Avamere at Newberg

    730 Foothills Dr, Newberg, OR 97132
    • Independent Living
    • Assisted Living
    • Memory Care

    Friendly staff, clean secure community

    I'm very pleased with this senior living community. The staff - especially Sasha, Nicole, Megan and Chad - plus a wonderful executive director and incredible chef, are friendly, knowledgeable and caring; night staff are amazing and maintenance is proactive. The remodeled, clean, odor-free facility feels like home with lots of activities, a secure garden, great meals and fast medical/hospice support; it's a very good choice and I would consider it for loved ones.

    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 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

    3.44·(36)

    Overall rating

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

      2.8
    • Staff

      3.4
    • Meals

      3.4
    • Amenities

      3.5
    • Value

      2.0

    Pros

    • Caring and attentive caregivers
    • Engaging, varied activity program
    • Clean, well-maintained common areas
    • Pleasant dining atmosphere with meal choices
    • Remodeled and attractive interior spaces
    • Spacious one-bedroom units with kitchenettes
    • Secure outdoor garden and accessible outdoor spaces
    • Regular offsite outings and shopping transportation
    • Live music and musical programming
    • Attentive housekeeping and proactive maintenance
    • Supportive hospice and end-of-life services
    • Strong night-shift and several long-tenured staff members
    • Welcoming, home-like atmosphere

    Cons

    • High caregiver and medication-aide turnover
    • Inconsistent staffing levels and responsiveness
    • Weak medication-administration and refill controls
    • Communication and handoff gaps between shifts
    • Gaps in emergency notification and clinical follow-up
    • Inconsistent housekeeping, laundry, and personal-item management
    • Inconsistent meal quality and menu limitations
    • Weaknesses in fall-prevention and routine safety checks
    • Administrative and billing process delays with pricing-transparency concerns
    • Limited availability of specialized therapeutic diets
    • Transportation and parking limitations

    Summary of reviews

    Overall impression: Reviews describe a facility with many appealing elements—clean, recently remodeled common spaces; a robust activities program; a pleasant dining environment; and multiple staff members and shifts that families praise for compassion and attentiveness. Several reviewers highlighted strong night staff, an engaged maintenance director, a proud kitchen and dining team, and supportive hospice services. The facility offers a range of social opportunities (live music, outings, exercise, games) and apartment options that include spacious one-bedroom units with kitchenettes.

    Care quality and staffing: Care quality appears uneven. Many families described individual caregivers who provide attentive, compassionate support, but there is a consistent pattern of high turnover among direct-care staff and medication aides. That turnover correlates with staffing shortfalls, slower response times, and variability in how tasks are performed. Reviewers described communication and handoff gaps between day and night shifts and inconsistent transfer procedures; these operational gaps have been linked to delayed assistance, inconsistent medication administration, and safety incidents. There are also serious family-level concerns about communication after acute events and administrative follow-up.

    Clinical processes and safety: Multiple reviews indicate problems with medication management (missed refills, delayed administration, and inconsistent med-aide practices) and with routine safety checks and transfer procedures. These items suggest weaknesses in medication-administration controls and fall-prevention processes. Families also noted gaps in emergency notification and clinical follow-up—examples include delayed callbacks and limited family notification after ambulance transports—which point to opportunities for clearer protocols around clinical events and family communication.

    Dining and special dietary needs: The dining program receives mixed feedback. Several commenters praised meal variety, pleasant dining rooms, and the kitchen staff’s engagement; others described inconsistent food quality and menu dissatisfaction. There are also mentions of limited availability of specialized diet options (for example, therapeutic or very specific diet plans), indicating the facility may not reliably accommodate all medical dietary needs.

    Activities and social environment: Activities are widely cited as a strength. The facility runs frequent on-site programming (cards, bingo, puzzles, exercise, music) and offsite outings such as shopping trips. Memory-care programming and a secure outdoor garden are also noted positively. Some families, however, indicated that access to activities outside the memory-care unit is inconsistent for certain residents, which suggests uneven outreach or inclusivity across care levels.

    Facilities, housekeeping, and logistics: The building’s recent remodel, clean common areas, cozy shared spaces, and secure garden are frequent positives. Simultaneously, reviewers described operational lapses around housekeeping and laundry (missing or piled clothing, inconsistent room upkeep), mail handling, parking constraints, and occasional maintenance delays. These items suggest that while communal spaces are maintained, personal-item management and logistical processes sometimes break down.

    Management and administration: Feedback about leadership is mixed. Several managers and staff members are singled out as proactive and effective, and some reviewers noted improvements under new management. At the same time, families raised concerns about administrative transparency (billing delays, unexpected charges, pricing clarity) and slow resolution of service failures. There are also serious allegations concerning financial exploitation and family communication in a few accounts; these are singular but significant and merit careful follow-up by prospective families and regulators.

    Patterns and recommendations for prospective families: The pattern in reviews is one of strong individual caregivers and attractive physical amenities offset by operational inconsistencies. Prospective residents and families should weigh the facility’s social and environmental strengths against evidence of staffing instability, medication- and safety-process gaps, and variable housekeeping/administrative reliability. Practical due diligence suggestions include meeting both day and night staff, asking for written medication and emergency-notification protocols, verifying availability of needed therapeutic diets and transportation, and confirming billing and laundry policies in writing.

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    Location

    Map showing location of Avamere at Newberg

    Avamere at Newberg is located at 730 Foothills Dr, Newberg, OR, 97132.

    About Avamere at Newberg

    Avamere at Newberg sits in a quiet residential area with access to the main roads leading to Portland, Hillsboro, and McMinnville, and the community has 54 rooms and provides different options like assisted living, independent living, memory care, respite care, and even on-site skilled nursing when someone might need more help than the everyday type. Residents get home-cooked meals served in an elegant dining room three times a day, and staff schedule outings and country drives for those who like to get out, making the place feel lively but also familiar and comfortable, especially in their Alzheimer's and Memory Care neighborhood where caregivers and a licensed nurse focus on the unique needs of people living with dementia. The activities calendar's pretty full, so there's often something to do, like Paint N' Sip events, and there's also a spa in the building, which helps with relaxation and self-care. Residents can have trained aides for companionship and non-medical help right at home, and staff stay on duty 24 hours a day, so support's always close by whether it's day or night. The executive director, Kelcie Mauser, leads the team, aiming to create a warm, family-like environment that centers on each person's needs and life journey. Reviews have shown a friendly, caring community with meals made from quality ingredients, and the staff handles many daily tasks like counseling, transitional care, and rehabilitation. There are extra things to know, like a $1,500 community fee, a $600 pet fee, and care points that cost $96 per point, and all the services have their licensing verified by A Place for Mom. Avamere at Newberg is managed by Areté Living, which means someone can expect typical senior living conveniences, but the main idea is a steady focus on comfortable surroundings, personal care, and activities made to keep life engaging and active for older adults, whether they live independently, need some help each day, or need more specialized memory care.

    About Avamere

    Avamere at Newberg is managed by Avamere.

    Founded in 1995 by Rick Miller in Oregon, Avamere is headquartered in Wilsonville and operates skilled nursing and rehabilitation facilities across the Pacific Northwest. Originally growing to 33 facilities, the company spun off its senior living division (Arete Living) in 2022, refocusing on skilled nursing care.

    People often ask...

    Avamere at Newberg offers competitive pricing, with rates starting at a cost of $5,890 per month.

    Avamere at Newberg offers independent living, assisted living, and memory care.

    There are 21 photos of Avamere at Newberg on Mirador.

    Yes, Avamere at Newberg allows residents to age in place and adjust their level of care as needed.

    The full address for this community is 730 Foothills Dr, Newberg, OR 97132.

    No, Avamere at Newberg does not offer respite care. Respite care in assisted living communities provides temporary, short-term relief for primary caregivers by offering professional care for their loved ones. It allows individuals to stay in an assisted living community for a limited time, giving caregivers a break while ensuring residents receive necessary support and assistance with daily activities.

    Safety & Compliance

    In Oregon, the Department of Human Services' Aging & People with Disabilities program licenses assisted living and residential care facilities, conducting inspections, complaint investigations, and renewals.

    License number5MA259
    StatusActive
    Facility typeResidential Care Facility
    Capacity22 residents
    LicenseeGenesis Newberg Operations Company, LLC
    EffectiveOctober 2nd, 2000
    Special certificationMemory Care
    View the official license record

    Inspection Reports

    147

    Reports

    0

    Type A Citations

    0

    Type B Citations

    3

    Complaints

    16

    Years

    28 Apr 2026Kitchen
    Identified sanitation and storage deficiencies in the kitchen, with failures to follow food sanitation rules.
    • DeficiencyResident Services Meals, Food Sanitation Rule
    03 Sept 2025Kitchen
    Identified sanitation and maintenance deficiencies in the kitchen and administration compliance concerns, with unclean surfaces and repairs needed.
    • DeficiencyResident Services Meals, Food Sanitation Rule
    • DeficiencyAdministration Compliance
    03 Sept 2025Kitchen
    Identified extensive sanitation deficiencies in the kitchen and noncompliance with meals and food sanitation requirements. Found failures to maintain sanitary conditions and proper food handling practices.
    • DeficiencyResident Services Meals, Food Sanitation Rule
    19 Aug 2025Inspection
    Identified a failure to have a written policy prohibiting falsification of records, with an incident report containing separate unsigned documentation and dated inconsistencies found in a reviewed file.
    • LicensingFailed to provide safe environment
    19 Aug 2025License Condition
    Identified a deficiency for failing to provide a safe environment because operable windows were not in place to prevent accidental falls.
    • Regulatory ActionFailed to provide safe environment
    13 Aug 2025Inspection
    Investigated findings showed ABST failed to accurately reflect care time and care elements for 1 of 1 sampled resident, with inconsistencies between the roster, care plans, and ABST.
    • LicensingFailed to use an ABST
    13 Aug 2025Inspection
    Investigated and found a serious deficiency in oversight and monitoring of a resident's change of condition and in communicating required actions to staff, contributing to a fall with serious injury and the resident's death.
    • LicensingFailed to provide oversight and monitoring of change of condition
    13 Aug 2025Inspection
    Investigated and found a serious window-safety violation after a resident fell from a second-story window, resulting in a fatality. Operable windows were not adequately secured on higher floors.
    • LicensingFailed to provide safe environment
    13 Aug 2025Inspection
    Investigated the allegation of inadequate care planning and found that service plans did not reflect identified resident needs or provide clear staff instructions for managing hallucinations.
    • LicensingFailed to properly plan care
    13 Aug 2025Inspection
    Found that a Registered Nurse did not assess all residents with a significant change of condition. Documented events for one resident included recurrent hallucinations and agitation with no documented interventions for staff on each shift.
    • LicensingFailed to provide oversight and monitoring of change of condition
    13 Aug 2025Inspection
    Identified that operable windows on the second floor were not secured, allowing openings that led to a resident fall and death.
    • LicensingFailed to provide safe environment
    13 Aug 2025Inspection
    Found that residents were at risk because second-floor windows lacked operable safety mechanisms to prevent falls.
    • LicensingFailed to provide safe environment
    13 Aug 2025Inspection
    Found failures to implement medication orders as prescribed, including an unsigned discontinue order and a duplicate-dose incident that caused sedation.
    • LicensingFailed to provide a safe medication administration system
    29 Jul 2025Inspection
    Investigated a resident's missing money and concluded that theft occurred due to failure to protect property, resulting in a rule violation.
    • LicensingFailed to provide safe environment
    24 May 2025Abuse: Neglect
    Concluded that neglect and abuse occurred due to failure to implement fall interventions and provide supervision for a resident with a known fall history, resulting in multiple falls and a toe fracture. The actions compromised resident safety.
    • AbuseFailed to properly plan care
    28 Apr 2025Abuse: Neglect
    Determined that a staff member abandoned a resident by leaving them unattended during toileting for about 10 to 15 minutes, creating a risk of serious harm; a $375 fine was assessed.
    • AbuseFailed to provide safe environment
    19 Apr 2025Abuse: Neglect
    Found neglect of care resulting in a resident fall and unsafe environment. A fine was assessed as part of the disciplinary action.
    • AbuseFailed to provide safe environment
    10 Apr 2025Licensure
    Identified deficiencies in resident rights, service planning, fire safety, and heating systems. Violations cited included inadequate meal service practices, outdated and unclear service plans, incomplete fire drills, and unsafe heater conditions.
    • DeficiencyResident Rights and Protection - General
    • DeficiencyService Plan: General
    • DeficiencyFire and Life Safety: Safety
    • DeficiencyHeating and Ventilation
    18 Mar 2025Complaint
    Investigated identified deficiencies in awake direct care staffing and in updating the acuity-based staffing tool.
    • DeficiencyLicensing Complaint Investigation
    • DeficiencyStaffing Requirements and Training: Staffing
    • DeficiencyAcuity Based Staffing Tool - Updates & Plan
    25 Jan 2025Inspection
    Found deficiencies in carrying out prescribed medication orders, including missed doses and missing physician orders, with potential for harm. The issues involved incorrect entry and timing of a medication order and inadequate documentation.
    • LicensingFailed to provide a safe medication administration system
    27 Sept 2024Abuse: Neglect
    Investigated and found that a safe medication administration system was not maintained, resulting in a resident going without blood pressure medication for two months and requiring emergency care. A fine was assessed.
    • AbuseFailed to provide a safe medication administration system
    25 Sept 2024Kitchen
    Found violations related to food sanitation and administration compliance. Extensive kitchen cleanliness issues and failure to follow licensing rules were noted.
    • DeficiencyResident Services Meals, Food Sanitation Rule
    • DeficiencyAdministration Compliance
    25 Sept 2024Kitchen
    Identified extensive sanitation deficiencies in kitchen practices, with widespread debris, grease, and dust buildup observed.
    • DeficiencyResident Services Meals, Food Sanitation Rule
    16 Jul 2024Complaint
    Found that the outbreak was not immediately reported to the Department Central Office and local public health authority.
    • DeficiencyFacility Administration: Notification
    01 Jul 2024Inspection
    Identified insufficient awake direct care staff to meet 24-hour needs, resulting in delayed call-light responses (up to 40 minutes).
    • LicensingFailed to answer call light in a timely manner
    16 Apr 2024Inspection
    Determined that a safe medication administration system was not provided, leading to a patient not receiving the requested pain medication and experiencing tremors, confusion, and anxiety.
    • LicensingFailed to provide a safe medication administration system
    18 Feb 2024Inspection
    Found insufficient qualified awake direct care staff to meet 24-hour scheduled and unscheduled resident needs.
    • LicensingFailed to provide appropriate staffing
    30 Oct 2023Validation
    Identified widespread deficiencies in resident rights, activities, health services, and safety. The findings show failures in providing a homelike environment, reporting abuse, delivering individualized activities, monitoring changes of condition, administering health care, and maintaining fire safety.
    • DeficiencyComment
    • DeficiencyResident Rights and Protection - General
    • DeficiencyReporting & Investigating Abuse-Other Action
    • DeficiencyResident Services: Activities
    • DeficiencyResident Move-In and Eval: Res Evaluation
    • DeficiencyChange of Condition and Monitoring
    • DeficiencyResident Health Services
    • DeficiencySystems: Tracking Control Substances
    • DeficiencySystems: Treatment Orders
    • DeficiencySystems: Psychotropic Medication
    • DeficiencyAcuity-Based Staffing Tool
    • DeficiencyFire and Life Safety: Safety
    • DeficiencyInspections and Investigation: Insp Interval
    • DeficiencyDoors, Walls, Elevators, Odors
    • DeficiencyAdministration Compliance
    • DeficiencyStaff Training Requirements
    • DeficiencyCompliance With Rules Health Care
    • DeficiencyActivities
    03 Oct 2023Licensure
    Determined substantial compliance with state food service and sanitation rules following a kitchen evaluation. No deficiencies were cited.
    • DeficiencyComment
    03 Oct 2023Inspection
    Found fall prevention failures that contributed to multiple falls during self-transfers.
    • LicensingFailed to follow care plan
    03 Oct 2023Licensure
    Determined substantial compliance with applicable meal service and food sanitation rules.
    • DeficiencyComment
    13 Sept 2023License Condition
    Found that an Acuity Based Staffing Tool was not fully implemented as required.
    • Regulatory ActionFailed to use an ABST
    13 Sept 2023Inspection
    Found a failure to provide a safe medication administration system that led to a missed insulin dose.
    • LicensingFailed to provide a safe medication administration system
    09 Aug 2023Inspection
    Investigated a verbal abuse allegation and found that a staff member made an inappropriate verbal comment toward a resident in their presence, and that the resident was not protected from such comments.
    • LicensingFailed to protect resident from verbal abuse
    09 Aug 2023Inspection
    Investigated a complaint alleging physical abuse and an unsafe environment. Found evidence of physical abuse and a failure to provide a safe environment.
    • LicensingFailed to provide safe environment
    22 Jul 2023Abuse: Neglect
    Found abuse and neglect due to inadequate monitoring of residents, with a resident punched causing discomfort; a fine was assessed.
    • AbuseFailed to provide safe environment
    05 Jul 2023Abuse: Neglect
    Found inadequate oversight and monitoring of a resident's change of condition, leading to hospital transport for dehydration and a urinary tract infection; a $500 fine was assessed.
    • AbuseFailed to provide oversight and monitoring of change of condition
    04 Apr 2023Complaint
    Identified deficiencies in policy and procedure, staffing practices, acuity-based staffing tools, and general building standards.
    • DeficiencyLicensing Complaint Investigation
    • DeficiencyFacility Administration: Policy & Procedure
    • DeficiencyStaffing Requirements and Training: Staffing
    • DeficiencyAcuity-Based Staffing Tool
    • DeficiencyGeneral Building: Doors-Walls, Cleanable
    23 Mar 2023Inspection
    Identified a deficiency in staffing due to insufficient qualified awake direct care staff to meet residents' 24-hour needs.
    • LicensingFailed to provide safe environment
    17 Mar 2023Inspection
    Identified a deficiency in updating the ABST, leading to inconsistencies between the roster, care plans, and ABST data.
    • LicensingFailed to use an ABST
    17 Mar 2023Inspection
    Found that the acuity-based staffing tool was not fully implemented, resulting in safety concerns and a department-imposed condition. The finding noted a violation of Oregon Administrative Rules.
    • LicensingFailed to use an ABST
    24 Feb 2023Inspection
    Investigated and found ineffective methods for responding to and resolving resident complaints.
    • LicensingFailed to provide safe environment
    19 Dec 2022Inspection
    Investigated and found a violation related to cleanliness of interior and exterior surfaces. The finding indicated non-compliance with applicable rules.
    • LicensingFailed to provide safe environment
    19 Dec 2022Inspection
    Investigators found deficiencies in responding to and resolving resident complaints. The issue was categorized as minor harm or potential for moderate harm.
    • LicensingFailed to provide safe environment
    28 Jul 2022Licensure
    Determined substantial compliance with meal service and food sanitation requirements.
    • DeficiencyComment
    09 May 2022Abuse: Neglect
    Found neglect and abuse for failing to provide a safe environment, resulting in a resident fall with a forehead abrasion.
    • AbuseFailed to provide safe environment
    09 May 2022Abuse: Neglect
    Investigated allegations of neglect and abuse found failure to provide a safe environment and adequate supervision, leading to multiple falls and discomfort. A $1,000 fine was assessed.
    • AbuseFailed to provide safe environment
    19 Apr 2022Abuse: Neglect
    Investigated found that inadequate planning of care and supervision for a known fall risk led to three falls and injuries, constituting neglect and abuse; a fine was assessed.
    • AbuseFailed to properly plan care
    06 Dec 2021Validation
    Identified multiple deficiencies across abuse investigations, move-in evaluations, service plans, condition monitoring, staff training, and fire safety, indicating gaps in documentation and compliance at several levels.
    • DeficiencyComment
    • DeficiencyReporting & Investigating Abuse-Other Action
    • DeficiencyResident Move-In and Eval: Res Evaluation
    • DeficiencyService Plan: General
    • DeficiencyChange of Condition and Monitoring
    • DeficiencyStaffing Requirements and Training – Pre-Serv
    • DeficiencyTraining Within 30 Days: Direct Care Staff
    • DeficiencyAnnual and Biennial Inservice For All Staff
    • DeficiencyFire and Life Safety: Safety
    • DeficiencyFire and Life Safety: Training For Residents
    • DeficiencyInspections and Investigation: Insp Interval
    29 Nov 2021Abuse: Neglect
    Found neglect and abuse for failing to follow a care plan, resulting in pressure ulcers; a $250 fine was assessed.
    • AbuseFailed to follow care plan
    26 Nov 2021Abuse: Neglect
    Investigated an abuse/neglect allegation and found failure to plan and monitor care, resulting in a physical altercation and unreasonable discomfort to a resident.
    • AbuseFailed to properly plan care
    08 Jun 2021Inspection
    Determined that there was a failure to provide a safe environment that could threaten residents' health, safety, or welfare.
    • LicensingFailed to provide safe environment
    04 Jun 2021Inspection
    Verified a failure to coordinate on-site health services with outside providers, resulting in a resident being unable to go to the dining room due to lack of portable oxygen.
    • LicensingFailed to provide service
    22 May 2021Inspection
    Investigated and found an infection control deficiency due to staff not wearing masks properly.
    • LicensingFailed to provide infection control
    18 May 2021Abuse: Neglect
    Investigated the allegation and found neglect and abuse due to failure to plan care, resulting in several falls and injuries. A $1,500 fine was assessed.
    • AbuseFailed to properly plan care
    31 Dec 2020Abuse: Neglect
    Found that a resident did not receive proper foot care because the care plan was not followed, resulting in neglect. A $250 fine was assessed.
    • AbuseFailed to follow care plan
    09 Dec 2020Inspection
    Investigated the allegation that reasonable precautions against conditions that may threaten residents' health, safety, or welfare were not provided and verified the findings.
    • LicensingFailed to provide safe environment
    09 Dec 2020Inspection
    Investigated an allegation of insufficient qualified awake direct care staff and identified a staffing violation.
    • LicensingFailed to provide appropriate staffing
    30 Nov 2020Abuse: Neglect
    Investigated determined neglect and abuse for failing to provide a safe environment, resulting in multiple unwitnessed falls and injuries to a resident.
    • AbuseFailed to provide safe environment
    25 Aug 2020Inspection
    Determined that the allegation of failing to provide assistance with toileting and bowel and bladder management was substantiated.
    • LicensingFailed to assist with toileting
    24 Feb 2020Inspection
    Confirmed insufficient staffing to meet residents' scheduled and unscheduled needs.
    • LicensingFailed to provide appropriate staffing
    20 Feb 2020Inspection
    Confirmed insufficient qualified awake staffing to meet 24-hour needs of residents.
    • LicensingFailed to provide appropriate staffing
    14 Feb 2020Inspection
    Found that a resident's money went missing and that another individual admitted taking it, constituting financial exploitation, and that a safe environment was not provided.
    • LicensingFailed to protect resident from financial exploitation
    07 Feb 2020Abuse: Neglect
    Found abuse/neglect substantiated and a $375 fine assessed.
    • AbuseFailed to provide safe environment
    28 Jan 2020Inspection
    Investigated allegation of inadequate professional oversight of medication and treatment administration systems.
    • LicensingFailed to provide a safe medication administration system
    16 Jan 2020Inspection
    Investigated an allegation of failure to administer medication as ordered and found an incorrect dose entered, creating a period of potential harm due to failures in the medication administration review process.
    • LicensingFailed to administer medication as ordered
    07 Dec 2019Abuse: Neglect
    Investigated a failure to provide a safe medication administration system, which placed someone at serious risk of harm.
    • AbuseFailed to provide a safe medication administration system
    21 Nov 2019Abuse: Neglect
    Identified a failure to provide a safe medication administration system that led to not giving an anticoagulant as prescribed, with a fine assessed.
    • AbuseFailed to provide a safe medication administration system
    20 Nov 2019Inspection
    Investigated and found that a known fall risk was not supervised in common areas, resulting in a fall with a fractured clavicle.
    • LicensingFailed to provide safe environment
    21 Oct 2019Inspection
    Determined there was insufficient staffing, resulting in a Level 1 licensing violation.
    • LicensingFailed to provide appropriate staffing
    21 Oct 2019Inspection
    Determined that appropriate staffing was not provided.
    • LicensingFailed to provide appropriate staffing
    20 Oct 2019Abuse: Neglect
    Found a failure to provide a safe environment, resulting in a substantiated abuse/neglect finding and a $375 fine.
    • AbuseFailed to provide safe environment
    17 Oct 2019Abuse: Neglect
    Found a safety deficiency that created a risk of serious harm by failing to provide a safe environment.
    • AbuseFailed to provide safe environment
    08 Oct 2019Abuse: Neglect
    Found violations for an unsafe medication administration system that risked harm from incorrect MAR updates; a fine was assessed.
    • AbuseFailed to provide a safe medication administration system
    12 Sept 2019Abuse: Neglect
    Found that staff failed to plan care for a resident with a known history of aggression, leading to abusive incidents and neglect.
    • AbuseFailed to properly plan care
    10 Sept 2019Abuse: Neglect
    Investigated and found that medication was not given as ordered and basic medical care and supervision were lacking, resulting in a resident not receiving Buprenorphine on two dates. A $375 fine was assessed.
    • AbuseFailed to administer medication as ordered
    04 Sept 2019Abuse: Neglect
    Investigated a resident incident and found abuse and neglect due to failure to plan and intervene for known behavior after a resident was hit and later exposed to aggression.
    • AbuseFailed to provide safe environment
    23 Jul 2019Abuse: Neglect
    Investigated and found a failure to provide a safe medication administration system, creating a risk of serious harm.
    • AbuseFailed to provide a safe medication administration system
    29 Jun 2019Abuse: Neglect
    Investigated a complaint alleging neglect in providing a safe medication administration system. Found deficiencies in maintaining an accurate medication system that led to medications not being given as prescribed.
    • AbuseFailed to provide a safe medication administration system
    10 Jun 2019Inspection
    Investigated the allegation that medication was not administered as ordered and identified a deficiency in medication administration.
    • LicensingFailed to administer medication as ordered
    22 May 2019Inspection
    Concluded that a safe medication administration system was not provided.
    • LicensingFailed to provide a safe medication administration system
    24 Mar 2019Abuse: Neglect
    Determined a failure to provide a resident's scheduled medication, placing the resident at risk of harm from an untreated UTI.
    • AbuseFailed to provide a safe medication administration system
    31 Jan 2019Inspection
    Identified a deficiency in safe medication administration practices due to late administration of scheduled medications.
    • LicensingFailed to administer medication as ordered
    28 Jan 2019Abuse: Neglect
    Investigated and found a failure to provide a safe environment that allowed a resident to wander into another resident's room, resulting in a fracture, and care-plan noncompliance linked to abuse; a fine was assessed.
    • AbuseFailed to provide safe environment
    25 Aug 2018Inspection
    Found a violation for failing to provide a safe environment, with potential for moderate harm. The finding notes negligence in maintaining health and safety.
    • LicensingFailed to provide safe environment
    05 May 2018Inspection
    Found an inadequate medication management system that led to missed medications with no apparent harm. A $500 fine was assessed.
    • LicensingFailed to provide a safe medication administration system
    30 Apr 2018Abuse: Neglect
    Found an inadequate medication management system that resulted in missed medications and increased pain.
    • AbuseFailed to provide a safe medication administration system
    30 Apr 2018Inspection
    Investigated the allegation of failing to report potential or suspected abuse and concluded that failure to self-report occurred.
    • LicensingFailed to report potential or suspected abuse
    16 Mar 2018Inspection
    Investigated and found that bladder management assistance was not provided, including failure to check incontinent residents during the night shift.
    • LicensingFailed to assist with toileting
    01 Dec 2017Inspection
    Investigated an allegation and found a failure to provide a secure environment, resulting in an elopement.
    • LicensingFailed to provide safe environment
    08 Aug 2017Abuse: Neglect
    Determined neglect related to falls, with a resident injuring themselves after falling from bed due to inadequate prevention.
    • AbuseFailed to adequately care plan related to falls
    07 Aug 2017Inspection
    Found that safeguards failed to prevent elopement, allowing a resident to walk outside unsupervised for 15-20 minutes after a door was opened.
    • LicensingFailed to provide safe environment
    01 Apr 2017Inspection
    Investigated and determined a failure to provide a safe environment that led to a resident-to-resident altercation.
    • LicensingFailed to provide safe environment
    24 Mar 2017Inspection
    Found a failure to assess and intervene, resulting in resident-to-resident altercations with no injuries.
    • LicensingFailed to provide safe environment
    10 Feb 2017Inspection
    Investigated and found an unsafe environment due to inappropriate contact between residents.
    • LicensingFailed to provide safe environment
    21 Dec 2016Inspection
    Found a safety deficiency due to failure to protect residents from a resident-to-resident altercation.
    • LicensingFailed to provide safe environment
    04 Dec 2016Abuse: Neglect
    Investigated an abuse/neglect allegation and found that a refill for prescribed pain medication was not secured, causing the resident to experience increased pain for more than 24 hours.
    • AbuseFailed to administer ordered medication
    30 Nov 2016Abuse: Neglect
    Found a failure to protect residents from a resident-to-resident altercation, resulting in a noninjury fall.
    • AbuseFailed to provide safe environment
    11 Nov 2016Abuse: Neglect
    Found residents were not protected from a resident-to-resident altercation, resulting in a minor facial injury.
    • AbuseFailed to provide safe environment
    15 Oct 2016Inspection
    Investigated and determined a failure to provide a safe environment that resulted in an individual being shoved.
    • LicensingFailed to provide safe environment
    14 Sept 2016Abuse: Neglect
    Investigated and found a deficiency for failing to prevent resident-to-resident altercations.
    • AbuseFailed to provide safe environment
    07 Sept 2016Abuse: Neglect
    Investigated and found a failure to protect residents from a resident-to-resident altercation, resulting in a minor injury.
    • AbuseFailed to provide safe environment
    06 Sept 2016Inspection
    Found a deficiency for failing to provide a safe environment and assessed a $250 fine.
    • LicensingFailed to provide safe environment
    21 Aug 2016Inspection
    Investigated and found a deficiency for failing to provide a safe environment by not preventing a resident-to-resident altercation.
    • LicensingFailed to provide safe environment
    21 Aug 2016Abuse: Neglect
    Investigated a complaint and found failure to provide a safe environment, evidenced by a resident-to-resident altercation.
    • AbuseFailed to provide safe environment
    26 Jun 2016Abuse: Financial abuse
    Investigated the allegation and found money was not adequately protected from theft.
    • AbuseFailed to provide safe environment
    31 May 2016Inspection
    Found a deficiency in providing a safe environment due to failure to assess and intervene.
    • LicensingFailed to provide safe environment
    27 May 2016Inspection
    Investigated and found that staff failed to assess and intervene when a resident's condition changed.
    • LicensingFailed to intervene when resident's condition changed
    13 May 2016Inspection
    Investigated an allegation of an unsafe environment and found a deficiency in providing a secure environment for residents.
    • LicensingFailed to provide safe environment
    18 Jan 2016Inspection
    Investigated an allegation of an unsafe environment and found a resident was not protected from physical aggression.
    • LicensingFailed to provide safe environment
    19 Aug 2015Inspection
    Found that care plans were not followed, resulting in a physical altercation between residents.
    • LicensingFailed to follow care plan
    13 Jun 2015Abuse: Neglect
    Investigated a neglect allegation and found a failure to follow the care plan, with a substantiated finding and a $300 fine assessed.
    • AbuseFailed to follow care plan
    07 Mar 2015Abuse: Financial abuse
    Investigated allegations of financial abuse and a failure to provide a safe environment; found a resident was not protected from theft.
    • AbuseFailed to provide safe environment
    03 Mar 2015Abuse: Neglect
    Investigated an abuse/neglect allegation and found a failure to assess and intervene.
    • AbuseFailed to address resident's behavior
    12 Sept 2014Inspection
    Found a deficiency for not maintaining an adequate medication management system.
    • LicensingFailed to provide a safe medication administration system
    29 Aug 2014Abuse: Neglect
    Found a failure to provide a safe environment that resulted in a resident-to-resident altercation.
    • AbuseFailed to provide safe environment
    14 Aug 2014Abuse: Financial abuse
    Investigated a financial abuse allegation and found a failure to provide a secure environment.
    • AbuseFailed to provide safe environment
    08 Jul 2014Abuse: Neglect
    Investigated an allegation of neglect related to medication administration and found deficiencies in maintaining a safe medication system.
    • AbuseFailed to provide a safe medication administration system
    08 Nov 2013Abuse: Neglect
    Found a failure to provide a safe medication administration system and assessed a $300 fine.
    • AbuseFailed to provide a safe medication administration system
    09 May 2013Inspection
    Found that residents were not kept safe due to failure to properly plan care.
    • LicensingFailed to properly plan care
    07 Nov 2012Abuse: Neglect
    Determined that a resident-to-resident contact occurred due to failure to prevent it. The finding relates to neglect with potential for harm.
    • AbuseFailed to address resident's behavior
    24 Aug 2012Abuse: Neglect
    Found a deficiency for failing to prevent resident-to-resident contact.
    • AbuseFailed to address resident's behavior
    22 Aug 2012Abuse: Neglect
    Investigated an allegation of neglect and found that staff failed to follow the care plan and failed to prevent a resident-to-resident contact.
    • AbuseFailed to follow care plan
    15 Aug 2012Abuse: Neglect
    Investigated an allegation of abuse/neglect and found a failure to prevent resident-to-resident contact.
    • AbuseFailed to address resident's behavior
    05 Aug 2012Abuse: Neglect
    Identified a deficiency in maintaining an adequate medication system. The finding involved risk to safe medication administration.
    • AbuseFailed to provide a safe medication administration system
    25 Jul 2012Abuse: Neglect
    Investigated the allegation of failing to administer medication as ordered and found an inadequate medication system.
    • AbuseFailed to administer medication as ordered
    27 Jun 2012Abuse: Neglect
    Investigated the neglect allegation and found a failure to protect a resident from eloping, with a fine assessed.
    • AbuseFailed to maintain functional door alarm or call system
    25 Jun 2012Abuse: Neglect
    Concluded that the provider failed to provide an adequate medication system.
    • AbuseFailed to provide a safe medication administration system
    14 Jun 2012Abuse: Verbal/Mental abuse
    Investigated and found a failure to protect a resident from inappropriate verbal comments.
    • AbuseFailed to protect resident from verbal abuse
    04 May 2012Inspection
    Determined that the provider failed to provide a safe environment and appropriate care.
    • LicensingFailed to provide safe environment
    29 Nov 2011Abuse: Neglect
    Investigated a complaint and found a failure to provide a safe environment.
    • AbuseFailed to address resident's behavior
    29 Oct 2011Inspection
    Identified failure to follow the service plan, with potential for minor to moderate harm.
    • LicensingFailed to follow care plan
    19 Jul 2011Inspection
    Found a deficiency in the medication system due to failure to administer medication as ordered.
    • LicensingFailed to administer medication as ordered
    14 May 2011Inspection
    Found failure to maintain an adequate medication system.
    • LicensingFailed to provide a safe medication administration system
    14 May 2011Inspection
    Found a deficiency in the medication administration system. A $600 fine was assessed.
    • LicensingFailed to provide a safe medication administration system
    14 Apr 2011Inspection
    Found a deficiency in maintaining a safe medication administration system.
    • LicensingFailed to provide a safe medication administration system
    14 Apr 2011Inspection
    Investigated and found a violation for failing to protect a resident from inappropriate verbal comments.
    • LicensingFailed to assure resident rights
    14 Apr 2011Abuse: Neglect
    Investigated and found a failure to maintain an adequate medication system.
    • AbuseFailed to provide a safe medication administration system
    17 Mar 2011Abuse: Neglect
    Investigated an allegation of neglect for failing to administer medication as ordered. A $300 fine was assessed.
    • AbuseFailed to administer medication as ordered
    11 Feb 2011Abuse: Neglect
    Found a failure to provide a safe medication administration system. A $400 fine was assessed.
    • AbuseFailed to provide a safe medication administration system
    10 Dec 2010Abuse: Financial abuse
    Identified a substantiated financial abuse allegation and found a failure to provide a safe and secure environment.
    • AbuseFailed to provide safe environment
    08 Nov 2010Abuse: Neglect
    Found failure to follow the care plan resulting in inadequate care to a resident.
    • AbuseFailed to follow care plan
    01 Aug 2010Inspection
    Concluded that a safe medication administration system was not provided.
    • LicensingFailed to provide a safe medication administration system
    07 May 2010Inspection
    Investigated a complaint about medication safety and found an inadequate medication system.
    • LicensingFailed to provide a safe medication administration system
    22 Apr 2010Abuse: Neglect
    Investigated a complaint and found deficiencies related to screening/assessment, resulting in failure to provide appropriate care and a $300 fine assessed.
    • AbuseFailed to perform adequate screening or assessment
    31 Mar 2010Abuse: Neglect
    Investigated the allegation of neglect and found failures to assess and intervene when a resident's condition changed.
    • AbuseFailed to intervene when resident's condition changed
    03 Mar 2010Abuse: Financial abuse
    Investigated the allegation and found that a safe environment was not provided.
    • AbuseFailed to provide safe environment

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