Pricing ranges from

$6,218 – 8,083/month

Lakeview Senior Living

2690 NE Yacht Ave, Lincoln City, OR 97367

Independent Living
Assisted Living
Memory Care

4.0·59 reviews

For the front desk(541) 994-7400

Pricing

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

Amenities

Healthcare services

Activities of daily living assistance
Assistance with bathing
Assistance with dressing
Assistance with transfers
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

Air-conditioning
Cable
Fully furnished
Housekeeping and linen services
Kitchenettes
Private bathrooms
Telephone
Wifi

Memory care community services

Mild cognitive impairment
Specialized memory care programming

Transportation

Community operated transportation
Transportation arrangement

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

4.00·(59)

Overall rating

Care
4.1
Staff
4.2
Meals
3.5
Amenities
3.9
Value
2.9

Pros

Compassionate, personable caregiving staff
Well-maintained, attractive campus and grounds
Hotel-style common areas and modern design
Spacious, sunlit apartments and cottages
Diverse dining options including in-room service
Robust activities program and regular outings
On-site salon and personal-care amenities
Reliable housekeeping and maintenance services
Shuttle and transportation services
On-site Memory Care unit
Pet-friendly policies
Proximity to hospital and medical services

Cons

Chronic understaffing and high staff turnover
Inadequate caregiver training and supervision
Medication-management practices
Delays in resident assistance and long response times
Inconsistent meal-service reliability and food quality
Billing transparency and unexpected price-change issues
Variable administrative communication and coordination
Workplace-culture problems affecting morale
Gaps in environmental-safety monitoring and temperature control
Inconsistent housekeeping and hallway clutter management
Marketing and brochure information not consistently matching service delivery

Summary of reviews

Lakeview Senior Living presents a mixed but generally positive picture for prospective residents who prioritize amenities, a social community, and an attractive physical environment. Reviewers consistently praise the campus appearance — including hotel-like lobbies, well-kept grounds, sunlit apartments and cottages — and note conveniences such as an on-site salon, housekeeping and maintenance services, shuttle transportation, and close proximity to a hospital. The community offers a variety of living arrangements (spacious one-bedroom units, cottages with garages), a dedicated Memory Care unit, pet-friendly policies, and numerous common-area features that many families find appealing.

Staff and caregiving are areas of clear divergence. Many families and residents describe staff as warm, compassionate, and personally invested in residents’ wellbeing; individual staff members and leadership (several directors and aides were named positively) received praise for responsiveness and support during moves and transitions. At the same time, reviews indicate persistent operational issues: chronic understaffing and turnover, uneven training and supervision, and delays in responding to resident needs. Those operational weaknesses are associated with longer wait times for assistance and variability in the day-to-day experience in care areas, including memory care. There are also recurring concerns about medication-management practices that prospective families should investigate further with clinical leadership.

Dining and activities are frequently highlighted as strengths but with variability in execution. The community runs a full activities calendar — bingo, arts and crafts, regular outings to beaches and shopping, and on-site social events — and many residents report an active social life. Dining options include restaurant-style dining, in-room meal delivery, and a diverse menu; however, reviewers also describe inconsistent meal delivery, occasional delays or cold meals, and uneven food quality and produce availability. Prospective residents should ask about current dining procedures, menu cycles, and how dietary restrictions are handled.

Management and administrative processes show both strengths and gaps. Several reviewers commended specific administrators for helpful tours, smooth move-ins, and problem resolution. Conversely, there are notable patterns of billing discrepancies, unexpected price increases, and administrative miscommunications that in some accounts required extended resolution efforts. Workplace-culture issues and staff morale concerns were also mentioned, and reviewers linked these factors to service inconsistency in certain areas.

Overall, Lakeview is well suited to people who value an attractive campus, active programming, and an engaged, compassionate staff when present. However, the facility demonstrates operational variability linked to staffing, training, medication oversight, and administrative transparency. Families considering Lakeview should tour multiple times, speak directly with nursing leadership about staffing ratios and medication protocols, request written billing and pricing policies, observe meal service, and ask for references from current families — particularly if memory care or higher-dependency services are being considered.

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Location

Lakeview Senior Living is located at 2690 NE Yacht Ave, Lincoln City, OR, 97367.

About Lakeview Senior Living

Lakeview Senior Living sits at 2690 NE Yacht Avenue in Lincoln City, Oregon, right by quiet lake views and treed lawns that make for a peaceful setting, and the place shows off Northwestern-style architecture along with open, pleasant common areas both indoors and outside, where residents often gather. The community gives choices with independent living, assisted living, and memory care, providing support depending on what folks need, so people can manage most things on their own or get help when daily tasks get to be too much. Lakeview Senior Living has rooms in different sizes, from studio spots to one- and two-bedroom options, and some even offer cottages if you like your privacy but don't want to fuss with maintenance, and there are also two private dining rooms if family wants to stop by or if you're sharing a meal with friends, all meals covered in your stay and served restaurant-style to help with ease and comfort.

Staff stays awake around the clock for emergencies, and nurses are available to make sure everyone's safe, while you'll find the building is always kept clean and residents say the staff act with true caring. The community allows pets and has policies in place to keep animals and humans happy. Lakeview's Memory Care has secure features with alarms and bracelet technology so that those who wander, especially those with Alzheimer's or dementia, stay safe, plus, experienced staff manage big behavior changes and help manage diabetes, insulin, and even sliding scale therapies, which can be a relief for folks requiring specialized care. Most of the residents are over 55, and there's an emphasis on dignity, safety, and keeping up independence, so you'll see care plans personalized-along with reminders, help with medicine, errands, and chores, and there's always staff who can assist with things like moving from a bed to a wheelchair but who will also encourage as much independent living as possible.

There are both common rooms and outdoor patios for games, socializing, and relaxation, and regular activities, classes, hobby groups, devotional services off site, and entertainment keep residents active and engaged. The Compass Rose program stands out for memory care, focusing on those with Alzheimer's or dementia, and activities are made to help with mental stimulation and social connections. People at Lakeview Senior Living get their meals, utilities, cable TV, and transportation included-except for phone service-so there's not much left to worry about, and there's quick help with planning, financial resources, and guidance for veterans and their spouses looking at senior living expenses.

The building offers respite care, so caregivers in the community can get a break or residents can try out the facility for a brief stay. Staff help residents who can manage some of their own needs, even those with incontinence who just need reminders. The grounds are easy to enjoy, the indoors have a classic lobby and large lounge for gatherings, and the place has a high review rating, so people who live there and their families seem to be happy with it overall. Tours let folks get a look at daily life, the food, and what goes on in a day, and the facility is always open so visitors and emergencies can be taken care of any time.

Lakeview Senior Living gives a range of care options, from those who need little help to folks needing consistent medical attention or memory care, with 75% of residents usually needing medium help and 25% needing heavier care, so most find a fit no matter what stage of life they're in. There's a steady focus on well-being, with programs that encourage friendships, and overall, Lakeview tends to help seniors live with comfort and a sense of belonging, letting them handle as much or as little as they want to.

People often ask...

Lakeview Senior Living offers competitive pricing, with rates starting at a cost of $6,218 per month.

Lakeview Senior Living offers independent living, assisted living, and memory care.

There are 58 photos of Lakeview Senior Living on Mirador.

Yes, Lakeview Senior Living allows residents to age in place and adjust their level of care as needed.

The full address for this community is 2690 NE Yacht Ave, Lincoln City, OR 97367.

No, Lakeview 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.

License number	50R311
Status	Active
Facility type	Residential Care Facility
Capacity	43 residents
Licensee	Lakeview Operations, LLC
Effective	March 21st, 2003
Special certification	Memory Care

View the official license record

Inspection Reports

322

Reports

Type A Citations

Type B Citations

Complaints

Years

23 Sept 2026Licensure		23 Sept 2026Licensure Identified multiple deficiencies related to resident rights, service planning, monitoring of condition changes, health services, medication management, staffing, and complaint handling. Deficiency—Facility Administration: Policy & Procedure Deficiency—Resident Rights and Protection - General Deficiency—Service Plan: General Deficiency—Change of Condition and Monitoring Deficiency—Resident Health Services Deficiency—Systems: Treatment Orders Deficiency—Systems: Medication Administration Deficiency—Acuity Based Staffing Tool - ABST Time
10 Sept 2026Licensure		10 Sept 2026Licensure Identified widespread deficiencies across postings, resident rights, activities, move-in evaluations, monitoring of condition changes, health services, infection control, staffing, safety, privacy, and staff training. Deficiency—Facility Administration: Required Postings Deficiency—Resident Rights and Protection - General Deficiency—Resident Services: Activities Deficiency—Resident Move-in & Evaluation: Res Evaluation Deficiency—Change of Condition and Monitoring Deficiency—Resident Health Services Deficiency—Infection Prevention & Control Deficiency—Acuity Based Staffing Tool - ABST Time Deficiency—Acuity Based Staffing Tool - Updates & Staffing Plan Deficiency—Training Within 30 Days of Hire ? Direct Care Staff Deficiency—Fire and Life Safety: Safety Deficiency—Doors, Walls, Elevators, Odors Deficiency—Individual Privacy: Own Unit Deficiency—Individual Door Locks: Key Access Deficiency—Facility Administration: Required Postings Deficiency—Administration Responsibilities Deficiency—Administration Compliance Deficiency—Staff Training Requirements Deficiency—Compliance with Rules Health Care Deficiency—Activities Deficiency—Secure Outdoor Recreation Area
05 Aug 2026Kitchen		05 Aug 2026Kitchen Found violations of food sanitation rules due to improper kitchen storage, including unlabeled, undated, and uncovered items and food past use-by dates. Deficiency—Resident Services Meals, Food Sanitation Rule
05 Aug 2026Kitchen		05 Aug 2026Kitchen Found deficiencies in food sanitation practices in the kitchen and administration compliance related to licensing rules. Deficiency—Resident Services Meals, Food Sanitation Rule Deficiency—Administration Compliance
29 Jun 2026Inspection		29 Jun 2026Inspection Identified failure to provide requested records to the Department, constituting a rule violation. Licensing—Failed to make facility or resident records accessible
29 Jun 2026Inspection		29 Jun 2026Inspection Investigated the allegation and found failure to provide requested documentation, resulting in a licensing violation. Licensing—Failed to cooperate with an investigation
29 Jun 2026Inspection		29 Jun 2026Inspection Investigated the allegation and found a deficiency for failing to provide documentation upon request. Licensing—Failed to cooperate with an investigation
29 Jun 2026Inspection		29 Jun 2026Inspection Investigated the records request process and determined that records were not provided to the Department upon request. This constituted a violation of Oregon records access rules. Licensing—Failed to make facility or resident records accessible
29 Jun 2026Inspection		29 Jun 2026Inspection Investigated and found a deficiency for failing to provide records to the Department upon request. Licensing—Failed to make facility or resident records accessible
10 Mar 2026Inspection		10 Mar 2026Inspection Concluded that staffing levels indicated by the ABST were not met, with inconsistencies between ABST data and the staffing schedule that affected resident needs. Licensing—Failed to staff as indicated by ABST
11 Feb 2026Inspection		11 Feb 2026Inspection Investigated a staffing allegation and determined a violation for insufficient staffing levels on one shift as indicated by ABST. Licensing—Failed to use an ABST
21 Nov 2025Kitchen		21 Nov 2025Kitchen Found sanitation deficiencies in the kitchen areas, including dirty surfaces, disrepair, and unrestrained facial hair among staff. Deficiency—Resident Services Meals, Food Sanitation Rule
21 Nov 2025Kitchen		21 Nov 2025Kitchen Identified deficiencies in food sanitation and administration compliance, including dirty kitchen areas and unaddressed repairs, and noncompliance with licensing rules. Deficiency—Resident Services Meals, Food Sanitation Rule Deficiency—Administration Compliance
11 Oct 2025Inspection		11 Oct 2025Inspection Investigated and found a deficiency regarding an outdated ABST that failed to reflect the resident population and care needs, with inconsistencies among the roster, care plans, and ABST. Licensing—Failed to use an ABST
09 Sept 2025Abuse: Neglect		09 Sept 2025Abuse: Neglect Found failure to address ongoing fall risk, leading to a fall and injuries; a $500 fine was assessed. Abuse—Failed to properly plan care
07 Sept 2025Abuse: Neglect		07 Sept 2025Abuse: Neglect Investigated alleged abuse by neglect and found inadequate interventions to mitigate ongoing fall risk, leading to a fall and emergency department transport. Abuse—Failed to properly plan care
06 Sept 2025Abuse: Neglect		06 Sept 2025Abuse: Neglect Investigated an allegation of neglect and found ongoing fall risk was not properly mitigated, resulting in a skin tear after a fall. Abuse—Failed to properly plan care
03 Sept 2025Abuse: Neglect		03 Sept 2025Abuse: Neglect Found abuse by neglect due to failure to plan care to mitigate ongoing fall risk, resulting in a resident sustaining a head injury after a fall. Abuse—Failed to properly plan care
01 Sept 2025Abuse: Neglect		01 Sept 2025Abuse: Neglect Investigated a neglect allegation and found failure to plan and implement adequate interventions to mitigate fall risk, resulting in injuries and a fine was assessed. Abuse—Failed to properly plan care
31 Aug 2025Abuse: Neglect		31 Aug 2025Abuse: Neglect Investigated a neglect allegation and found failure to plan care to mitigate fall risk, resulting in unwitnessed falls and injury. Abuse—Failed to properly plan care
23 Aug 2025Abuse: Neglect		23 Aug 2025Abuse: Neglect Found abuse by neglect due to failing to plan and implement interventions to address ongoing fall risk, with a $500 fine assessed. Abuse—Failed to properly plan care
22 Aug 2025Abuse: Neglect		22 Aug 2025Abuse: Neglect Investigated and found abuse by neglect due to failure to develop sufficient person-centered interventions to mitigate fall risk, resulting in an unwitnessed fall and injuries; a $500 fine was assessed. Abuse—Failed to properly plan care
15 Aug 2025Abuse: Neglect		15 Aug 2025Abuse: Neglect Found abuse by neglect due to failure to implement suitable interventions to reduce fall risk, leading to a fall and EMS transport for evaluation. Abuse—Failed to properly plan care
12 Aug 2025Inspection		12 Aug 2025Inspection Found deficiencies in the Acuity-Based Staffing Tool that failed to reflect resident care needs, with inconsistencies between the roster, care plans, and ABST data. Licensing—Failed to use an ABST
10 Aug 2025Abuse: Neglect		10 Aug 2025Abuse: Neglect Investigated a complaint and found failure to plan care that increased fall risk, leading to injury. Abuse—Failed to properly plan care
30 Jul 2025Abuse: Neglect		30 Jul 2025Abuse: Neglect Investigated abuse by neglect due to failure to plan care to prevent falls, which resulted in a $250 fine. Abuse—Failed to properly plan care
29 Jul 2025Inspection		29 Jul 2025Inspection Found staffing deficiencies where ABST indicated higher levels and qualifications than provided, with inconsistencies between ABST data and the staffing schedule. Licensing—Failed to staff as indicated by ABST
29 Jul 2025Abuse: Neglect		29 Jul 2025Abuse: Neglect Investigated and found that staff failed to supervise a resident as required by the care plan, resulting in an injury fall. Abuse—Failed to provide safe environment
22 Jul 2025Abuse: Neglect		22 Jul 2025Abuse: Neglect Found abuse by neglect due to failing to plan care and mitigate fall risk for a resident, and a 250 fine was assessed. Abuse—Failed to properly plan care
12 May 2025Inspection		12 May 2025Inspection Found that the Acuity-Based Staffing Tool was not updated to reflect resident needs, with inconsistencies between the resident roster, care plans, and ABST data. Licensing—Failed to update staffing plan based on ABST
07 Apr 2025Inspection		07 Apr 2025Inspection Found violations for failing to staff consistent with ABST indicators, with inconsistencies between ABST data and the staffing schedule leading to under-staffing. Licensing—Failed to staff as indicated by ABST
02 Apr 2025Inspection		02 Apr 2025Inspection Found inconsistencies between the resident roster, care plans, and ABST data due to an outdated ABST. This was a violation of Oregon Administrative Rules. Licensing—Failed to use an ABST
16 Mar 2025Inspection		16 Mar 2025Inspection Found failure to update resident profiles quarterly in ABST. Licensing—Failed to use an ABST
26 Feb 2025Abuse: Neglect		26 Feb 2025Abuse: Neglect Found that the facility inadequately planned and implemented interventions to address increasing falls, resulting in injury to a resident. Abuse—Failed to properly plan care
15 Feb 2025Inspection		15 Feb 2025Inspection Determined that the staffing plan based on ABST was not updated to reflect resident care needs, with inconsistencies among the roster, care plans, and ABST, violating Oregon Administrative Rules. Licensing—Failed to update staffing plan based on ABST
11 Feb 2025Inspection		11 Feb 2025Inspection Found that the Acuity-Based Staffing Tool wasn't updated to reflect residents' care needs, with inconsistencies between the roster, care plans, and ABST data. Licensing—Failed to use an ABST
11 Feb 2025Complaint		11 Feb 2025Complaint Investigated a complaint about medications and treatments and an acuity-based staffing tool; two deficiencies were cited. Deficiency—Systems: Medications and Treatments Deficiency—Acuity-Based Staffing Tool Deficiency—General Comments
11 Feb 2025Complaint		11 Feb 2025Complaint Investigated acuity-based staffing tool usage and found quarterly reviews incomplete for several residents and staffing plans not aligned with acuity. Identified a failure to fully implement and update the ABST. Deficiency—Acuity-Based Staffing Tool Deficiency—Acuity Based Staffing Tool - Updates & Plan
27 Dec 2024Abuse: Neglect		27 Dec 2024Abuse: Neglect Found a failure to provide a safe environment that could harm residents, constituting abuse and neglect. Abuse—Failed to provide safe environment
16 Dec 2024Abuse: Neglect		16 Dec 2024Abuse: Neglect Investigated a complaint of abuse and neglect; found failure to follow the care plan and supervise a resident, placing them at risk, and assessed a $500 fine. Abuse—Failed to follow care plan
26 Nov 2024Inspection		26 Nov 2024Inspection Investigated and found that the care plan requiring two trained staff for transferring was not followed, resulting in a fall and a serious back injury. Licensing—Failed to follow care plan
28 Oct 2024Inspection		28 Oct 2024Inspection Found staffing deficiencies due to an inaccurate acuity-based staffing tool and inconsistencies between roster, care plans, and ABST, resulting in under-staffing relative to resident needs. Licensing—Failed to staff as indicated by ABST
28 Oct 2024Abuse: Neglect		28 Oct 2024Abuse: Neglect Investigated and found a failure to provide a safe environment, constituting neglect and abuse. Abuse—Failed to provide safe environment
25 Oct 2024Inspection		25 Oct 2024Inspection Identified staffing deficiencies and ABST data inconsistencies that failed to reflect resident needs and required ADLs, resulting in inadequate staffing. Licensing—Failed to staff as indicated by ABST
24 Sept 2024Inspection		24 Sept 2024Inspection Found that a resident was not adequately protected from financial exploitation, with narcotics reportedly removed from the room during hospital visits. Licensing—Failed to protect resident from financial exploitation
22 Sept 2024Abuse: Neglect		22 Sept 2024Abuse: Neglect Investigated an allegation that a resident's rights were violated when medications were removed and not delivered on time, causing pain and diarrhea. Found violations related to medication management and resident rights. Abuse—Failed to assure resident rights
11 Sept 2024Inspection		11 Sept 2024Inspection Identified deficiencies in ABST accuracy and staffing levels, with mismatches between roster, care plans, and ABST data, resulting in staffing not aligned with resident needs. Licensing—Failed to staff as indicated by ABST
11 Sept 2024Abuse: Neglect		11 Sept 2024Abuse: Neglect Investigated an abuse/neglect allegation and concluded that fall-prevention care planning was not properly addressed, resulting in a fall and injury; a $750 fine was assessed. Abuse—Failed to properly plan care
27 Aug 2024Inspection		27 Aug 2024Inspection Identified deficiencies in ABST accuracy and staffing alignment with resident needs, with inconsistencies among the roster, care plans, and ABST data, and inadequate staffing to cover scheduled and unscheduled needs. Licensing—Failed to staff as indicated by ABST
22 Jul 2024Inspection		22 Jul 2024Inspection Found that an updated Acuity-Based Staffing Tool did not accurately reflect residents' care needs, with inconsistencies between the roster, care plans, and ABST data. Licensing—Failed to use an ABST
09 Jul 2024Abuse: Neglect		09 Jul 2024Abuse: Neglect Found failures to follow the resident's oral care plan for dentures, resulting in a gum sore and discomfort for the resident. Abuse—Failed to follow care plan
08 Jul 2024Complaint		08 Jul 2024Complaint Investigated complaints and identified deficiencies in resident records, service plan updates, and staffing, including mismatched POLST/health care preferences, incomplete quarterly evaluations, and failure to implement an acuity-based staffing tool. Deficiency—Facility Administration: Records Deficiency—Service Plan: General Deficiency—Acuity-Based Staffing Tool
08 Jul 2024Inspection		08 Jul 2024Inspection Investigated and identified a violation related to updating the Acuity-Based Staffing Tool and ensuring consistency with resident rosters and care plans. Licensing—Failed to use an ABST
03 Jul 2024Inspection		03 Jul 2024Inspection Investigated the allegation of failing to properly plan care and found that a quarterly service plan was not completed. Licensing—Failed to properly plan care
03 Jul 2024Inspection		03 Jul 2024Inspection Found that resident records were not complete or accurate. Licensing—Failed to properly plan care
17 Jun 2024License Condition		17 Jun 2024License Condition Found a failure to provide a safe environment. Non-compliance with Oregon Administrative Rules was identified. Regulatory Action—Failed to provide safe environment
13 Jun 2024License Condition		13 Jun 2024License Condition Found a failure to provide a safe environment. Regulatory Action—Failed to provide safe environment
12 Jun 2024Complaint		12 Jun 2024Complaint Found multiple deficiencies related to residents' service plans not reflecting needs, medication observation, staffing adequacy, acuity-based staffing, and abuse reporting training. Deficiency—Service Plan: General Deficiency—Systems: Medication Administration Deficiency—Staffing Requirements and Training: Staffing Deficiency—Acuity-Based Staffing Tool Deficiency—Staffing Requirements and Training – Pre-Serv
12 Jun 2024Complaint		12 Jun 2024Complaint Investigated a licensure complaint and identified isolated concerns in resident rights and protection and medication/treatment review, with potential for moderate harm. Deficiency—Licensing Complaint Investigation Deficiency—Resident Rights and Protection: Personal Rela Deficiency—Systems: Medication and Treatment Review
01 Jun 2024Inspection		01 Jun 2024Inspection Found failure to administer medication as ordered, constituting a licensing violation. Licensing—Failed to administer medication as ordered
20 May 2024Validation		20 May 2024Validation Identified numerous deficiencies across governance, care delivery, health services, safety, and staffing, resulting in multiple citations for noncompliance with state regulations. Deficiency—Comment Deficiency—Facility Administration: Operation Deficiency—Facility Administration: Policy & Procedure Deficiency—Facility Administration: Quality Improvement Deficiency—Resident Rights and Protection - General 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: Medication Administration Deficiency—Systems: Medication Administration Deficiency—Systems: Self-Administration of Meds Deficiency—Systems: Psychotropic Medication Deficiency—Staffing Requirements and Training: Staffing Deficiency—Staffing Requirements and Training – Pre-Serv Deficiency—Training Within 30 Days: Direct Care Staff Deficiency—Fire and Life Safety: Safety Deficiency—Fire and Life Safety: Training For Residents Deficiency—General Building: Doors-Walls, Cleanable Deficiency—Resident Units Deficiency—Heating and Ventilation Deficiency—Plumbing Systems Deficiency—Call System
20 May 2024Validation		20 May 2024Validation Identified multiple deficiencies across administration, resident rights, health services, activities, safety, and infection control during the licensing review, with a follow-up revisit determining substantial compliance. Deficiency—Comment Deficiency—Facility Administration: Operation Deficiency—Resident Rights and Protection - General Deficiency—Resident Services: Activities Deficiency—Resident Move-In and Eval: Res Evaluation Deficiency—Service Plan: General Deficiency—Change of Condition and Monitoring Deficiency—Resident Health Services Deficiency—Infection Prevention & Control Deficiency—Systems: Treatment Orders Deficiency—Systems: Resident Right to Refuse Deficiency—Systems: Psychotropic Medication Deficiency—Restraints and Supportive Devices Deficiency—Training Within 30 Days: Direct Care Staff Deficiency—Fire and Life Safety: Safety Deficiency—Fire and Life Safety: Training For Residents Deficiency—Doors, Walls, Elevators, Odors Deficiency—Individual Rights Settings Right to Freedom Deficiency—Individual Door Locks: Key Access Deficiency—Limitations: Threats to Health and Safety Deficiency—General Comments Deficiency—Administration Compliance Deficiency—Staff Training Requirements Deficiency—Compliance With Rules Health Care Deficiency—Nutrition and Hydration Deficiency—Activities Deficiency—Behavior Deficiency—Secure Outdoor Recreation Area
03 May 2024Inspection		03 May 2024Inspection Investigated and identified a violation of resident rights under HCBS rules. Licensing—Failed to assure resident rights
26 Apr 2024Inspection		26 Apr 2024Inspection Investigated and determined a violation of HCBS resident rights. The resident's right to choose a roommate was not ensured. Licensing—Failed to assure resident rights
26 Apr 2024Abuse: Neglect		26 Apr 2024Abuse: Neglect Investigated neglect related to dental care and found that timely dental care was not provided. Abuse—Failed to assure dental treatment
26 Apr 2024Inspection		26 Apr 2024Inspection Investigated and identified a deficiency for failing to provide a lockable door. Licensing—Failed to assure resident rights
25 Apr 2024Inspection		25 Apr 2024Inspection Identified that a training program including abuse and reporting requirements was not in place and that training records for staff were incomplete. Licensing—Failed to provide inservice
25 Apr 2024Inspection		25 Apr 2024Inspection Found that service plans did not reflect residents' needs and were not consistently followed. Missed showers and grooming concerns were documented for multiple residents. Licensing—Failed to properly plan care
25 Apr 2024Inspection		25 Apr 2024Inspection Found that staff failed to visually observe a resident taking medications during administration and there was no current order to leave medications at bedside. Licensing—Failed to provide a safe medication administration system
09 Apr 2024Complaint		09 Apr 2024Complaint Found that transportation for medical services was not provided for a sampled resident and other ride options required advance notice, despite an agreement assigning transport responsibility to the facility. Deficiency—Resident Services: Auxilary Services
09 Apr 2024Complaint		09 Apr 2024Complaint Identified deficiencies related to medications and treatments, staffing requirements and training, and inspections. Deficiency—Systems: Medications and Treatments Deficiency—Staffing Rqmt and Training: Training Rqmts Deficiency—Inspections and Investigations
02 Apr 2024Inspection		02 Apr 2024Inspection Identified deficiencies related to the ABST not accurately reflecting resident needs and ADLs, with staffing not aligned to ABST levels. Licensing—Failed to use an ABST
02 Apr 2024Inspection		02 Apr 2024Inspection Found that an updated ABST was not maintained and inconsistencies existed between the resident roster, care plans, and ABST data. Licensing—Failed to use an ABST
25 Mar 2024Inspection		25 Mar 2024Inspection Determined that transportation for medical services was not provided, constituting a licensing violation. Licensing—Failed to provide transportation for medical or social purposes
18 Mar 2024Abuse: Neglect		18 Mar 2024Abuse: Neglect Found neglect and abuse due to failure to properly plan care, after an unwitnessed fall with injuries. Abuse—Failed to properly plan care
17 Mar 2024Abuse: Neglect		17 Mar 2024Abuse: Neglect Identified neglect and abuse for failing to properly plan care to reduce frequent falls. A $375 fine was assessed. Abuse—Failed to properly plan care
13 Mar 2024Inspection		13 Mar 2024Inspection Investigated a complaint and found a failure to provide a safe medication administration system, resulting in multiple falls after dosing. Licensing—Failed to provide a safe medication administration system
12 Mar 2024Inspection		12 Mar 2024Inspection Found a violation for failing to answer call lights in a timely manner. Licensing—Failed to answer call light in a timely manner
12 Mar 2024Inspection		12 Mar 2024Inspection Found a rule violation for failing to observe medication administration. Licensing—Failed to administer medication as ordered
11 Mar 2024Abuse: Neglect		11 Mar 2024Abuse: Neglect Investigated a neglect allegation found that ordered pain medication was not provided, leading to a $250 fine. Abuse—Failed to provide appropriate pain control
21 Feb 2024Complaint		21 Feb 2024Complaint Found deficiencies in several clinical and administrative areas related to condition monitoring, RN delegation, medications and treatments, treatment orders, and staff training. Deficiency—Facility Administration: Policy & Procedure Deficiency—Change of Condition and Monitoring Deficiency—Rn Delegation and Teaching Deficiency—Systems: Medications and Treatments Deficiency—Systems: Treatment Orders Deficiency—Staffing Rqmt and Training: Training Rqmts
21 Feb 2024Inspection		21 Feb 2024Inspection Found insufficient staff to meet residents' scheduled and unscheduled needs, causing needs to be unmet or delayed. Licensing—Failed to meet the scheduled and unscheduled needs of residents
21 Feb 2024Inspection		21 Feb 2024Inspection Found a violation for failing to keep equipment in good repair, essential for residents' health, safety, and comfort. Licensing—Failed to maintain a safe physical environment
21 Feb 2024Inspection		21 Feb 2024Inspection Investigated and found insufficient staffing to meet residents' scheduled and unscheduled needs, causing delays or unmet needs. Determined to violate Oregon Administrative Rules. Licensing—Failed to meet the scheduled and unscheduled needs of residents
21 Feb 2024Inspection		21 Feb 2024Inspection Identified a failure to maintain a safe physical environment due to equipment not kept clean and in good repair. Licensing—Failed to maintain a safe physical environment
21 Feb 2024Complaint		21 Feb 2024Complaint Identified deficiencies in care planning, staffing adequacy, and elevator-related equipment maintenance. The findings showed mismatches between residents' needs and care plans, insufficient awake direct-care staffing due to the broken elevator, and failed maintenance of essential equipment. Deficiency—Service Plan: General Deficiency—Staffing Requirements and Training: Staffing Deficiency—General Building: Doors-Walls, Cleanable
20 Feb 2024Inspection		20 Feb 2024Inspection Investigated a complaint and found a deficiency for failing to include an Oregon licensed nurse regularly scheduled for onsite duties and available for phone consultation. Licensing—Failed to obtain appropriate consultation
20 Feb 2024Inspection		20 Feb 2024Inspection Found a failure to meet nursing delegation requirements because delegation and teaching were not provided and documented by an RN. Licensing—Failed to comply with nursing delegation requirement
16 Feb 2024Inspection		16 Feb 2024Inspection Found insufficient staff to meet residents' scheduled and unscheduled needs, leading to delays or unmet care. Licensing—Failed to meet the scheduled and unscheduled needs of residents
16 Feb 2024Inspection		16 Feb 2024Inspection Identified a violation for failing to keep equipment necessary for resident health, safety, and comfort in good repair. Licensing—Failed to provide or maintain resident care equipment
16 Feb 2024Inspection		16 Feb 2024Inspection Found that a service plan failed to reflect residents' needs. Licensing—Failed to properly plan care
12 Feb 2024Inspection		12 Feb 2024Inspection Identified a deficiency for lacking written policies to ensure a 24-hour resident monitoring and reporting system. Licensing—Failed to provide safe environment
12 Feb 2024Inspection		12 Feb 2024Inspection Found failure to administer medication as ordered, violating safe medication administration practices. Licensing—Failed to administer medication as ordered
12 Feb 2024Inspection		12 Feb 2024Inspection Found a deficiency in resolving resident complaints due to ineffective methods. Licensing—Failed to assure resident rights
12 Feb 2024Inspection		12 Feb 2024Inspection Found that a call light was not answered promptly. Licensing—Failed to answer call light in a timely manner
12 Feb 2024Abuse: Neglect		12 Feb 2024Abuse: Neglect Found violations of resident rights due to inadequate oversight of change in condition, which led to a fall and head injury and constituted neglect and abuse; a fine was assessed. Abuse—Failed to provide oversight and monitoring of change of condition
05 Feb 2024Inspection		05 Feb 2024Inspection Found that records were not made available to the Department upon request, resulting in a substantiated licensing violation. Licensing—Failed to cooperate with an investigation
26 Jan 2024Abuse: Neglect		26 Jan 2024Abuse: Neglect Investigated a falls risk issue and found the care plan was not updated to address safety, resulting in a fall and injury. Abuse—Failed to properly plan care
17 Jan 2024Abuse: Neglect		17 Jan 2024Abuse: Neglect Found a deficient safe medication administration system that led to a resident not receiving medications for several days and experiencing pain; a $375 fine was assessed. Abuse—Failed to provide a safe medication administration system
06 Jan 2024Abuse: Neglect		06 Jan 2024Abuse: Neglect Investigated a fall-risk case and found failure to plan care to reduce fall risk, leading to a fall and hospital evaluation; a fine was assessed. Abuse—Failed to properly plan care
29 Dec 2023License Condition		29 Dec 2023License Condition Investigated an allegation that an acuity-based staffing tool was not used. Determined there was a failure to fully implement and update ABST as required. Regulatory Action—Failed to use an ABST
28 Dec 2023License Condition		28 Dec 2023License Condition Found failure to use an ABST as required. Regulatory Action—Failed to use an ABST
26 Dec 2023Abuse: Neglect		26 Dec 2023Abuse: Neglect Investigated concluded fall prevention interventions were not implemented and care planning was improper, placing a resident at risk of harm. Abuse—Failed to properly plan care
11 Nov 2023Abuse: Neglect		11 Nov 2023Abuse: Neglect Found neglect and abuse for failing to mitigate fall risk and assessed a fine of $375. Abuse—Failed to properly plan care
11 Nov 2023Abuse: Neglect		11 Nov 2023Abuse: Neglect Investigated allegations of neglect and abuse and found that care planning failed to address fall risk, contributing to an unwitnessed fall and injury. Abuse—Failed to properly plan care
11 Oct 2023Complaint		11 Oct 2023Complaint Identified deficiencies in acuity-based staffing tool implementation and room-entry controls, including incomplete ABST updates and a resident's entry through another resident's bedroom. Deficiency—Licensing Complaint Investigation Deficiency—Acuity-Based Staffing Tool Deficiency—Resident Units
11 Oct 2023Complaint		11 Oct 2023Complaint Identified insufficient awake direct care staffing, failure to adopt an acuity-based staffing tool, and missing lockable storage spaces. Deficiency—Licensing Complaint Investigation Deficiency—Staffing Requirements and Training: Staffing Deficiency—Acuity-Based Staffing Tool Deficiency—Resident Units
07 Oct 2023Abuse: Neglect		07 Oct 2023Abuse: Neglect Found violations related to neglect and abuse after an unwitnessed fall caused an injury due to improper care planning and fall-prevention interventions. Abuse—Failed to properly plan care
29 Sept 2023Inspection		29 Sept 2023Inspection Investigated the allegation that resident rights were not assured and found that residents could enter another resident's bedroom, violating rules. Licensing—Failed to assure resident rights
18 Sept 2023Abuse: Neglect		18 Sept 2023Abuse: Neglect Investigated found neglect and abuse due to failure to provide a safe environment, which allowed a resident to enter another resident's room and be harmed; a fine was assessed. Abuse—Failed to provide safe environment
03 Sept 2023Abuse: Neglect		03 Sept 2023Abuse: Neglect Investigated and found that a resident's purse was taken by an unknown person, constituting financial exploitation and abuse; a $500 fine was assessed. Abuse—Failed to protect resident from financial exploitation
26 Aug 2023Abuse: Neglect		26 Aug 2023Abuse: Neglect Determined that neglect and abuse occurred due to failure to properly plan care for ongoing falls and implement interventions. Abuse—Failed to properly plan care
17 Aug 2023Licensure		17 Aug 2023Licensure Found deficiencies in kitchen cleanliness, storage practices, and staff food handler documentation. A later follow-up determined substantial compliance. Deficiency—Comment Deficiency—Resident Services Meals, Food Sanitation Rule
17 Aug 2023Licensure		17 Aug 2023Licensure Found deficiencies in kitchen cleanliness, improper food handling and storage, and administration compliance. Deficiency—Comment Deficiency—Resident Services Meals, Food Sanitation Rule Deficiency—Administration Compliance
16 May 2023Inspection		16 May 2023Inspection Found lack of a lockable storage space, violating Oregon Administrative Rules. Licensing—Failed to assure resident rights
09 May 2023Abuse: Neglect		09 May 2023Abuse: Neglect Investigated and found that a resident's narcotics were stolen and no lockable storage was provided to protect valuables, risking financial exploitation. Abuse—Failed to protect resident from financial exploitation
23 Apr 2023Inspection		23 Apr 2023Inspection Found insufficient qualified awake direct care staff to meet 24-hour needs, resulting in a failure to provide a safe environment. Licensing—Failed to provide safe environment
11 Apr 2023Complaint		11 Apr 2023Complaint Found deficiencies in keeping equipment clean and in good repair, including a non-working oven. Deficiency—Licensing Complaint Investigation Deficiency—General Building: Doors-Walls, Cleanable
05 Apr 2023Abuse: Neglect		05 Apr 2023Abuse: Neglect Found neglect and abuse due to failure to follow the care plan for catheter care, causing discomfort and loss of personal dignity; a $500 fine was assessed. Abuse—Failed to follow care plan
05 Apr 2023Inspection		05 Apr 2023Inspection Investigated and concluded that neglect of care and abuse occurred, resulting in harm to a resident. Licensing—Failed to provide service
05 Apr 2023Inspection		05 Apr 2023Inspection Determined that a resident's rights were violated and neglect/abuse occurred due to improper restraint use. Licensing—Failed to use restraint properly
03 Apr 2023Inspection		03 Apr 2023Inspection Found failure to keep interior and exterior surfaces and equipment clean and in good repair, affecting residents' health and safety. Licensing—Failed to provide safe environment
07 Mar 2023Complaint		07 Mar 2023Complaint Found deficiencies related to general service plan requirements during a complaint investigation. Deficiency—Licensing Complaint Investigation Deficiency—Service Plan: General
07 Mar 2023Inspection		07 Mar 2023Inspection Investigated and found that a staff action caused emotional distress and violated resident rights, constituting neglect and verbal abuse and failing to protect from emotional abuse. Licensing—Failed to protect resident from mental or emotional abuse
14 Feb 2023Inspection		14 Feb 2023Inspection Investigated and found that staff did not exercise reasonable precautions to protect residents' health and safety, including not using masks and screening staff/visitors. Licensing—Failed to provide safe environment
22 Jan 2023Abuse: Neglect		22 Jan 2023Abuse: Neglect Investigated a resident's fall-risk care plan and hazard removal; found failures to implement interventions that resulted in serious injuries. Abuse—Failed to properly plan care
21 Jan 2023Abuse: Neglect		21 Jan 2023Abuse: Neglect Found neglect and abuse due to failure to follow orders and maintain a safe medication administration system, leading to withdrawal symptoms and hospital transport after missing four doses. Abuse—Failed to provide a safe medication administration system
11 Jan 2023Abuse: Neglect		11 Jan 2023Abuse: Neglect Investigated a complaint about safety and care planning; found failures to implement interventions and provide a safe environment, placing a resident at risk of harm. Abuse—Failed to provide safe environment
06 Jan 2023Abuse: Neglect		06 Jan 2023Abuse: Neglect Investigated a complaint and found care did not follow the resident's Service Plan and staff were not properly trained. A forced shower caused injury, and a fine was assessed. Abuse—Failed to follow care plan
06 Jan 2023Abuse: Neglect		06 Jan 2023Abuse: Neglect Investigated the complaint and found neglect, concluding that care was not provided as planned, resulting in skin breakdown and irritation. Abuse—Failed to provide service
10 Nov 2022License Condition		10 Nov 2022License Condition Investigated the ABST-related allegation and identified failure to use ABST. Regulatory Action—Failed to use an ABST
06 Nov 2022Abuse: Neglect		06 Nov 2022Abuse: Neglect Investigated the complaint and found a failure to provide a safe medication administration system, which led to partial dosing of narcotic pain medication and related pain and distress. Abuse—Failed to provide a safe medication administration system
04 Nov 2022Abuse: Neglect		04 Nov 2022Abuse: Neglect Found violations for neglect and abuse due to failure to adjust care plans to address continued inappropriate behaviors between residents. Assessed a $375 fine. Abuse—Failed to properly plan care
01 Nov 2022Inspection		01 Nov 2022Inspection Investigated allegation found quarterly service plans were not completed. Licensing—Failed to properly plan care
18 Oct 2022Complaint		18 Oct 2022Complaint Investigated a complaint and found deficiencies in acuity-based staffing tool implementation; no tool or resident data were entered and no staffing plan was posted. Deficiency—Acuity-Based Staffing Tool
01 Oct 2022Inspection		01 Oct 2022Inspection Found a violation for failing to submit timely weekly reporting of vaccinated individuals, residents and staff for 30 days. Licensing—Failed to submit timely or adequate staffing documentation
14 Sept 2022Abuse: Neglect		14 Sept 2022Abuse: Neglect Found violations related to unsafe medication administration and failure to manage meds when a resident was out, risking serious harm. Abuse—Failed to provide a safe medication administration system
02 Sept 2022License Condition		02 Sept 2022License Condition Found insufficient staffing to meet residents' scheduled and unscheduled needs, including help with bathing and dressing. Regulatory Action—Failed to provide appropriate staffing
02 Sept 2022License Condition		02 Sept 2022License Condition Found that residents did not receive proper hygiene assistance, including bathing, dressing, and undressing, as required. Regulatory Action—Failed to provide or assist with hygiene
02 Sept 2022License Condition		02 Sept 2022License Condition Investigated the allegation of ABST non-use. Found ABST was not implemented as required. Regulatory Action—Failed to use an ABST
01 Sept 2022Inspection		01 Sept 2022Inspection Identified a deficiency for failing to submit timely weekly vaccination reporting for residents, staff, and vaccinated individuals from August 1 to August 31, 2022. A $7,500 fine was assessed. Licensing—Failed to submit timely or adequate staffing documentation
26 Aug 2022Abuse: Neglect		26 Aug 2022Abuse: Neglect Found abuse and neglect; identified safety failures and a missing background check, with a fine assessed. Abuse—Failed to provide safe environment
26 Aug 2022Abuse: Neglect		26 Aug 2022Abuse: Neglect Investigated and found failures in care planning that resulted in neglect and abuse, with a $500 fine assessed. Abuse—Failed to properly plan care
25 Aug 2022Abuse: Neglect		25 Aug 2022Abuse: Neglect Investigated an allegation of neglect and found failure to provide appropriate services and care for the Alleged Victim, who later died from a wound-related sepsis. Abuse—Failed to provide service
22 Aug 2022Abuse: Neglect		22 Aug 2022Abuse: Neglect Found deficiencies in fall-risk care planning and interventions after multiple documented falls and injuries, with a fine assessed. Abuse—Failed to properly plan care
16 Aug 2022Inspection		16 Aug 2022Inspection Found a deficiency in medication administration safety due to failure to ensure medications were administered as ordered. Licensing—Failed to provide a safe medication administration system
15 Aug 2022Abuse: Neglect		15 Aug 2022Abuse: Neglect Found neglect and abuse due to failure to provide timely transportation and services for a resident's medical appointment, resulting in a rescheduled procedure and a fine assessed. Abuse—Failed to provide service
10 Aug 2022Complaint		10 Aug 2022Complaint Found that an acuity-based staffing tool was not implemented or updated and that no staffing plan was posted; several resident service plans were outdated, hindering input into the ABST. Deficiency—Acuity-Based Staffing Tool
09 Aug 2022Abuse: Neglect		09 Aug 2022Abuse: Neglect Determined neglect and abuse due to failure to provide timely pain medication, resulting in withdrawal symptoms and hospital transport; a fine was assessed. Abuse—Failed to provide appropriate pain control
01 Aug 2022Abuse: Neglect		01 Aug 2022Abuse: Neglect Found a failure to provide a safe medication administration system, resulting in untimely or missing medications and resident agitation; a $500 fine was assessed. Abuse—Failed to provide a safe medication administration system
16 Jul 2022Abuse: Neglect		16 Jul 2022Abuse: Neglect Determined that neglect occurred due to failure to provide timely medical treatment, causing ongoing pain and emotional hardship. Abuse—Failed to assure timely medical treatment
16 Jul 2022Abuse: Neglect		16 Jul 2022Abuse: Neglect Investigated and found failure to provide appropriate services after a fall, resulting in neglect and abuse findings. Abuse—Failed to provide service
19 Jun 2022Abuse: Neglect		19 Jun 2022Abuse: Neglect Investigated a resident care allegation and found neglect and abuse due to failure to care plan and implement reasonable interventions for a resident, leading to hospital transfer and risk of serious harm. A $375 fine was assessed. Abuse—Failed to cooperate with an investigation
18 Jun 2022Inspection		18 Jun 2022Inspection Investigated an allegation that a resident was not protected from inappropriate sexual contact and identified deficiencies in records retention, documentation, and service planning; no abuse occurred. Licensing—Failed to protect resident from inappropriate sexual contact
17 Jun 2022Inspection		17 Jun 2022Inspection Investigated a complaint and found violations related to timely medical treatment and record-keeping. Licensing—Failed to assure timely medical treatment
21 May 2022Abuse: Neglect		21 May 2022Abuse: Neglect Investigated and found a failure to provide a safe medication administration system, which resulted in neglect and abuse. Abuse—Failed to provide a safe medication administration system
02 May 2022Abuse: Neglect		02 May 2022Abuse: Neglect Investigated a fall-related care issue and found failures to address increasing fall risk, resulting in neglect and abuse. Abuse—Failed to properly plan care
21 Apr 2022Abuse: Neglect		21 Apr 2022Abuse: Neglect Found failure to plan and implement care for a known fall risk, leading to a resident's fall with injuries requiring hospital treatment. Abuse—Failed to properly plan care
20 Apr 2022Abuse: Neglect		20 Apr 2022Abuse: Neglect Determined that a resident did not receive needed services, resulting in a fall and inadequate staff response. A $375 fine was assessed. Abuse—Failed to provide service
10 Apr 2022Abuse: Neglect		10 Apr 2022Abuse: Neglect Identified neglect and abuse related to failure to protect a resident from inappropriate sexual contact and to provide a safe environment. This led to a resident-to-resident interaction with risk of serious harm and loss of personal dignity, and a fine was assessed. Abuse—Failed to protect resident from inappropriate sexual contact
11 Mar 2022Inspection		11 Mar 2022Inspection Investigated and found that a care plan was not followed. This resulted in a resident injury and concerns of neglect and abuse. Licensing—Failed to follow care plan
05 Mar 2022Inspection		05 Mar 2022Inspection Determined that a resident was financially exploited and protections against exploitation were inadequate. Licensing—Failed to protect resident from financial exploitation
02 Mar 2022Abuse: Neglect		02 Mar 2022Abuse: Neglect Investigated a complaint and found a failure to provide a safe medication administration system, resulting in neglect and abuse. Abuse—Failed to provide a safe medication administration system
22 Feb 2022Abuse: Neglect		22 Feb 2022Abuse: Neglect Found neglect and abuse due to failure to plan and implement care for a resident's known fall risk, resulting in a fall and hospital transfer. Abuse—Failed to properly plan care
14 Feb 2022Abuse: Neglect		14 Feb 2022Abuse: Neglect Found neglect and abuse due to an unsafe medication administration system that resulted in missed doses and patient discomfort. Abuse—Failed to provide a safe medication administration system
31 Jan 2022Abuse: Neglect		31 Jan 2022Abuse: Neglect Found that multiple medication doses were given more than one hour late, causing repeated discomfort and constituting neglect and abuse; a $1,500 fine was assessed. Abuse—Failed to administer ordered medication
07 Jan 2022Abuse: Neglect		07 Jan 2022Abuse: Neglect Investigated allegations of neglect and abuse and found a failure to document interventions and care planning to mitigate fall risk. Abuse—Failed to cooperate with an investigation
24 Dec 2021Abuse: Neglect		24 Dec 2021Abuse: Neglect Concluded that neglect occurred due to failure to provide appropriate services and care planning, resulting in multiple falls, weight loss, infection, and injuries. Abuse—Failed to provide service
22 Dec 2021Abuse: Neglect		22 Dec 2021Abuse: Neglect Found that a safe medication administration system was not provided, resulting in a resident receiving another resident’s medication and hospital transfer; a $375 fine was assessed. Abuse—Failed to provide a safe medication administration system
12 Dec 2021Abuse: Neglect		12 Dec 2021Abuse: Neglect Found that the care plan for a resident was not followed, resulting in the resident being found soiled and in an unsanitary room due to staffing shortages. Abuse—Failed to follow care plan
07 Dec 2021Abuse: Neglect		07 Dec 2021Abuse: Neglect Investigated and found violations related to inadequate care and safety, including multiple falls and failure to follow care plans due to staffing shortages. The failures resulted in harm and neglect. Abuse—Failed to provide service
28 Nov 2021Abuse: Neglect		28 Nov 2021Abuse: Neglect Investigated an abuse/neglect allegation related to falls and found failure to properly plan care and implement fall-risk interventions, resulting in a head injury from a fall. Abuse—Failed to properly plan care
18 Nov 2021Abuse: Neglect		18 Nov 2021Abuse: Neglect Investigated found that required services were not provided during a decline in condition, causing unnecessary discomfort and loss of dignity. A $500 fine was assessed. Abuse—Failed to provide service
17 Nov 2021Abuse: Neglect		17 Nov 2021Abuse: Neglect Found neglect and abuse due to failing to follow the resident's care plan, including catheter care, and to maintain cleanliness and safety; a fine was assessed. Abuse—Failed to follow care plan
14 Nov 2021Abuse: Neglect		14 Nov 2021Abuse: Neglect Found that fall-risk care was not properly planned, resulting in a second fall with pain; a $500 fine was assessed. Abuse—Failed to properly plan care
09 Nov 2021Abuse: Neglect		09 Nov 2021Abuse: Neglect Investigated the complaint found inadequate care planning for fall risk, resulting in another fall and head injury. The finding identified neglect and abuse, with a $1500 fine assessed. Abuse—Failed to properly plan care
07 Nov 2021Abuse: Neglect		07 Nov 2021Abuse: Neglect Found a failure to provide a safe medication administration system, resulting in pain medication not being administered and the resident experiencing withdrawal requiring hospital care. A $500 fine was assessed. Abuse—Failed to administer medication as ordered
02 Nov 2021Abuse: Neglect		02 Nov 2021Abuse: Neglect Investigated found that inadequate health assessment and monitoring of a resident's changing condition led to an untreated decline and hospitalization for cellulitis. Abuse—Failed to provide oversight and monitoring of change of condition
31 Oct 2021Abuse: Neglect		31 Oct 2021Abuse: Neglect Identified a failure to follow the care plan for toileting due to staffing shortages, risking harm to a resident. A violation was found and a $500 fine was assessed. Abuse—Failed to follow care plan
14 Oct 2021Inspection		14 Oct 2021Inspection Investigated and determined that a resident was left saturated in urine after staff assisted, causing discomfort and loss of dignity. The actions violated resident rights and constituted abuse and neglect, and a $500 fine was assessed. Licensing—Failed to follow care plan
14 Oct 2021Abuse: Neglect		14 Oct 2021Abuse: Neglect Investigated found verbal aggression toward a resident and failure to protect from it, causing emotional distress; a fine was assessed. Abuse—Failed to protect resident from verbal abuse
11 Oct 2021Abuse: Neglect		11 Oct 2021Abuse: Neglect Found verbal abuse toward a resident and failure to protect them, causing emotional harm; a $1,000 fine was assessed. Abuse—Failed to protect resident from verbal abuse
11 Oct 2021Abuse: Neglect		11 Oct 2021Abuse: Neglect Investigated a complaint and found care failures left a resident soaked in urine or covered in feces, constituting neglect and abuse; a $500 fine was assessed. Abuse—Failed to provide service
11 Oct 2021Abuse: Neglect		11 Oct 2021Abuse: Neglect Found violations related to neglect and failure to follow the care plan, resulting in a $1000 fine. Abuse—Failed to follow care plan
11 Oct 2021Inspection		11 Oct 2021Inspection Found a violation for verbal abuse toward a resident and for failing to protect the resident from verbal abuse. A $500 fine was assessed. Licensing—Failed to protect resident from verbal abuse
09 Oct 2021Abuse: Neglect		09 Oct 2021Abuse: Neglect Investigated a complaint about verbal abuse toward a resident with dementia and found that staff verbally abused the resident and failed to protect them from abuse. Abuse—Failed to protect resident from verbal abuse
30 Sept 2021Abuse: Neglect		30 Sept 2021Abuse: Neglect Found a violation of safe medication administration due to missed antibiotic doses after a pill was crushed or misplaced and not replaced. Abuse—Failed to provide a safe medication administration system
28 Sept 2021Abuse: Neglect		28 Sept 2021Abuse: Neglect Investigated and found neglect of care and abuse due to failure to follow the catheter care plan. A $500 fine was assessed. Abuse—Failed to follow care plan
22 Sept 2021Abuse: Neglect		22 Sept 2021Abuse: Neglect Investigated allegations of neglect and abuse related to fall risk care; found that fall risk planning was not properly implemented, leading to another fall with a bruise. Abuse—Failed to properly plan care
21 Sept 2021Validation		21 Sept 2021Validation Identified multiple deficiencies in resident care, service planning, nutrition, infection control, and safety across several revisits. The findings showed failures to implement proper reporting, planning, monitoring, and training processes. Deficiency—Comment Deficiency—Reasonable Precautions Deficiency—Reporting & Investigating Abuse-Other Action Deficiency—Resident Services Meals, Food Sanitation Rule Deficiency—Resident Move-In and Eval: Res Evaluation Deficiency—Service Plan: General Deficiency—Change of Condition and Monitoring Deficiency—Resident Health Services Deficiency—Systems: Treatment Orders Deficiency—Systems: Resident Right to Refuse Deficiency—Training Within 30 Days: Direct Care Staff Deficiency—Fire and Life Safety: Safety Deficiency—Inspections and Investigation: Insp Interval Deficiency—Administration Compliance Deficiency—Administrator Training Deficiency—Staff Training Requirements Deficiency—Compliance With Rules Health Care Deficiency—Nutrition and Hydration Deficiency—Activities Deficiency—Behavior
20 Sept 2021Validation		20 Sept 2021Validation Determined substantial compliance after follow-up reviews, though multiple deficiencies were identified in infection control, resident assessments and service plans, medication management, staff training, and building maintenance during the prior re-licensure activities. Deficiency—Comment Deficiency—Reasonable Precautions Deficiency—Resident Services Meals, Food Sanitation Rule Deficiency—Resident Move-In and Eval: Res Evaluation Deficiency—Service Plan: General Deficiency—Service Plan: Service Planning Team Deficiency—Change of Condition and Monitoring Deficiency—Resident Health Services Deficiency—Res Hlth Srvc: On- and Off-Site Health Srvc Deficiency—Systems: Tracking Control Substances Deficiency—Systems: Resident Right to Refuse Deficiency—Systems: Medication Administration Deficiency—Systems: Psychotropic Medication Deficiency—Staffing Requirements and Training – Pre-Serv Deficiency—Training Within 30 Days: Direct Care Staff Deficiency—Fire and Life Safety: Safety Deficiency—Inspections and Investigation: Insp Interval Deficiency—General Building Exterior Deficiency—General Building: Doors-Walls, Cleanable
12 Jul 2021Abuse: Neglect		12 Jul 2021Abuse: Neglect Found neglect and abuse due to failure to properly plan care and implement interventions to address ongoing threatening behavior toward a resident; a $500 fine was assessed. Abuse—Failed to properly plan care
08 Jul 2021Abuse: Neglect		08 Jul 2021Abuse: Neglect Found neglect and abuse due to failure to properly plan care for falls, resulting in a $1000 fine. Abuse—Failed to properly plan care
08 Jul 2021Abuse: Neglect		08 Jul 2021Abuse: Neglect Found neglect of care and abuse due to failure to properly plan for falls, and assessed a $1,000 fine. Abuse—Failed to properly plan care
28 Jun 2021Abuse: Neglect		28 Jun 2021Abuse: Neglect Investigated and found a deficient safe medication administration system due to multiple missed doses and delays in pharmacy delivery. This indicates neglect and abuse. Abuse—Failed to provide a safe medication administration system
24 Jun 2021Abuse: Neglect		24 Jun 2021Abuse: Neglect Investigated found that care planning failed for a resident who refused care, risking skin breakdown; a $500 fine was assessed. Abuse—Failed to properly plan care
04 Jun 2021Abuse: Neglect		04 Jun 2021Abuse: Neglect Found failures to properly plan care for a resident with a Foley catheter, resulting in neglect and abuse, with a $500 fine assessed. Abuse—Failed to properly plan care
24 May 2021Abuse: Neglect		24 May 2021Abuse: Neglect Found a failure to provide a safe environment. A resident was found with knives shortly after moving in, showing risk of harm. Abuse—Failed to provide safe environment
19 May 2021Abuse: Neglect		19 May 2021Abuse: Neglect Investigated a complaint and found a safe-environment violation that led to an injury; a $1500 fine was assessed. Abuse—Failed to provide safe environment
04 May 2021Abuse: Neglect		04 May 2021Abuse: Neglect Investigated and found failure to plan care to prevent falls, leading to a spine fracture. Abuse—Failed to properly plan care
12 Dec 2020Abuse: Neglect		12 Dec 2020Abuse: Neglect Investigated and found neglect and abuse due to failure to intervene when a resident refused needed personal care, creating risk of harm; a $500 fine was assessed. Abuse—Failed to follow care plan
12 Dec 2020Abuse: Neglect		12 Dec 2020Abuse: Neglect Found neglect and abuse due to failure to address a resident's reluctance to receive needed personal care, and a $250 fine was assessed. Abuse—Failed to follow care plan
25 Nov 2020Abuse: Neglect		25 Nov 2020Abuse: Neglect Found inadequate care planning for a resident with dementia, risking harm to the resident and others. The findings indicate abuse and neglect due to lack of clear behaviors, interventions, and protection from a negative outcome. Abuse—Failed to properly plan care
07 Nov 2020Abuse: Neglect		07 Nov 2020Abuse: Neglect Found unsafe medication administration practices and delegation issues, resulting in neglect and abuse, with a fine assessed. Abuse—Failed to provide a safe medication administration system
30 Oct 2020Abuse: Neglect		30 Oct 2020Abuse: Neglect Found violations due to failure to plan care, risking neglect and harm. Abuse—Failed to properly plan care
23 Oct 2020Abuse: Neglect		23 Oct 2020Abuse: Neglect Found failure to plan care around a resident's fall history, resulting in multiple falls and injuries; a $2,500 fine was assessed. Abuse—Failed to properly plan care
13 Sept 2020Abuse: Neglect		13 Sept 2020Abuse: Neglect Investigated a wandering-related neglect allegation and found the provider failed to provide a safe environment. Abuse—Failed to provide safe environment
08 Sept 2020Abuse: Neglect		08 Sept 2020Abuse: Neglect Investigated a complaint and found the provider failed to plan care, resulting in seven falls with injuries. A $500 fine was assessed. Abuse—Failed to properly plan care
13 Aug 2020Abuse: Neglect		13 Aug 2020Abuse: Neglect Found neglect and abuse due to failure to ensure the back brace was worn as prescribed and insufficient documentation of encouragement and monitoring. Abuse—Failed to follow care plan
26 May 2020Abuse: Neglect		26 May 2020Abuse: Neglect Found unsafe medication administration practices and inadequate care planning that put a resident at risk; a $500 fine was assessed. Abuse—Failed to provide a safe medication administration system
15 Mar 2020Abuse: Neglect		15 Mar 2020Abuse: Neglect Investigated and found that care planning and interventions for a resident's increasing needs were not completed, leading to neglect and abuse. A fine was assessed. Abuse—Failed to properly plan care
18 Feb 2020Abuse: Neglect		18 Feb 2020Abuse: Neglect Found that the provider failed to properly plan care and implement fall-prevention interventions, leading to neglect and abuse related to multiple falls. Abuse—Failed to properly plan care
23 Jan 2020Abuse: Neglect		23 Jan 2020Abuse: Neglect Found that a resident was exposed to verbal/emotional abuse because staff failed to protect them, constituting neglect and abuse. Abuse—Failed to protect resident from verbal abuse
16 Jan 2020Inspection		16 Jan 2020Inspection Concluded that a qualified caregiver was not present as required. Licensing—Failed to assure that a qualified caregiver was present
16 Jan 2020Inspection		16 Jan 2020Inspection Determined that a service was not provided. Identified a level 1 minor violation. Licensing—Failed to provide service
05 Jan 2020Abuse: Neglect		05 Jan 2020Abuse: Neglect Found a failure to properly plan care for a resident with a falls history, leading to repeated falls and head injuries requiring medical treatment. Abuse—Failed to properly plan care
26 Nov 2019Abuse: Neglect		26 Nov 2019Abuse: Neglect Investigated and identified failures to provide catheter care and to update care plans, resulting in risk of harm and abuse/neglect findings. Abuse—Failed to provide peri care
12 Nov 2019Inspection		12 Nov 2019Inspection Found failure to report suspected abuse. A fine was assessed for the violation. Licensing—Failed to report potential or suspected abuse
12 Nov 2019Abuse: Neglect		12 Nov 2019Abuse: Neglect Investigated a neglect allegation related to falls and found inadequate care planning and safety, resulting in physical harm. Abuse—Failed to adequately care plan related to falls
10 Nov 2019Abuse: Neglect		10 Nov 2019Abuse: Neglect Substantiated neglect related to falls care and safety, resulting in physical harm. The finding notes failure to provide basic care. Abuse—Failed to adequately care plan related to falls
10 Nov 2019Inspection		10 Nov 2019Inspection Determined a failure to report suspected abuse occurred. Licensing—Failed to report potential or suspected abuse
07 Nov 2019Abuse: Neglect		07 Nov 2019Abuse: Neglect Investigated an allegation of neglect and found that basic care and safety were not provided, creating risk of serious harm. Abuse—Failed to provide safe environment
22 Oct 2019Abuse: Neglect		22 Oct 2019Abuse: Neglect Found that a known fall risk suffered repeated falls and injuries due to inadequate care planning and interventions, constituting abuse and neglect. Abuse—Failed to provide safe environment
13 Oct 2019Abuse: Neglect		13 Oct 2019Abuse: Neglect Found neglect by failing to provide basic care, resulting in physical harm. Abuse—Failed to follow care plan
11 Oct 2019Abuse: Neglect		11 Oct 2019Abuse: Neglect Found neglect of a resident, creating risk of serious harm. Abuse—Failed to provide safe environment
11 Oct 2019Abuse: Neglect		11 Oct 2019Abuse: Neglect Investigated the allegation of neglect related to falls and found that basic care and safety were not provided, resulting in harm. Abuse—Failed to adequately care plan related to falls
11 Oct 2019Abuse: Neglect		11 Oct 2019Abuse: Neglect Found neglect of a vulnerable adult by failing to provide basic care and safety, resulting in risk of serious harm. Abuse—Failed to provide safe environment
02 Oct 2019Abuse: Neglect		02 Oct 2019Abuse: Neglect Found neglect and abuse due to failure to assist with eating and hygiene, leading to dehydration and other complications. Abuse—Failed to assist with eating
27 Sept 2019Abuse: Neglect		27 Sept 2019Abuse: Neglect Identified neglect that passively failed to provide basic care, creating risk of serious harm to a resident; a 188 dollar fine was assessed. Abuse—Failed to provide safe environment
25 Sept 2019Inspection		25 Sept 2019Inspection Investigated the allegation of failing to provide service and found noncompliance with resident service requirements. Licensing—Failed to provide service
08 Sept 2019Abuse: Neglect		08 Sept 2019Abuse: Neglect Investigated an allegation of abuse and neglect and found failures to investigate and document reports and to provide meaningful safety interventions, putting a resident at risk. Abuse—Failed to protect resident from physical abuse
23 Aug 2019Inspection		23 Aug 2019Inspection Investigated and determined that a staff member financially exploited a resident and that a safe environment was not provided. Licensing—Failed to provide safe environment
20 Aug 2019Inspection		20 Aug 2019Inspection Identified a licensing violation for neglecting basic care, services, or safety, which resulted in physical harm to a person in care. Licensing—Failed to properly plan care
29 Jul 2019Abuse: Neglect		29 Jul 2019Abuse: Neglect Investigated a neglect allegation and found that basic care and safety were not provided, resulting in physical harm. A fine was assessed. Abuse—Failed to provide safe environment
26 Jul 2019Abuse: Neglect		26 Jul 2019Abuse: Neglect Investigated a complaint and found abuse and neglect due to failure to provide a safe environment for a resident, with a fine assessed. Abuse—Failed to provide service
05 Jun 2019Inspection		05 Jun 2019Inspection Identified insufficient staffing and lack of trained direct care staff, contributing to medication errors. Licensing—Failed to provide safe environment
05 Jun 2019Inspection		05 Jun 2019Inspection Investigated an allegation that medication was not administered as ordered and found a deficiency in medication administration practices. Licensing—Failed to administer medication as ordered
05 Jun 2019Inspection		05 Jun 2019Inspection Found that housekeeping services and dressing assistance were not provided timely due to insufficient staff. Licensing—Failed to provide appropriate housekeeping services
01 Jun 2019Abuse: Neglect		01 Jun 2019Abuse: Neglect Found violations for neglect and abuse and assessed a $500 fine. Abuse—Failed to provide service
12 Mar 2019Inspection		12 Mar 2019Inspection Investigated an allegation that food safety was not assured. Found a Level 1 licensing violation. Licensing—Failed to assure food safety
10 Jan 2019Abuse: Neglect		10 Jan 2019Abuse: Neglect Investigated the hygiene-related neglect allegation and found neglect of safety that caused unreasonable discomfort. A $188 fine was assessed. Abuse—Failed to provide or assist with hygiene
12 Sept 2018Inspection		12 Sept 2018Inspection Found neglect of basic care and services that violated the care plan, creating a risk of serious harm. Licensing—Failed to follow care plan
02 Mar 2018Condition		02 Mar 2018Condition Found failure to intervene when a resident's condition changed. Regulatory Action—Failed to intervene when resident's condition changed
13 Feb 2018Abuse: Neglect		13 Feb 2018Abuse: Neglect Investigated an allegation that staff failed to intervene when a resident's condition changed. Found deficiencies indicating noncompliance. Abuse—Failed to intervene when resident's condition changed
28 Dec 2017Abuse: Neglect		28 Dec 2017Abuse: Neglect Found a failure to provide a secure environment. Abuse—Failed to provide safe environment
12 Oct 2017Abuse: Verbal/Mental abuse		12 Oct 2017Abuse: Verbal/Mental abuse Investigated the verbal/mental abuse allegation and found that a resident was not protected from mental or emotional abuse, indicating a safety and respect deficiency. Abuse—Failed to protect resident from mental or emotional abuse
25 Apr 2017Inspection		25 Apr 2017Inspection Identified a deficiency in maintaining sanitary kitchen conditions. Licensing—Failed to provide sanitary food service conditions
15 Jan 2017Abuse: Neglect		15 Jan 2017Abuse: Neglect Found neglect for failing to protect a resident from financial exploitation, resulting in harm. A $375.00 fine was assessed. Abuse—Failed to protect resident from financial exploitation
03 Feb 2016Inspection		03 Feb 2016Inspection Investigated a staffing allegation and found insufficient staffing in violation of staffing requirements. Licensing—Failed to provide appropriate staffing
03 Feb 2016Inspection		03 Feb 2016Inspection Investigated an allegation of failing to provide service and substantiated a service plan violation. Licensing—Failed to provide service
19 Jan 2016Abuse: Neglect		19 Jan 2016Abuse: Neglect Found that the facility failed to provide a safe environment for resident(s), and a $300 fine was assessed. Abuse—Failed to provide safe environment
22 Dec 2015Abuse: Neglect		22 Dec 2015Abuse: Neglect Investigated a complaint and found a resident grabbed/scratched another, causing bruising. Abuse—Failed to provide safe environment
17 Dec 2015Abuse: Sexual abuse		17 Dec 2015Abuse: Sexual abuse Found deficiencies in administrative oversight of residents' quality of care and services. The record noted a substantiated sexual abuse allegation and ongoing APS complaint reports; no fine was assessed. Abuse—Failed to protect resident from inappropriate sexual contact
14 Nov 2015Inspection		14 Nov 2015Inspection Investigated an allegation of a failure to provide a safe environment. Found a resident-to-resident incident where RV2 smacked RV1 in the chest. Licensing—Failed to provide safe environment
30 Oct 2015Abuse: Neglect		30 Oct 2015Abuse: Neglect Investigated a neglect allegation and found a failure to follow the service plan that created an unsafe environment for residents. Abuse—Failed to follow care plan
28 Oct 2015Abuse: Neglect		28 Oct 2015Abuse: Neglect Investigated and found a safety deficiency. A resident hit another due to a failure to provide a safe environment. Abuse—Failed to provide safe environment
17 Oct 2015Abuse: Neglect		17 Oct 2015Abuse: Neglect Investigated an allegation of failing to assure timely medical treatment after an unwitnessed fall and concluded there was a failure to provide prompt care. Abuse—Failed to assure timely medical treatment
11 Oct 2015Abuse: Neglect		11 Oct 2015Abuse: Neglect Investigated an allegation of neglect related to falls and found care planning for falls inadequate, with an unwitnessed fall resulting in hospitalization. Abuse—Failed to adequately care plan related to falls
11 Oct 2015Abuse: Neglect		11 Oct 2015Abuse: Neglect Investigated found unsafe medication management due to medication not being available. Abuse—Failed to have medication available
27 Sept 2015Inspection		27 Sept 2015Inspection Investigated and found that staff failed to prevent one resident from hitting another. Licensing—Failed to address resident's behavior
16 Sept 2015Abuse: Neglect		16 Sept 2015Abuse: Neglect Found a failure to follow the care plan and to prevent one resident from striking another. Abuse—Failed to follow care plan
05 Sept 2015Abuse: Neglect		05 Sept 2015Abuse: Neglect Found safety deficiencies related to protecting a resident from a physical altercation, resulting in a head injury and hospital visit. A $300 fine was assessed. Abuse—Failed to address resident's behavior
01 Sept 2015Abuse: Neglect		01 Sept 2015Abuse: Neglect Found that a resident-to-resident incident occurred because the care plan was not followed. Abuse—Failed to follow care plan
31 Aug 2015Inspection		31 Aug 2015Inspection Found a deficiency in providing a safe environment. Licensing—Failed to provide safe environment
29 Aug 2015Abuse: Neglect		29 Aug 2015Abuse: Neglect Investigated an allegation of neglect and concluded that RV1 was not kept safe from altercations with RV2. Abuse—Failed to provide safe environment
12 Aug 2015Inspection		12 Aug 2015Inspection Found deficiencies in medication management resulting in two missed doses of scheduled medication. Licensing—Failed to administer ordered medication
05 Aug 2015Inspection		05 Aug 2015Inspection Found a failure to provide a safe medication management system, resulting in a resident receiving medication not prescribed by a doctor. Licensing—Failed to provide a safe medication administration system
29 Jul 2015Abuse: Neglect		29 Jul 2015Abuse: Neglect Investigated an abuse/neglect allegation and found that medical orders for a lab draw were not followed, resulting in hospitalization. Abuse—Failed to assure timely medical treatment
19 Jul 2015Abuse: Neglect		19 Jul 2015Abuse: Neglect Investigated a medication safety allegation and found a failure to provide a safe medication management system, resulting in a medication error with harm; a fine was assessed. Abuse—Failed to provide a safe medication administration system
15 Jun 2015Inspection		15 Jun 2015Inspection Determined there was a failure to provide a safe environment resulting in elopement. Licensing—Failed to provide safe environment
13 Jun 2015Inspection		13 Jun 2015Inspection Investigated the allegation of failing to provide a safe environment and found that a safe environment was not provided, resulting in elopement. Licensing—Failed to provide safe environment
10 Jun 2015Inspection		10 Jun 2015Inspection Found that a secure environment was not provided, resulting in elopement. Licensing—Failed to provide safe environment
10 Jun 2015Abuse: Neglect		10 Jun 2015Abuse: Neglect Investigated the allegation of failing to properly plan care; bruising of unknown origin was observed. Abuse—Failed to properly plan care
13 May 2015Abuse: Neglect		13 May 2015Abuse: Neglect Found neglect due to failure to provide appropriate skin care, resulting in sacral Stage II and Stage III wounds; a $300 fine was assessed. Abuse—Failed to provide appropriate skin care
30 Apr 2015Inspection		30 Apr 2015Inspection Investigated a complaint and identified deficiencies related to following the care plan and providing a safe environment. Licensing—Failed to follow care plan
29 Apr 2015Abuse: Neglect		29 Apr 2015Abuse: Neglect Found inadequate care planning related to falls, resulting in a fall with head injury and brain bleed. Abuse—Failed to adequately care plan related to falls
24 Apr 2015Abuse: Neglect		24 Apr 2015Abuse: Neglect Investigated an abuse/neglect allegation. Found care planning did not reflect the assessment, and care was not provided. Abuse—Failed to care plan in accordance with assessment
23 Apr 2015Abuse: Neglect		23 Apr 2015Abuse: Neglect Investigated an abuse/neglect allegation and substantiated it; an injury occurred due to an unsafe environment. Abuse—Failed to investigate injury of unknown origin to rule out abuse
20 Apr 2015Abuse: Neglect		20 Apr 2015Abuse: Neglect Found a violation for failing to provide a safe medication management system, leading to hospitalization. A $300 fine was assessed. Abuse—Failed to provide a safe medication administration system
19 Apr 2015Inspection		19 Apr 2015Inspection Found a deficient medication management system due to failure to provide a safe medication administration system. The finding carried potential for minor harm. Licensing—Failed to provide a safe medication administration system
15 Apr 2015Abuse: Neglect		15 Apr 2015Abuse: Neglect Investigated a neglect allegation of failing to follow the care plan. Findings showed a staff-assisted transfer fall resulting in a hospital visit. Abuse—Failed to follow care plan
06 Apr 2015Abuse: Neglect		06 Apr 2015Abuse: Neglect Investigated a neglect allegation and found that medical treatment was not provided after a resident's fall, resulting in a fractured hip. A $300 fine was assessed. Abuse—Failed to provide service
02 Apr 2015Abuse: Neglect		02 Apr 2015Abuse: Neglect Investigated a failure to adequately plan and provide care related to falls, with findings of neglect and a $300 fine assessed. Abuse—Failed to adequately care plan related to falls
23 Mar 2015Abuse: Neglect		23 Mar 2015Abuse: Neglect Investigated an allegation of abuse/neglect and found physical abuse. Multiple rule violations were cited. Abuse—Failed to address resident's behavior
19 Feb 2015Abuse: Neglect		19 Feb 2015Abuse: Neglect Investigated an allegation of neglect and found deficiencies related to failure to provide care and to intervene when a resident's condition changed. Abuse—Failed to intervene when resident's condition changed
28 Jan 2015Abuse: Neglect		28 Jan 2015Abuse: Neglect Found that a resident was not protected from a physical altercation, resulting in a fall with a fractured hip. Abuse—Failed to follow care plan
22 Jan 2015Abuse: Neglect		22 Jan 2015Abuse: Neglect Determined that care was not provided to residents and a $300 fine was assessed. Abuse—Failed to provide service
20 Oct 2014Inspection		20 Oct 2014Inspection Investigated and found a violation involving failure to protect a resident's rights and to guard against physical abuse. Licensing—Failed to assure resident rights
02 Oct 2014Abuse: Neglect		02 Oct 2014Abuse: Neglect Investigated the complaint and found a failure to provide a safe environment, resulting in an elopement with a fall and injuries. Abuse—Failed to provide safe environment
14 Sept 2014Abuse: Neglect		14 Sept 2014Abuse: Neglect Found that residents were not provided a safe environment, resulting in wandering and a fall with injury. Abuse—Failed to provide safe environment
25 Aug 2014Inspection		25 Aug 2014Inspection Investigated a failure to provide a safe environment that resulted in elopement. Licensing—Failed to provide safe environment
12 Aug 2014Inspection		12 Aug 2014Inspection Found a failure to provide a safe environment resulting in elopement. Licensing—Failed to provide safe environment
01 Aug 2014Inspection		01 Aug 2014Inspection Investigated the allegation of an unsafe environment and found it resulted in elopement on 2014-08-01. Licensing—Failed to provide safe environment
30 Jul 2014Abuse: Neglect		30 Jul 2014Abuse: Neglect Concluded that there was a failure to provide a safe environment and adequate interventions to reduce falls. Abuse—Failed to provide safe environment
18 Jul 2014Abuse: Neglect		18 Jul 2014Abuse: Neglect Found failure to provide care and follow the service plan. It involved an abuse/neglect concern with moderate harm or potential for serious harm. Abuse—Failed to provide service
08 Apr 2014Abuse: Neglect		08 Apr 2014Abuse: Neglect Investigated a fall-related neglect allegation and found failure to provide adequate safety measures resulting in a fall with hospitalization. Abuse—Failed to adequately care plan related to falls
27 Feb 2014Abuse: Neglect		27 Feb 2014Abuse: Neglect Found inadequate care that led to a resident developing wounds and assessed a $400 fine. Abuse—Failed to provide service
08 Dec 2013Abuse: Neglect		08 Dec 2013Abuse: Neglect Investigated the neglect allegation and found failure to follow care plan, leading to a resident being hospitalized after being left on the floor unattended for an extended period. Abuse—Failed to follow care plan
30 Mar 2013Abuse: Physical Abuse		30 Mar 2013Abuse: Physical Abuse Found that a resident was subjected to rough treatment by staff, resulting in physical injury. Abuse—Failed to protect resident from rough treatment
01 Feb 2013Abuse: Neglect		01 Feb 2013Abuse: Neglect Found that a resident did not receive care as specified in the care plan. Abuse—Failed to answer call light in a timely manner
25 Jan 2013Abuse: Neglect		25 Jan 2013Abuse: Neglect Found continued noncompliance due to inadequate RN coverage and administrative oversight concerns. Sanction assessed with no monetary fine. Abuse—Failed to provide oversight and monitoring of change of condition
24 Jan 2013Abuse: Neglect		24 Jan 2013Abuse: Neglect Investigated an allegation of neglect due to inadequate oversight and monitoring of change of condition; found continued noncompliance and insufficient RN coverage with concerns about administrative oversight. Abuse—Failed to provide oversight and monitoring of change of condition
14 Jan 2013Abuse: Physical Abuse		14 Jan 2013Abuse: Physical Abuse Found a deficiency for failing to protect resident from rough treatment. Abuse—Failed to protect resident from rough treatment
20 Dec 2012Abuse: Financial abuse		20 Dec 2012Abuse: Financial abuse Found that a resident's resources were not protected from misappropriation by others or without the resident's consent. Abuse—Failed to protect resident from financial exploitation
20 Sept 2012Abuse: Neglect		20 Sept 2012Abuse: Neglect Found that medical care was not provided as ordered by the care plan and service plan through the oxygen supplier; a $300 fine was assessed. Abuse—Failed to provide medical treatment as ordered
01 Sept 2012Abuse: Neglect		01 Sept 2012Abuse: Neglect Investigated a neglect allegation and found failure to provide appropriate care to a resident. Abuse—Failed to assure resident was safe
31 Aug 2012Abuse: Neglect		31 Aug 2012Abuse: Neglect Found violations for neglect and failing to follow care plan, with a $300 fine assessed. Abuse—Failed to provide medical treatment as ordered
28 Aug 2012Abuse: Neglect		28 Aug 2012Abuse: Neglect Investigated and found neglect due to failure to follow the care plan. Abuse—Failed to follow care plan
23 Aug 2012Abuse: Financial abuse		23 Aug 2012Abuse: Financial abuse Investigated a financial abuse allegation and found a failure to provide a safe medication administration system. Abuse—Failed to provide a safe medication administration system
28 Jun 2012Abuse: Neglect		28 Jun 2012Abuse: Neglect Found that oversight and monitoring of changes in condition failed, resulting in a Stage 4 decubitus; a $300 fine was assessed. Abuse—Failed to provide oversight and monitoring of change of condition
27 Jun 2012Abuse: Neglect		27 Jun 2012Abuse: Neglect Found that a qualified caregiver was not assured to be present, risking resident safety. Found a deficiency in care with a monetary penalty issued. Abuse—Failed to assure that a qualified caregiver was present
31 May 2012Inspection		31 May 2012Inspection Determined deficiencies in safe medication administration and adherence to prescribed diet were substantiated. Licensing—Failed to provide a safe medication administration system
16 May 2012Abuse: Neglect		16 May 2012Abuse: Neglect Found neglect related to failure to provide a therapeutic diet and to follow care plan and doctors' orders. Abuse—Failed to provide a therapeutic diet
15 May 2012Abuse: Neglect		15 May 2012Abuse: Neglect Investigated an allegation of neglect and found that a secure environment was not provided. Abuse—Failed to provide safe environment
12 May 2012Inspection		12 May 2012Inspection Determined that the allegation of failing to cooperate with an investigation was upheld, and that a secure environment was not provided. Licensing—Failed to cooperate with an investigation
14 Apr 2012Abuse: Neglect		14 Apr 2012Abuse: Neglect Found improper dispensing of medication that caused a negative outcome; a $250 fine was assessed. Abuse—Failed to provide a safe medication administration system
13 Apr 2012Abuse: Neglect		13 Apr 2012Abuse: Neglect Investigated an allegation of neglect and found that medication was not administered as ordered, causing a negative outcome. A $300 fine was assessed. Abuse—Failed to administer medication as ordered
23 Mar 2012Inspection		23 Mar 2012Inspection Identified a violation for not administering medication as prescribed. Licensing—Failed to administer medication as ordered
27 Jan 2012Abuse: Neglect		27 Jan 2012Abuse: Neglect Investigated the allegation of failing to adequately plan discharge; found a discharge planning deficiency and assessed a $400 fine. Abuse—Failed to adequately plan discharge
07 Jun 2011Abuse: Neglect		07 Jun 2011Abuse: Neglect Found a deficiency for failing to provide a safe environment, resulting in a resident eloping from the Memory Care Unit for about 21–22 hours. Abuse—Failed to provide safe environment
07 Jun 2011Abuse: Neglect		07 Jun 2011Abuse: Neglect Concluded that there was a failure to supervise, resulting in a resident eloping from the memory care unit for about 21-22 hours. Abuse—Failed to provide safe environment
11 Jun 2010Abuse: Neglect		11 Jun 2010Abuse: Neglect Investigated a records-related complaint and identified failures to oversee and monitor change of condition, with multiple rule violations and a monetary penalty. Abuse—Failed to provide oversight and monitoring of change of condition

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