I placed my mom at Table Rock Memory Care and have been very pleased - intake and transition were professional and smooth, the facility is clean and homey, and caregivers, nurses and med techs (shout-out to Tyler and Robin) are skilled, kind and engaging. New leadership is clearly improving operations, meals and activities are enjoyable, and I feel my mom is safe, well cared for and treated like family; I highly recommend this dementia-focused community.
Loved one of resident
Jul 2026
Pricing
Prices shown are estimates and subject to change. Contact your senior living advisor for current pricing.
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Amenities
Healthcare services
Activities of daily living assistance
Assistance with bathing
Assistance with dressing
Assistance with transfers
Coordination with health care providers
Hospice waiver
Medication management
Mental wellness program
Healthcare staffing
12-16 hour nursing
24-hour call system
24-hour supervision
Meals and dining
Diabetes diet
Meal preparation and service
Restaurant-style dining
Special dietary restrictions
Room
Air-conditioning
Cable
Fully furnished
Housekeeping and linen services
Kitchenettes
Private bathrooms
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
3.63·(56)
Overall rating
5
4
3
2
1
Care
3.6
Staff
3.7
Meals
2.9
Amenities
4.0
Value
1.0
Pros
Compassionate, resident-focused staff
Dedicated and experienced night-shift team
Skilled nurses and medication-technology support
Smooth, professional intake and transition process
Memory-care specialization and dementia-focused programming
Engaging daily activities and therapy programs
Secure, attractive, and home-like facility
Physical-therapy and rehabilitation assistance
Long-tenured staff and strong teamwork
Helpful front-desk and admissions personnel
Clean, well-maintained rooms and common areas
Convenient Rogue Valley location
Cons
High staff turnover and inconsistent staffing levels
Gaps in family and incident communication
Medication-management inconsistencies
Sanitation and incontinence-care concerns in resident rooms
Billing, payment, and refund transparency issues
Frequent leadership and management instability
Training and clinical-competence gaps among some caregivers
Inconsistent meal quality and food-service continuity
Weak discharge/return-to-facility procedures after hospital transfers
Regulatory compliance issues and state-identified violations
Delays in clinical response and pain-management practices
Summary of reviews
Table Rock Memory Care Community elicits a highly mixed set of impressions. Many families and observers describe a compassionate, resident-focused culture with staff who are engaged, patient, and knowledgeable about dementia care; several accounts highlight strong night-shift coverage, attentive nursing and med-tech support, effective physical-therapy assistance, and a smooth admission or transition experience. The building and grounds are frequently described as secure, attractive, and home-like, and activity programming and memory-care specialization receive positive mentions as contributing to resident engagement.
At the same time, a consistent pattern of operational weaknesses appears across reviews. Staffing instability and turnover are recurring concerns that reviewers link to variability in daily care continuity and morale. Multiple families describe gaps in communication — both routine family updates and critical incident notifications — which undermines confidence during clinical events. Specific clinical-process issues are described, including medication-management inconsistencies and delays in clinical response and pain management; these are operational vulnerabilities rather than isolated praises of individuals, and they suggest areas where process and oversight may be uneven.
Sanitation and incontinence-care practices are another area of concern, with some accounts indicating inconsistencies in room and bathroom upkeep and incontinence management. Food-service quality is described as variable: while some reviewers find meals acceptable and engaging, others note limited variety, freshness issues, and occasional service disruptions. Billing, payment, and refund transparency issues are also repeatedly noted, including disputes with insurance or Medicaid, double charges, and slow or incomplete refunds, which can cause significant family stress.
Management and regulatory oversight emerge as important themes. Several reviewers describe frequent leadership changes and management instability; others reference state-identified violations and regulatory involvement. These systemic signals reinforce perceived variability in training, supervision, and compliance. In a few instances, serious allegations have been raised (including theft and suspected substance misuse among staff); such allegations merit careful scrutiny and, where appropriate, regulatory follow-up.
Taken together, the pattern is of a facility with demonstrable strengths in compassionate, memory-focused caregiving and a welcoming environment, alongside persistent operational challenges that affect consistency of care. Prospective families should weigh the facility’s memory-care programming, positive staff interactions, and clean, secure environment against the documented concerns about staffing stability, clinical-process consistency, sanitation practices, billing transparency, and management turnover. When considering Table Rock, request current staffing ratios, recent state inspection reports, medication-administration and incident-response policies, training records, and examples of how recent management changes have addressed identified deficiencies. An in-person visit and direct conversations with current families can help validate the reliability of daily care and administrative practices.
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Location
Table Rock Memory Care Community is located at 2636 Table Rock Rd, Medford, OR, 97501.
About Table Rock Memory Care Community
Table Rock Memory Care Community is a dedicated senior living community that specializes in providing personalized memory care services. Designed to create a supportive and engaging environment for individuals experiencing memory loss, this community places a strong emphasis on ensuring residents’ well-being, comfort, and dignity throughout their stay. The community is known for its thoughtful design and professional staff, all geared toward meeting the unique needs of residents navigating various stages of memory impairment.
At Table Rock Memory Care, nutritious and appetizing meals are a vital part of the daily experience, with chefs and meal planners focusing on the right balance of vitamins and minerals. Meals are prepared with quality ingredients, served in a welcoming dining environment, and tailored to satisfy both nutritional requirements and personal preferences. The culinary team is dedicated to creating dining experiences that are both healthy and enjoyable, ensuring residents look forward to each meal.
The living arrangements at Table Rock Memory Care include both studio and semi-private apartments. These spaces are thoughtfully designed to offer comfort, safety, and a sense of independence while providing the necessary support for daily living activities. Residents benefit from a secure environment where they can enjoy peace of mind as they participate in daily routines and interact with peers.
Beyond basic care, Table Rock Memory Care is committed to providing engaging activities that foster social, physical, mental, and emotional well-being. The community offers a calendar full of events and activities that encourage residents to connect, learn, and stay active. The staff aims to build a warm, friendly atmosphere where everyone feels valued and involved, supporting meaningful engagement and personal fulfillment.
The overarching mission at Table Rock Memory Care is to deliver exceptional support to residents living with memory challenges, focusing on individualized care, enriching activities, and quality dining. Every aspect of community life is crafted to inspire comfort, engagement, and a sense of belonging for each individual. The team prides itself on cultivating a culture of kindness and attentiveness, helping residents and their families feel secure and supported in their journey.
Frontier Management is a leading senior living provider in the United States, operating over 120 communities across 19 states. Headquartered in Durham, Oregon, Frontier offers a range of senior living options, including independent living, assisted living, and memory care. Founded in 2000, Frontier has grown significantly and has been recognized for its excellence in senior care, earning multiple prestigious industry awards.
One of Frontier's hallmark programs is the Spark program, rooted in Montessori-style practices, which promotes purpose and engagement among residents. Initially designed for memory care, this program has been expanded to other types of care within Frontier's communities. The Spark program empowers residents to have an active role in their community, enhancing their daily lives through meaningful activities.
Frontier is also known for its dedication to resident health and well-being. Their communities offer comprehensive services tailored to individual needs, including customized healthcare plans through the Frontier Advantage Network, which aims to extend residents' stay by keeping them healthier for longer periods.
The company has undergone significant changes and growth in recent years, including a rebranding effort to refresh its image and enhance its services. Frontier's communities are spread across various states including Arizona, California, Florida, Georgia, Idaho, Illinois, Indiana, Iowa, Louisiana, Massachusetts, Mississippi, Missouri, Montana, Nebraska, Nevada, Oregon, Tennessee, Texas, Utah, Washington, and Wisconsin.
Frontier Management's commitment to quality care, innovative programs, and extensive service options makes it a prominent name in senior living, continually striving to meet the evolving needs of its residents.
People often ask...
Table Rock Memory Care Community offers competitive pricing, with rates starting at a cost of $5,423 per month.
Table Rock Memory Care Community offers assisted living and memory care.
There are 26 photos of Table Rock Memory Care Community on Mirador.
The full address for this community is 2636 Table Rock Rd, Medford, OR 97501.
No, Table Rock Memory Care Community 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.
Identified extensive sanitation and administration deficiencies, including numerous kitchen cleanliness, maintenance, and storage issues and failure to meet licensing rules. Observations spanned the main kitchen and cottage areas.
Found that a fall mat was not placed as required by the care plan, leading to a resident fall and injury with findings of neglect and abuse and a fine assessed.
Abuse—Failed to follow care plan
17 Sept 2025Abuse: Neglect
17 Sept 2025Abuse: Neglect
Investigated and concluded abuse/neglect due to failure to monitor and follow the care plan, with a fine assessed.
Abuse—Failed to provide service
22 Jul 2025Inspection
22 Jul 2025Inspection
Determined that a deficiency related to providing a safe environment existed.
Licensing—Failed to provide safe environment
22 Jul 2025Abuse: Neglect
22 Jul 2025Abuse: Neglect
Investigated and found neglect due to failure to monitor a resident in hot outdoor conditions, resulting in heat-related injuries; a fine was assessed.
Abuse—Failed to provide service
03 Jul 2025Licensure
03 Jul 2025Licensure
Identified numerous deficiencies across activities, service planning, medication management, infection control, staffing, fire safety, privacy, and building upkeep.
Deficiency—Resident Services: Activities
Deficiency—Service Plan: General
Deficiency—Change of Condition and Monitoring
Deficiency—Infection Prevention & Control
Deficiency—Systems: Tracking Control Substances
Deficiency—Systems: Medication Administration
Deficiency—Systems: Psychotropic Medication
Deficiency—Staffing Requirements and Training: Staffing
Deficiency—Acuity Based Staffing Tool - ABST Time
Deficiency—Fire and Life Safety: Safety
Deficiency—Fire and Life Safety: Training for Residents
Deficiency—Doors, Walls, Elevators, Odors
Deficiency—Individual Rights Settings: Privacy, Dignity
Deficiency—Individual Privacy: Own Unit
Deficiency—Administration Compliance
Deficiency—Compliance with Rules Health Care
21 May 2025Abuse: Neglect
21 May 2025Abuse: Neglect
Investigated and found neglect and abuse related to unsanitary living conditions and incomplete medical care, leading to multiple infections; guardians were not consistently notified and a monetary penalty was assessed.
Abuse—Failed to provide service
18 Mar 2025Abuse: Neglect
18 Mar 2025Abuse: Neglect
Investigated a complaint and found abuse and neglect involving failure to provide services and a safe environment, resulting in emotional harm and loss of dignity for a resident.
Abuse—Failed to provide service
03 Jan 2025Abuse: Neglect
03 Jan 2025Abuse: Neglect
Investigated a complaint and found violations related to neglect and abuse due to failure to properly plan care, resulting in repeated falls.
Abuse—Failed to properly plan care
31 Dec 2024Abuse: Neglect
31 Dec 2024Abuse: Neglect
Investigated a complaint and found neglect due to failure to monitor a resident and follow the care plan, resulting in a fall and injuries. A fine was assessed.
Abuse—Failed to provide service
20 Dec 2024Abuse: Neglect
20 Dec 2024Abuse: Neglect
Investigated allegations of neglect and abuse related to care planning and fall risk. Found failures to provide appropriate care, leading to multiple falls and injuries; a fine was assessed.
Abuse—Failed to properly plan care
18 Dec 2024Abuse: Neglect
18 Dec 2024Abuse: Neglect
Identified a failure to properly plan care for a known fall risk, resulting in multiple unwitnessed falls and injuries; found violations of resident rights with a fine assessed.
Abuse—Failed to properly plan care
11 Dec 2024Abuse: Neglect
11 Dec 2024Abuse: Neglect
Investigated a complaint and found that staff actions and staffing shortages endangered a resident, constituting abuse and neglect. A $375 fine was assessed.
Abuse—Failed to provide service
09 Dec 2024Abuse: Neglect
09 Dec 2024Abuse: Neglect
Found violations for failing to protect a resident from inappropriate sexual contact, with a $2,000 fine assessed.
Abuse—Failed to protect resident from inappropriate sexual contact
02 Dec 2024Abuse: Neglect
02 Dec 2024Abuse: Neglect
Found neglect and abuse due to failure to provide services and interventions to prevent falls, resulting in injuries and repeated discomfort. A fine was assessed.
Abuse—Failed to provide service
29 Nov 2024Abuse: Neglect
29 Nov 2024Abuse: Neglect
Determined that the provider failed to provide a safe environment, allowing residents with aggressive histories to harm each other; a fine was assessed.
Abuse—Failed to provide safe environment
29 Nov 2024Abuse: Neglect
29 Nov 2024Abuse: Neglect
Identified safety violations involving failure to provide a safe environment, resulting in abuse and neglect, with a fine assessed.
Abuse—Failed to provide safe environment
24 Nov 2024Abuse: Neglect
24 Nov 2024Abuse: Neglect
Concluded neglect occurred due to failure to follow the care plan, resulting in a fall and injury, with a fine assessed.
Abuse—Failed to follow care plan
04 Nov 2024Abuse: Neglect
04 Nov 2024Abuse: Neglect
Investigated an allegation that care safety was not maintained and harm occurred; found neglect and abuse due to failure to address aggressive behavior and provide a safe environment.
Abuse—Failed to provide safe environment
04 Nov 2024Abuse: Neglect
04 Nov 2024Abuse: Neglect
Found that interventions to address aggressive behavior were not implemented, placing a resident at risk for harm and constituting neglect and abuse.
Abuse—Failed to properly plan care
29 Oct 2024Abuse: Neglect
29 Oct 2024Abuse: Neglect
Found neglect due to failure to provide a safe medication administration system, leading to a low platelet count and risk of serious harm; a $188 fine was assessed.
Abuse—Failed to provide a safe medication administration system
02 Oct 2024Abuse: Neglect
02 Oct 2024Abuse: Neglect
Investigated the complaint and found that inadequate staffing left a resident unattended, resulting in a head injury after falling without an assistive device; one allegation against another staff member was inconclusive.
Abuse—Failed to meet the scheduled and unscheduled needs of residents
20 Sept 2024Abuse: Neglect
20 Sept 2024Abuse: Neglect
Investigated and identified failures to provide prescribed medications and to maintain a safe medication system, creating risk of serious harm to a resident. The resident did not receive medications for about three days and pain relief after a fall.
Abuse—Failed to administer medication as ordered
17 Sept 2024Abuse: Neglect
17 Sept 2024Abuse: Neglect
Investigated and found neglect and abuse due to failed care planning and insufficient interventions to prevent falls.
Abuse—Failed to properly plan care
29 Aug 2024Abuse: Neglect
29 Aug 2024Abuse: Neglect
Determined that the allegation of failing to protect a resident from inappropriate sexual contact was sustained, constituting abuse and neglect, with a fine assessed.
Abuse—Failed to protect resident from inappropriate sexual contact
28 Aug 2024Abuse: Neglect
28 Aug 2024Abuse: Neglect
Found neglect of care and abuse for failing to protect a resident from inappropriate sexual contact.
Abuse—Failed to protect resident from inappropriate sexual contact
12 Aug 2024Abuse: Neglect
12 Aug 2024Abuse: Neglect
Investigated allegations of neglect related to failure to properly plan care for a resident with a history of falls, and found safety planning deficiencies.
Abuse—Failed to properly plan care
07 Aug 2024Abuse: Neglect
07 Aug 2024Abuse: Neglect
Investigated and found neglect and abuse due to failing to provide a safe environment and to address repeated aggressive behaviors.
Abuse—Failed to provide safe environment
08 Jul 2024Abuse: Neglect
08 Jul 2024Abuse: Neglect
Investigated and found neglect due to failure to provide a safe environment. A resident with dementia was left unattended in a waiting area for about five hours after transport to the emergency department, causing discomfort and distress.
Abuse—Failed to provide safe environment
04 Jul 2024Abuse: Neglect
04 Jul 2024Abuse: Neglect
Found neglect and abuse due to failure to properly plan care, leading to approximately four falls with injuries. A $1,125 fine was assessed.
Abuse—Failed to properly plan care
04 Jun 2024Licensure
04 Jun 2024Licensure
Identified deficiencies in kitchen sanitation, food handling, and staff training across locations, including unsanitary surfaces, unlabeled foods, and missing food handler cards. Follow-up visits showed ongoing noncompliance but final status reported substantial compliance on the later visit.
Deficiency—Staffing Requirements and Training – Pre-Serv
Deficiency—Inspections and Investigation: Insp Interval
Deficiency—Administration Compliance
09 Mar 2024Inspection
09 Mar 2024Inspection
Determined that a staff member grabbed and restrained a resident, and protection from physical abuse was lacking.
Licensing—Failed to protect resident from physical abuse
26 Feb 2024Abuse: Neglect
26 Feb 2024Abuse: Neglect
Investigated found that fall-risk care planning was not implemented, leaving a resident at risk for serious harm and constituting abuse and neglect.
Abuse—Failed to properly plan care
06 Feb 2024Abuse: Neglect
06 Feb 2024Abuse: Neglect
Found a failure to provide a safe medication administration system and ensure adequate staff to check on residents, resulting in an injury to a resident.
Abuse—Failed to provide a safe medication administration system
31 Dec 2023Abuse: Neglect
31 Dec 2023Abuse: Neglect
Found neglect and abuse due to failure to ensure timely medical treatment, resulting in unreasonable discomfort for a resident and a $500 fine assessed.
Abuse—Failed to assure timely medical treatment
31 Dec 2023Inspection
31 Dec 2023Inspection
Investigated an allegation that services were not provided to meet a resident's needs and found neglect of care and abuse in violation of rules.
Licensing—Failed to provide service
31 Dec 2023Inspection
31 Dec 2023Inspection
Concluded that emotional/verbal abuse occurred and violated state rules, harming a resident's dignity.
Licensing—Failed to protect resident from verbal abuse
18 Dec 2023Abuse: Neglect
18 Dec 2023Abuse: Neglect
Found neglect and abuse due to failure to properly plan care for a known fall risk, leading to multiple falls and injuries, with a $375 fine assessed.
Abuse—Failed to properly plan care
08 Dec 2023Inspection
08 Dec 2023Inspection
Found violations of resident rights and neglect after a staff member yelled at and grabbed a resident, causing injuries.
Licensing—Failed to protect resident from physical abuse
08 Nov 2023Abuse: Neglect
08 Nov 2023Abuse: Neglect
Investigated a complaint about care planning for a resident; findings show failure to properly plan for behaviors led to an incident and constituted neglect and abuse.
Abuse—Failed to properly plan care
08 Nov 2023Abuse: Neglect
08 Nov 2023Abuse: Neglect
Investigated and found a failure to properly plan care for aggressive behaviors, which placed a resident at risk and led to an injury, constituting abuse and neglect.
Abuse—Failed to properly plan care
02 Nov 2023License Condition
02 Nov 2023License Condition
Found deficiencies in providing a safe environment. Evidence and interviews supported the finding.
Regulatory Action—Failed to provide safe environment
16 Oct 2023Validation
16 Oct 2023Validation
Identified widespread deficiencies across postings, resident rights, abuse reporting, service planning, health services, infection control, medication, staffing, nutrition, activities, and facility operations.
Deficiency—Resident Move-In and Eval: Res Evaluation
Deficiency—Service Plan: General
Deficiency—Change of Condition and Monitoring
Deficiency—Resident Health Services
Deficiency—Rn Delegation and Teaching
Deficiency—Infection Prevention & Control
Deficiency—Systems: Treatment Orders
Deficiency—Systems: Medication Administration
Deficiency—Staffing Requirements and Training: Staffing
Deficiency—Acuity-Based Staffing Tool
Deficiency—Acuity Based Staffing Tool - Abst Time
Deficiency—Inspections and Investigation: Insp Interval
Deficiency—General Building Exterior
Deficiency—Doors, Walls, Elevators, Odors
Deficiency—Individual Rights Settings: Privacy, Dignity
Deficiency—Individual Door Locks: Key Access
Deficiency—Administration Compliance
Deficiency—Compliance With Rules Health Care
Deficiency—Nutrition and Hydration
Deficiency—Activities
Deficiency—Behavior
Deficiency—Outside Area
Deficiency—Resident Rooms
08 Sept 2023Abuse: Neglect
08 Sept 2023Abuse: Neglect
Identified violations related to medication administration oversight and neglect, resulting in a resident not receiving medication for three days.
Abuse—Failed to provide a safe medication administration system
28 Aug 2023License Condition
28 Aug 2023License Condition
Identified a failure to use an acuity-based staffing tool to determine appropriate staffing levels.
Regulatory Action—Failed to use an ABST
04 Jul 2023Abuse: Neglect
04 Jul 2023Abuse: Neglect
Found violations of resident rights involving physical abuse and neglect when staff used force to move a resident indoors to change clothing, and found inadequate staff training related to this situation.
Abuse—Failed to protect resident from physical abuse
15 Jun 2023Abuse: Neglect
15 Jun 2023Abuse: Neglect
Found that improper care planning led to safety violations resulting in injury; assessed a $188 fine.
Abuse—Failed to properly plan care
06 Jun 2023Abuse: Neglect
06 Jun 2023Abuse: Neglect
Investigated and found that medications were not provided as ordered due to delays and incorrect pharmacy and physician arrangements, placing a resident at risk for harm. A $250 fine was assessed.
Abuse—Failed to provide a safe medication administration system
26 Apr 2023Complaint
26 Apr 2023Complaint
Investigated a licensure complaint; no specific deficiencies were described in the provided text.
Deficiency—Licensing Complaint Investigation
Deficiency—Acuity-Based Staffing Tool
18 Apr 2023Abuse: Neglect
18 Apr 2023Abuse: Neglect
Concluded that the care plan was not followed, resulting in abuse and neglect, with a fine assessed.
Abuse—Failed to follow care plan
16 Mar 2023Abuse: Neglect
16 Mar 2023Abuse: Neglect
Found violations of resident rights due to neglect and abuse from failing to intervene when a resident's condition changed and from failing to ensure safety.
Abuse—Failed to intervene when resident's condition changed
16 Feb 2023Inspection
16 Feb 2023Inspection
Found that a care plan for ambulation was not followed, resulting in a resident fall and head injury. This violated resident rights and constituted neglect and abuse.
Licensing—Failed to follow care plan
15 Feb 2023Abuse: Neglect
15 Feb 2023Abuse: Neglect
Concluded that a safe environment was not provided, constituting neglect and abuse; a fine was assessed.
Abuse—Failed to provide safe environment
27 Jan 2023Abuse: Neglect
27 Jan 2023Abuse: Neglect
Found neglect due to failure to provide or assist with hygiene, resulting in months of untrimmed nails and resident discomfort.
Abuse—Failed to provide or assist with hygiene
18 Jan 2023Licensure
18 Jan 2023Licensure
Confirmed substantial compliance with meal service and food sanitation requirements. No deficiencies were cited.
Deficiency—Comment
04 Jan 2023Inspection
04 Jan 2023Inspection
Investigated and found that a staff member failed to follow the resident's care plan, leaving the resident in a soiled brief with a soaked bed and causing unnecessary discomfort.
Licensing—Failed to follow care plan
02 Jan 2023Inspection
02 Jan 2023Inspection
Investigated found a resident was not assisted with toileting or diaper changes, leaving a soaked brief; neglect and abuse were identified.
Licensing—Failed to assist with toileting
07 Dec 2022Inspection
07 Dec 2022Inspection
Found deficiencies in wound care that led to an open wound worsening and transfer to ED for outside wound care.
Licensing—Failed to provide appropriate skin care
30 Nov 2022Inspection
30 Nov 2022Inspection
Investigated an allegation and identified a deficiency in updating the Acuity-Based Staffing Tool, with inconsistencies between the resident roster, care plans, and ABST data.
Licensing—Failed to use an ABST
04 Nov 2022Inspection
04 Nov 2022Inspection
Investigated allegation found a resident did not have access to all of their records. Found a violation of Oregon Administrative Rules.
Licensing—Failed to assure resident rights
10 Oct 2022Inspection
10 Oct 2022Inspection
Investigated and identified a records-keeping deficiency for failing to make records available upon request.
Licensing—Failed to cooperate with an investigation
10 Oct 2022Inspection
10 Oct 2022Inspection
Investigated an ABST usage allegation and found noncompliance due to an outdated ABST not reflecting resident needs, with inconsistencies between the roster, care plans, and ABST data.
Licensing—Failed to use an ABST
10 Oct 2022Inspection
10 Oct 2022Inspection
Found staffing levels did not consistently align with ABST indications. Inconsistencies between the staffing schedule and ABST data indicated under-staffing to meet resident needs.
Licensing—Failed to staff as indicated by ABST
06 Sept 2022Inspection
06 Sept 2022Inspection
Identified deficiencies due to an outdated ABST and inconsistencies between the resident roster, care plans, and ABST data, constituting a violation of Oregon Administrative Rules.
Licensing—Failed to use an ABST
17 Aug 2022Abuse: Neglect
17 Aug 2022Abuse: Neglect
Found improper hygiene resulting in neglect and abuse, causing discomfort to a resident. A $250 fine was assessed.
Abuse—Failed to provide or assist with hygiene
17 Aug 2022Complaint
17 Aug 2022Complaint
Identified deficiencies in staffing requirements and the acuity-based staffing tool.
Deficiency—Licensing Complaint Investigation
Deficiency—Staffing Requirements and Training: Staffing
Deficiency—Acuity-Based Staffing Tool
20 Jul 2022Inspection
20 Jul 2022Inspection
Investigated the staffing allegation and found that an acuity-based staffing tool was not fully implemented or updated.
Licensing—Failed to staff as indicated by ABST
20 Jul 2022Inspection
20 Jul 2022Inspection
Found an insufficient number of awake qualified direct care staff to meet residents' scheduled and unscheduled needs.
Licensing—Failed to provide appropriate staffing
03 Jun 2022Inspection
03 Jun 2022Inspection
Found that equipment was not kept in good repair, creating a potential for harm due to a broken washer.
Licensing—Failed to provide service
28 May 2022Abuse: Neglect
28 May 2022Abuse: Neglect
Investigated and found that a resident was not protected from mental and emotional abuse, causing fear and prompting consideration of relocation.
Abuse—Failed to protect resident from mental or emotional abuse
28 May 2022Abuse: Neglect
28 May 2022Abuse: Neglect
Investigated an abuse/neglect allegation and found a failure to provide a safe environment. A $500 fine was assessed.
Abuse—Failed to provide safe environment
22 Apr 2022Inspection
22 Apr 2022Inspection
Identified a deficiency for lacking written policies and procedures and accounting records for handling residents' personal incidental funds.
Licensing—Failed to assure resident rights
22 Apr 2022Inspection
22 Apr 2022Inspection
Identified a deficiency in maintaining an accurate Medication Administration Record for medications administered.
Licensing—Failed to keep medication record current or accurate
22 Apr 2022Inspection
22 Apr 2022Inspection
Investigated a complaint and found a deficiency related to safekeeping of residents' possessions. A rule violation was cited.
Licensing—Failed to assure resident rights
22 Apr 2022Inspection
22 Apr 2022Inspection
Investigated staffing issues and found insufficient staff to meet residents' scheduled and unscheduled needs, violating Oregon Administrative Rules.
Licensing—Failed to meet the scheduled and unscheduled needs of residents
15 Mar 2022Abuse: Neglect
15 Mar 2022Abuse: Neglect
Determined that a safe environment was not provided, constituting neglect and abuse. The incident placed residents at risk of harm.
Abuse—Failed to provide safe environment
04 Mar 2022Abuse: Neglect
04 Mar 2022Abuse: Neglect
Found deficiencies in care planning and safety when a resident suffered two falls and the care plan was not updated promptly.
Abuse—Failed to properly plan care
04 Mar 2022Inspection
04 Mar 2022Inspection
Investigated found a night-shift staff member failed to assist with toileting, leaving the resident in a soiled brief overnight; findings indicated neglect and abuse.
Licensing—Failed to assist with toileting
02 Mar 2022Inspection
02 Mar 2022Inspection
Found violations of care standards due to failing to follow the care plan and provide timely safety checks, leaving the resident at risk for harm and discomfort.
Licensing—Failed to follow care plan
15 Feb 2022Inspection
15 Feb 2022Inspection
Found a deficiency for failing to provide a safe environment due to no policy for safekeeping of residents possessions.
Licensing—Failed to provide safe environment
15 Feb 2022Abuse: Neglect
15 Feb 2022Abuse: Neglect
Found that inadequate care planning failed to prevent repeated falls and related injuries, constituting abuse and neglect. A $1,000 fine was assessed.
Abuse—Failed to properly plan care
15 Feb 2022Abuse: Neglect
15 Feb 2022Abuse: Neglect
Investigated and found a failure to provide a safe environment, resulting in abuse and neglect of a resident.
Abuse—Failed to provide safe environment
11 Feb 2022Inspection
11 Feb 2022Inspection
Found a deficiency for failing to provide a safe environment due to bloody and soiled sheets on a resident's bed.
Licensing—Failed to provide safe environment
11 Feb 2022Inspection
11 Feb 2022Inspection
Investigated an allegation that ordered medications were not administered and found that medication orders were not carried out as ordered.
Licensing—Failed to administer ordered medication
02 Feb 2022Abuse: Neglect
02 Feb 2022Abuse: Neglect
Found a failure to follow the care plan resulting in injuries and abuse; a fine was assessed.
Abuse—Failed to follow care plan
13 Jan 2022Abuse: Neglect
13 Jan 2022Abuse: Neglect
Investigated a case of abuse/neglect where staff failed to intervene as a resident's condition worsened, leading to hospitalization and a $375 fine.
Abuse—Failed to intervene when resident's condition changed
05 Jan 2022Inspection
05 Jan 2022Inspection
Identified a deficiency for not having a policy to safekeep residents belongings. The finding noted absence of a policy governing residents belongings.
Licensing—Failed to provide safe environment
25 Dec 2021Abuse: Neglect
25 Dec 2021Abuse: Neglect
Investigated and found failure to provide a safe environment, constituting abuse and neglect; a $500 fine was assessed.
Abuse—Failed to provide safe environment
25 Dec 2021Abuse: Neglect
25 Dec 2021Abuse: Neglect
Investigated a resident's bowel-care; bowel movements were not consistently logged and hospice status was not known to staff, placing the resident at risk for serious harm. A $500 fine was assessed.
Abuse—Failed to provide service
03 Dec 2021Inspection
03 Dec 2021Inspection
Found a deficiency for odor control due to interior smells described as bowel movement and urine.
Licensing—Failed to provide safe environment
14 Nov 2021Abuse: Neglect
14 Nov 2021Abuse: Neglect
Investigated neglect and abuse due to failure to properly plan for a resident, risking harm to others.
Abuse—Failed to properly plan care
13 Nov 2021Abuse: Neglect
13 Nov 2021Abuse: Neglect
Found that the care plan was not followed, resulting in a fall and neglect/abuse due to missing fall-prevention measures.
Abuse—Failed to follow care plan
10 Nov 2021Abuse: Neglect
10 Nov 2021Abuse: Neglect
Found that staff failed to follow the care plan, putting a resident at risk of harm and causing discomfort.
Abuse—Failed to follow care plan
08 Nov 2021Inspection
08 Nov 2021Inspection
Investigated the staffing allegation and found insufficient staff to meet scheduled and unscheduled resident needs.
Licensing—Failed to provide appropriate staffing
08 Nov 2021Inspection
08 Nov 2021Inspection
Investigated the complaint and found equipment not kept in good repair, including a call system that wasn't working.
Licensing—Failed to provide safe environment
20 Oct 2021Abuse: Neglect
20 Oct 2021Abuse: Neglect
Found violations for failing to provide a safe environment and neglect of care constituting abuse.
Abuse—Failed to provide safe environment
09 Oct 2021Abuse: Neglect
09 Oct 2021Abuse: Neglect
Found a violation of resident rights due to neglect and abuse after failing to follow the care plan, leading to an altercation between residents.
Abuse—Failed to follow care plan
21 Aug 2021Abuse: Neglect
21 Aug 2021Abuse: Neglect
Found that a safe environment was not provided, resulting in a bruise after an unwitnessed altercation; a $375 fine was assessed.
Abuse—Failed to provide safe environment
14 Aug 2021Abuse: Neglect
14 Aug 2021Abuse: Neglect
Identified a failure to provide a safe environment that harmed a resident, with confirmed violations. A $375 fine was assessed.
Abuse—Failed to provide safe environment
07 Aug 2021Abuse: Neglect
07 Aug 2021Abuse: Neglect
Investigated and found a failure to provide a safe environment, constituting abuse and neglect. Both residents had aggressive behaviors and prior altercations.
Abuse—Failed to provide safe environment
23 Jun 2021Inspection
23 Jun 2021Inspection
Found insufficient qualified awake direct care staff to meet residents' 24-hour needs, compromising safe environment.
Licensing—Failed to provide safe environment
23 Jun 2021Inspection
23 Jun 2021Inspection
Determined that the allegation of failing to provide a safe environment was substantiated, and found a deficiency related to safekeeping residents' possessions.
Licensing—Failed to provide safe environment
19 Jun 2021Abuse: Neglect
19 Jun 2021Abuse: Neglect
Found neglect and abuse due to failure to record a catheter after hospital return, risking staff not knowing about the catheter. A $250 fine was assessed.
Abuse—Failed to provide service
10 Jun 2021Abuse: Neglect
10 Jun 2021Abuse: Neglect
Found a violation for failing to follow a care plan, risking harm to a resident.
Abuse—Failed to follow care plan
05 Jun 2021Inspection
05 Jun 2021Inspection
Investigated insufficient staffing to meet residents' scheduled and unscheduled needs. Found that this violated Oregon Administrative Rules.
Licensing—Failed to provide service
05 Jun 2021Inspection
05 Jun 2021Inspection
Found that residents were not assisted with bathing and personal hygiene, violating Oregon Administrative Rules.
Licensing—Failed to provide service
05 Jun 2021Inspection
05 Jun 2021Inspection
Concluded that the provider failed to ensure the implementation of services, violating Oregon Administrative Rules.
Licensing—Failed to provide service
04 Jun 2021Abuse: Neglect
04 Jun 2021Abuse: Neglect
Determined that a safe medication administration system was not provided, resulting in a resident going without prescribed medication. A $500 fine was assessed.
Abuse—Failed to provide a safe medication administration system
06 May 2021Abuse: Neglect
06 May 2021Abuse: Neglect
Investigated an altercation that placed a resident at risk. Violations were found for failing to provide a safe environment.
Abuse—Failed to provide safe environment
30 Apr 2021Abuse: Neglect
30 Apr 2021Abuse: Neglect
Investigated findings showed hygiene neglect and insufficient care due to staffing, resulting in feces in the resident's room and on the resident. Violations were cited and a fine assessed.
Abuse—Failed to provide or assist with hygiene
30 Apr 2021Abuse: Neglect
30 Apr 2021Abuse: Neglect
Found medication safety failures, including medications left unsecured and later misused by a staff member, violating resident rights and constituting neglect. A civil fine was assessed.
Abuse—Failed to provide a safe medication administration system
30 Apr 2021Abuse: Neglect
30 Apr 2021Abuse: Neglect
Found that a resident was allowed to ambulate without a walker, creating a fall risk; a $1,500 fine was assessed.
Abuse—Failed to provide safe environment
30 Apr 2021Abuse: Neglect
30 Apr 2021Abuse: Neglect
Found a failure to provide a safe medication administration system that placed a resident at risk for serious harm; a fine was assessed.
Abuse—Failed to provide a safe medication administration system
22 Apr 2021Abuse: Neglect
22 Apr 2021Abuse: Neglect
Found a failure to provide a safe environment resulting in minor harm, with a $500 fine assessed.
Abuse—Failed to provide safe environment
07 Apr 2021Abuse: Neglect
07 Apr 2021Abuse: Neglect
Found neglect and abuse due to failure to timely change a resident's soaked brief, resulting in red skin. A $250 fine was assessed.
Abuse—Failed to assist with toileting
07 Apr 2021Abuse: Neglect
07 Apr 2021Abuse: Neglect
Identified neglect of hygiene care due to insufficient staffing, leading to missed showers and poor personal hygiene for a resident, risking harm.
Abuse—Failed to provide or assist with hygiene
05 Apr 2021Inspection
05 Apr 2021Inspection
Investigated the complaint and found deficiencies in infection prevention and control protocols. The finding noted a bed soiled with dried fecal material.
Licensing—Failed to provide service
05 Apr 2021Inspection
05 Apr 2021Inspection
Investigated a complaint and found deficiencies in assisting residents with eating and toileting.
Licensing—Failed to provide service
05 Apr 2021Inspection
05 Apr 2021Inspection
Found failure to keep the interior free from unpleasant odors based on a complaint about a resident's room. The finding cited odor-related requirements.
Licensing—Failed to provide safe environment
18 Mar 2021Abuse: Neglect
18 Mar 2021Abuse: Neglect
Investigated found a resident had multiple falls; internal investigations were not completed to rule out abuse, and staffing was insufficient to keep the resident safe, indicating neglect and abuse. A $500 fine was assessed.
Abuse—Failed to provide safe environment
20 Feb 2021Abuse: Neglect
20 Feb 2021Abuse: Neglect
Investigated and found neglect and abuse due to failure to monitor bowel movements, which led to a bowel obstruction requiring surgery and a $1500 fine.
Abuse—Failed to care plan in accordance with assessment
16 Feb 2021Abuse: Neglect
16 Feb 2021Abuse: Neglect
Investigated a complaint and found that a resident did not receive shower assistance, waited over an hour for staff, and faced unsafe conditions due to a non-working call system and failure to follow care plans; violations were cited and a fine assessed.
Abuse—Failed to provide safe environment
23 Jan 2021Abuse: Neglect
23 Jan 2021Abuse: Neglect
Investigated and found that care planning for an individual involved in altercations was inadequate, constituting neglect and abuse. A $500 fine was assessed.
Abuse—Failed to properly plan care
18 Dec 2020Abuse: Neglect
18 Dec 2020Abuse: Neglect
Investigated a safety issue due to insufficient staff to protect residents, resulting in an altercation and minor injury.
Abuse—Failed to provide safe environment
02 Dec 2020Abuse: Neglect
02 Dec 2020Abuse: Neglect
Investigated and identified neglect and abuse due to failing to intervene when a resident's condition changed, leading to an unresponsive resident during a med pass and delayed medical intervention.
Abuse—Failed to intervene when resident's condition changed
13 Nov 2020Abuse: Neglect
13 Nov 2020Abuse: Neglect
Found that transportation to medical appointments and pain medication were not provided, causing missed appointments and uncontrolled pain for a resident.
Abuse—Failed to provide service
11 Nov 2020Abuse: Neglect
11 Nov 2020Abuse: Neglect
Found violations of resident rights due to neglect and abuse, including failure to follow the resident's care plan and causing loss of dignity and risk of harm.
Abuse—Failed to assure resident rights
04 Nov 2020Abuse: Neglect
04 Nov 2020Abuse: Neglect
Found failure to properly plan care for falls risk after six falls caused skin tears and rug burns. A $250 fine was assessed.
Abuse—Failed to properly plan care
18 Oct 2020Abuse: Neglect
18 Oct 2020Abuse: Neglect
Found that a safe environment was not provided, resulting in neglect and abuse; a fine was assessed.
Abuse—Failed to provide safe environment
25 Jul 2020Abuse: Neglect
25 Jul 2020Abuse: Neglect
Investigated an allegation of abuse and neglect; found failure to follow the incontinence care plan, resulting in a rash.
Abuse—Failed to follow care plan
25 Jul 2020Abuse: Neglect
25 Jul 2020Abuse: Neglect
Found that the care plan for incontinence assistance was not followed, resulting in an injury from not being checked or toileted for 12-24 hours.
Abuse—Failed to follow care plan
04 Jul 2020Inspection
04 Jul 2020Inspection
Found that a resident was subjected to involuntary seclusion when a door was tied closed with a scarf for about two and a half hours. This act was identified as abuse and a failure to protect the resident from involuntary seclusion.
Licensing—Failed to protect resident from involuntary seclusion
04 Jul 2020Inspection
04 Jul 2020Inspection
Found neglect and abuse due to tying the door shut and failing to perform safety checks, creating risk of serious harm.
Licensing—Failed to follow care plan
04 Jul 2020Inspection
04 Jul 2020Inspection
Found a violation for failing to protect a resident from involuntary seclusion when a door was tied closed for several hours.
Licensing—Failed to protect resident from involuntary seclusion
29 Jun 2020Abuse: Neglect
29 Jun 2020Abuse: Neglect
Investigated and found that staff failed to intervene and timely obtain medical treatment for a resident whose condition changed, resulting in a later UTI diagnosis and pain.
Abuse—Failed to intervene when resident's condition changed
25 Jun 2020Abuse: Neglect
25 Jun 2020Abuse: Neglect
Investigated a complaint and found failure to follow the care plan for a known fall risk, creating a risk of serious harm.
Abuse—Failed to follow care plan
20 May 2020Inspection
20 May 2020Inspection
Investigated and found that staff failed to administer diabetic medication as ordered and failed to document administration, including withholding medication on two dates.
Licensing—Failed to administer medication as ordered
01 May 2020Abuse: Neglect
01 May 2020Abuse: Neglect
Investigated and found that a resident's known intrusive behavior was not adequately care planned for, leading to a resident-to-resident altercation and harm. A $375 fine was assessed.
Abuse—Failed to provide safe environment
23 Apr 2020Inspection
23 Apr 2020Inspection
Investigated found that a caregiver did not follow a resident's care plan, leading to an aggressive incident, and the environment was not kept safe.
Licensing—Failed to provide safe environment
18 Apr 2020Abuse: Neglect
18 Apr 2020Abuse: Neglect
Found that a safe environment was not provided, leading to a resident fall and injury.
Abuse—Failed to provide safe environment
15 Apr 2020Abuse: Neglect
15 Apr 2020Abuse: Neglect
Found that two alleged caregivers did not follow the resident's care plan, leading to neglect and abuse, and a fine was assessed.
Abuse—Failed to follow care plan
15 Apr 2020Abuse: Neglect
15 Apr 2020Abuse: Neglect
Identified a failure to provide a safe environment, resulting in substantiated abuse/neglect and a $375 fine.
Abuse—Failed to provide safe environment
05 Apr 2020Abuse: Neglect
05 Apr 2020Abuse: Neglect
Investigated a complaint and found a failure to provide a safe environment that allowed abuse and neglect of a resident.
Abuse—Failed to provide safe environment
02 Apr 2020Inspection
02 Apr 2020Inspection
Confirmed the allegation that the administrator failed to ensure the implementation of services per the rule.
Licensing—Failed to follow care plan
01 Apr 2020Abuse: Neglect
01 Apr 2020Abuse: Neglect
Found that the care plan for transfers and toileting was not followed, resulting in a resident fall and injuries. The finding involved neglect and abuse.
Abuse—Failed to follow care plan
31 Mar 2020Abuse: Neglect
31 Mar 2020Abuse: Neglect
Found a failure to provide a safe environment that led to injury; the allegation was substantiated and a fine was assessed.
Abuse—Failed to provide safe environment
31 Mar 2020Abuse: Neglect
31 Mar 2020Abuse: Neglect
Investigated a fall event and found the fall-prevention care plan was not followed, resulting in a skin tear.
Abuse—Failed to follow care plan
18 Mar 2020Inspection
18 Mar 2020Inspection
Found that a staff member verbally abused a resident and the resident was not protected from verbal abuse.
Licensing—Failed to protect resident from verbal abuse
18 Mar 2020Abuse: Neglect
18 Mar 2020Abuse: Neglect
Found a failure to provide a safe environment that caused minor harm to a resident.
Abuse—Failed to provide safe environment
17 Mar 2020Abuse: Neglect
17 Mar 2020Abuse: Neglect
Investigated and found a safe-environment violation involving abuse and neglect; a $375 fine was assessed.
Abuse—Failed to provide safe environment
02 Mar 2020Inspection
02 Mar 2020Inspection
Investigated the allegation of failing to administer medications as ordered; found that medication orders were not carried out as prescribed.
Licensing—Failed to administer medication as ordered
25 Feb 2020Abuse: Neglect
25 Feb 2020Abuse: Neglect
Investigated a complaint alleging abuse and neglect; found a staff member with a history of inappropriate interactions touched a resident and preventive interventions were not implemented, resulting in violations and a fine.
Abuse—Failed to provide safe environment
24 Jan 2020Abuse: Neglect
24 Jan 2020Abuse: Neglect
Investigated and found a failure to follow the care plan, putting a resident at risk for harm and constituting abuse and neglect.
Abuse—Failed to follow care plan
20 Jan 2020Abuse: Neglect
20 Jan 2020Abuse: Neglect
Investigated a complaint about failing to provide a safe environment. Findings showed staff did not intervene during a behavioral incident and did not follow the care plan, constituting abuse and neglect, with a fine assessed.
Abuse—Failed to provide safe environment
20 Jan 2020Abuse: Neglect
20 Jan 2020Abuse: Neglect
Investigated a care-violation where staff failed to redirect two residents, leading to a tense incident and pain; abuse and neglect were identified.
Abuse—Failed to provide safe environment
11 Jan 2020Abuse: Neglect
11 Jan 2020Abuse: Neglect
Investigated and found abuse and neglect due to inappropriate use of electronics by a person with access to care, resulting in a fine. A $1,125 fine was assessed.
Abuse—Failed to provide safe environment
27 Nov 2019Abuse: Neglect
27 Nov 2019Abuse: Neglect
Investigated a complaint and found a failure to provide a safe environment that constitutes abuse/neglect, with a fine assessed.
Abuse—Failed to properly plan care
13 Nov 2019Abuse: Neglect
13 Nov 2019Abuse: Neglect
Investigated a complaint alleging neglect and abuse; found failure to follow the care plan leading to a resident-to-resident altercation and unsafe conditions.
Abuse—Failed to provide safe environment
13 Nov 2019Abuse: Neglect
13 Nov 2019Abuse: Neglect
Investigated a resident-to-resident altercation and found that care plans were not followed, resulting in abuse and neglect, with a fine assessed.
Abuse—Failed to provide safe environment
11 Nov 2019Abuse: Neglect
11 Nov 2019Abuse: Neglect
Found that care plan was not followed and safety was not ensured, leading to a resident-to-resident incident; a fine was assessed.
Abuse—Failed to provide safe environment
27 Sept 2019Abuse: Neglect
27 Sept 2019Abuse: Neglect
Determined neglect for failing to follow a care plan, resulting in significant harm; assessed a $2,500 fine.
Abuse—Failed to follow care plan
27 Sept 2019Abuse: Neglect
27 Sept 2019Abuse: Neglect
Found neglect due to failure to provide basic care that resulted in significant physical harm.
Abuse—Failed to follow care plan
11 Sept 2019Abuse: Neglect
11 Sept 2019Abuse: Neglect
Determined neglect due to failure to provide basic care and services, resulting in harm. A $375 fine was assessed.
Abuse—Failed to provide safe environment
11 Sept 2019Abuse: Neglect
11 Sept 2019Abuse: Neglect
Found that basic care and services were not provided, resulting in physical harm, significant emotional harm, and loss of dignity.
Abuse—Failed to provide safe environment
31 Aug 2019Abuse: Neglect
31 Aug 2019Abuse: Neglect
Found neglect by failing to prevent repeated resident-to-resident altercations, resulting in harm and risk of harm.
Abuse—Failed to properly plan care
29 Aug 2019Inspection
29 Aug 2019Inspection
Found that suspected abuse was not reported, resulting in a moderate-harm violation.
Licensing—Failed to report potential or suspected abuse
29 Aug 2019Abuse: Neglect
29 Aug 2019Abuse: Neglect
Investigated and found neglect of care that created risk of physical harm to a care recipient. A fine of $500 was assessed.
Abuse—Failed to provide safe environment
24 Aug 2019Abuse: Neglect
24 Aug 2019Abuse: Neglect
Investigated an allegation of abuse and neglect and found that a safe environment was not provided, resulting in a resident injury during an intervention.
Abuse—Failed to provide safe environment
14 Aug 2019Abuse: Neglect
14 Aug 2019Abuse: Neglect
Investigated the case, found neglect of care resulting in physical harm, and assessed a fine.
Abuse—Failed to provide safe environment
11 Aug 2019Abuse: Neglect
11 Aug 2019Abuse: Neglect
Investigated a neglect allegation and found that basic care was not provided, creating a risk of serious harm; a $375 fine was assessed.
Abuse—Failed to provide safe environment
10 Aug 2019Abuse: Neglect
10 Aug 2019Abuse: Neglect
Investigated and found failures to provide a safe environment resulting in falls and injuries, with a fine assessed.
Abuse—Failed to provide safe environment
03 Aug 2019Inspection
03 Aug 2019Inspection
Investigated and identified a failure to report suspected abuse, with a $1000 fine assessed.
Licensing—Failed to report potential or suspected abuse
03 Aug 2019Abuse: Neglect
03 Aug 2019Abuse: Neglect
Investigated a neglect allegation related to basic care and safety and found that care failures led to harm, with a $500 fine assessed.
Abuse—Failed to provide safe environment
31 Jul 2019Abuse: Neglect
31 Jul 2019Abuse: Neglect
Investigated a resident-to-resident incident and found failure to properly plan care and an unsafe environment. This constitutes abuse and neglect.
Abuse—Failed to properly plan care
20 Jul 2019Abuse: Neglect
20 Jul 2019Abuse: Neglect
Investigated an allegation of neglect and found that basic care essential for health and safety was not provided, risking serious harm; a fine was assessed.
Abuse—Failed to provide safe environment
20 Jul 2019Abuse: Neglect
20 Jul 2019Abuse: Neglect
Found neglect of basic care that risked health and safety for a resident, and a fine was assessed.
Abuse—Failed to provide safe environment
16 Jul 2019Abuse: Neglect
16 Jul 2019Abuse: Neglect
Investigated a neglect allegation and found failure to provide basic care and services, resulting in physical harm.
Abuse—Failed to follow care plan
16 Jul 2019Abuse: Neglect
16 Jul 2019Abuse: Neglect
Investigated an allegation of neglect and determined the alleged perpetrator failed to provide basic care and services, creating a risk of serious harm to the resident.
Abuse—Failed to provide safe environment
12 Jul 2019Abuse: Physical Abuse
12 Jul 2019Abuse: Physical Abuse
Investigated an allegation of physical abuse and found failure to protect a resident from rough treatment.
Abuse—Failed to protect resident from rough treatment
28 Jun 2019Abuse: Neglect
28 Jun 2019Abuse: Neglect
Investigated and found neglect of care that posed risk of serious physical harm; $1,500 fine assessed.
Abuse—Failed to intervene when resident's condition changed
28 Jun 2019Inspection
28 Jun 2019Inspection
Investigated and found that suspected abuse was not reported, and a $1,000 fine was assessed.
Licensing—Failed to report potential or suspected abuse
06 Jun 2019Abuse: Neglect
06 Jun 2019Abuse: Neglect
Found neglectful care resulting in physical harm; a fine was assessed.
Abuse—Failed to provide safe environment
22 Mar 2019Abuse: Neglect
22 Mar 2019Abuse: Neglect
Concluded that neglect occurred due to lack of appropriate supervision, creating a risk of serious harm. A $375 fine was assessed.
Abuse—Failed to provide safe environment
04 Mar 2019Abuse: Neglect
04 Mar 2019Abuse: Neglect
Found neglect of care resulting in risk of serious injury.
Abuse—Failed to follow care plan
03 Mar 2019Abuse: Neglect
03 Mar 2019Abuse: Neglect
Found a failure to provide a safe environment, resulting in emotional harm and risk to a resident. A $375 fine was assessed.
Abuse—Failed to provide safe environment
03 Mar 2019Abuse: Neglect
03 Mar 2019Abuse: Neglect
Found neglect with minor harm and assessed a $375 fine.
Abuse—Failed to provide safe environment
15 Feb 2019Abuse: Neglect
15 Feb 2019Abuse: Neglect
Investigated a complaint and found neglect due to failure to provide appropriate care, resulting in potential harm to the resident.
Abuse—Failed to provide safe environment
08 Feb 2019Abuse: Neglect
08 Feb 2019Abuse: Neglect
Investigated the complaint and found neglect related to failing to provide a safe environment, with a $1,125 fine assessed.
Abuse—Failed to provide safe environment
06 Jan 2019Abuse: Neglect
06 Jan 2019Abuse: Neglect
Found neglect related to falls care which led to hospitalization of the Alleged Victim. A fine of $1125.00 was assessed.
Abuse—Failed to adequately care plan related to falls
02 Jan 2019Abuse: Verbal/Mental abuse
02 Jan 2019Abuse: Verbal/Mental abuse
Found that a resident was not protected from verbal abuse and did not receive basic care, causing discomfort.
Abuse—Failed to protect resident from verbal abuse
25 Dec 2018Abuse: Neglect
25 Dec 2018Abuse: Neglect
Investigated a complaint about care and safety; concluded that basic care was not provided and a resident was slapped by another resident, creating harm and risk, and a fine was assessed.
Abuse—Failed to properly plan care
22 Dec 2018Abuse: Neglect
22 Dec 2018Abuse: Neglect
Investigated the neglect allegation and found a failure to provide a secure environment, risking serious harm.
Abuse—Failed to provide safe environment
21 Dec 2018Abuse: Neglect
21 Dec 2018Abuse: Neglect
Found neglect of care for a person under care due to failure to protect them from an inappropriate interaction.
Abuse—Failed to provide safe environment
21 Dec 2018Abuse: Neglect
21 Dec 2018Abuse: Neglect
Concluded neglect by failing to protect a person from physical harm; the allegation was substantiated.
Abuse—Failed to provide safe environment
06 Dec 2018Abuse: Neglect
06 Dec 2018Abuse: Neglect
Concluded neglect occurred by failing to protect a resident from inappropriate sexual contact, creating a risk of serious harm. The finding was substantiated.
Abuse—Failed to protect resident from inappropriate sexual contact
04 Dec 2018Abuse: Neglect
04 Dec 2018Abuse: Neglect
Identified neglect of care due to inadequate supervision; a $375 fine was assessed.
Abuse—Failed to provide safe environment
30 Nov 2018Abuse: Neglect
30 Nov 2018Abuse: Neglect
Investigated a neglect allegation and found failure to follow the care plan and to provide a safe environment, resulting in a $375 fine.
Abuse—Failed to follow care plan
29 Oct 2018Abuse: Neglect
29 Oct 2018Abuse: Neglect
Found neglect in failing to administer medications as ordered, creating a serious risk of harm.
Abuse—Failed to administer ordered medication
26 Oct 2018Abuse: Neglect
26 Oct 2018Abuse: Neglect
Found neglect due to failure to provide proper supervision and basic care, with a $375 fine assessed.
Abuse—Failed to properly plan care
13 Oct 2018Abuse: Neglect
13 Oct 2018Abuse: Neglect
Determined neglect by failing to provide basic services led to physical harm, and a fine was assessed.
Abuse—Failed to properly plan care
26 Sept 2018Inspection
26 Sept 2018Inspection
Found a violation for failing to protect residents from inappropriate physical contact, with a $375 fine assessed.
Licensing—Failed to provide safe environment
17 Sept 2018Abuse: Neglect
17 Sept 2018Abuse: Neglect
Investigated a neglect allegation and found that basic care was not provided to maintain residents' physical safety.
Abuse—Failed to properly plan care
15 Sept 2018Abuse: Neglect
15 Sept 2018Abuse: Neglect
Identified neglect of care due to failure to provide appropriate supervision, creating the risk of serious harm.
Abuse—Failed to properly plan care
12 Sept 2018Inspection
12 Sept 2018Inspection
Determined that the licensee failed to report suspected abuse. A $1,000 fine was assessed.
Licensing—Failed to report potential or suspected abuse
12 Sept 2018Abuse: Neglect
12 Sept 2018Abuse: Neglect
Investigated a neglect allegation and concluded the facility failed to protect a resident from physical harm, resulting in a serious injury. A $2,500 fine was assessed.
Abuse—Failed to provide service
11 Sept 2018Inspection
11 Sept 2018Inspection
Confirmed an allegation that there was a failure to provide a safe environment by not exercising reasonable precautions against conditions that may threaten residents' health, safety, or welfare.
Licensing—Failed to provide safe environment
11 Sept 2018Inspection
11 Sept 2018Inspection
Investigated a complaint and found a deficiency for not keeping interior surfaces and materials clean.
Licensing—Failed to provide safe environment
11 Sept 2018Abuse: Neglect
11 Sept 2018Abuse: Neglect
Found neglect for failing to protect residents from an inappropriate interaction that caused physical harm. A fine of $2,500 was assessed.
Abuse—Failed to provide safe environment
07 Sept 2018Inspection
07 Sept 2018Inspection
Investigated a report of failure to report suspected abuse; found a substantiated licensing violation and a $1000 fine was assessed.
Licensing—Failed to report potential or suspected abuse
07 Sept 2018Abuse: Neglect
07 Sept 2018Abuse: Neglect
Investigated a complaint of neglect and found failure to provide appropriate care. A $500 fine was assessed.
Abuse—Failed to intervene when resident's condition changed
23 Aug 2018Inspection
23 Aug 2018Inspection
Investigated an allegation of failing to report suspected abuse. Found a reporting deficiency and assessed a $1000 fine.
Licensing—Failed to report potential or suspected abuse
23 Aug 2018Abuse: Neglect
23 Aug 2018Abuse: Neglect
Investigated a complaint and found neglect due to delayed incontinence care that led to a wound; a $1,500 fine was assessed.
Abuse—Failed to follow care plan
09 Jul 2018Inspection
09 Jul 2018Inspection
Determined a failure to report suspected abuse, with a $1000 fine assessed.
Licensing—Failed to report potential or suspected abuse
09 Jul 2018Abuse: Neglect
09 Jul 2018Abuse: Neglect
Found violations of care standards related to neglect and failure to intervene when a resident's condition changed, with a $250 fine assessed.
Abuse—Failed to intervene when resident's condition changed
29 Jun 2018Abuse: Neglect
29 Jun 2018Abuse: Neglect
Found neglect for failing to protect a resident from physical harm and assessed a $375 fine.
Abuse—Failed to provide safe environment
14 Jun 2018Inspection
14 Jun 2018Inspection
Found failure to provide a safe medication administration system. A $375 fine was assessed.
Licensing—Failed to provide a safe medication administration system
20 Mar 2018Abuse: Neglect
20 Mar 2018Abuse: Neglect
Investigated an allegation of abuse/neglect and found failure to follow the care plan, resulting in inadequate care. A $500 fine was assessed.
Abuse—Failed to follow care plan
20 Mar 2018Inspection
20 Mar 2018Inspection
Investigated an allegation of failure to report potential abuse; violations observed and a civil penalty assessed.
Licensing—Failed to report potential or suspected abuse
31 Jan 2018Inspection
31 Jan 2018Inspection
Investigated the allegation and found a failure to provide an adequate medication system. The finding indicates potential for harm.
Licensing—Failed to provide a safe medication administration system
22 Jan 2018Inspection
22 Jan 2018Inspection
Found a violation involving an unsafe medication administration system and financial exploitation of residents, with a $375 fine assessed.
Licensing—Failed to provide a safe medication administration system
19 Oct 2017Inspection
19 Oct 2017Inspection
Investigated and found failure to provide appropriate care.
Licensing—Failed to follow care plan
12 Sept 2017Inspection
12 Sept 2017Inspection
Investigated and substantiated the allegation of inadequate staffing. A regulatory rule was violated.
Licensing—Failed to provide appropriate staffing
20 Aug 2017Inspection
20 Aug 2017Inspection
Investigated a complaint that a safe environment wasn't provided; supervision was found to be improper.
Licensing—Failed to provide safe environment
19 Aug 2017Inspection
19 Aug 2017Inspection
Investigated allegation of an unsafe environment and found that proper supervision was not provided.
Licensing—Failed to provide safe environment
07 Aug 2017Abuse: Neglect
07 Aug 2017Abuse: Neglect
Investigated an allegation of neglect related to providing a safe environment and found that reported victims were not given appropriate supervision.
Abuse—Failed to provide safe environment
03 Aug 2017Inspection
03 Aug 2017Inspection
Investigated the allegation and found that a resident's rights were not allowed to be exercised.
Licensing—Failed to assure resident rights
26 Jul 2017Inspection
26 Jul 2017Inspection
Investigated the allegation of failing to provide a safe environment; found a licensing violation and assessed a $200 civil penalty.
Licensing—Failed to provide safe environment
18 Jul 2017Abuse: Neglect
18 Jul 2017Abuse: Neglect
Investigated an allegation of neglect and found supervision was inadequate, risking resident safety.
Abuse—Failed to assure resident was safe
03 Jul 2017Inspection
03 Jul 2017Inspection
Investigated and found a safety violation involving failure to protect residents from inappropriate interaction.
Licensing—Failed to provide safe environment
22 Jun 2017Abuse: Neglect
22 Jun 2017Abuse: Neglect
Investigated and found the facility failed to protect a reported victim from physical harm.
Abuse—Failed to provide safe environment
14 Jun 2017Inspection
14 Jun 2017Inspection
Concluded that a safe environment was not provided due to insufficient supervision.
Licensing—Failed to provide safe environment
09 Jun 2017Abuse: Neglect
09 Jun 2017Abuse: Neglect
Found that a resident was not protected from physical harm.
Abuse—Failed to follow care plan
08 Jun 2017Abuse: Financial abuse
08 Jun 2017Abuse: Financial abuse
Investigated the allegation of financial exploitation and found a failure to protect a resident from wrongful taking of resources.
Abuse—Failed to protect resident from financial exploitation
05 Jun 2017Abuse: Neglect
05 Jun 2017Abuse: Neglect
Investigated and substantiated a failure to provide a safe environment and protect residents from inappropriate interactions; a $250 fine was assessed.
Abuse—Failed to provide safe environment
31 May 2017Inspection
31 May 2017Inspection
Concluded the allegation of failing to provide a safe environment and identified a deficiency related to protecting residents from inappropriate interaction.
Licensing—Failed to provide safe environment
25 May 2017Inspection
25 May 2017Inspection
Investigated the allegation and found a failure to provide a safe environment.
Licensing—Failed to provide safe environment
25 May 2017Inspection
25 May 2017Inspection
Found a failure to report injuries of unknown cause to the local SPD as required.
Licensing—Failed to investigate injury of unknown origin to rule out abuse
22 May 2017Inspection
22 May 2017Inspection
Found a substantiated deficiency where residents were not protected from inappropriate physical contact.
Licensing—Failed to provide safe environment
22 May 2017Inspection
22 May 2017Inspection
Concluded that there was a failure to protect a resident from physical harm; a $250 fine was assessed.
Licensing—Failed to provide safe environment
17 May 2017Inspection
17 May 2017Inspection
Investigated the allegation of failing to notify the Department 90 days prior to remodeling when moving a resident from their room; found a deficiency under the cited rule.
Licensing—Failed to comply with move-out, transfer or discharge requirements
15 May 2017Inspection
15 May 2017Inspection
Found inadequate supervision resulting in a resident-to-resident incident.
Licensing—Failed to provide safe environment
15 May 2017Inspection
15 May 2017Inspection
Determined a deficiency for failing to provide a safe environment due to inadequate supervision, which led to one resident grabbing another.
Licensing—Failed to provide safe environment
15 May 2017Inspection
15 May 2017Inspection
Found that a resident was not protected from physical harm.
Licensing—Failed to provide safe environment
09 May 2017Inspection
09 May 2017Inspection
Investigated the allegation and identified a deficiency for failing to provide a safe environment, including not protecting residents from inappropriate physical contact.
Licensing—Failed to provide safe environment
06 May 2017Abuse: Neglect
06 May 2017Abuse: Neglect
Found a failure to provide a safe environment.
Abuse—Failed to provide safe environment
01 May 2017Inspection
01 May 2017Inspection
Found a licensing violation for failing to protect residents from inappropriate interaction, with potential for minor to moderate harm.
Licensing—Failed to provide safe environment
28 Apr 2017Inspection
28 Apr 2017Inspection
Investigated an allegation of failing to provide a safe environment and found that proper supervision was not provided.
Licensing—Failed to provide safe environment
27 Apr 2017Abuse: Neglect
27 Apr 2017Abuse: Neglect
Found failure to follow the care plan that risked a resident's physical harm.
Abuse—Failed to follow care plan
21 Apr 2017Inspection
21 Apr 2017Inspection
Investigated a complaint and identified a deficiency related to failing to protect residents from inappropriate physical contact.
Licensing—Failed to provide safe environment
18 Apr 2017Inspection
18 Apr 2017Inspection
Found that residents were not protected from inappropriate physical contact.
Licensing—Failed to provide safe environment
24 Mar 2017Condition
24 Mar 2017Condition
Investigated the abuse/neglect allegation and determined that the allegation of failing to provide a safe environment was supported.
Regulatory Action—Failed to provide safe environment
23 Mar 2017Abuse: Neglect
23 Mar 2017Abuse: Neglect
Investigated and found deficiencies related to an unsafe environment and failure to protect residents from inappropriate physical contact.
Abuse—Failed to provide safe environment
20 Mar 2017Abuse: Neglect
20 Mar 2017Abuse: Neglect
Investigated a complaint about neglect; found residents were not protected from inappropriate physical contact and a $300 fine was assessed.
Abuse—Failed to address resident's behavior
17 Mar 2017Inspection
17 Mar 2017Inspection
Concluded that a safety failure left a resident exposed to physical harm.
Licensing—Failed to provide safe environment
08 Mar 2017Abuse: Neglect
08 Mar 2017Abuse: Neglect
Investigated an abuse/neglect allegation and found inadequate supervision, with a $300 fine assessed.
Abuse—Failed to address resident's behavior
16 Feb 2017Abuse: Neglect
16 Feb 2017Abuse: Neglect
Investigated an allegation of neglect and found violations for failing to provide proper supervision.
Abuse—Failed to provide safe environment
13 Feb 2017Abuse: Neglect
13 Feb 2017Abuse: Neglect
Found residents were not protected from inappropriate interaction, creating a risk of harm.
Abuse—Failed to provide safe environment
07 Feb 2017Abuse: Neglect
07 Feb 2017Abuse: Neglect
Found failure to follow the care plan and inadequate supervision, and assessed a $200 fine.
Abuse—Failed to follow care plan
29 Jan 2017Abuse: Neglect
29 Jan 2017Abuse: Neglect
Investigated an allegation of neglect and identified a deficiency in protecting residents from inappropriate physical contact.
Abuse—Failed to address resident's behavior
17 Jan 2017Abuse: Neglect
17 Jan 2017Abuse: Neglect
Found residents were not protected from inappropriate physical contact.
Abuse—Failed to address resident's behavior
14 Jan 2017Abuse: Neglect
14 Jan 2017Abuse: Neglect
Found that residents were not adequately protected from inappropriate interactions.
Abuse—Failed to address resident's behavior
02 Jan 2017Abuse: Neglect
02 Jan 2017Abuse: Neglect
Found failure to provide proper medical treatment during an investigation; a $300 fine was assessed.
Abuse—Failed to intervene when resident's condition changed
28 Dec 2016Inspection
28 Dec 2016Inspection
Found insufficient staffing to meet the schedule and unscheduled needs, resulting in excessive wait times for call-light responses.
Licensing—Failed to answer call light in a timely manner
28 Dec 2016Inspection
28 Dec 2016Inspection
Identified inadequate staff training in violation of training requirements.
Licensing—Failed to hire according to administrative rules
28 Dec 2016Inspection
28 Dec 2016Inspection
Investigated an allegation of inadequate housekeeping and odors. Found a deficiency for not being free from unpleasant odors.
Licensing—Failed to provide appropriate housekeeping services
28 Dec 2016Inspection
28 Dec 2016Inspection
Found premises not kept clean and in good repair.
Licensing—Failed to provide or maintain resident care equipment
28 Dec 2016Inspection
28 Dec 2016Inspection
Found that residents were not provided activities as required by regulation.
Licensing—Failed to provide appropriate activities
10 Dec 2016Abuse: Neglect
10 Dec 2016Abuse: Neglect
Investigated and determined that residents were not protected from physical harm.
Abuse—Failed to address resident's behavior
19 Nov 2016Abuse: Neglect
19 Nov 2016Abuse: Neglect
Investigated an allegation of failing to address resident behavior and found residents were not protected from inappropriate interactions.
Abuse—Failed to address resident's behavior
07 Nov 2016Abuse: Neglect
07 Nov 2016Abuse: Neglect
Found supervision deficient that led to a resident-to-resident altercation.
Abuse—Failed to address resident's behavior
02 Nov 2016Abuse: Neglect
02 Nov 2016Abuse: Neglect
Investigated a report of abuse/neglect; found that a resident was harmed when another resident pushed them, showing failure to protect residents from physical harm.
Abuse—Failed to address resident's behavior
02 Nov 2016Abuse: Neglect
02 Nov 2016Abuse: Neglect
Investigated a complaint and found violations related to failing to address resident behavior and failing to protect residents from inappropriate interactions.
Abuse—Failed to address resident's behavior
27 Oct 2016Inspection
27 Oct 2016Inspection
Investigated the allegation of improper care planning and found deficiencies related to failure to provide appropriate care.
Licensing—Failed to properly plan care
22 Oct 2016Abuse: Neglect
22 Oct 2016Abuse: Neglect
Found that residents were not protected from inappropriate physical contact.
Abuse—Failed to address resident's behavior
18 Oct 2016Abuse: Neglect
18 Oct 2016Abuse: Neglect
Determined that falls-related care planning was inadequate and care was not provided appropriately.
Abuse—Failed to adequately care plan related to falls
09 Oct 2016Abuse: Neglect
09 Oct 2016Abuse: Neglect
Investigated and found that residents were not provided with appropriate supervision. This substantiated neglect finding indicated violations were cited.
Abuse—Failed to address resident's behavior
27 Sept 2016Abuse: Neglect
27 Sept 2016Abuse: Neglect
Investigated an allegation of abuse/neglect and found failure to protect residents from inappropriate physical contact, with a $300 fine assessed.
Abuse—Failed to address resident's behavior
26 Sept 2016Inspection
26 Sept 2016Inspection
Investigated an allegation of failing to investigate an injury of unknown origin to rule out abuse and identified a deficiency in reporting injuries of unknown causes.
Licensing—Failed to investigate injury of unknown origin to rule out abuse
21 Sept 2016Abuse: Neglect
21 Sept 2016Abuse: Neglect
Found inadequate care planning related to falls.
Abuse—Failed to adequately care plan related to falls
13 Sept 2016Abuse: Neglect
13 Sept 2016Abuse: Neglect
Found supervision inadequate, creating risk to residents.
Abuse—Failed to address resident's behavior
19 Aug 2016Inspection
19 Aug 2016Inspection
Found deficiencies in supervision that compromised a safe environment.
Licensing—Failed to provide safe environment
19 Aug 2016Abuse: Neglect
19 Aug 2016Abuse: Neglect
Investigated an abuse/neglect allegation and identified a failure to provide proper supervision, creating a safety risk.
Abuse—Failed to provide safe environment
02 Aug 2016Abuse: Neglect
02 Aug 2016Abuse: Neglect
Found residents were not protected from inappropriate interaction.
Abuse—Failed to address resident's behavior
18 Jul 2016Abuse: Neglect
18 Jul 2016Abuse: Neglect
Found residents were not protected from inappropriate interaction.
Abuse—Failed to address resident's behavior
15 Jul 2016Abuse: Neglect
15 Jul 2016Abuse: Neglect
Investigated a complaint and identified a failure to provide a safe environment, with a $300 fine assessed.
Abuse—Failed to address resident's behavior
11 Jul 2016Inspection
11 Jul 2016Inspection
Investigated the allegation and found that appropriate care was not provided to residents.
Licensing—Failed to address resident's behavior
07 Jul 2016Abuse: Neglect
07 Jul 2016Abuse: Neglect
Identified neglect involving failing to address resident's behavior and failing to provide a safe environment.
Abuse—Failed to address resident's behavior
05 Jul 2016Abuse: Neglect
05 Jul 2016Abuse: Neglect
Found deficiencies in providing a safe environment and assessed a $300 fine.
Abuse—Failed to address resident's behavior
28 Jun 2016Abuse: Neglect
28 Jun 2016Abuse: Neglect
Investigated and concluded that residents were not protected from inappropriate interaction, resulting in a rug burn.
Abuse—Failed to provide safe environment
20 Jun 2016Abuse: Neglect
20 Jun 2016Abuse: Neglect
Investigated an abuse/neglect allegation and found a failure to protect a resident from inappropriate interactions.
Abuse—Failed to address resident's behavior
15 Jun 2016Abuse: Neglect
15 Jun 2016Abuse: Neglect
Concluded that a resident was not protected from nonconsensual sexual contact.
Abuse—Failed to protect resident from inappropriate sexual contact
15 Jun 2016Abuse: Neglect
15 Jun 2016Abuse: Neglect
Investigated the abuse/neglect allegation and found residents were not protected from inappropriate interaction, resulting in an altercation.
Abuse—Failed to address resident's behavior
10 Jun 2016Abuse: Neglect
10 Jun 2016Abuse: Neglect
Investigated an abuse/neglect allegation and found a resident protection deficiency related to failure to address inappropriate interaction.
Abuse—Failed to address resident's behavior
08 Jun 2016Abuse: Neglect
08 Jun 2016Abuse: Neglect
Found that a provider failed to protect a resident from inappropriate interaction and upheld the allegation that it failed to address the resident's behavior.
Abuse—Failed to address resident's behavior
05 Jun 2016Abuse: Neglect
05 Jun 2016Abuse: Neglect
Found that residents were not protected from inappropriate interaction, and a $300 fine was assessed.
Abuse—Failed to address resident's behavior
05 Jun 2016Abuse: Neglect
05 Jun 2016Abuse: Neglect
Investigated a complaint alleging neglect related to addressing a resident's behavior and protecting them from inappropriate interaction; found that a resident was not protected from inappropriate interaction.
Abuse—Failed to address resident's behavior
24 May 2016Inspection
24 May 2016Inspection
Investigated and substantiated a safety violation involving failure to protect a resident from physical harm.
Licensing—Failed to provide safe environment
05 May 2016Abuse: Neglect
05 May 2016Abuse: Neglect
Determined neglect occurred due to failure to follow care plan and failure to protect a resident from physical harm; a $300 fine was assessed.
Abuse—Failed to follow care plan
29 Mar 2016Abuse: Neglect
29 Mar 2016Abuse: Neglect
Investigated an allegation of unsafe environment and found a failure to protect residents from physical harm.
Abuse—Failed to provide safe environment
23 Mar 2016Abuse: Neglect
23 Mar 2016Abuse: Neglect
Found a deficiency where residents were not protected from inappropriate interaction.
Abuse—Failed to address resident's behavior
25 Feb 2016Abuse: Restraints
25 Feb 2016Abuse: Restraints
Investigated a restraint-related allegation and found improper restraint use and harm from rough treatment.
Abuse—Failed to properly use restraint
21 Jan 2016Abuse: Neglect
21 Jan 2016Abuse: Neglect
Found failure to address resident's behavior and failure to provide a safe environment.
Abuse—Failed to address resident's behavior
13 Jan 2016Inspection
13 Jan 2016Inspection
Found insufficient staffing to meet residents' needs. The finding was substantiated.
Licensing—Failed to provide appropriate staffing
13 Jan 2016Inspection
13 Jan 2016Inspection
Found that program staff failed to implement a policy for safekeeping of resident belongings.
Licensing—Failure to provide a system that prevents theft or misuse of medication
21 Dec 2015Abuse: Neglect
21 Dec 2015Abuse: Neglect
Investigated an allegation of abuse/neglect and found that proper supervision was not provided.
Abuse—Failed to address resident's behavior
05 Dec 2015Abuse: Neglect
05 Dec 2015Abuse: Neglect
Found a neglect-related failure to intervene when a resident's condition changed and assessed a $300 fine.
Abuse—Failed to intervene when resident's condition changed
30 Nov 2015Abuse: Neglect
30 Nov 2015Abuse: Neglect
Investigated a complaint alleging neglect and identified a safety deficiency.
Abuse—Failed to address resident's behavior
24 Nov 2015Abuse: Neglect
24 Nov 2015Abuse: Neglect
Found violations for failing to address resident behavior and for failing to protect a resident from physical harm.
Abuse—Failed to address resident's behavior
23 Nov 2015Abuse: Neglect
23 Nov 2015Abuse: Neglect
Identified a failure to provide a safe environment.
Abuse—Failed to provide safe environment
05 Nov 2015Abuse: Neglect
05 Nov 2015Abuse: Neglect
Investigated the allegation and found residents were not adequately protected from inappropriate interactions.
Abuse—Failed to address resident's behavior
05 Nov 2015Abuse: Neglect
05 Nov 2015Abuse: Neglect
Investigated and found deficiencies in the medication administration system.
Abuse—Failed to provide a safe medication administration system
17 Oct 2015Abuse: Physical Abuse
17 Oct 2015Abuse: Physical Abuse
Found that a resident was not protected from rough treatment.
Abuse—Failed to protect resident from rough treatment
11 Oct 2015Abuse: Neglect
11 Oct 2015Abuse: Neglect
Investigated a complaint and found residents were not protected from physical harm.
Abuse—Failed to address resident's behavior
02 Oct 2015Abuse: Neglect
02 Oct 2015Abuse: Neglect
Determined that an abuse/neglect incident occurred due to failure to provide medical treatment as ordered, resulting in hospitalization; a $300 fine was assessed.
Abuse—Failed to provide medical treatment as ordered
02 Oct 2015Inspection
02 Oct 2015Inspection
Investigated and found a failure to protect a resident from physical harm.
Licensing—Failed to provide safe environment
28 Sept 2015Abuse: Neglect
28 Sept 2015Abuse: Neglect
Investigated an abuse/neglect allegation and found residents were not protected from inappropriate physical contact.
Abuse—Failed to address resident's behavior
23 Sept 2015Inspection
23 Sept 2015Inspection
Determined licensing violation due to failure to protect residents from inappropriate interaction.
Licensing—Failed to provide safe environment
11 Sept 2015Abuse: Neglect
11 Sept 2015Abuse: Neglect
Found that a safe environment was not provided.
Abuse—Failed to provide safe environment
10 Sept 2015Abuse: Neglect
10 Sept 2015Abuse: Neglect
Investigated an abuse/neglect allegation and documented that residents were not protected from inappropriate interaction.
Abuse—Failed to address resident's behavior
05 Sept 2015Abuse: Neglect
05 Sept 2015Abuse: Neglect
Investigated an abuse/neglect allegation and found a failure to protect residents from inappropriate physical contact.
Abuse—Failed to address resident's behavior
23 Jul 2015Abuse: Neglect
23 Jul 2015Abuse: Neglect
Found deficiencies in the medication administration system and assessed a $300 fine.
Abuse—Failed to provide a safe medication administration system
13 Jul 2015Abuse: Sexual abuse
13 Jul 2015Abuse: Sexual abuse
Investigated an allegation of sexual abuse and found that appropriate supervision was not provided.
Abuse—Failed to protect resident from inappropriate sexual contact
09 Jul 2015Abuse: Physical Abuse
09 Jul 2015Abuse: Physical Abuse
Determined that abuse occurred and protection from rough treatment was not provided. The findings cited several regulatory requirements.
Abuse—Failed to protect resident from rough treatment
02 Jul 2015Abuse: Neglect
02 Jul 2015Abuse: Neglect
Identified a failure to provide a safe environment. The finding indicated minor harm or potential for moderate harm.
Abuse—Failed to provide safe environment
01 Jul 2015Abuse: Neglect
01 Jul 2015Abuse: Neglect
Found a neglect violation involving failure to address a resident's behavior and protect residents from harm, with a $400 fine assessed.
Abuse—Failed to address resident's behavior
26 Jun 2015Abuse: Neglect
26 Jun 2015Abuse: Neglect
Investigated the allegation of abuse and neglect and found that safe environment and appropriate care were not provided; a $300 fine was assessed.
Abuse—Failed to provide safe environment
10 Jun 2015Inspection
10 Jun 2015Inspection
Determined that the provider failed to protect a resident from physical harm.
Licensing—Failed to provide safe environment
08 Jun 2015Abuse: Neglect
08 Jun 2015Abuse: Neglect
Investigated an abuse/neglect allegation. Identified failures to perform adequate screening or assessment and to provide appropriate care, with a $300 fine assessed.
Abuse—Failed to perform adequate screening or assessment
20 May 2015Inspection
20 May 2015Inspection
Determined that a care plan was not followed and a resident was not protected from physical harm.
Licensing—Failed to follow care plan
03 May 2015Abuse: Neglect
03 May 2015Abuse: Neglect
Investigated an abuse/neglect allegation and found a failure to protect residents from physical harm.
Abuse—Failed to address resident's behavior
30 Apr 2015Inspection
30 Apr 2015Inspection
Found a failure to provide a safe medication administration system.
Licensing—Failed to administer medication as ordered
30 Apr 2015Inspection
30 Apr 2015Inspection
Determined that a resident was not protected from a physical altercation and that behavior concerns were not adequately addressed.
Licensing—Failed to address resident's behavior
30 Apr 2015Abuse: Neglect
30 Apr 2015Abuse: Neglect
Found failures to perform adequate screening or assessment and to intervene.
Abuse—Failed to perform adequate screening or assessment
30 Apr 2015Abuse: Neglect
30 Apr 2015Abuse: Neglect
Investigated a neglect allegation and identified deficiencies in care. A $400 fine was assessed.
Abuse—Failed to address resident's behavior
30 Apr 2015Abuse: Neglect
30 Apr 2015Abuse: Neglect
Investigated and found a failure to protect residents from inappropriate physical contact.
Abuse—Failed to provide safe environment
24 Apr 2015Inspection
24 Apr 2015Inspection
Found a failure to protect residents from inappropriate physical contact, classified as a level 2 licensing violation.
Licensing—Failed to address resident's behavior
24 Apr 2015Inspection
24 Apr 2015Inspection
Investigated an allegation that a resident's behavior was not addressed and found residents were not protected from inappropriate physical contact.
Licensing—Failed to address resident's behavior
14 Apr 2015Inspection
14 Apr 2015Inspection
Investigated the allegation that a resident's behavior was not addressed; substantiated the failure to assess and intervene.
Licensing—Failed to address resident's behavior
06 Apr 2015Inspection
06 Apr 2015Inspection
Identified a failure to protect residents from inappropriate physical contact.
Licensing—Failed to address resident's behavior
02 Apr 2015Abuse: Neglect
02 Apr 2015Abuse: Neglect
Determined that the allegation of failing to address a resident's behavior was upheld and found a failure to protect a resident from physical harm, resulting in a $400 fine.
Abuse—Failed to address resident's behavior
24 Mar 2015Abuse: Neglect
24 Mar 2015Abuse: Neglect
Found residents were not protected from inappropriate physical contact.
Abuse—Failed to provide safe environment
10 Mar 2015Abuse: Neglect
10 Mar 2015Abuse: Neglect
Found residents were not protected from physical harm.
Abuse—Failed to address resident's behavior
25 Feb 2015Abuse: Neglect
25 Feb 2015Abuse: Neglect
Found residents were not protected from inappropriate physical contact.
Abuse—Failed to address resident's behavior
18 Feb 2015Inspection
18 Feb 2015Inspection
Investigated the allegation of an unsafe environment and found a supervision deficiency.
Licensing—Failed to provide safe environment
13 Feb 2015Abuse: Neglect
13 Feb 2015Abuse: Neglect
Determined neglect occurred and residents were not protected from inappropriate interaction.
Abuse—Failed to address resident's behavior
03 Feb 2015Inspection
03 Feb 2015Inspection
Investigated a complaint about resident safety and behavior management. Found residents were not protected from physical assault.
Licensing—Failed to address resident's behavior
03 Feb 2015Abuse: Neglect
03 Feb 2015Abuse: Neglect
Investigated a neglect allegation and found that residents were not protected from physical assault.
Abuse—Failed to address resident's behavior
27 Jan 2015Inspection
27 Jan 2015Inspection
Found a deficiency for failing to protect a resident from inappropriate verbal comments.
Licensing—Failed to assure resident rights
27 Jan 2015Inspection
27 Jan 2015Inspection
Found a violation of resident rights due to failure to protect a resident from inappropriate physical interaction. The issue was rated as minor harm or potential for moderate harm.
Licensing—Failed to assure resident rights
16 Jan 2015Abuse: Neglect
16 Jan 2015Abuse: Neglect
Found that appropriate supervision was not provided.
Abuse—Failed to address resident's behavior
13 Jan 2015Abuse: Neglect
13 Jan 2015Abuse: Neglect
Found residents were not protected from inappropriate physical contact.
Abuse—Failed to address resident's behavior
05 Jan 2015Abuse: Neglect
05 Jan 2015Abuse: Neglect
Identified a deficiency related to inadequate supervision that created a safety risk.
Abuse—Failed to provide safe environment
26 Dec 2014Abuse: Neglect
26 Dec 2014Abuse: Neglect
Investigated the abuse/neglect allegation and found a deficiency for failing to protect residents from inappropriate physical fondling.
Abuse—Failed to provide safe environment
13 Dec 2014Abuse: Neglect
13 Dec 2014Abuse: Neglect
Investigated the neglect allegation and determined inadequate supervision created an unsafe environment.
Abuse—Failed to provide safe environment
13 Dec 2014Abuse: Neglect
13 Dec 2014Abuse: Neglect
Investigated and determined there was a failure to provide appropriate supervision, indicating a safety concern due to neglect risk.
Abuse—Failed to provide safe environment
13 Dec 2014Inspection
13 Dec 2014Inspection
Found inadequate supervision that could risk residents' safety.
Licensing—Failed to provide safe environment
13 Dec 2014Inspection
13 Dec 2014Inspection
Investigated the allegation that a safe environment was not provided and found inadequate supervision.
Licensing—Failed to provide safe environment
13 Dec 2014Inspection
13 Dec 2014Inspection
Determined that inadequate supervision resulted in a failure to provide a safe environment.
Licensing—Failed to provide safe environment
03 Dec 2014Abuse: Neglect
03 Dec 2014Abuse: Neglect
Investigated and substantiated a neglect allegation related to inadequate falls care planning and an unsafe environment.
Abuse—Failed to adequately care plan related to falls
25 Nov 2014Abuse: Neglect
25 Nov 2014Abuse: Neglect
Investigated a complaint and found a failure to provide a safe environment.
Abuse—Failed to provide safe environment
17 Nov 2014Inspection
17 Nov 2014Inspection
Found a deficiency in providing a safe environment.
Licensing—Failed to provide safe environment
22 Oct 2014Inspection
22 Oct 2014Inspection
Found a safety deficiency where a resident was not protected from inappropriate sexual contact.
Licensing—Failed to provide safe environment
07 Oct 2014Abuse: Neglect
07 Oct 2014Abuse: Neglect
Found deficient supervision of a resident. The finding relates to failing to address resident behavior.
Abuse—Failed to address resident's behavior
07 Oct 2014Abuse: Neglect
07 Oct 2014Abuse: Neglect
Found neglect due to failure to assess and intervene.
Abuse—Failed to perform adequate screening or assessment
07 Oct 2014Abuse: Neglect
07 Oct 2014Abuse: Neglect
Investigated the complaint and concluded that residents were not adequately protected from inappropriate physical contact.
Abuse—Failed to address resident's behavior
07 Oct 2014Abuse: Neglect
07 Oct 2014Abuse: Neglect
Substantiated the neglect allegation that a safe environment was not provided and that care planning related to falls was inadequate.
Abuse—Failed to adequately care plan related to falls
07 Oct 2014Abuse: Neglect
07 Oct 2014Abuse: Neglect
Found a failure to protect a resident from inappropriate interactions, indicating a safety concern.
Abuse—Failed to provide safe environment
18 Sept 2014Abuse: Neglect
18 Sept 2014Abuse: Neglect
Identified a neglect allegation involving failure to protect residents from inappropriate physical contact.
Abuse—Failed to address resident's behavior
17 Sept 2014Abuse: Neglect
17 Sept 2014Abuse: Neglect
Investigated a complaint and substantiated a deficiency for failing to provide a safe environment.
Abuse—Failed to address resident's behavior
10 Sept 2014Abuse: Neglect
10 Sept 2014Abuse: Neglect
Investigated the allegation of neglect related to falls and found a failure to provide a safe environment.
Abuse—Failed to adequately care plan related to falls
05 Sept 2014Abuse: Neglect
05 Sept 2014Abuse: Neglect
Investigated the fall-related care allegation and identified a supervision deficiency.
Abuse—Failed to adequately care plan related to falls
05 Sept 2014Abuse: Neglect
05 Sept 2014Abuse: Neglect
Identified deficiencies in protecting residents from inappropriate interactions. The allegation regarding failing to address resident behavior was acknowledged in the findings.
Abuse—Failed to address resident's behavior
05 Sept 2014Abuse: Neglect
05 Sept 2014Abuse: Neglect
Investigated a complaint alleging neglect related to falls; identified an unsafe environment and a $350 fine was assessed.
Abuse—Failed to adequately care plan related to falls
03 Sept 2014Abuse: Neglect
03 Sept 2014Abuse: Neglect
Investigated an allegation related to falls care planning and found a failure to provide a safe environment.
Abuse—Failed to adequately care plan related to falls
01 Sept 2014Abuse: Neglect
01 Sept 2014Abuse: Neglect
Investigated an allegation of neglect involving a failure to provide a safe environment.
Abuse—Failed to provide safe environment
23 Aug 2014Abuse: Neglect
23 Aug 2014Abuse: Neglect
Investigated an allegation of neglect regarding addressing a resident's behavior and concluded there was inadequate supervision.
Abuse—Failed to address resident's behavior
13 Aug 2014Abuse: Neglect
13 Aug 2014Abuse: Neglect
Investigated a neglect allegation and found a failure to provide a safe environment and inadequate falls care planning.
Abuse—Failed to adequately care plan related to falls
13 Aug 2014Abuse: Neglect
13 Aug 2014Abuse: Neglect
Found a failure to provide a safe environment due to inadequate supervision.
Abuse—Failed to provide safe environment
12 Aug 2014Abuse: Neglect
12 Aug 2014Abuse: Neglect
Found violations for failing to provide a safe environment.
Abuse—Failed to provide safe environment
11 Aug 2014Abuse: Neglect
11 Aug 2014Abuse: Neglect
Investigated and found that a resident was not protected from physical harm due to failing to address behavior.
Abuse—Failed to address resident's behavior
06 Aug 2014Abuse: Neglect
06 Aug 2014Abuse: Neglect
Determined that a resident was not protected from physical harm.
Abuse—Failed to provide safe environment
29 Jul 2014Inspection
29 Jul 2014Inspection
Found safety-related deficiencies in falls care planning and in providing a safe environment.
Licensing—Failed to adequately care plan related to falls
18 Jul 2014Abuse: Neglect
18 Jul 2014Abuse: Neglect
Investigated a complaint and found deficiencies in fall-related care planning and intervention; a $300 fine was assessed.
Abuse—Failed to adequately care plan related to falls
18 Jul 2014Abuse: Neglect
18 Jul 2014Abuse: Neglect
Investigated an allegation of abuse involving inappropriate sexual contact and found insufficient protection for a resident and an inadequate assessment of RV1.
Abuse—Failed to protect resident from inappropriate sexual contact
17 Jul 2014Abuse: Neglect
17 Jul 2014Abuse: Neglect
Investigated and found that a resident was not protected from nonconsensual sexual contact.
Abuse—Failed to protect resident from inappropriate sexual contact
04 Jul 2014Inspection
04 Jul 2014Inspection
Concluded that deficiencies in providing a safe environment and appropriate care were substantiated.
Licensing—Failed to provide safe environment
12 Jun 2014Inspection
12 Jun 2014Inspection
Investigated an allegation of an unsafe medication administration system and found deficiencies in following doctor's orders.
Licensing—Failed to provide a safe medication administration system
27 May 2014Inspection
27 May 2014Inspection
Investigated the allegation of inadequate care planning and found a failure to provide a safe environment.
Licensing—Failed to properly plan care
06 May 2014Abuse: Neglect
06 May 2014Abuse: Neglect
Investigated a fall-related neglect allegation and found inadequate care planning, and a $300 fine was assessed.
Abuse—Failed to adequately care plan related to falls
03 Feb 2014Inspection
03 Feb 2014Inspection
Found deficiencies in care due to failing to answer call lights promptly.
Licensing—Failed to answer call light in a timely manner
03 Jan 2014Inspection
03 Jan 2014Inspection
Determined that a falls-related care plan was not adequately implemented, exposing a resident to harm.
Licensing—Failed to adequately care plan related to falls
20 Dec 2013Inspection
20 Dec 2013Inspection
Investigated an allegation of failing to assure resident rights and found an inappropriate verbal comment occurred.
Licensing—Failed to assure resident rights
04 Nov 2013Abuse: Neglect
04 Nov 2013Abuse: Neglect
Investigated an abuse/neglect allegation and found that medication was not administered as ordered and care was not provided appropriately.
Abuse—Failed to administer medication as ordered
16 Oct 2013Abuse: Neglect
16 Oct 2013Abuse: Neglect
Investigated the allegation of abuse/neglect and found a failure to protect residents from inappropriate physical contact.
Abuse—Failed to address resident's behavior
10 Oct 2013Abuse: Neglect
10 Oct 2013Abuse: Neglect
Found inadequate supervision that could compromise resident safety.
Abuse—Failed to provide safe environment
01 Aug 2013Abuse: Neglect
01 Aug 2013Abuse: Neglect
Investigated a resident care incident and found failure to properly plan and provide appropriate care, with moderate harm potential.
Abuse—Failed to properly plan care
25 Jun 2013Abuse: Verbal/Mental abuse
25 Jun 2013Abuse: Verbal/Mental abuse
Investigated found inappropriate verbal comments toward residents and a failure to protect them.
Abuse—Failed to provide safe environment
18 May 2013Inspection
18 May 2013Inspection
Investigated a resident-behavior allegation and found a deficiency in providing a safe environment by failing to address the resident's behavior.
Licensing—Failed to address resident's behavior
23 Feb 2013Abuse: Verbal/Mental abuse
23 Feb 2013Abuse: Verbal/Mental abuse
Investigated an allegation of verbal abuse and found a resident was not protected from inappropriate verbalizations.
Abuse—Failed to protect resident from verbal abuse
17 Jan 2013Abuse: Physical Abuse
17 Jan 2013Abuse: Physical Abuse
Found that a resident was not protected from physical harm.
Abuse—Failed to provide safe environment
17 Sept 2012Abuse: Financial abuse
17 Sept 2012Abuse: Financial abuse
Investigated an allegation of financial abuse and found a failure to maintain an adequate medication system.
Abuse—Failure to provide a system that prevents theft or misuse of medication
25 Apr 2012Abuse: Neglect
25 Apr 2012Abuse: Neglect
Investigated and found that timely medical attention for a resident was not provided.
Abuse—Failed to assure timely medical treatment
20 Jan 2012Inspection
20 Jan 2012Inspection
Investigated the complaint and found a deficiency related to failing to maintain an appropriate bowel regimen.
Licensing—Failed to provide service
11 Jan 2012Inspection
11 Jan 2012Inspection
Found a failure to keep a resident safe from elopement.
Licensing—Failed to assure resident was safe
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