McMinnville Memory Care

    320 SW Hill Rd S, McMinnville, OR 97128
    • Assisted Living
    • Memory Care

    Caring knowledgeable staff excellent facilities

    I moved my mom here and I'm very pleased - the staff are genuinely caring and knowledgeable about memory care, and the director and team are clearly engaged. The food is excellent, common areas are bright and home-like, and activities are varied and social, which gave our family real peace of mind. It's a well-managed, welcoming community I would recommend.

    Loved one of resident
    Jul 2026

    Pricing

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

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    Amenities

    Healthcare services

    • Activities of daily living assistance
    • Assistance with bathing
    • Assistance with dressing
    • Assistance with transfers
    • Coordination with health care providers
    • Hospice waiver
    • Medication management
    • Mental wellness program

    Healthcare staffing

    • 12-16 hour nursing
    • 24-hour call system
    • 24-hour supervision

    Meals and dining

    • Diabetes diet
    • Meal preparation and service
    • Restaurant-style dining
    • Special dietary restrictions

    Room

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

    Memory care community services

    • Dementia waiver
    • Mild cognitive impairment
    • Specialized memory care programming

    Transportation

    • Community operated transportation
    • Transportation arrangement
    • Transportation arrangement (medical)
    • Transportation arrangement (non-medical)
    • Transportation to doctors appointments

    Common areas

    • Beauty salon
    • Computer center
    • Dining room
    • Fitness room
    • Gaming room
    • Garden
    • Outdoor space
    • Small library
    • Wellness center

    Community services

    • Concierge services
    • Fitness programs
    • Move-in coordination

    Activities

    • Community-sponsored activities
    • Planned day trips
    • Resident-run activities
    • Scheduled daily activities

    Reviews

    4.28·(67)

    Overall rating

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

      4.3
    • Staff

      4.5
    • Meals

      4.0
    • Amenities

      4.3
    • Value

      2.5

    Pros

    • Compassionate, attentive caregiving staff
    • Engaged, resident-focused director leadership
    • Family-like, home-like atmosphere
    • Memory-care–focused design and programming
    • Robust activities program with music and entertainment
    • Therapy dog visits and pet-friendly policy
    • Nutritious, varied meal program
    • On-site salon and personal-care services
    • Well-maintained, modern common areas
    • Opportunities for socialization and new friendships
    • Smooth admissions and move-in assistance
    • Knowledgeable nursing and clinical staff
    • Convenient location and unit availability

    Cons

    • Inconsistent leadership presence and managerial follow-through
    • Staffing instability and high caregiver turnover
    • Delays in responsiveness to resident requests
    • Medication administration and clinical oversight
    • Cleanliness and sanitation issues in some rooms and areas
    • Inconsistent investigation of family complaints and follow-up
    • Variable food quality across shifts
    • Billing and post-discharge/post-death charge disputes
    • Gaps in staff training and engagement culture
    • Perceived favoritism and problematic staff communication

    Summary of reviews

    Reviews of McMinnville Memory Care present a largely mixed but strongly polarized picture. Many families describe a warm, family-like setting with staff who demonstrate compassion, frequent engagement, and individualized attention. The facility's memory-care focus is frequently highlighted: reviewers praise the layout and design for dementia care, a program of purposeful activities, and staff members who know residents by name. Multiple comments single out an engaged director and activities team who organize musical events, piano performances, and therapy dog visits that support resident engagement and socialization.

    Care quality and staff behavior are central themes. A substantial body of feedback praises attentive caregivers, knowledgeable nursing presence, effective communication with families, and consistent personal care. Those positive reports describe dependable daily care, stimulating activities, and staff who form close relationships with residents. Conversely, a clear cluster of concerns relates to operational reliability: reviewers cite staffing instability and turnover, delays in responding to resident requests, and isolated but serious concerns about medication administration and clinical oversight. These items point to variability in day-to-day execution of care rather than to a single uniform experience.

    Dining and activity programming are commonly reported strengths. Many reviewers mention nutritious, varied menus, fresh fruit, and a well-regarded cook; salon and grooming services and regular entertainment are also frequently noted. At the same time, a minority of accounts raise inconsistent food quality across shifts. The activities department receives consistent praise for creativity and resident engagement, with social spaces such as a Bistro and Fireside Room supporting communal interaction.

    Facility condition and cleanliness receive mixed comments. Numerous reviewers describe a modern, well-maintained interior with pleasant common areas and a cozy, home-like environment. However, there are also sanitation and odor concerns reported in some resident rooms and areas, and at least one account described inadequate housekeeping in a specific room. These differences suggest variability in unit-level upkeep and highlight the importance of inspecting individual rooms during a tour.

    Management and administrative issues appear to be a dividing line among reviewers. Several families commend hands-on leadership, clear communication, and a smooth move-in process; others describe inconsistent leadership presence, poor complaint follow-up, perceived favoritism, and billing disputes including contested charges after a resident’s death. Those operational weaknesses—when present—affect trust and perceived reliability even when caregiving staff are praised.

    Taken together, the reviews indicate a facility with many genuine strengths in memory-care programming, compassionate direct care, and social/dining amenities, alongside recurring operational concerns around staffing consistency, responsiveness, clinical oversight, unit-level cleanliness, and administrative practices. Prospective families should tour multiple times, observe staff–resident interactions across shifts, review medication-management and staffing-stability practices, ask about housekeeping protocols and complaint-resolution processes, and clarify billing policies before making a placement decision.

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    Location

    Map showing location of McMinnville Memory Care

    McMinnville Memory Care is located at 320 SW Hill Rd S, McMinnville, OR, 97128.

    About McMinnville Memory Care

    McMinnville Memory Care sits in Oregon wine country and offers a safe and comfortable place for older adults with Alzheimer's, dementia, or memory loss, and the staff there has over 25 years of experience supporting people at different stages of memory challenges. The community scores a 4.6 out of 5 in community sentiment and a 4.5 out of 5 in overall care, and that matches what folks say about the place being clean, well-kept, and friendly, with rooms that are nice and common spaces that have good visibility. Residents live in a secure memory care unit with safety checks, wander prevention features, an emergency call system, and sprinkler systems throughout the property, all designed to cut down on confusion and keep everyone safe, plus all indoor areas are non-smoking.

    The staff, described as warm, caring, and attentive, supports residents around the clock and always take time to know each person as an individual, providing personal care with things like medication reminders, help with washing, mobility, daily activities, and customized care plans that fit each resident's needs. The community has a relaxed, home-like feel with lots of activities that help keep minds and bodies active, including social events, music gatherings, sing-alongs at the Grand Piano, bingo, art classes, games, group outings, gardening projects, and reminiscence therapy. There are activities both inside and outside the building, plus programs like Adult Day Care, respite care for short stays, hospice support, and meetings for families, with an Activities Director planning a full calendar so there's always something to do.

    Amenities around the property include a Bistro, a Fireside Room, a TV lounge, raised garden beds, indoor and outdoor walking paths, enclosed courtyards, butterfly and hummingbird gardens, and pet therapy, and the grounds get described as beautiful and peaceful. Residents have access to a resident library, meeting rooms, wifi, cable TV, washers and dryers, a game and crafts room, a salon and barbershop, and even a spa room, with housekeeping and laundry provided each week. The facility also offers dining with chef-prepared, international meals served in restaurant-style dining rooms or in residents' own rooms, with three balanced meals per day, snacks, and special diet accommodations always available.

    There's transportation services for shopping, medical appointments, and outings, with guest and resident parking, and the community accepts different insurance types, including long-term care. Residents get help with daily living needs, and pets are welcome. The Secure Memory Unit has cognitive-enhancing programs and support for memory loss, plus staff has specialized dementia care training and run regular safety checks. There's also a focus on engaging residents through things like arts and crafts, exercise programs in the fitness center, and regular outings or adventures, all aimed at helping folks stay as independent and active as possible in a suburb that feels inviting and homelike, where visitors can come in for a tour, try the meals, and see what daily life is like at McMinnville Memory Care.

    People often ask...

    McMinnville Memory Care offers competitive pricing, with rates starting at a cost of $6,125 per month.

    McMinnville Memory Care offers assisted living and memory care.

    There are 71 photos of McMinnville Memory Care on Mirador.

    The full address for this community is 320 SW Hill Rd S, McMinnville, OR 97128.

    No, McMinnville Memory Care 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 number5MA170
    StatusActive
    Facility typeResidential Care Facility
    Capacity57 residents
    LicenseeMcminnville Memory Care, LLC
    EffectiveSeptember 1st, 1998
    Special certificationMemory Care
    View the official license record

    Inspection Reports

    278

    Reports

    0

    Type A Citations

    0

    Type B Citations

    8

    Complaints

    16

    Years

    15 Sept 2025Abuse: Neglect
    Investigated an elopement incident and found warning signs were not addressed, resulting in an unsupervised departure and a resident rights violation.
    • AbuseFailed to properly plan care
    11 Sept 2025Inspection
    Concluded that a caregiver left a resident unattended in a wheelchair after moving outside, causing a fall and injuries; found neglect of care and abuse and an unsafe environment.
    • LicensingFailed to provide safe environment
    11 Sept 2025Inspection
    Found that the service plan did not reflect the resident's needs and lacked documented behavioral interventions despite observed behaviors.
    • LicensingFailed to properly plan care
    11 Sept 2025Inspection
    Investigated and found a safety deficiency when a wheelchair brake was not secured, causing a resident to fall and suffer injuries. The health decline led to hospice admission and death.
    • LicensingFailed to provide safe environment
    20 Aug 2025Abuse: Neglect
    Investigated found inadequate supervision allowed a resident to wander unsupervised, leading to an altercation causing pain and discomfort.
    • AbuseFailed to provide safe environment
    25 Mar 2025Abuse: Neglect
    Identified inadequate monitoring that allowed a resident to physically injure another, causing harm and discomfort. Violations of resident safety and care were documented.
    • AbuseFailed to provide safe environment
    25 Mar 2025Abuse: Neglect
    Investigated, found supervision failures led to a resident-to-resident punch causing injury and deemed abuse/neglect; a fine was assessed.
    • AbuseFailed to provide safe environment
    20 Mar 2025Abuse: Neglect
    Concluded that care planning and interventions were insufficient to protect a resident, resulting in an injury from an altercation and constituting abuse and neglect; a fine was assessed.
    • AbuseFailed to provide safe environment
    04 Aug 2024Abuse: Neglect
    Investigated and found a failure to implement fall interventions and care planning for a high fall risk resident, resulting in severe pain and a broken hip; a $2,500 fine was assessed.
    • AbuseFailed to properly plan care
    31 May 2024Abuse: Neglect
    Found that staff did not follow the resident's care plan and supervision requirements, allowing a resident-to-resident altercation that caused injury requiring hospital care.
    • AbuseFailed to follow care plan
    15 May 2024Abuse: Neglect
    Found violations of resident rights due to failure to monitor a resident's known behavior, resulting in a resident-to-resident assault and injury. A fine was assessed.
    • AbuseFailed to provide safe environment
    08 May 2024Licensure
    Identified deficiencies in kitchen sanitation during the first visit, including debris on lower shelves, grease on walls, dust around vents, dirty blender bases, and no hair restraints. On follow-up, substantial compliance with sanitation and licensing rules was confirmed.
    • DeficiencyComment
    • DeficiencyResident Services Meals, Food Sanitation Rule
    • DeficiencyAdministration Compliance
    23 Apr 2024Abuse: Neglect
    Found neglect due to inadequate supervision that led to unwitnessed falls and injury, with a $375 fine assessed.
    • AbuseFailed to follow care plan
    19 Mar 2024Inspection
    Found a deficiency for failing to ensure the implementation of services, with potential for harm.
    • LicensingFailed to provide or assist with hygiene
    19 Mar 2024Complaint
    Found that a resident did not receive showering assistance as required by the service plan. Documentation showed showers were skipped when staff prioritized other tasks.
    • DeficiencyService Plan: General
    30 Jan 2024Abuse: Neglect
    Investigated and found failures to monitor a resident according to known behavior and to remove them from a loud environment, resulting in an aggressive incident and discomfort to another resident.
    • AbuseFailed to provide safe environment
    27 Nov 2023Validation
    Found deficiencies in abuse reporting, service planning, changes of condition monitoring, health services, and environmental maintenance. The follow-up determined substantial compliance with licensing rules.
    • DeficiencyComment
    • DeficiencyReporting & Investigating Abuse-Other Action
    • DeficiencyService Plan: General
    • DeficiencyChange of Condition and Monitoring
    • DeficiencyResident Health Services
    • DeficiencyDoors, Walls, Elevators, Odors
    • DeficiencyPlumbing Systems
    • DeficiencyAdministration Compliance
    • DeficiencyCompliance With Rules Health Care
    • DeficiencyResident Rooms
    16 Sept 2023Abuse: Neglect
    Investigated and found neglect and abuse due to failure to provide a safe environment, resulting in a resident fall and discomfort.
    • AbuseFailed to provide safe environment
    07 Sept 2023Abuse: Neglect
    Found neglect related to hygiene needs, resulting in the resident not receiving bathing assistance and losing personal dignity. A $1500 fine was assessed.
    • AbuseFailed to provide or assist with hygiene
    07 Sept 2023Abuse: Neglect
    Found neglect and abuse due to failure to plan care and supervision, which led to multiple falls and discomfort for a resident.
    • AbuseFailed to properly plan care
    07 Sept 2023Abuse: Neglect
    Found neglect and abuse for failing to provide appropriate toileting and wound care, causing discomfort. A $1500 fine was assessed.
    • AbuseFailed to assist with toileting
    05 Aug 2023Abuse: Neglect
    Investigated and found that one resident slapped another during an argument and interventions to monitor behavior were not properly implemented, resulting in neglect and abuse.
    • AbuseFailed to provide safe environment
    18 Jul 2023License Condition
    Found ABST not fully implemented as required.
    • Regulatory ActionFailed to use an ABST
    22 Jun 2023Licensure
    Determined substantial compliance with applicable rules governing meals and food sanitation. No deficiencies were cited.
    • DeficiencyComment
    13 Jun 2023Abuse: Neglect
    Found neglect and abuse due to failure to provide a safe environment.
    • AbuseFailed to provide safe environment
    11 Jun 2023Abuse: Neglect
    Investigated and found that staff failed to implement interventions and monitor a resident's known behavior, resulting in a physical altercation and abuse/neglect; a $375 fine was assessed.
    • AbuseFailed to provide safe environment
    05 Jun 2023Abuse: Neglect
    Found that staff failed to provide a safe environment, leading to a physical altercation and emotional harm; a $500 fine was assessed.
    • AbuseFailed to provide safe environment
    29 May 2023Abuse: Neglect
    Found neglect and abuse due to failure to implement interventions and monitor behavior, resulting in a physical altercation and discomfort to a resident.
    • AbuseFailed to provide safe environment
    22 May 2023Abuse: Neglect
    Investigated the incident and found a substantiated neglect/abuse due to inadequate monitoring, resulting in a resident-to-resident altercation that caused discomfort; a fine was assessed.
    • AbuseFailed to provide safe environment
    21 May 2023Inspection
    Investigated a complaint of verbal and emotional abuse and found that a caregiver yelled at and ridiculed a resident, creating a hostile and unsafe environment.
    • LicensingFailed to provide safe environment
    17 Apr 2023Complaint
    Identified deficiencies related to medications and treatments, staffing requirements, and acuity-based staffing tools.
    • DeficiencyLicensing Complaint Investigation
    • DeficiencySystems: Medications and Treatments
    • DeficiencyStaffing Requirements and Training: Staffing
    • DeficiencyAcuity-Based Staffing Tool
    17 Feb 2023Abuse: Neglect
    Determined that inadequate fall-prevention care caused repeated falls and contributed to the resident's death.
    • AbuseFailed to properly plan care
    10 Jan 2023Abuse: Neglect
    Determined there was a failure to provide a safe medication administration system, resulting in missed medications and potential harm to a resident.
    • AbuseFailed to provide a safe medication administration system
    29 Nov 2022Abuse: Neglect
    Investigated an allegation of neglect for failing to provide peri-care to an incontinent resident. Found deficiencies and a $450 fine assessed.
    • AbuseFailed to provide peri care
    29 Nov 2022Abuse: Neglect
    Found neglect and abuse due to failure to provide peri-care, leading to a rash and discomfort. A $225 fine was assessed.
    • AbuseFailed to provide peri care
    21 Nov 2022Inspection
    Found a deficiency related to unsafe medication handling, with failure to implement safe medication and treatment administration systems.
    • LicensingFailed to provide a safe medication administration system
    21 Nov 2022Inspection
    Determined that direct care staffing was insufficient to meet residents' scheduled and unscheduled needs. This resulted in a licensing violation.
    • LicensingFailed to meet the scheduled and unscheduled needs of residents
    05 Sept 2022Abuse: Neglect
    Investigated found that failure to implement interventions and monitor a resident according to known behavior led to a physical altercation and unreasonable discomfort to the resident.
    • AbuseFailed to provide safe environment
    02 Sept 2022Abuse: Neglect
    Investigated the complaint and found that interventions and monitoring were insufficient for known behavior, leading to a physical altercation and undue discomfort for a resident, indicating neglect and abuse.
    • AbuseFailed to provide safe environment
    09 Jul 2022Abuse: Neglect
    Found that staff failed to provide a safe environment by not implementing interventions or monitoring for known behavior, resulting in a physical altercation and discomfort to the alleged victim.
    • AbuseFailed to provide safe environment
    09 Jul 2022Abuse: Neglect
    Investigated found a failure to monitor and intervene for residents according to behavior, leading to an altercation and unreasonable discomfort.
    • AbuseFailed to provide safe environment
    14 Jun 2022Abuse: Neglect
    Identified a failure to provide a safe medication administration system, resulting in unnecessary discomfort and classified as neglect and abuse.
    • AbuseFailed to provide a safe medication administration system
    25 May 2022Inspection
    Investigated and found a violation for failing to provide a safe environment, including staff not wearing masks, not washing hands between residents, and leaving dirty briefs on the floor.
    • LicensingFailed to provide safe environment
    25 May 2022Inspection
    Found deficiencies in cleanliness of interior and exterior materials and surfaces, including dirty laundry and soiled briefs left on floors.
    • LicensingFailed to provide appropriate housekeeping services
    21 May 2022Abuse: Neglect
    Investigated found a failure to provide a safe environment, leading to a physical altercation and unreasonable discomfort to a resident.
    • AbuseFailed to provide safe environment
    29 Mar 2022License Condition
    Identified failure to provide a safe environment during a re-licensure survey.
    • Regulatory ActionFailed to provide safe environment
    14 Mar 2022Validation
    Found widespread deficiencies across administration, resident care planning, health services, nutrition, safety, and resident rights. Multiple areas failed to meet Oregon regulations and licensing rules.
    • DeficiencyComment
    • DeficiencyFacility Administration: Operation
    • DeficiencyFacility Administration: Quality Improvement
    • DeficiencyReasonable Precautions
    • DeficiencyResident Rights and Protection - General
    • DeficiencyReporting & Investigating Abuse-Other Action
    • DeficiencyResident Services Meals, Food Sanitation Rule
    • DeficiencyResident Move-In and Eval: Res Evaluation
    • DeficiencyService Plan: General
    • DeficiencyService Plan: Service Planning Team
    • DeficiencyChange of Condition and Monitoring
    • DeficiencyResident Health Services
    • DeficiencyRn Delegation and Teaching
    • DeficiencyRes Hlth Srvc: On- and Off-Site Health Srvc
    • DeficiencySystems: Treatment Orders
    • DeficiencySystems: Resident Right to Refuse
    • DeficiencySystems: Medication Administration
    • DeficiencySystems: Psychotropic Medication
    • DeficiencyRestraints and Supportive Devices
    • DeficiencyTraining Within 30 Days: Direct Care Staff
    • DeficiencyFire and Life Safety: Safety
    • DeficiencyFire and Life Safety: Training For Residents
    • DeficiencyInspections and Investigation: Insp Interval
    • DeficiencyGeneral Building Exterior
    • DeficiencyDoors, Walls, Elevators, Odors
    • DeficiencyAdministration Compliance
    • DeficiencyStaff Training Requirements
    • DeficiencyCompliance With Rules Health Care
    • DeficiencyNutrition and Hydration
    • DeficiencyActivities
    • DeficiencyBehavior
    • DeficiencyResident Rooms
    20 Jan 2022Complaint
    Found insufficient staffing and missing acuity documentation that jeopardized resident health and safety. Swing shift did not meet staffing plan, leaving residents without required care and contributing to laundry and toileting issues.
    • DeficiencyStaffing Requirements and Training: Staffing
    20 Jan 2022Complaint
    Determined that staffing shortages created an immediate jeopardy to resident health or safety due to insufficient swing shift coverage and unaddressed care needs.
    • DeficiencyStaffing Requirements and Training: Staffing
    20 Jan 2022Complaint
    Found insufficient staffing to meet residents' needs, leading to care gaps and inadequate acuity documentation on the swing shift.
    • DeficiencyLicensing Complaint Investigation
    • DeficiencyStaffing Requirements and Training: Staffing
    20 Jan 2022Complaint
    Investigated serious deficiencies in infection control and staffing that placed residents at risk, including failure to follow COVID-19 guidelines and insufficient swing-shift coverage.
    • DeficiencyLicensing Complaint Investigation
    • DeficiencyReasonable Precautions
    • DeficiencyStaffing Requirements and Training: Staffing
    20 Jan 2022Complaint
    Investigated and found staffing shortages that created an immediate jeopardy to resident health and safety.
    • DeficiencyStaffing Requirements and Training: Staffing
    20 Jan 2022Complaint
    Found failures to follow infection control guidelines that could have allowed COVID-19 to spread, risking residents' health.
    • DeficiencyReasonable Precautions
    11 Jan 2022Inspection
    Found insufficient staff to meet scheduled and unscheduled resident needs, violating staffing requirements.
    • LicensingFailed to provide appropriate staffing
    07 Jan 2022Inspection
    Investigated the allegation of failing to provide a safe environment and found a violation of safety rules due to not exercising reasonable precautions to prevent conditions that may threaten residents' health, safety, or welfare.
    • LicensingFailed to provide safe environment
    07 Jan 2022Inspection
    Investigated the allegation that a homelike environment was not provided and found offensive odors violated state rules.
    • LicensingFailed to provide a homelike environment
    07 Jan 2022Inspection
    Investigated an allegation of inadequate housekeeping and found a violation for failing to provide appropriate housekeeping services.
    • LicensingFailed to provide appropriate housekeeping services
    03 Dec 2021Abuse: Neglect
    Investigated and found neglect and abuse due to failure to protect a resident from inappropriate sexual contact, with a $250 fine assessed.
    • AbuseFailed to protect resident from inappropriate sexual contact
    27 Oct 2021Inspection
    Found insufficient staff to meet scheduled and unscheduled resident needs, violating Oregon rules.
    • LicensingFailed to provide appropriate staffing
    19 Oct 2021Abuse: Neglect
    Investigated found that a resident suffered four falls and injuries due to inadequate care planning and insufficient interventions after the first fall.
    • AbuseFailed to properly plan care
    02 Oct 2021Abuse: Neglect
    Investigated an abuse/neglect allegation and found that a resident was touched inappropriately by a person with known sexualized behaviors, leaving the resident fearful and upset, with insufficient safety interventions.
    • AbuseFailed to protect resident from inappropriate sexual contact
    01 Sept 2021Inspection
    Concluded that a resident experienced physical abuse by a staff member and protections against abuse were inadequate.
    • LicensingFailed to assure resident rights
    21 Jun 2021Inspection
    Found insufficient qualified awake direct care staffing in numbers sufficient to meet residents' 24-hour needs.
    • LicensingFailed to provide appropriate staffing
    21 Jun 2021Inspection
    Investigated the allegation and identified a deficiency for failing to provide reasonable precautions against conditions that may threaten residents' health, safety, or welfare.
    • LicensingFailed to provide safe environment
    27 May 2021Inspection
    Investigated a staffing allegation and concluded there was insufficient staff to meet residents' scheduled and unscheduled needs.
    • LicensingFailed to meet the scheduled and unscheduled needs of residents
    01 Mar 2021Abuse: Neglect
    Investigated a complaint and found a failure to provide a safe environment for a resident with a history of falls, leading to injuries.
    • AbuseFailed to provide safe environment
    06 Jan 2021Abuse: Neglect
    Found that the resident did not receive appropriate services, leading to not being dressed and embarrassment from a visitor.
    • AbuseFailed to provide service
    04 Jan 2021Inspection
    Found a violation for failing to assist residents with toileting.
    • LicensingFailed to provide service
    04 Jan 2021Inspection
    Found deficiencies related to interior cleanliness and odors.
    • LicensingFailed to provide a homelike environment
    04 Jan 2021Inspection
    Identified a staffing deficiency due to insufficient staff to meet residents' needs.
    • LicensingFailed to provide appropriate staffing
    14 Dec 2020Inspection
    Investigated an allegation of involuntary seclusion. Found that a resident was confined by a plastic bag on a door handle and that protection from involuntary seclusion failed.
    • LicensingFailed to assure resident was safe
    22 Oct 2020Abuse: Neglect
    Investigated and found violations for failing to provide a safe environment, resulting in wandering that led to an altercation and injury.
    • AbuseFailed to provide safe environment
    22 Oct 2020Abuse: Neglect
    Investigated and found neglect and abuse due to failure to implement interventions and care planning for wandering behavior, which led to a resident wandering into another resident's room and being injured.
    • AbuseFailed to provide safe environment
    24 Aug 2020Inspection
    Investigated a complaint about staff not wearing masks properly and found a deficiency in providing reasonable precautions to protect residents' health and safety.
    • LicensingFailed to assure resident was safe
    20 Aug 2020Inspection
    Investigated a report of wrongful restraint during a meal; found a staff member restrained a resident and would not allow movement, and the provider failed to protect the resident from the restraint.
    • LicensingFailed to protect resident from involuntary seclusion
    20 Aug 2020Inspection
    Investigated the allegation and found that a staff member forcefully grabbed a resident's wrist during a meal, constituting physical abuse. The investigation found a failure to protect the resident from abuse.
    • LicensingFailed to protect resident from physical abuse
    20 Aug 2020Inspection
    Identified a staff member restraining a resident during a meal by pushing the wheelchair to the table, violating resident rights and constituting abuse.
    • LicensingFailed to assure resident rights
    20 Aug 2020Inspection
    Concluded that there was a failure to provide a safe medication administration system.
    • LicensingFailed to provide a safe medication administration system
    10 Aug 2020Abuse: Neglect
    Concluded that care planning and follow-through failed, leading to abuse and neglect, with a fine assessed.
    • AbuseFailed to properly plan care
    04 Jul 2020Abuse: Neglect
    Found failure to follow the care plan to monitor a resident in a chair, leading to a fall and discomfort.
    • AbuseFailed to follow care plan
    15 May 2020Inspection
    Found a substantiated violation of safe medication administration practices due to failure to carry out prescribed medication orders.
    • LicensingFailed to provide a safe medication administration system
    24 Apr 2020Inspection
    Investigated and confirmed failure to provide meaningful activities that promote residents' physical and emotional well-being.
    • LicensingFailed to provide appropriate activities
    05 Jan 2020Abuse: Neglect
    Investigated an allegation of abuse and neglect; found the care planning did not address known prior behaviors, leading to a physical altercation and unreasonable discomfort.
    • AbuseFailed to assure resident was safe
    03 Jan 2020Abuse: Neglect
    Investigated the allegation and found a failure to follow the care plan, leading to a physical altercation and harm.
    • AbuseFailed to follow care plan
    07 Oct 2019Inspection
    Investigated the allegation of failing to provide a safe environment and found failure to maintain substantial compliance.
    • LicensingFailed to provide safe environment
    07 Sept 2019Abuse: Neglect
    Investigated and found neglect related to falls care planning, resulting in a resident falling from a wheelchair and sustaining a head injury.
    • AbuseFailed to adequately care plan related to falls
    26 Aug 2019Inspection
    Identified a deficiency in supervision that led to the AVs care plan not being followed.
    • LicensingFailed to provide service
    13 Aug 2019Abuse: Verbal/Mental abuse
    Investigated and found a failure to protect a resident from verbal abuse and noncompliance with regulatory requirements.
    • AbuseFailed to protect resident from verbal abuse
    08 Aug 2019Abuse: Neglect
    Concluded neglect occurred by failing to adequately maintain safety and prevent inappropriate touching, and a fine was assessed.
    • AbuseFailed to protect resident from inappropriate sexual contact
    05 Aug 2019Abuse: Neglect
    Found neglect led to a resident being inappropriately touched, with a $375 fine assessed.
    • AbuseFailed to protect resident from inappropriate sexual contact
    15 Jul 2019Abuse: Neglect
    Found neglect resulted in insufficient care and supervision, creating risk of harm, and a fine was assessed.
    • AbuseFailed to adequately care plan related to falls
    18 Jun 2019Abuse: Neglect
    Found neglect and abuse due to failure to implement interventions and care planning for falls history, resulting in an unwitnessed fall with skin injury; assessed a $375 fine.
    • AbuseFailed to properly plan care
    26 May 2019Inspection
    Found that staff failed to follow the care plan by not providing basic care and supervision, which led to a resident falling out of bed.
    • LicensingFailed to follow care plan
    17 May 2019Abuse: Neglect
    Found deficiencies in care planning for fall history, resulting in an unwitnessed injury fall and indicating neglect and abuse.
    • AbuseFailed to properly plan care
    15 May 2019Inspection
    Investigated and substantiated a deficiency for failing to administer medications per prescriber orders.
    • LicensingFailed to provide a safe medication administration system
    06 May 2019Inspection
    Concluded that there was a failure to provide a safe environment. No fine was assessed.
    • LicensingFailed to provide safe environment
    04 May 2019Abuse: Neglect
    Found neglect for failing to provide basic care, leaving the person in urine-saturated clothes and wheelchair for over two hours in the community; a $1500 fine was assessed.
    • AbuseFailed to assist with toileting
    04 May 2019Inspection
    Investigated and identified a failure to report suspected abuse.
    • LicensingFailed to report potential or suspected abuse
    26 Apr 2019Abuse: Neglect
    Investigated the neglect allegation and found failure to provide basic care, resulting in a resident falling out of bed without a fall mat.
    • AbuseFailed to follow care plan
    23 Apr 2019Abuse: Neglect
    Found neglect due to failure to provide basic care and supervision needed to keep the resident safe, resulting in risk. A $375 fine was assessed.
    • AbuseFailed to assure resident was safe
    22 Apr 2019Abuse: Neglect
    Found neglect resulting in harm to a person under care. A $4,500 fine was assessed.
    • AbuseFailed to provide service
    22 Apr 2019Abuse: Neglect
    Investigated and found neglect resulting from leaving a resident in wet pants and barefoot after a juice spill, causing loss of personal dignity; a fine was assessed.
    • AbuseFailed to provide service
    22 Apr 2019Inspection
    Found insufficient care staff to meet residents' scheduled and unscheduled needs.
    • LicensingFailed to provide appropriate staffing
    22 Apr 2019Abuse: Neglect
    Investigated a complaint of neglect of basic services; findings showed failure to provide basic care resulting in loss of personal dignity, with a civil penalty assessed.
    • AbuseFailed to provide service
    18 Apr 2019Abuse: Neglect
    Found a substantiated neglect violation due to failure to provide basic care, causing a resident to pace for 4 hours while crying without staff intervention; a $1,500 fine was assessed.
    • AbuseFailed to follow care plan
    18 Apr 2019Inspection
    Found failure to report suspected abuse and assessed a $1,000 fine.
    • LicensingFailed to report potential or suspected abuse
    18 Apr 2019Abuse: Neglect
    Found neglect by failing to provide basic care in a timely manner, risking serious harm to the individual, and a $500 fine was assessed.
    • AbuseFailed to provide service
    17 Apr 2019Abuse: Neglect
    Concluded neglect occurred due to failure to provide basic care related to falls, resulting in a resident’s fall and knee injury.
    • AbuseFailed to adequately care plan related to falls
    17 Apr 2019Inspection
    Investigated the allegation of failing to report suspected abuse. Found a level 3 licensing violation and assessed a $1,000 fine.
    • LicensingFailed to report potential or suspected abuse
    15 Apr 2019Inspection
    Identified a staffing deficiency that left residents without direct care during the night shift.
    • LicensingFailed to provide appropriate staffing
    14 Apr 2019Abuse: Neglect
    Found neglect due to failure to provide basic care and supervision. This led to a resident fall and a minor injury.
    • AbuseFailed to follow care plan
    14 Apr 2019Abuse: Neglect
    Investigated alleged neglect of basic care and nighttime toileting that put a resident at serious risk of harm. A fine was assessed as a sanction.
    • AbuseFailed to follow care plan
    10 Apr 2019Abuse: Neglect
    Found a failure to provide a safe medication administration system, resulting in about ten days without the resident's medications and risk of serious harm.
    • AbuseFailed to provide a safe medication administration system
    24 Mar 2019Abuse: Neglect
    Found neglect related to fall prevention care, resulting in a resident falling and bleeding from the forehead; a fine was assessed.
    • AbuseFailed to adequately care plan related to falls
    24 Mar 2019Abuse: Neglect
    Found neglect related to falls resulting in injury; a $375 fine was assessed.
    • AbuseFailed to adequately care plan related to falls
    24 Mar 2019Abuse: Neglect
    Investigated and found neglect due to inadequate supervision that led to falls and a skin tear.
    • AbuseFailed to adequately care plan related to falls
    21 Mar 2019Abuse: Verbal/Mental abuse
    Found verbal/mental abuse and neglect that harmed a resident's dignity; a $375 fine was assessed.
    • AbuseFailed to protect resident from mental or emotional abuse
    20 Mar 2019Abuse: Neglect
    Investigated neglect due to failing to provide supervision for safety, resulting in a resident fall. A $375 fine was assessed.
    • AbuseFailed to adequately care plan related to falls
    09 Mar 2019Abuse: Neglect
    Investigated a neglect allegation and found failure to provide supervision for safety, resulting in a resident falling from bed and sustaining an injury.
    • AbuseFailed to follow care plan
    12 Jan 2019Abuse: Neglect
    Found neglect that failed to provide basic care and placed a resident at serious risk of harm.
    • AbuseFailed to provide safe environment
    28 Dec 2018Abuse: Neglect
    Determined that neglect by staff created an unsafe environment for a resident, resulting in minor injuries and risk of serious harm.
    • AbuseFailed to provide safe environment
    28 Dec 2018Abuse: Neglect
    Investigated a neglect allegation and concluded that basic care was not provided to keep a resident safe, resulting in minor injuries and risk of serious harm.
    • AbuseFailed to provide safe environment
    24 Dec 2018Abuse: Neglect
    Determined neglect occurred by failing to provide adequate supervision, which led to a resident-to-resident altercation and risk of serious harm.
    • AbuseFailed to provide safe environment
    24 Dec 2018Abuse: Neglect
    Identified neglect due to inadequate supervision, creating risk of harm between residents. Violations of supervision and safety requirements were found.
    • AbuseFailed to provide safe environment
    17 Dec 2018Abuse: Neglect
    Found neglect compromising safety, resulting in a resident being slapped with an open hand. A $375 fine was assessed.
    • AbuseFailed to provide safe environment
    15 Dec 2018Abuse: Neglect
    Investigated and substantiated neglect, including failing to administer medication as ordered and not providing basic care that kept the individual safe from serious risk of harm; a fine was assessed.
    • AbuseFailed to administer medication as ordered
    14 Dec 2018Abuse: Neglect
    Identified neglect in medication administration that risked serious harm by not administering medications as ordered.
    • AbuseFailed to provide a safe medication administration system
    13 Dec 2018Abuse: Neglect
    Found a neglect related to an unsafe medication administration system, resulting in a resident not receiving pain medication for five days and at risk of pain.
    • AbuseFailed to provide a safe medication administration system
    12 Dec 2018Abuse: Neglect
    Found neglect and failure to administer needed medication, placing a resident at risk of serious harm.
    • AbuseFailed to provide a safe medication administration system
    08 Dec 2018Inspection
    Investigated and determined that suspected abuse was not reported. A $1,000 fine was assessed.
    • LicensingFailed to report potential or suspected abuse
    08 Dec 2018Abuse: Neglect
    Found neglect causing physical harm and a $500 fine was assessed.
    • AbuseFailed to provide service
    05 Dec 2018Inspection
    Found deficiencies in assessing dementia-related behavioral symptoms and in including appropriate intervention techniques in the resident's service plan.
    • LicensingFailed to perform adequate screening or assessment
    05 Dec 2018Abuse: Neglect
    Found neglect related to failing to provide a safe medication administration system, resulting in the AV not receiving pain medication for several days.
    • AbuseFailed to provide a safe medication administration system
    05 Dec 2018Abuse: Neglect
    Investigated an abuse/neglect allegation and determined neglect occurred; a $375 fine was assessed.
    • AbuseFailed to follow care plan
    04 Dec 2018Abuse: Neglect
    Investigated and found neglect due to inadequate supervision that resulted in a resident being pushed.
    • AbuseFailed to provide safe environment
    01 Dec 2018Inspection
    Found a violation for failing to report potential or suspected abuse. A $1,000 fine was assessed.
    • LicensingFailed to report potential or suspected abuse
    01 Dec 2018Abuse: Neglect
    Investigated a complaint and found a failure to provide a safe medication administration system, by not providing insulin for 4 to 5 days, risking serious harm.
    • AbuseFailed to provide a safe medication administration system
    27 Nov 2018Abuse: Neglect
    Found a failure to provide a safe medication administration system, risking potential serious harm to a resident. No additional civil penalties were imposed due to prior penalties in the same 90-day period.
    • AbuseFailed to provide a safe medication administration system
    25 Nov 2018Abuse: Neglect
    Identified abuse and neglect due to failure to provide a safe environment, resulting in a physical altercation and injury.
    • AbuseFailed to provide safe environment
    23 Nov 2018Abuse: Neglect
    Found neglect related to medication administration that posed a risk of serious harm. A fine was assessed.
    • AbuseFailed to provide a safe medication administration system
    22 Nov 2018Abuse: Neglect
    Investigated an allegation of neglect related to medication administration and identified neglect of basic care that could put a resident at risk.
    • AbuseFailed to provide a safe medication administration system
    22 Nov 2018Abuse: Neglect
    Found neglect related to a medication administration system that posed a risk of serious harm.
    • AbuseFailed to provide a safe medication administration system
    21 Nov 2018Condition
    Found substantial noncompliance related to providing a safe environment.
    • Regulatory ActionFailed to provide safe environment
    16 Nov 2018Abuse: Neglect
    Investigated abuse allegation and found neglect that compromised safety, resulting in an altercation.
    • AbuseFailed to assure resident was safe
    11 Nov 2018Abuse: Neglect
    Investigated and found a deficiency in providing a safe environment; a $375 fine was assessed.
    • AbuseFailed to provide safe environment
    11 Nov 2018Abuse: Neglect
    Investigated an allegation of neglect and found a failure to provide a safe environment that could cause harm.
    • AbuseFailed to provide safe environment
    10 Nov 2018Abuse: Neglect
    Found neglect that resulted in physical harm and a fine was assessed.
    • AbuseFailed to follow care plan
    08 Nov 2018Abuse: Neglect
    Found neglect related to medication administration that caused harm to a resident.
    • AbuseFailed to provide a safe medication administration system
    06 Nov 2018Inspection
    Found the allegation of failing to report suspected abuse to be substantiated and assessed a $1,000 fine.
    • LicensingFailed to report potential or suspected abuse
    06 Nov 2018Abuse: Neglect
    Investigated a neglect allegation and found neglectful failure to provide basic care, risking skin breakdown for a resident; a $2,500 fine was assessed.
    • AbuseFailed to provide service
    06 Nov 2018Abuse: Neglect
    Investigated and found neglect resulting in serious loss of personal dignity. A $5,000 fine was assessed.
    • AbuseFailed to provide service
    05 Nov 2018Abuse: Neglect
    Investigated an allegation of neglect and found unsafe care resulting in potential harm, with a $375 fine assessed.
    • AbuseFailed to properly plan care
    01 Nov 2018Abuse: Neglect
    Investigated a neglect allegation and found neglect that risked serious harm to a resident. A fine was assessed.
    • AbuseFailed to provide safe environment
    01 Nov 2018Abuse: Neglect
    Investigated and found a neglect violation for failing to provide a safe environment, which led to a resident hitting another resident.
    • AbuseFailed to provide safe environment
    01 Nov 2018Abuse: Neglect
    Found a neglect violation resulting in a $375 fine for failing to keep AV safe from risk of serious harm.
    • AbuseFailed to provide safe environment
    31 Oct 2018Abuse: Neglect
    Investigated the allegation and found neglect due to failure to provide basic care to keep the resident safe. A $375 fine was assessed.
    • AbuseFailed to provide safe environment
    31 Oct 2018Abuse: Neglect
    Found neglect due to failure to follow the care plan, resulting in inadequate basic care and risk of serious harm to a person in care.
    • AbuseFailed to follow care plan
    29 Oct 2018Abuse: Neglect
    Identified neglect due to inadequate supervision, creating risk of serious harm. A $500 fine was assessed.
    • AbuseFailed to provide safe environment
    29 Oct 2018Inspection
    Found failure to report suspected abuse. A $1000 fine was assessed.
    • LicensingFailed to report potential or suspected abuse
    25 Oct 2018Inspection
    Investigated an allegation of failing to report suspected abuse and found a deficiency; a $1,000 fine was assessed.
    • LicensingFailed to report potential or suspected abuse
    25 Oct 2018Abuse: Neglect
    Found neglect of a resident resulting in physical harm; a $2,500 fine was assessed.
    • AbuseFailed to assure resident was safe
    19 Oct 2018Inspection
    Found a deficiency for failing to provide or assist with personal hygiene, grooming, and showers.
    • LicensingFailed to provide or assist with hygiene
    19 Oct 2018Inspection
    Investigated the allegation that medications were not properly secured and found failures to administer medications correctly.
    • LicensingFailed to provide a safe medication administration system
    19 Oct 2018Inspection
    Found hallways and resident units not kept free from unpleasant odors.
    • LicensingFailed to provide appropriate housekeeping services
    19 Oct 2018Inspection
    Investigated a complaint and found that the provider failed to notify the resident's medical care provider of a change in condition.
    • LicensingFailed to provide service
    14 Oct 2018Abuse: Neglect
    Identified neglect by failing to provide basic care to maintain safety, resulting in a substantiated finding. A $375 fine was assessed.
    • AbuseFailed to provide safe environment
    12 Oct 2018Abuse: Neglect
    Found neglect that resulted in a large coccyx sore on a resident, causing moderate harm, and a $500 fine was assessed.
    • AbuseFailed to provide service
    12 Oct 2018Abuse: Neglect
    Determined that the failure to report suspected abuse was substantiated, and a $1,000 fine was assessed.
    • AbuseFailed to report potential or suspected abuse
    09 Oct 2018Abuse: Neglect
    Investigated abuse allegation and found neglect that resulted in a pressure sore and physical harm to the individual.
    • AbuseFailed to properly plan care
    09 Oct 2018Inspection
    Determined that laundry services were not provided as required.
    • LicensingFailed to provide service
    09 Oct 2018Inspection
    Investigated a complaint and substantiated a violation for grooming concerns and failure to meet resident service requirements.
    • LicensingFailed to assist with dressing or grooming
    09 Oct 2018Inspection
    Investigated and found a failure to report suspected abuse, resulting in a $1000 fine.
    • LicensingFailed to report potential or suspected abuse
    09 Oct 2018Inspection
    Investigated an allegation of inadequate staffing and found a staffing deficiency.
    • LicensingFailed to provide appropriate staffing
    08 Oct 2018Abuse: Neglect
    Investigated a complaint and found neglect that resulted in physical harm from failure to provide basic care and services.
    • AbuseFailed to provide service
    08 Oct 2018Abuse: Neglect
    Found neglect by failing to supervise residents, placing them at risk of serious harm during a resident-to-resident altercation.
    • AbuseFailed to provide safe environment
    08 Oct 2018Abuse: Neglect
    Found neglect resulting in physical harm by failing to provide basic care and services to maintain health and safety.
    • AbuseFailed to provide safe environment
    03 Oct 2018Abuse: Neglect
    Investigated the allegation and found neglect due to inadequate supervision, creating risk of serious harm. A $375 fine was assessed.
    • AbuseFailed to provide safe environment
    03 Oct 2018Inspection
    Found failure to report suspected abuse, resulting in a $1000 fine.
    • LicensingFailed to report potential or suspected abuse
    03 Oct 2018Abuse: Neglect
    Found neglect related to falls care that put a resident at risk, resulting in multiple falls; a $1,500 fine was assessed.
    • AbuseFailed to adequately care plan related to falls
    02 Oct 2018Abuse: Neglect
    Found neglect due to failure to provide basic care, creating a risk of serious harm; a $500 fine was assessed.
    • AbuseFailed to provide service
    02 Oct 2018Inspection
    Investigated an allegation of failing to report potential or suspected abuse and determined that the failure to report occurred. A $1000 fine was assessed.
    • LicensingFailed to report potential or suspected abuse
    20 Sept 2018Inspection
    Identified failure to report suspected abuse and assessed a $750 fine.
    • LicensingFailed to report potential or suspected abuse
    20 Sept 2018Abuse: Neglect
    Found neglect of basic care that left AV at risk of harm and imposed a $2,500 fine.
    • AbuseFailed to provide safe environment
    13 Sept 2018Abuse: Neglect
    Identified neglect due to failure to provide basic care, resulting in risk of serious harm; a $500 fine was assessed.
    • AbuseFailed to properly plan care
    05 Sept 2018Inspection
    Found that suspected abuse was not reported. A $1,000 fine was assessed.
    • LicensingFailed to report potential or suspected abuse
    05 Sept 2018Abuse: Neglect
    Investigated and found neglect due to failure to provide basic care, resulting in multiple UTIs and unreasonable discomfort.
    • AbuseFailed to provide service
    03 Sept 2018Abuse: Neglect
    Investigated and concluded neglect occurred, resulting in risk to health and safety; a $375 fine was assessed.
    • AbuseFailed to provide safe environment
    02 Sept 2018Abuse: Neglect
    Investigated an allegation of neglect and found that the individual failed to provide basic care to keep the resident safe; a $375.00 fine was assessed.
    • AbuseFailed to provide safe environment
    02 Sept 2018Abuse: Neglect
    Found neglect for failing to provide basic care to keep a resident safe from significant harm.
    • AbuseFailed to provide safe environment
    30 Aug 2018Abuse: Neglect
    Investigated a complaint and found neglect that failed to maintain health and safety, creating a risk of serious harm. A $375 fine was assessed.
    • AbuseFailed to provide safe environment
    07 Jun 2018Inspection
    Found inadequate housekeeping leading to persistent offensive odors and a persistent urine smell.
    • LicensingFailed to provide appropriate housekeeping services
    06 May 2018Abuse: Neglect
    Substantiated neglect due to failure to properly plan care, which led to a noninjury resident-to-resident altercation; a $450 fine was assessed.
    • AbuseFailed to properly plan care
    04 May 2018Abuse: Neglect
    Found a failure to provide a safe environment that led to a resident-to-resident altercation with minor injury, and assessed a $375 fine.
    • AbuseFailed to provide safe environment
    11 Apr 2018Inspection
    Found a staffing deficiency due to failure to provide appropriate staffing.
    • LicensingFailed to provide appropriate staffing
    18 Mar 2018Abuse: Neglect
    Investigated an abuse/neglect allegation and identified a failure to provide a safe environment, resulting in a resident-to-resident altercation with minor injuries. A $375 fine was assessed.
    • AbuseFailed to provide safe environment
    25 Dec 2017Inspection
    Found an inadequate medication administration system that led to a resident missing medications.
    • LicensingFailed to administer medication as ordered
    13 Dec 2017Abuse: Neglect
    Investigated the allegation and found a failure to provide a safe environment, resulting in minor bleeding during a resident-to-resident incident.
    • AbuseFailed to provide safe environment
    20 Oct 2017Abuse: Neglect
    Investigated a complaint and found a failure to meet care needs that led to an emergency room visit for hyperglycemia.
    • AbuseFailed to provide service
    15 Aug 2017Abuse: Verbal/Mental abuse
    Found a violation involving verbal abuse and failure to protect a resident from inappropriate verbal behaviors.
    • AbuseFailed to provide safe environment
    12 Aug 2017Inspection
    Investigated a complaint and found a safety deficiency where residents were not protected from a resident-to-resident altercation, resulting in a $250 fine assessed.
    • LicensingFailed to provide safe environment
    16 Apr 2017Abuse: Neglect
    Investigated an allegation of neglect and found failure to properly plan care, resulting in a resident injury; a $400 fine was assessed.
    • AbuseFailed to properly plan care
    30 Oct 2016Abuse: Neglect
    Investigated a neglect allegation and found that a safe environment was not provided, resulting in a skin tear to the resident's hand due to a physical assault.
    • AbuseFailed to provide safe environment
    11 Sept 2016Abuse: Neglect
    Investigated a neglect allegation. Found a failure to provide a safe environment, leading to multiple resident-to-resident altercations.
    • AbuseFailed to provide safe environment
    25 Sept 2014Abuse: Neglect
    Found that the care plan was not followed, with potential for minor to moderate harm.
    • AbuseFailed to follow care plan
    29 Aug 2014Abuse: Neglect
    Found failure to provide a secure environment.
    • AbuseFailed to provide safe environment
    29 Aug 2014Abuse: Neglect
    Found an abuse/neglect allegation of failing to provide a secure environment. The allegation involved minor harm or potential for moderate harm.
    • AbuseFailed to provide safe environment
    26 Aug 2014Abuse: Neglect
    Investigated the allegation and found a failure to provide a safe environment.
    • AbuseFailed to provide safe environment
    22 May 2014Abuse: Neglect
    Investigated an allegation of failing to administer medication as ordered and found an inadequate medication management system.
    • AbuseFailed to administer medication as ordered
    26 Sept 2013Inspection
    Investigated the allegation of not addressing a resident's behavior and found RV2 was not kept safe.
    • LicensingFailed to address resident's behavior
    27 May 2013Inspection
    Investigated an allegation of not providing service and found residents were not kept safe.
    • LicensingFailed to provide service
    22 May 2013Abuse: Neglect
    Investigated an abuse/neglect allegation of failing to follow the care plan and substantiated a safety deficiency. The finding indicated safety was not maintained for a resident.
    • AbuseFailed to follow care plan
    05 Apr 2013Inspection
    Found an inadequate medication system and a failure to administer medication as ordered.
    • LicensingFailed to administer medication as ordered
    22 Mar 2013Inspection
    Determined that the allegation of failing to assure resident rights was substantiated and funds were mismanaged.
    • LicensingFailed to assure resident rights
    18 Feb 2013Abuse: Neglect
    Investigated substantiated neglect allegations and found a failure to create a safe environment.
    • AbuseFailed to address resident's behavior
    08 Feb 2013Abuse: Neglect
    Investigated an allegation of neglect related to failing to address a resident's behavior; found a failure to provide a safe environment.
    • AbuseFailed to address resident's behavior
    08 Feb 2013Abuse: Neglect
    Investigated the allegation of failing to provide a safe environment and identified a condition tied to intent to revoke.
    • AbuseFailed to provide safe environment
    15 Jan 2013Abuse: Verbal/Mental abuse
    Found that two residents were subjected to verbal/mental abuse and were not protected from it.
    • AbuseFailed to protect resident from mental or emotional abuse
    01 Jan 2013Abuse: Neglect
    Investigated an abuse allegation of neglect and found failure to properly plan care.
    • AbuseFailed to properly plan care
    01 Jan 2013Abuse: Neglect
    Investigated a neglect allegation and found that a resident was not protected from inappropriate verbal comments.
    • AbuseFailed to address resident's behavior
    24 Dec 2012Abuse: Neglect
    Identified a deficiency in providing a safe environment.
    • AbuseFailed to address resident's behavior
    08 Dec 2012Abuse: Neglect
    Found deficiencies in care and oversight of change in condition, resulting in a monetary sanction of $2,500.
    • AbuseFailed to provide oversight and monitoring of change of condition
    03 Nov 2012Abuse: Neglect
    Investigated the allegation of failing to provide a safe medication administration system and identified deficiencies.
    • AbuseFailed to provide a safe medication administration system
    15 Oct 2012Inspection
    Found that resident rights were not assured and that verbal mistreatment was not prevented.
    • LicensingFailed to assure resident rights
    28 Aug 2012Inspection
    Investigated an allegation and found a failure to provide a safe environment.
    • LicensingFailed to provide safe environment
    23 Aug 2012Abuse: Neglect
    Investigated a neglect allegation and found failure to properly plan care; a $350 fine was assessed.
    • AbuseFailed to properly plan care
    12 Jul 2012Abuse: Neglect
    Investigated an allegation of neglect and found an inadequate medication system. This indicates risk of harm from improper medication practices.
    • AbuseFailed to communicate necessary information
    18 May 2012Abuse: Neglect
    Investigated an allegation of neglect related to care planning; found an unsafe environment and assessed a $200 fine.
    • AbuseFailed to properly plan care
    04 Apr 2012Inspection
    Found failure to properly plan care. Findings substantiated.
    • LicensingFailed to properly plan care
    08 Mar 2012Abuse: Neglect
    Investigated an abuse/neglect allegation and determined that oversight of changes in condition was inadequate and physician's orders were not followed, with a $350 fine assessed.
    • AbuseFailed to provide oversight and monitoring of change of condition
    25 Feb 2012Abuse: Neglect
    Found neglect due to failure to follow the care plan and protect residents from a physical altercation; a $200 fine was assessed.
    • AbuseFailed to follow care plan
    15 Jan 2012Abuse: Neglect
    Found a safety deficiency and assessed a $200 fine.
    • AbuseFailed to properly plan care
    05 Jan 2012Inspection
    Identified deficiencies in resident rights and safety; the allegation was substantiated.
    • LicensingFailed to assure resident rights
    13 Dec 2011Abuse: Neglect
    Determined a neglect finding for failing to provide medical treatment as ordered and assessed a $600 fine.
    • AbuseFailed to provide medical treatment as ordered
    13 Dec 2011Inspection
    Investigated a complaint and identified a failure to provide a safe environment due to issues with medication administration safety.
    • LicensingFailed to provide a safe medication administration system
    13 Dec 2011Abuse: Neglect
    Investigated an allegation of neglect and substantiated a failure to provide a safe environment.
    • AbuseFailed to follow care plan
    13 Dec 2011Abuse: Neglect
    Concluded that residents were not provided a safe environment due to inadequate care planning related to falls.
    • AbuseFailed to adequately care plan related to falls
    24 Nov 2011Abuse: Neglect
    Found that interventions to prevent residents from aggressing upon other residents were not provided.
    • AbuseFailed to address resident's behavior
    20 Nov 2011Abuse: Neglect
    Investigated a complaint and found that a resident was not protected from physical mistreatment.
    • AbuseFailed to follow care plan
    20 Oct 2011Abuse: Neglect
    Investigated and found a neglect related to falls substantiated; the resident identified as RV2 was not assessed for fall risk and no interventions were implemented.
    • AbuseFailed to adequately care plan related to falls
    01 Oct 2011Abuse: Physical Abuse
    Found a failure to protect a resident from physical assault.
    • AbuseFailed to provide safe environment
    23 Sept 2011Abuse: Neglect
    Investigated a neglect case and found that interventions to protect a resident from falling were not put in place.
    • AbuseFailed to adequately care plan related to falls
    03 Sept 2011Inspection
    Found a safe medication administration system was not provided.
    • LicensingFailed to provide a safe medication administration system
    19 Aug 2011Abuse: Neglect
    Investigated a neglect allegation and found care failed to meet standards. A failure to properly plan care was identified.
    • AbuseFailed to properly plan care
    19 Aug 2011Abuse: Neglect
    Investigated an allegation of neglect for failing to administer ordered medication. Found medications were not provided to a resident and a $300 fine was assessed.
    • AbuseFailed to administer ordered medication
    11 Aug 2011Abuse: Neglect
    Investigated the complaint and found that fall interventions were not provided.
    • AbuseFailed to follow care plan
    08 Aug 2011Abuse: Neglect
    Determined that a neglect allegation was substantiated due to lack of oversight of change of condition and inadequate care, with a $300 fine assessed.
    • AbuseFailed to provide oversight and monitoring of change of condition
    25 Jul 2011Abuse: Neglect
    Found neglect due to failure to prevent a physical altercation between residents.
    • AbuseFailed to address resident's behavior
    01 Jul 2011Abuse: Neglect
    Investigated the allegation of neglect and found that a safe environment for RV2 was not provided.
    • AbuseFailed to investigate injury of unknown origin to rule out abuse
    18 May 2011Abuse: Neglect
    Found that a safe environment was not provided to residents.
    • AbuseFailed to assure resident rights
    16 Apr 2011Abuse: Neglect
    Investigated an allegation of neglect and found a failure to provide a safe environment.
    • AbuseFailed to address resident's behavior
    06 Mar 2011Abuse: Neglect
    Found a deficiency in assessing and intervening to provide a safe environment.
    • AbuseFailed to provide safe environment
    21 Jan 2011Abuse: Neglect
    Investigated the allegation of neglect and found failure to follow the care plan, resulting in inadequate care.
    • AbuseFailed to follow care plan
    20 Jan 2011Inspection
    Determined that the allegation of failing to address resident behavior resulted in an unsafe environment.
    • LicensingFailed to address resident's behavior
    30 Dec 2010Inspection
    Found a deficiency for failing to provide a safe and sanitary environment.
    • LicensingFailed to provide or assist with hygiene
    30 Dec 2010Inspection
    Investigated an allegation of an unsafe medication administration system. Found that a safe medication system was not provided.
    • LicensingFailed to provide a safe medication administration system
    08 Dec 2010Inspection
    Concluded that a safe environment was not provided.
    • LicensingFailed to provide safe environment
    23 Nov 2010Abuse: Neglect
    Found a safety deficiency due to inadequate fall-related care planning and resulting unsafe environment; assessed a $300 fine.
    • AbuseFailed to adequately care plan related to falls
    20 Nov 2010Inspection
    Found a failure to provide a safe medication administration system.
    • LicensingFailed to provide a safe medication administration system
    18 Nov 2010Abuse: Neglect
    Investigated an allegation of neglect and found a failure to provide appropriate care. A $300 fine was assessed.
    • AbuseFailed to properly plan care
    01 Nov 2010Inspection
    Found an inadequate medication administration system.
    • LicensingFailed to provide a safe medication administration system
    07 Oct 2010Abuse: Neglect
    Found neglect related to inadequate care planning for falls. Assessed a $300 fine.
    • AbuseFailed to adequately care plan related to falls
    20 Sept 2010Inspection
    Investigated a complaint and found a failure to follow the care plan, resulting in inappropriate care for RV.
    • LicensingFailed to follow care plan
    28 Jul 2010Inspection
    Investigated the allegation and found a failure to provide a safe environment.
    • LicensingFailed to provide safe environment
    10 Jul 2010Abuse: Neglect
    Found failure to provide appropriate care, including toileting assistance.
    • AbuseFailed to assist with toileting
    07 Jul 2010Inspection
    Investigated an allegation that staff failed to assist with dressing or grooming. Found a deficiency in providing appropriate care.
    • LicensingFailed to assist with dressing or grooming
    06 Jul 2010Abuse: Neglect
    Investigated and found a failure to provide appropriate care related to falls.
    • AbuseFailed to adequately care plan related to falls
    07 May 2010Inspection
    Found a failure to provide a secure environment.
    • LicensingFailed to provide safe environment
    16 Apr 2010Inspection
    Found a deficiency for not providing a safe environment.
    • LicensingFailed to provide safe environment
    09 Apr 2010Abuse: Neglect
    Found that a safe environment was not provided.
    • AbuseFailed to provide safe environment
    17 Mar 2010Abuse: Neglect
    Found a failure to provide a safe environment.
    • AbuseFailed to provide safe environment
    14 Mar 2010Inspection
    Investigated an allegation of failing to administer medication as ordered and found an inadequate medication system.
    • LicensingFailed to administer medication as ordered
    06 Mar 2010Abuse: Neglect
    Investigated a complaint alleging neglect and identified a failure to assess and timely intervene in medical treatment.
    • AbuseFailed to assure timely medical treatment
    03 Mar 2010Abuse: Neglect
    Investigated and found failure to provide appropriate care.
    • AbuseFailed to follow care plan
    03 Mar 2010Inspection
    Investigated and found failure to maintain an adequate medication system related to administering medications as ordered.
    • LicensingFailed to administer medication as ordered
    01 Mar 2010Inspection
    Found an inadequate medication administration system.
    • LicensingFailed to provide a safe medication administration system
    21 Feb 2010Abuse: Neglect
    Investigated a complaint and found a failure to provide a safe environment.
    • AbuseFailed to provide medical treatment as ordered
    01 Feb 2010Inspection
    Investigated and identified a violation related to medication administration due to an inadequate medication system. The allegation that medication was not administered as ordered was substantiated.
    • LicensingFailed to administer medication as ordered
    24 Jan 2010Abuse: Neglect
    Found that a safe environment was not provided.
    • AbuseFailed to provide safe environment

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