Neglect
Found neglect and abuse due to failure to properly plan fall-risk care, leading to multiple falls and injuries. A $1,500 fine was assessed.
Abuse—Failed to properly plan care
08 Feb 2019Abuse: Neglect
08 Feb 2019Abuse: Neglect
Found neglect and abuse due to failure to plan care for fall risk during sedation; a fine was assessed.
Abuse—Failed to properly plan care
08 Feb 2019Abuse: Neglect
08 Feb 2019Abuse: Neglect
Investigated a neglect allegation and found that basic care was not provided to maintain health and safety, resulting in a $375 fine.
Abuse—Failed to follow care plan
11 Jan 2019Abuse: Verbal/Mental abuse
11 Jan 2019Abuse: Verbal/Mental abuse
Determined neglect of a resident, creating a serious risk of harm.
Abuse—Failed to protect resident from mental or emotional abuse
15 Nov 2018Abuse: Physical Abuse
15 Nov 2018Abuse: Physical Abuse
Investigated an allegation of physical abuse and found neglect of a resident's basic care and safety.
Abuse—Failed to protect resident from rough treatment
25 Oct 2018Abuse: Neglect
25 Oct 2018Abuse: Neglect
Found a failure to provide a safe environment after investigating an abuse/neglect allegation.
Abuse—Failed to provide safe environment
05 Oct 2018Inspection
05 Oct 2018Inspection
Determined that the allegation of failing to administer a prescribed medication was sustained, resulting in the resident's unreasonable discomfort.
Licensing—Failed to provide service
02 Sept 2018Abuse: Neglect
02 Sept 2018Abuse: Neglect
Found neglect led to significant weight loss and multiple falls due to failure to assess and intervene appropriately. A $500 fine was assessed.
Abuse—Failed to adequately care plan related to falls
30 Aug 2018Inspection
30 Aug 2018Inspection
Found failure to report suspected abuse and assessed a $750 fine.
Licensing—Failed to report potential or suspected abuse
06 Jul 2018Abuse: Financial abuse
06 Jul 2018Abuse: Financial abuse
Investigated and found that a resident was financially exploited by taking the resident's medication.
Abuse—Failed to protect resident from financial exploitation
24 Jun 2018Abuse: Restraints
24 Jun 2018Abuse: Restraints
Investigated a complaint about restraint use and found that a staff member used physical force to keep a resident standing when the resident wanted to sit.
Abuse—Failed to protect resident from rough treatment
14 May 2018Inspection
14 May 2018Inspection
Found a failure to provide a safe and secure medication administration system after investigating an allegation of failing to administer ordered medication.
Licensing—Failed to administer ordered medication
28 Mar 2018Abuse: Neglect
28 Mar 2018Abuse: Neglect
Investigated the allegation of failing to follow the care plan and found a failure to provide a safe and secure environment. A $375 fine was assessed.
Abuse—Failed to follow care plan
12 Jan 2018Inspection
12 Jan 2018Inspection
Found a safety deficiency due to failure to provide a safe and secure environment for residents. This indicates safety requirements were not met.
Licensing—Failed to provide safe environment
11 Jul 2017Inspection
11 Jul 2017Inspection
Found a deficiency related to measures to prevent the entry of insects.
Licensing—Failed to control pests
05 Oct 2016Abuse: Neglect
05 Oct 2016Abuse: Neglect
Investigated an allegation of neglect and found care plans were not followed.
Abuse—Failed to follow care plan
21 Jun 2016Inspection
21 Jun 2016Inspection
Investigated a complaint and found the provider failed to provide services, resulting in two meals being missed.
Licensing—Failed to provide service
29 Jan 2015Abuse: Restraints
29 Jan 2015Abuse: Restraints
Found a failure to protect the resident from rough treatment.
Abuse—Failed to protect resident from rough treatment
29 Jan 2015Abuse: Neglect
29 Jan 2015Abuse: Neglect
Investigated the neglect allegation related to falls and identified failures to assess and intervene.
Abuse—Failed to adequately care plan related to falls
20 Nov 2014Abuse: Neglect
20 Nov 2014Abuse: Neglect
Found neglect resulting in harm and assessed a $300 fine.
Abuse—Failed to intervene when resident's condition changed
22 Apr 2014Abuse: Neglect
22 Apr 2014Abuse: Neglect
Investigated the allegation of unsafe medication administration and found that an appropriate medication administration system was not maintained.
Abuse—Failed to provide a safe medication administration system
08 Apr 2014Inspection
08 Apr 2014Inspection
Investigated allegation of failing to communicate necessary information. Found a failure to assess and intervene.
Licensing—Failed to communicate necessary information
01 Apr 2014Abuse: Neglect
01 Apr 2014Abuse: Neglect
Found substantiated neglect related to falls care planning and unsafe environment, resulting in harm to a resident.
Abuse—Failed to adequately care plan related to falls
19 Mar 2014Abuse: Neglect
19 Mar 2014Abuse: Neglect
Investigated the allegation and found that appropriate care was not provided.
Abuse—Failed to provide service
15 Feb 2014Abuse: Neglect
15 Feb 2014Abuse: Neglect
Found that care was not followed per the care plan, risking harm to a resident.
Abuse—Failed to follow care plan
31 Jan 2014Inspection
31 Jan 2014Inspection
Investigated allegations found failures to adequately care plan related to falls and to maintain a safe environment, resulting in injury.
Licensing—Failed to adequately care plan related to falls
08 Jan 2014Abuse: Physical Abuse
08 Jan 2014Abuse: Physical Abuse
Found a failure to provide a safe and secure environment that caused physical harm to a resident.
Abuse—Failed to protect resident from rough treatment
17 Nov 2013Inspection
17 Nov 2013Inspection
Found a failure to follow the care plan that could cause minor harm or potential for moderate harm.
Licensing—Failed to follow care plan
28 Aug 2013Abuse: Neglect
28 Aug 2013Abuse: Neglect
Found deficiencies in fall-related care planning and overall care and services.
Abuse—Failed to adequately care plan related to falls
28 Aug 2013Abuse: Neglect
28 Aug 2013Abuse: Neglect
Determined that there was a failure to properly plan care, resulting in moderate harm or potential for serious harm. A civil penalty of $300 was assessed.
Abuse—Failed to properly plan care
12 Aug 2013Abuse: Neglect
12 Aug 2013Abuse: Neglect
Found a failure to address resident behavior and to provide a safe environment.
Abuse—Failed to address resident's behavior
18 Jun 2013Abuse: Financial abuse
18 Jun 2013Abuse: Financial abuse
Found substantiated allegations of financial abuse and a failure to provide a secure environment.
Abuse—Failed to provide a safe medication administration system
10 Feb 2013Inspection
10 Feb 2013Inspection
Found a failure to provide a safe and secure environment related to falls.
Licensing—Failed to adequately care plan related to falls
25 Nov 2012Abuse: Neglect
25 Nov 2012Abuse: Neglect
Investigated an allegation of neglect and concluded oversight of changes in condition was inadequate, resulting in an unsafe environment.
Abuse—Failed to provide oversight and monitoring of change of condition
10 Oct 2012Abuse: Neglect
10 Oct 2012Abuse: Neglect
Investigated an allegation of inadequate falls care planning and an unsafe environment that led to harm.
Abuse—Failed to adequately care plan related to falls
12 Sept 2012Abuse: Neglect
12 Sept 2012Abuse: Neglect
Investigated identified a failure to provide a safe environment that caused harm to a resident.
Abuse—Failed to provide safe environment
14 Aug 2012Abuse: Neglect
14 Aug 2012Abuse: Neglect
Determined that a fall-related neglect allegation was substantiated and that care planning and the environment did not ensure safety.
Abuse—Failed to adequately care plan related to falls
10 Jul 2012Inspection
10 Jul 2012Inspection
Investigated and found that a qualified caregiver was not present, resulting in potential harm.
Licensing—Failed to assure that a qualified caregiver was present
27 Apr 2012Inspection
27 Apr 2012Inspection
Found failure to maintain an adequate medication administration system. This was categorized as a licensing violation with minor harm potential.
Licensing—Failed to provide a safe medication administration system
06 Apr 2012Abuse: Neglect
06 Apr 2012Abuse: Neglect
Found that staff failed to intervene when a resident's condition changed, resulting in harm and an unsafe environment.
Abuse—Failed to intervene when resident's condition changed
12 Mar 2012Abuse: Neglect
12 Mar 2012Abuse: Neglect
Found unsafe conditions that resulted in harm due to inadequate care planning and safety measures.
Abuse—Failed to adequately care plan related to falls
22 Jan 2012Abuse: Neglect
22 Jan 2012Abuse: Neglect
Found that the care plan was not followed and residents did not receive adequate care, creating potential harm. A $300 fine was assessed.
Abuse—Failed to follow care plan
22 Jan 2012Inspection
22 Jan 2012Inspection
Found a deficiency in medication administration that could harm a resident.
Licensing—Failed to provide a safe medication administration system
29 Jul 2011Abuse: Neglect
29 Jul 2011Abuse: Neglect
Investigated an abuse/neglect allegation and identified deficiencies in screening or assessment, with residents experiencing multiple falls and severe weight loss.
Abuse—Failed to perform adequate screening or assessment
27 Jul 2011Abuse: Neglect
27 Jul 2011Abuse: Neglect
Concluded abuse/neglect occurred and assessed a $600 fine.
Abuse—Failed to perform adequate screening or assessment
01 Jul 2011Inspection
01 Jul 2011Inspection
Investigated a records-keeping issue and found that medication records were not kept current or accurate.
Licensing—Failed to keep medication record current or accurate
10 Jun 2011Abuse: Neglect
10 Jun 2011Abuse: Neglect
Investigated and found failures to provide a safe and secure environment for residents.
Abuse—Failed to address resident's behavior
26 Apr 2011Inspection
26 Apr 2011Inspection
Found that medication was not administered as ordered, constituting a licensing violation.
Licensing—Failed to administer medication as ordered
28 Sept 2010Inspection
28 Sept 2010Inspection
Investigated the nursing delegation allegation and found deficiencies in medication administration to RV1–RV4.
Licensing—Failed to comply with nursing delegation requirement
03 Apr 2010Abuse: Neglect
03 Apr 2010Abuse: Neglect
Found substantiated deficiencies related to physician services and providing adequate care.
Abuse—Failed to assure physician services
Disclaimer
Mirador Living is not affiliated with the owner or operator(s) of Wildflower Lodge Senior Living. The information above has not been verified or approved by the owner or operator. For exact information, please contact Wildflower Lodge Senior Living directly. There is no cost for this service. We are compensated by the community you select.
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