I toured and moved my mom in here and have been very pleased. The staff are compassionate, personable and responsive, management made the transition smooth, and they keep families updated. The community feels like home - clean, safe, with great food, diverse activities and plenty of social opportunities; I would recommend it.
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
24-hour emergency response system
Activities of daily living assistance
Assistance with bathing
Assistance with dressing
Assistance with transfers
Incontinence care
Medication management
Mental wellness program
Personal care assistance
Healthcare staffing
24-hour call system
24-hour supervision
Meals and dining
Diabetes diet
Meal preparation and service
Restaurant-style dining
Special dietary restrictions
Dining options
Chef-prepared cuisine
Multiple Dining Venues
Private dining
Room
Air conditioning
Air-conditioning
Cable
Fully furnished
Housekeeping and linen services
Kitchenette
Kitchenettes
Private bathrooms
Spa
Telephone
Walk-in-closet
Wifi
Memory care community services
Mild cognitive impairment
Specialized memory care programming
Transportation
Community operated transportation
Transportation arrangement
Common areas
Beauty salon
Computer center
Courtyard
Dining room
Fitness center
Fitness room
Gaming room
Garden
Outdoor space
Pet friendly
Small library
Theater
Walking paths
Wellness center
Community services
Apartment maintenance
Concierge services
Escorts to meals and activities
Fitness programs
Housekeeping
Laundry Services
Move-in coordination
Outdoor maintenance
Personal Laundry
Activities
Community-sponsored activities
Planned day trips
Resident-run activities
Scheduled daily activities
Reviews
3.60·(84)
Overall rating
5
4
3
2
1
Care
3.4
Staff
3.6
Meals
3.4
Amenities
3.7
Value
2.5
Pros
Friendly, attentive caregiving staff
Welcoming move-in and transition support
On-site memory care and assisted-living levels
Engaging activities program (exercise, bingo, music, pet visits)
Accepts Medicaid with equitable treatment options
Secure memory-care unit and sense of safety
Home-like atmosphere and calming decor
Convenient location and pleasant grounds
Regular family communication by some administrators
Clean, well-maintained common areas (per many accounts)
Varied social opportunities and outings
Nightly checks and routine monitoring in some units
Cons
Inconsistent staffing and high staff turnover
Frequent staffing shortages during shifts and weekends
Variable caregiver training and competency
Inconsistent hygiene and incontinence-care practices
Sanitation concerns in some rooms and common areas
Resident-safety and room-security process gaps
Inconsistent medication administration and clinical follow-up
Misplacement and loss of residents' personal belongings
Billing, refund, and extra-charge transparency issues
Variable dining quality and limited menu choice in memory care
Management communication and responsiveness inconsistency
High cost relative to perceived value
Summary of reviews
The reviews for Atrium at McLoughlin Place present a polarized picture: many families praise friendly, compassionate staff, a welcoming move-in experience, and a range of on-site services (assisted living and memory care), while other accounts identify persistent operational weaknesses that affected care and resident experience. Strengths commonly cited include an active activities calendar (exercise, bingo, puzzles, live music, pet visits), a home-like feel and calming decor, a secure memory-care unit, and a convenient location with pleasant grounds. Several reviews also highlight positive transitions and supportive administrators who provide regular family updates and routine monitoring.
Care quality and clinical operations show marked variability across accounts. Positive descriptions emphasize attentive nurses and caregivers, improved resident engagement, and helpful hospice coordination when needed. Contrastingly, some families reported gaps in clinical follow-up, inconsistent medication administration, and failures to implement physician orders—issues that contributed to concerns about mobility decline, falls, and other adverse outcomes. There are also repeated concerns about training and competency consistency among caregivers, and about staffing levels sufficient to meet care needs, particularly on certain shifts and weekends.
Staffing and management present a mixed portrait. Many reviews single out individual caregivers and unit staff as hardworking and kind; at the same time, high turnover, reliance on temporary staff, and understaffed shifts were common themes. Communication from management and corporate offices was described as responsive by some families and inadequate by others; billing and refund disputes, unexpected extra charges, and delays in resolution were recurrent administrative complaints. Several reviewers advised that leadership consistency and proactive management appear to be key determinants of the day-to-day experience.
Dining and activities likewise vary by account. The assisted-living menu is reported as having choices, while the memory-care menu is more structured with limited selection. Some families praise varied, enjoyable meals and frequent snacks; others describe bland or inconsistently prepared food. The activities program is frequently cited as a strength—regular games, group exercise, music and pet visits—but a few reviewers noted that programming can skew toward female interests and that male-focused or weekend activities may be limited.
Facility condition and safety patterns are mixed. Many reviewers describe clean, cheery common areas, regular room cleaning, and an overall safe environment. Conversely, some accounts raise sanitation concerns in specific rooms or shifts, uneven housekeeping, odor issues at times, and maintenance lapses. Safety-process gaps were implied by incidents such as residents found outside their rooms or falls; these were not uniform but indicate potential weaknesses in room-security, supervision, and resident-transfer practices.
Notable patterns to consider: staffing consistency and training repeatedly influence the difference between positive and negative experiences; property-management and billing transparency are recurring administrative concerns; and care continuity—especially around medication administration, incontinence care, and implementing physician directives—is uneven. Prospective residents and families who value warm, community-oriented staff and robust activities may find strong elements here, but those prioritizing consistently high clinical oversight and strict housekeeping protocols should verify staffing ratios, sanitation policies, incident-response procedures, property-inventory practices, and billing terms during an in-person visit. Asking to observe multiple shifts, reviewing state inspection records, and requesting recent family references are practical steps to clarify how current management addresses the operational issues noted in several reviews.
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Location
Atrium at Mc Loughlin Place is located at 1153 Molalla Ave, Oregon City, OR, 97045.
About Atrium at Mc Loughlin Place
Atrium At Mc Loughlin Place offers a welcoming and vibrant environment designed to support optimal well-being for its residents. The community strives to cultivate a sense of belonging, compassion, and support through attentive team members and a culture built on empathy and kindness. Residents can enjoy a lifestyle where rent, meals, transportation, housekeeping, and a variety of daily events are included, with services and amenities starting at $4,200 per month. From the moment you arrive, it’s evident that Atrium At Mc Loughlin Place focuses on providing comfort, connection, and the freedom to live life on your own terms.
Life at Atrium At Mc Loughlin Place is full of opportunities to engage, learn, and enjoy social interaction. Residents are encouraged to meet friends for a healthy snack, gather for delicious, chef-prepared meals, or participate in the many events and activities hosted within the community. Whether it’s joining a game in the Billiards Room, hosting guests in the Private Dining Room, relaxing in the Game Room, or spending quiet time in the Library, there are spaces designed for every interest and preference. Onsite Laundry services add to the convenience, allowing residents to focus on activities they love rather than day-to-day chores.
The environment at Atrium At Mc Loughlin Place emphasizes the importance of well-being and offers a selection of floorplans to fit individual needs. The community features vibrant spaces where residents can pursue new hobbies or simply enjoy the company of others. Daily life may include enjoying time spent with family and caregivers, participating in seasonal events such as painting pumpkins, or finding peace and inspiration while tending to plants. Personal moments and shared experiences, whether it’s enjoying a visit from a puppy in a coffee mug or laughing with friends outside, are cherished and fostered within this supportive setting.
Every aspect of Atrium At Mc Loughlin Place is designed to help residents feel truly cared for. The supportive environment helps nurture a sense of purpose and joy—whether through enjoying the creative arts, taking part in group activities, or relishing quiet, restorative time. The staff is dedicated to providing kind and attentive service, understanding that when residents feel appreciated and supported, they, in turn, contribute to a positive and thriving community. At Atrium At Mc Loughlin Place, the focus is always on celebrating life’s moments, big and small, in a place that feels like home.
People often ask...
Atrium at Mc Loughlin Place offers competitive pricing, with rates starting at a cost of $6,826 per month.
Atrium at Mc Loughlin Place offers assisted living and memory care.
There are 25 photos of Atrium at Mc Loughlin Place on Mirador.
The full address for this community is 1153 Molalla Ave, Oregon City, OR 97045.
No, Atrium at Mc Loughlin Place 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.
Investigated a complaint about care planning and found service plans did not reflect residents' needs or preferences.
Licensing—Failed to properly plan care
24 Oct 2025Inspection
24 Oct 2025Inspection
Investigated a medication administration incident and found a failure to provide a safe medication administration system, with opioids given early to a resident.
Licensing—Failed to provide a safe medication administration system
08 Aug 2025Abuse: Neglect
08 Aug 2025Abuse: Neglect
Investigated the allegation of abuse by neglect and found that the individual did not receive adequate care, resulting in gangrene; a $500 fine was assessed.
Abuse—Failed to provide service
07 Aug 2025Abuse: Neglect
07 Aug 2025Abuse: Neglect
Concluded that a resident experienced neglect and abuse due to inadequate oversight, leading to an emergency department visit; a fine was assessed.
Abuse—Failed to provide service
16 Jun 2025Inspection
16 Jun 2025Inspection
Found that a service plan was not developed by the required Service Planning Team.
Licensing—Failed to properly plan care
10 Jun 2025License Condition
10 Jun 2025License Condition
Found that qualified awake direct care staffing was insufficient to meet residents' 24-hour needs.
Regulatory Action—Failed to use an ABST
06 Jun 2025Inspection
06 Jun 2025Inspection
Identified a records access deficiency due to failure to provide records upon request.
Licensing—Failed to provide safe environment
27 May 2025Licensure
27 May 2025Licensure
Identified widespread deficiencies across administration, resident rights, safety, staffing, and medication management with multiple risks to residents’ health and safety.
Deficiency—Resident Move-in & Evaluation: Res Evaluation
21 May 2025Abuse: Neglect
21 May 2025Abuse: Neglect
Investigated an abuse by neglect case involving failure to protect a resident from inappropriate sexual contact, resulting in fear and discomfort for the resident.
Abuse—Failed to protect resident from inappropriate sexual contact
21 May 2025Abuse: Neglect
21 May 2025Abuse: Neglect
Investigated the allegation of abuse by neglect and found failures to plan care and provide needed services that led to isolation and fear among residents.
Abuse—Failed to properly plan care
21 May 2025Abuse: Neglect
21 May 2025Abuse: Neglect
Found abuse by neglect for failing to protect a resident from inappropriate sexual contact; a $1500 fine was assessed.
Abuse—Failed to protect resident from inappropriate sexual contact
18 May 2025Abuse: Neglect
18 May 2025Abuse: Neglect
Found unsafe medication administration practices, including narcotic doses crossed out and untrained staff, leaving a resident in discomfort; financial abuse allegations were inconclusive.
Abuse—Failed to provide a safe medication administration system
17 May 2025Abuse: Neglect
17 May 2025Abuse: Neglect
Investigated allegations of abuse and neglect; concluded that failure to plan care around known behaviors led to multiple incidents in the dining area.
Abuse—Failed to properly plan care
13 May 2025Kitchen
13 May 2025Kitchen
Found deficiencies in food sanitation practices and administration compliance, including extensive unsanitary kitchen conditions and sanitizer levels below guidelines.
Found a violation of a safe medication administration system and assessed a $500 fine.
Abuse—Failed to provide a safe medication administration system
01 May 2025Abuse: Neglect
01 May 2025Abuse: Neglect
Investigated a complaint and found neglect of care and abuse due to failure to plan care and supervise transfers. A $500 fine was assessed.
Abuse—Failed to properly plan care
25 Apr 2025License Condition
25 Apr 2025License Condition
Identified multiple rule violations related to providing a safe environment.
Regulatory Action—Failed to provide safe environment
24 Apr 2025Inspection
24 Apr 2025Inspection
Found that records were not made available to the Department upon request.
Licensing—Failed to provide safe environment
17 Apr 2025Inspection
17 Apr 2025Inspection
Investigated and found a failure to promptly investigate all reports of abuse and suspected abuse and to take protective actions to prevent recurrence.
Licensing—Failed to provide safe environment
17 Apr 2025Inspection
17 Apr 2025Inspection
Found a deficiency for not having written policies to ensure a 24-hour resident monitoring and reporting system.
Licensing—Failed to provide safe environment
17 Apr 2025Inspection
17 Apr 2025Inspection
Investigated the allegation of failing to properly plan care and found the service plan did not reflect residents' needs.
Licensing—Failed to properly plan care
17 Apr 2025Inspection
17 Apr 2025Inspection
Identified inconsistencies between the resident roster, care plans, and ABST, and staffing levels not aligned with residents' needs as reflected by the ABST.
Licensing—Failed to use an ABST
15 Apr 2025Inspection
15 Apr 2025Inspection
Found that an acuity-based staffing tool was not developed, maintained, or implemented as required.
Licensing—Failed to use an ABST
12 Apr 2025Abuse: Neglect
12 Apr 2025Abuse: Neglect
Found abuse by neglect due to failure to provide a safe environment, resulting in resident altercations.
Abuse—Failed to provide safe environment
03 Apr 2025Abuse: Neglect
03 Apr 2025Abuse: Neglect
Found neglect-related deficiencies in medication administration. A $375 fine was assessed.
Abuse—Failed to provide a safe medication administration system
01 Apr 2025Abuse: Neglect
01 Apr 2025Abuse: Neglect
Investigated and found a safety failure led to abuse and neglect of a resident. A $250 fine was assessed.
Abuse—Failed to provide safe environment
24 Feb 2025Abuse: Neglect
24 Feb 2025Abuse: Neglect
Identified neglect for failing to provide a safe environment, leading to elopement and discovery on another floor.
Abuse—Failed to provide safe environment
08 Jan 2025Abuse: Neglect
08 Jan 2025Abuse: Neglect
Found abuse by neglect due to lack of staff monitoring during meals, allowing inappropriate contact between residents.
Abuse—Failed to protect resident from inappropriate sexual contact
10 Sept 2024Abuse: Neglect
10 Sept 2024Abuse: Neglect
Found a failure to provide a safe medication administration system, resulting in delayed scabies treatment and risk of harm to a resident. A $250 fine was assessed.
Abuse—Failed to provide a safe medication administration system
19 Jul 2024Abuse: Neglect
19 Jul 2024Abuse: Neglect
Found that a resident eloped from the facility due to a failure to provide a safe environment, putting them at risk of harm. A $500 fine was assessed.
Abuse—Failed to provide safe environment
11 Jun 2024Abuse: Neglect
11 Jun 2024Abuse: Neglect
Determined there was a failure to provide a safe environment, leading to substantiated abuse and neglect findings; a $500 fine was assessed.
Abuse—Failed to provide safe environment
07 May 2024License Condition
07 May 2024License Condition
Found deficiencies related to providing a safe environment across multiple rules.
Regulatory Action—Failed to provide safe environment
30 Jan 2024Abuse: Neglect
30 Jan 2024Abuse: Neglect
Investigated an allegation of neglect and abuse involving failure to follow a care plan for anxiety, which contributed to a fall and pain; a fine was assessed.
Abuse—Failed to follow care plan
11 Jan 2024Abuse: Neglect
11 Jan 2024Abuse: Neglect
Investigated the complaint and found that a staff member gave another resident’s medication and failed to provide a safe medication administration system. A $500 fine was assessed.
Abuse—Failed to provide a safe medication administration system
12 Nov 2023Abuse: Neglect
12 Nov 2023Abuse: Neglect
Identified a failure to provide a safe environment resulting in bruising; a fine was assessed.
Abuse—Failed to provide safe environment
30 Oct 2023Abuse: Neglect
30 Oct 2023Abuse: Neglect
Investigated a failure to provide 1:1 supervision per the care plan, resulting in an unwitnessed altercation and hair-pulling that violated resident rights and constituted neglect and abuse. A fine was assessed.
Abuse—Failed to provide safe environment
28 Oct 2023Abuse: Neglect
28 Oct 2023Abuse: Neglect
Investigated and found that one-to-one supervision required by a resident's care plan was not provided, allowing a resident to enter another's room and trigger a physical altercation. This violated resident rights and constituted abuse/neglect.
Abuse—Failed to follow care plan
09 Oct 2023Validation
09 Oct 2023Validation
Investigated multiple deficiencies across care, safety, infection control, and operations; later determined substantial compliance.
Deficiency—Resident Move-In and Eval: Res Evaluation
Deficiency—Change of Condition and Monitoring
Deficiency—Infection Prevention & Control
Deficiency—Systems: Tracking Control Substances
Deficiency—Systems: Treatment Orders
Deficiency—Acuity-Based Staffing Tool
Deficiency—Training Within 30 Days: Direct Care Staff
Deficiency—Fire and Life Safety: Safety
Deficiency—Fire and Life Safety: Training For Residents
Deficiency—Inspections and Investigation: Insp Interval
Deficiency—Doors, Walls, Elevators, Odors
Deficiency—Housekeeping and Laundry
Deficiency—Administration Compliance
Deficiency—Staff Training Requirements
Deficiency—Compliance With Rules Health Care
09 Oct 2023Validation
09 Oct 2023Validation
Identified widespread deficiencies across administration, resident care, health services, infection control, and safety systems with multiple regulatory citations.
Investigated a complaint and found neglect and abuse due to failing to provide proper care, exposing the resident's legs for hours and risking infection. A $1500 fine was assessed.
Abuse—Failed to provide service
15 Sept 2023Abuse: Neglect
15 Sept 2023Abuse: Neglect
Found violations of resident rights and neglect due to failure to provide one-on-one care per the care plan, which led to an altercation and unreasonable discomfort.
Abuse—Failed to follow care plan
05 Sept 2023Abuse: Neglect
05 Sept 2023Abuse: Neglect
Found failure to properly plan care and provide timely supervision, resulting in neglect and abuse.
Abuse—Failed to properly plan care
01 Sept 2023Abuse: Neglect
01 Sept 2023Abuse: Neglect
Found violations related to failure to plan and implement care for an unknown-origin bruising history, resulting in repeated bruising and discomfort. A $375 fine was assessed.
Abuse—Failed to properly plan care
21 Jul 2023Abuse: Neglect
21 Jul 2023Abuse: Neglect
Found that failure to follow the care plan led to an altercation and was identified as neglect and abuse; a fine was assessed.
Abuse—Failed to follow care plan
16 Jul 2023Abuse: Neglect
16 Jul 2023Abuse: Neglect
Investigated and found that care planning and interventions for a resident's aggressive behavior were not properly implemented, resulting in an altercation that risked serious harm to another resident.
Abuse—Failed to properly plan care
30 Jun 2023Abuse: Neglect
30 Jun 2023Abuse: Neglect
Investigated the allegation found that one-on-one care was not provided as required, leading to an altercation where a resident was punched, indicating abuse and neglect.
Abuse—Failed to provide safe environment
12 Jun 2023Abuse: Neglect
12 Jun 2023Abuse: Neglect
Found neglect and abuse due to failure to monitor a resident in common areas and follow the care plan. This lapse led to the resident striking another person in the back of the head, causing unreasonable discomfort.
Abuse—Failed to follow care plan
10 Jun 2023Abuse: Neglect
10 Jun 2023Abuse: Neglect
Determined that staff failed to follow a resident care plan and provide appropriate supervision, resulting in a physical altercation. A $375 fine was assessed.
Abuse—Failed to follow care plan
01 Jun 2023Complaint
01 Jun 2023Complaint
Found staffing deficiencies and delayed call-light responses due to insufficient qualified awake direct care staff to meet 24-hour needs.
Deficiency—Licensing Complaint Investigation
Deficiency—Service Plan: General
Deficiency—Staffing Requirements and Training: Staffing
01 Jun 2023Complaint
01 Jun 2023Complaint
Found that quarterly service plans were not updated for a resident. The last three plans dated 05/15/23, 12/08/22, and 8/26/22 were reviewed.
Deficiency—Licensing Complaint Investigation
Deficiency—Service Plan: General
25 May 2023Inspection
25 May 2023Inspection
Investigated an allegation that care was not properly planned and found the service plan did not reflect residents' needs.
Licensing—Failed to properly plan care
25 May 2023Inspection
25 May 2023Inspection
Found insufficient awake direct care staffing to meet residents' 24-hour needs, with a substantiated staffing deficiency.
Licensing—Failed to provide appropriate staffing
16 May 2023Abuse: Neglect
16 May 2023Abuse: Neglect
Found a failure to provide a safe environment for a resident who was found outside unsupervised, with a $375 fine assessed.
Abuse—Failed to provide safe environment
16 May 2023Abuse: Neglect
16 May 2023Abuse: Neglect
Investigated a complaint and found a failure to provide a safe environment when a resident was found outside the memory care unit in the parking lot, with staff unaware of the elopement, risking harm.
Abuse—Failed to provide safe environment
22 Apr 2023Abuse: Neglect
22 Apr 2023Abuse: Neglect
Found deficiencies in care planning and interventions related to fall history and intoxication, resulting in an unwitnessed fall and hospital transfer.
Abuse—Failed to properly plan care
20 Apr 2023Inspection
20 Apr 2023Inspection
Identified failure to update service plans quarterly, a licensing violation with potential for harm.
Licensing—Failed to properly plan care
26 Mar 2023Abuse: Neglect
26 Mar 2023Abuse: Neglect
Identified a failure to provide a safe medication administration system, resulting in a resident not receiving prescribed medication and experiencing unnecessary discomfort.
Abuse—Failed to provide a safe medication administration system
06 Feb 2023Validation
06 Feb 2023Validation
Identified multiple deficiencies across abuse reporting, care planning, monitoring of condition changes, health services, medications, staffing, safety, and environment during a licensure survey. Violations were cited for these findings.
Deficiency—Res Hlth Srvc: On- and Off-Site Health Srvc
Deficiency—Systems: Treatment Orders
Deficiency—Systems: Resident Right to Refuse
Deficiency—Systems: Medication Administration
Deficiency—Systems: Psychotropic Medication
Deficiency—Staffing Requirements and Training: Staffing
Deficiency—Fire and Life Safety: Safety
Deficiency—General Building Exterior
Deficiency—Doors, Walls, Elevators, Odors
Deficiency—Housekeeping and Laundry
Deficiency—Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable
Deficiency—Administration Responsibilities
Deficiency—Administration Compliance
Deficiency—Staff Training Requirements
Deficiency—Compliance With Rules Health Care
Deficiency—Nutrition and Hydration
Deficiency—Activities
Deficiency—Behavior
05 Feb 2023Abuse: Neglect
05 Feb 2023Abuse: Neglect
Investigated and found failure to oversee and monitor a resident's change of condition, leading to injuries and falls.
Abuse—Failed to provide oversight and monitoring of change of condition
02 Feb 2023License Condition
02 Feb 2023License Condition
Found non-compliance with the acuity-based staffing tool requirement to determine appropriate staffing levels.
Regulatory Action—Failed to use an ABST
15 Jan 2023Abuse: Neglect
15 Jan 2023Abuse: Neglect
Investigated a near-physical confrontation and found an unsafe environment that constitutes neglect and abuse, with a fine assessed.
Abuse—Failed to provide safe environment
02 Dec 2022Inspection
02 Dec 2022Inspection
Found a failure to provide a safe medication administration system when medication was found in a resident's room that had not been taken.
Licensing—Failed to provide a safe medication administration system
13 Nov 2022Abuse: Neglect
13 Nov 2022Abuse: Neglect
Found a failure to plan care for exit-seeking behavior, leading to a missing resident and safety concerns.
Abuse—Failed to properly plan care
09 Nov 2022Inspection
09 Nov 2022Inspection
Investigated improper administration of medication. The wrong insulin type was given because MAR wasn't checked, and medications were not administered as ordered.
Licensing—Failed to administer medication as ordered
27 Oct 2022Abuse: Neglect
27 Oct 2022Abuse: Neglect
Identified a deficiency for failing to provide a safe environment after an incident where a resident was pushed into a wall; a fine was assessed.
Abuse—Failed to provide safe environment
25 Oct 2022License Condition
25 Oct 2022License Condition
Found that an acuity-based staffing tool was not used to determine appropriate staffing levels.
Regulatory Action—Failed to use an ABST
20 Oct 2022Complaint
20 Oct 2022Complaint
Investigated a complaint and identified deficiencies in regulatory compliance.
Deficiency—Definitions
Deficiency—Acuity-Based Staffing Tool
14 Sept 2022Licensure
14 Sept 2022Licensure
Identified deficiencies in kitchen cleanliness, missing data plate on the dish machine, and refrigerator temperatures above 41 degrees; subsequent follow-up concluded substantial compliance.
Investigated allegations of abuse and neglect; found that staff forced a resident to a room and restrained the resident, violating resident rights, with a fine assessed.
Abuse—Failed to protect resident from physical abuse
06 Sept 2022Abuse: Neglect
06 Sept 2022Abuse: Neglect
Investigated a failure to properly plan care for a resident during transfers and toileting, which caused pain and inconsistent change methods; a civil penalty was assessed.
Abuse—Failed to properly plan care
05 Sept 2022Abuse: Neglect
05 Sept 2022Abuse: Neglect
Found that a staff member changed a resident's brief in a common area, exposing the resident and violating rights, constituting abuse and neglect; a fine was assessed.
Abuse—Failed to assure resident rights
24 Aug 2022Abuse: Neglect
24 Aug 2022Abuse: Neglect
Investigated allegation of abuse and neglect and found failures to plan care and mitigate fall risk.
Abuse—Failed to properly plan care
17 Aug 2022Abuse: Neglect
17 Aug 2022Abuse: Neglect
Identified that a resident's change in condition was not updated in the care plan, contributing to an unwitnessed fall and hospitalization. Violations were cited with a $500 fine assessed.
Abuse—Failed to properly plan care
04 Aug 2022Complaint
04 Aug 2022Complaint
Found deficiencies in safe medication administration and tracking of controlled substances.
Deficiency—Systems: Medications and Treatments
Deficiency—Systems: Tracking Control Substances
04 Aug 2022Complaint
04 Aug 2022Complaint
Identified deficiencies in acuity-based staffing usage and planning; ABST was not fully implemented, did not include all required activities of daily living, and staffing plans were not aligned with the posted plan.
Deficiency—Acuity-Based Staffing Tool
04 Aug 2022Complaint
04 Aug 2022Complaint
Investigated the complaint and found no deficiencies.
Deficiency—Definitions
24 Jul 2022Abuse: Neglect
24 Jul 2022Abuse: Neglect
Found a lack of a safe medication administration system, resulting in missed doses of several medications.
Abuse—Failed to provide a safe medication administration system
22 Jul 2022Abuse: Neglect
22 Jul 2022Abuse: Neglect
Found a neglect and abuse violation due to failing to provide a safe environment, resulting in harm, with a $500 fine assessed.
Abuse—Failed to provide safe environment
23 Jun 2022Inspection
23 Jun 2022Inspection
Found that the service plan did not reflect the resident's needs identified in the evaluation.
Licensing—Failed to properly plan care
17 Jun 2022Inspection
17 Jun 2022Inspection
Investigated and identified a failure to have a policy to safeguard residents' possessions, resulting in a licensing violation.
Licensing—Failed to provide a homelike environment
08 May 2022Abuse: Neglect
08 May 2022Abuse: Neglect
Found a safety violation due to failure to provide a safe environment, leading to multiple unwitnessed falls and injuries.
Abuse—Failed to provide safe environment
31 Mar 2022Inspection
31 Mar 2022Inspection
Found that individuals acting as administrator did not have full administrator licenses, violating Oregon Administrative Rules.
Licensing—Failed to keep medication record current or accurate
25 Jan 2022Abuse: Neglect
25 Jan 2022Abuse: Neglect
Investigated an outing safety failure where staff did not perform a head count and failed to keep the resident safe, resulting in a $500 fine.
Abuse—Failed to assure resident was safe
24 Jan 2022Inspection
24 Jan 2022Inspection
Found a deficiency in the safe medication and treatment system related to failing to provide a safe medication administration system.
Licensing—Failed to provide a safe medication administration system
24 Jan 2022Inspection
24 Jan 2022Inspection
Found a deficiency for failing to document observation and evaluation of safe medication and treatment administration unsupervised.
Licensing—Failed to provide a safe medication administration system
24 Jan 2022Inspection
24 Jan 2022Inspection
Determined that resident rights were violated by failing to treat residents with dignity and respect.
Licensing—Failed to assure resident rights
24 Jan 2022Inspection
24 Jan 2022Inspection
Identified a deficiency for not providing pre-service orientation to employees before they began their job responsibilities.
Licensing—Failed to provide safe environment
24 Jan 2022Inspection
24 Jan 2022Inspection
Investigated and identified a deficiency in tracking controlled substances due to absence of an approved system.
Licensing—Failed to provide a safe medication administration system
07 Jan 2022Abuse: Neglect
07 Jan 2022Abuse: Neglect
Investigated and found that involuntary seclusion occurred due to failure to implement a behavioral support plan and relocating a resident without proper direction. This led to increased aggressive incidents and was identified as abuse and neglect.
Abuse—Failed to protect resident from involuntary seclusion
09 Nov 2021Inspection
09 Nov 2021Inspection
Found cleanliness deficiencies related to interior materials and surfaces, including floors, rugs, and the kitchen.
Licensing—Failed to provide safe environment
03 Nov 2021Abuse: Neglect
03 Nov 2021Abuse: Neglect
Investigated and found a safety lapse due to inadequate staff training related to an assaultive resident; a $500 fine was assessed.
Abuse—Failed to assure resident was safe
02 Nov 2021Abuse: Neglect
02 Nov 2021Abuse: Neglect
Investigated a complaint alleging failure to provide a safe environment, after a resident-to-resident incident caused an injury; findings supported abuse and neglect.
Abuse—Failed to provide safe environment
19 Oct 2021Inspection
19 Oct 2021Inspection
Investigated a complaint and found that the service planning team was not included in developing the resident service plan, and care conferences were not conducted as required.
Licensing—Failed to properly plan care
30 Sept 2021Abuse: Neglect
30 Sept 2021Abuse: Neglect
Found neglect due to failure to follow the care plan and cover leg wounds, risking serious harm to the resident. A $250 fine was assessed.
Abuse—Failed to follow care plan
27 Sept 2021Inspection
27 Sept 2021Inspection
Found a failure to provide a safe environment due to furniture obstructing a doorway, constituting abuse.
Licensing—Failed to provide safe environment
27 Sept 2021Abuse: Neglect
27 Sept 2021Abuse: Neglect
Concluded that the care plan was not followed to ensure resident safety, resulting in abuse and neglect after an altercation.
Abuse—Failed to follow care plan
27 Sept 2021Inspection
27 Sept 2021Inspection
Investigated an allegation of neglect and found a doorway obstruction created an unsafe environment for a resident. Violations of safety rules were identified.
Licensing—Failed to provide safe environment
14 Aug 2021Inspection
14 Aug 2021Inspection
Found that a resident was not protected from financial exploitation and protections failed, with potential harm.
Licensing—Failed to protect resident from financial exploitation
20 Jul 2021Abuse: Neglect
20 Jul 2021Abuse: Neglect
Investigated and found a transportation failure to arrange medical or social transportation, causing missed appointments and indicating neglect and abuse.
Abuse—Failed to provide transportation for medical or social purposes
20 Jul 2021Abuse: Neglect
20 Jul 2021Abuse: Neglect
Found that timely medical treatment for a resident after a fall was not assured, constituting neglect and abuse. A $500 fine was assessed.
Abuse—Failed to assure timely medical treatment
08 Jul 2021Inspection
08 Jul 2021Inspection
Investigated and verified that a safe physical environment was not maintained.
Licensing—Failed to maintain a safe physical environment
05 Jun 2021Abuse: Neglect
05 Jun 2021Abuse: Neglect
Investigated a failure to provide a safe medication administration system, which led to missing narcotics and potential harm to a resident. Found deficiencies in medication handling that violated resident rights and constituted abuse.
Abuse—Failed to provide a safe medication administration system
05 Jun 2021Abuse: Neglect
05 Jun 2021Abuse: Neglect
Found neglect and abuse for failing to protect a resident from financial exploitation, with a $500 fine assessed.
Abuse—Failed to protect resident from financial exploitation
18 May 2021Abuse: Neglect
18 May 2021Abuse: Neglect
Found a violation for failing to provide a safe environment, resulting in abuse and neglect.
Abuse—Failed to provide safe environment
16 May 2021Abuse: Neglect
16 May 2021Abuse: Neglect
Investigated a complaint alleging neglect and abuse and found a failure to provide a safe environment, resulting in serious harm and the resident's death.
Abuse—Failed to provide safe environment
06 Apr 2021Abuse: Neglect
06 Apr 2021Abuse: Neglect
Found that a safe environment was not provided, resulting in a resident fall and injury.
Abuse—Failed to provide safe environment
17 Mar 2021Abuse: Neglect
17 Mar 2021Abuse: Neglect
Investigated an abuse and neglect allegation. The care plan was not followed, leading to aggressive behavior and safety risks for others.
Abuse—Failed to follow care plan
26 Feb 2021Abuse: Neglect
26 Feb 2021Abuse: Neglect
Investigated and found that falls were not properly addressed in the care plan, constituting neglect and abuse; a fine was assessed.
Abuse—Failed to properly plan care
26 Feb 2021Abuse: Neglect
26 Feb 2021Abuse: Neglect
Found neglect of care and abuse for failing to treat a pressure sore, leaving the resident at risk for harm.
Abuse—Failed to provide service
23 Feb 2021Inspection
23 Feb 2021Inspection
Found a safe medication administration system was not provided, resulting in incorrect medication dosing.
Licensing—Failed to provide a safe medication administration system
11 Feb 2021Inspection
11 Feb 2021Inspection
Determined that a resident experienced physical abuse and that protections against abuse were inadequate. The incident led to hospital transport.
Licensing—Failed to protect resident from physical abuse
09 Feb 2021Abuse: Neglect
09 Feb 2021Abuse: Neglect
Found staff failed to follow the resident's care plan, resulting in abuse/neglect; a fine was assessed.
Abuse—Failed to follow care plan
20 Jan 2021Abuse: Neglect
20 Jan 2021Abuse: Neglect
Investigated an abuse and neglect allegation and found failure to follow the care plan when responding to an aggressive resident, resulting in bruising.
Abuse—Failed to follow care plan
20 Nov 2020Abuse: Neglect
20 Nov 2020Abuse: Neglect
Investigated and found a failure to provide a safe medication administration system, with 35 unaccounted oxycodone tablets and no system to audit narcotics prior to November 14, 2020.
Abuse—Failed to provide a safe medication administration system
20 Nov 2020Abuse: Neglect
20 Nov 2020Abuse: Neglect
Found an unsafe medication administration system and unaccounted fentanyl patches, indicating abuse and neglect.
Abuse—Failed to provide a safe medication administration system
20 Nov 2020Abuse: Neglect
20 Nov 2020Abuse: Neglect
Found a failure to provide a safe medication administration system, resulting in missing narcotics and no audit of narcotic records.
Abuse—Failed to provide a safe medication administration system
20 Nov 2020Abuse: Neglect
20 Nov 2020Abuse: Neglect
Investigated a complaint about medication management and found a failure to provide a safe medication administration system, with unaccounted oxycodone and issues auditing narcotic records. A $500 fine was assessed.
Abuse—Failed to provide a safe medication administration system
20 Nov 2020Abuse: Neglect
20 Nov 2020Abuse: Neglect
Found a violation for failing to provide a safe medication administration system. Assessed a $500 fine.
Abuse—Failed to provide a safe medication administration system
20 Nov 2020Abuse: Neglect
20 Nov 2020Abuse: Neglect
Found a deficient safe medication administration system and assessed a $500 fine for the deficiency.
Abuse—Failed to provide a safe medication administration system
20 Nov 2020Abuse: Neglect
20 Nov 2020Abuse: Neglect
Found that medications were not properly secured or stored and narcotics records were not maintained, with unaccounted clonazepam and missing dose counts.
Abuse—Failed to properly secure or store medication
20 Nov 2020Abuse: Neglect
20 Nov 2020Abuse: Neglect
Investigated a failure to provide a system that prevents theft or misuse of medication; found medications unaccounted for and missing destruction logs, and a $500 fine was assessed.
Abuse—Failure to provide a system that prevents theft or misuse of medication
18 Nov 2020Abuse: Neglect
18 Nov 2020Abuse: Neglect
Found unsafe medication administration practices and a lack of narcotics auditing, resulting in unaccounted medication.
Abuse—Failed to provide a safe medication administration system
18 Nov 2020Abuse: Neglect
18 Nov 2020Abuse: Neglect
Investigated found a failure to provide a safe medication administration system, resulting in missing prescribed opioids and inadequate narcotics auditing; a $500 fine was assessed.
Abuse—Failed to provide a safe medication administration system
18 Nov 2020Abuse: Neglect
18 Nov 2020Abuse: Neglect
Determined that a safe medication administration system was not provided, leading to unaccounted narcotics and related abuse.
Abuse—Failed to provide a safe medication administration system
18 Nov 2020Abuse: Neglect
18 Nov 2020Abuse: Neglect
Found a violation for an unsafe medication administration system that left opioids unaccounted for. A $500 fine was assessed.
Abuse—Failed to provide a safe medication administration system
18 Nov 2020Abuse: Neglect
18 Nov 2020Abuse: Neglect
Investigated a narcotics administration lapse and found a failure to provide a safe medication administration system, with unaccounted oxycodone and missing destruction logs. The finding notes a lack of an audit system prior to a specific date.
Abuse—Failed to provide a safe medication administration system
15 Nov 2020Abuse: Neglect
15 Nov 2020Abuse: Neglect
Investigated an allegation of unsafe medication administration and found a failure to provide a safe medication system, with unaccounted tablets identified during the period in question.
Abuse—Failed to provide a safe medication administration system
14 Nov 2020Abuse: Neglect
14 Nov 2020Abuse: Neglect
Found violations for failing to maintain a safe medication administration system, including unaccounted narcotics, and assessed a $1,500 fine.
Abuse—Failed to provide a safe medication administration system
14 Nov 2020Abuse: Neglect
14 Nov 2020Abuse: Neglect
Found a failure to provide a safe medication administration system, risking harm to a resident. The failures included not following narcotics policies and lacking proper narcotic logging.
Abuse—Failed to provide a safe medication administration system
05 Nov 2020Abuse: Neglect
05 Nov 2020Abuse: Neglect
Found a violation for failing to provide a safe environment, constituting abuse.
Abuse—Failed to provide safe environment
14 Sept 2020Inspection
14 Sept 2020Inspection
Investigated the allegation and found that medication and treatment orders were not carried out as prescribed.
Licensing—Failed to administer medication as ordered
14 Sept 2020Inspection
14 Sept 2020Inspection
Investigated the staffing documentation allegation and verified that training records for employees were not maintained.
Licensing—Failed to submit timely or adequate staffing documentation
14 Sept 2020Inspection
14 Sept 2020Inspection
Investigated and determined that there was a failure to immediately report potential or suspected abuse, and the incident investigations did not include administrator's review.
Licensing—Failed to report potential or suspected abuse
24 Aug 2020Inspection
24 Aug 2020Inspection
Found that medication orders were not carried out as prescribed.
Licensing—Failed to administer ordered medication
29 Jul 2020Abuse: Neglect
29 Jul 2020Abuse: Neglect
Investigated and found a failure to provide a safe medication administration system that put a resident at risk when nine morning medications were not ordered timely; a $500 fine was assessed.
Abuse—Failed to provide a safe medication administration system
15 Jul 2020Abuse: Neglect
15 Jul 2020Abuse: Neglect
Investigated an allegation that a safe medication administration system was not provided and found a failure in medication management that risked harm from insulin administration.
Abuse—Failed to provide a safe medication administration system
06 Jul 2020License Condition
06 Jul 2020License Condition
Investigated infection control and found practices were not consistently followed, putting staff and residents at risk.
Regulatory Action—Failed to provide infection control
30 Jun 2020Inspection
30 Jun 2020Inspection
Investigated and found that a resident's pill organizer was taken by a staff member, constituting financial exploitation and abuse.
Licensing—Failed to protect resident from financial exploitation
30 Jun 2020Inspection
30 Jun 2020Inspection
Found a resident’s medications were left unsecured and later taken by an unknown staff member, resulting in financial exploitation; identified a deficiency for protection of personal property.
Licensing—Failed to protect resident from financial exploitation
29 Jun 2020Inspection
29 Jun 2020Inspection
Investigated and found that resident service plans failed to provide clear direction to staff.
Licensing—Failed to follow care plan
17 Jun 2020Abuse: Neglect
17 Jun 2020Abuse: Neglect
Investigated a report of neglect involving medication administration. Found a failure to provide a safe system resulting in missed doses and withdrawal symptoms; a fine was assessed.
Abuse—Failed to provide a safe medication administration system
11 Jun 2020Abuse: Neglect
11 Jun 2020Abuse: Neglect
Investigated a complaint about a resident's care plan not being followed, which constituted neglect and abuse. A $500 fine was assessed.
Abuse—Failed to follow care plan
09 Jun 2020Inspection
09 Jun 2020Inspection
Investigated found a violation involving failure to protect a resident from financial exploitation and inconsistent narcotics documentation surrounding oxycodone administration.
Licensing—Failed to protect resident from financial exploitation
09 Jun 2020Inspection
09 Jun 2020Inspection
Investigated an allegation of financial exploitation of a resident by a staff member's narcotics documentation. Found substantiated violations related to protecting a resident from exploitation and to inaccurate narcotics documentation.
Licensing—Failed to protect resident from financial exploitation
29 May 2020Inspection
29 May 2020Inspection
Identified deficiencies in resident telephone access, including inadequate telephones and restricted private use.
Licensing—Failed to provide service
29 May 2020Inspection
29 May 2020Inspection
Investigated the complaint and found that interior and exterior materials, surfaces, and equipment were not kept clean or in good repair, compromising health and safety.
Licensing—Failed to provide safe environment
29 May 2020Inspection
29 May 2020Inspection
Found insufficient staffing to meet scheduled and unscheduled resident needs.
Licensing—Failed to provide appropriate staffing
12 May 2020Abuse: Neglect
12 May 2020Abuse: Neglect
Investigated a medication safety issue and found a deficient medication administration system, with missing oxycodone and conflicting administration records.
Abuse—Failed to provide a safe medication administration system
28 Mar 2020Abuse: Neglect
28 Mar 2020Abuse: Neglect
Investigated a complaint and found violations related to improper readmission, resulting in harm to a resident.
Abuse—Failed to properly admit or re-admit
03 Mar 2020Inspection
03 Mar 2020Inspection
Verified that ordered medication was not administered as prescribed.
Licensing—Failed to administer ordered medication
14 Feb 2020Inspection
14 Feb 2020Inspection
Determined that the allegation regarding not providing an administrator for at least 40 hours per week was supported.
Licensing—
14 Feb 2020Inspection
14 Feb 2020Inspection
Investigated an allegation of failing to assure resident rights and found records were not kept confidential as required by law.
Licensing—Failed to assure resident rights
14 Feb 2020Inspection
14 Feb 2020Inspection
Found insufficient professional oversight of the medication and treatment administration system.
Licensing—Failed to provide a safe medication administration system
14 Feb 2020Inspection
14 Feb 2020Inspection
Investigated and found a licensing violation for failing to administer medication as ordered.
Licensing—Failed to administer medication as ordered
17 Jan 2020Abuse: Neglect
17 Jan 2020Abuse: Neglect
Found violations involving financial exploitation and neglect of a resident, including missing money and property and staff accepting gifts; a $250 fine was assessed.
Abuse—Failed to protect resident from financial exploitation
11 Jan 2020Abuse: Neglect
11 Jan 2020Abuse: Neglect
Investigated and found that a licensee's staff did not administer prescribed anti-constipation medication as ordered, leading to pain and subsequent hospitalization.
Abuse—Failed to administer medication as ordered
16 Dec 2019Inspection
16 Dec 2019Inspection
Confirmed insufficient staffing to meet residents' needs.
Licensing—Failed to provide appropriate staffing
16 Dec 2019Inspection
16 Dec 2019Inspection
Determined that the provider failed to provide assistance with bathing, dressing, and toileting.
Licensing—Failed to provide or assist with hygiene
15 Dec 2019Abuse: Neglect
15 Dec 2019Abuse: Neglect
Investigated a fall-risk resident who wasn't timely assessed after reporting falls, resulting in neglect and abuse findings and a $250 fine.
Abuse—Failed to perform adequate screening or assessment
06 Dec 2019Abuse: Neglect
06 Dec 2019Abuse: Neglect
Investigated neglect allegations and found a failure to provide a safe environment and to implement fall-prevention planning, risking resident harm.
Abuse—Failed to provide safe environment
11 Sept 2019Abuse: Neglect
11 Sept 2019Abuse: Neglect
Investigated the failure to administer prescribed medications; found that two ordered drugs were not given to a resident, risking harm and resulting in a fine.
Abuse—Failed to administer ordered medication
23 Aug 2019Abuse: Neglect
23 Aug 2019Abuse: Neglect
Found a failure to provide a safe medication administration system, leading to a resident taking mismatched pills and becoming ill after leaving with medications packaged by staff.
Abuse—Failed to provide a safe medication administration system
20 Aug 2019Abuse: Neglect
20 Aug 2019Abuse: Neglect
Found neglect due to failing to provide basic care and services necessary to maintain health and safety, creating risk of serious harm; a fine of $188.00 assessed.
Abuse—Failed to provide safe environment
20 Jun 2019Inspection
20 Jun 2019Inspection
Found a failure to provide a safe medication administration system.
Licensing—Failed to provide a safe medication administration system
21 May 2019Abuse: Neglect
21 May 2019Abuse: Neglect
Concluded neglect led to harm from failing to provide necessary services to maintain health and safety.
Abuse—Failed to properly plan care
21 May 2019Inspection
21 May 2019Inspection
Investigated a report of potential abuse and identified a failure to report suspected abuse.
Licensing—Failed to report potential or suspected abuse
08 May 2019Inspection
08 May 2019Inspection
Found that the Service Planning Team was not included in developing the resident's service plan.
Licensing—Failed to properly plan care
04 May 2019Abuse: Neglect
04 May 2019Abuse: Neglect
Determined that neglect occurred, resulting in a resident-to-resident altercation with injury. A $188 fine was assessed.
Abuse—Failed to provide safe environment
23 Apr 2019Inspection
23 Apr 2019Inspection
Identified insufficient direct care staff to meet residents' scheduled and unscheduled needs. This left residents' shower and laundry needs unmet.
Licensing—Failed to provide or assist with hygiene
26 Jan 2019Abuse: Neglect
26 Jan 2019Abuse: Neglect
Investigated the allegation of neglect and assessed a $500 fine.
Abuse—Failed to provide a safe medication administration system
26 Jan 2019Inspection
26 Jan 2019Inspection
Investigated and found a failure to report suspected abuse; a $1,000 fine was assessed.
Licensing—Failed to report potential or suspected abuse
07 Sept 2018Inspection
07 Sept 2018Inspection
Investigated a complaint and found that initial service plans were not developed for newly admitted residents with suicidal tendencies, allergies, and high fall risk.
Licensing—Failed to properly plan care
07 Sept 2018Inspection
07 Sept 2018Inspection
Found direct care staffing insufficient to meet residents' needs, including not following the posted staffing plan.
Licensing—Failed to provide appropriate staffing
04 Jun 2018Abuse: Neglect
04 Jun 2018Abuse: Neglect
Identified a neglect violation for failing to administer medication as ordered, which led to hospitalization. A $500 fine was assessed.
Abuse—Failed to administer medication as ordered
04 Jun 2018Inspection
04 Jun 2018Inspection
Found failure to report suspected abuse and assessed a $750 fine.
Licensing—Failed to report potential or suspected abuse
08 May 2018Inspection
08 May 2018Inspection
Found that quarterly service plans were not completed; a resident had not received an updated service plan since 2017.
Licensing—Failed to properly plan care
08 May 2018Inspection
08 May 2018Inspection
Found that residents' service plans were not developed with the Service Planning Team as required, and no updated service plan meeting has occurred since 2017.
Licensing—Failed to properly plan care
23 Mar 2018Inspection
23 Mar 2018Inspection
Found a deficiency for failing to control pests, with residents having head lice.
Licensing—Failed to control pests
23 Mar 2018Inspection
23 Mar 2018Inspection
Found a deficiency in housekeeping and interior cleanliness. The finding noted a failure to keep the interior clean and in good repair based on a complaint that it was dirty.
Licensing—Failed to provide appropriate housekeeping services
14 Mar 2018Abuse: Neglect
14 Mar 2018Abuse: Neglect
Investigated a complaint and found a failure to provide a safe environment resulting in a resident altercation; a $15,000 fine was assessed.
Abuse—Failed to provide safe environment
12 Mar 2018Inspection
12 Mar 2018Inspection
Identified failure to have a registered nurse on site as required. The issue was classified as a Level 1 licensing violation with no harm or potential for minor harm.
Licensing—Failed to assure that a qualified caregiver was present
12 Mar 2018Inspection
12 Mar 2018Inspection
Investigated the allegation that staffing was inadequate and found a deficiency due to insufficient staff for unscheduled needs.
Licensing—Failed to provide appropriate staffing
12 Mar 2018Inspection
12 Mar 2018Inspection
Investigated and substantiated a failure to investigate an unknown-origin injury and report incidents to Adult Protective Services.
Licensing—Failed to investigate injury of unknown origin to rule out abuse
21 Nov 2017Inspection
21 Nov 2017Inspection
Investigated an allegation of failing to provide a safe environment; identified a licensing violation and assessed a $200 fine.
Licensing—Failed to provide safe environment
03 Nov 2017Abuse: Financial abuse
03 Nov 2017Abuse: Financial abuse
Determined that a resident was exposed to financial exploitation resulting in theft due to failure to protect from financial exploitation.
Abuse—Failed to protect resident from financial exploitation
23 Oct 2017Abuse: Neglect
23 Oct 2017Abuse: Neglect
Found that staff failed to assess and intervene in a resident's change of condition, creating an unsafe environment and hospitalization; a $400 fine was assessed.
Abuse—Failed to intervene when resident's condition changed
15 Jun 2017Abuse: Neglect
15 Jun 2017Abuse: Neglect
Investigated an allegation of improper care planning and found a safety deficiency resulting in three resident-to-resident altercations.
Abuse—Failed to properly plan care
13 Aug 2016Abuse: Neglect
13 Aug 2016Abuse: Neglect
Found inadequate supervision that led to a fall requiring hospitalization. Violations were cited under multiple rules related to supervision and fall prevention.
Abuse—Failed to adequately care plan related to falls
01 May 2016Abuse: Neglect
01 May 2016Abuse: Neglect
Found a failure to provide a safe environment. A $300 fine was assessed.
Abuse—Failed to address resident's behavior
01 May 2016Abuse: Neglect
01 May 2016Abuse: Neglect
Found violations related to unsafe environment.
Abuse—Failed to address resident's behavior
13 Apr 2016Abuse: Neglect
13 Apr 2016Abuse: Neglect
Found a failure to provide a secure environment.
Abuse—Failed to provide safe environment
05 Feb 2016Inspection
05 Feb 2016Inspection
Found a deficiency in active supervision of a staff member with a preliminary criminal history check.
Licensing—Failed to assure that a qualified caregiver was present
21 Jan 2016Abuse: Neglect
21 Jan 2016Abuse: Neglect
Found the care plan was not followed, with potential for moderate harm.
Abuse—Failed to follow care plan
02 Jan 2015Abuse: Neglect
02 Jan 2015Abuse: Neglect
Determined there was a failure to provide a safe environment.
Abuse—Failed to provide safe environment
01 Jan 2015Abuse: Neglect
01 Jan 2015Abuse: Neglect
Investigated the neglect allegation and found a failure to provide a safe environment.
Abuse—Failed to address resident's behavior
26 Dec 2014Inspection
26 Dec 2014Inspection
Investigated a complaint and found failure to assess and intervene, creating a potential unsafe environment.
Licensing—Failed to provide safe environment
08 Nov 2014Abuse: Neglect
08 Nov 2014Abuse: Neglect
Investigated an allegation of failing to assure timely medical treatment and found that appropriate care was not provided.
Abuse—Failed to assure timely medical treatment
01 Nov 2014Abuse: Neglect
01 Nov 2014Abuse: Neglect
Found a failure to follow a safe medication administration system and assessed a $300 fine.
Abuse—Failed to provide a safe medication administration system
05 May 2014Abuse: Neglect
05 May 2014Abuse: Neglect
Investigated a neglect allegation and found a failure to follow the agreed service plan.
Abuse—Failed to follow care plan
05 May 2014Abuse: Neglect
05 May 2014Abuse: Neglect
Investigated a neglect allegation and found failure to provide needed services; a $300 fine assessed.
Abuse—Failed to properly plan care
12 Apr 2014Inspection
12 Apr 2014Inspection
Investigated a complaint and identified a violation for failing to prevent a resident-to-resident altercation.
Licensing—Failed to address resident's behavior
25 Feb 2014Inspection
25 Feb 2014Inspection
Found a violation of resident rights and care standards; a resident was forced to shower due to inadequate care.
Licensing—Failed to assure resident rights
25 Feb 2014Inspection
25 Feb 2014Inspection
Investigated a failure to have a safe medication administration system, which led to missed doses of medication.
Licensing—Failed to provide a safe medication administration system
30 Dec 2013Abuse: Neglect
30 Dec 2013Abuse: Neglect
Found a deficiency in care planning that led to a fall with injury.
Abuse—Failed to properly plan care
02 Jul 2013Abuse: Neglect
02 Jul 2013Abuse: Neglect
Investigated an abuse/neglect allegation of moderate harm. Found violations; a civil penalty was assessed.
Abuse—Failed to provide service
26 May 2013Inspection
26 May 2013Inspection
Investigated and found a deficiency in assessing and intervening with resident behavior, which led to a resident altercation.
Licensing—Failed to address resident's behavior
23 Jan 2013Inspection
23 Jan 2013Inspection
Investigated an allegation that staff failed to address resident behavior, resulting in a resident-to-resident altercation; violations were cited.
Licensing—Failed to address resident's behavior
08 Jan 2013Inspection
08 Jan 2013Inspection
Investigated an allegation of unsafe medication administration and found a failure to have a safe medication administration system.
Licensing—Failed to provide a safe medication administration system
07 Jan 2013Inspection
07 Jan 2013Inspection
Identified a deficiency in the safe medication administration system. The finding indicated potential for harm due to unsafe medication practices.
Licensing—Failed to provide a safe medication administration system
26 Dec 2012Abuse: Neglect
26 Dec 2012Abuse: Neglect
Determined that basic care was not provided. Violations were identified.
Abuse—Failed to provide service
12 Sept 2012Inspection
12 Sept 2012Inspection
Investigated an allegation of failing to administer medication as ordered; found a lack of a safe medication administration system.
Licensing—Failed to administer medication as ordered
31 Aug 2012Inspection
31 Aug 2012Inspection
Investigated an allegation of failing to assist with eating and found that a resident was not treated with dignity and respect.
Licensing—Failed to assist with eating
08 Jun 2012Abuse: Neglect
08 Jun 2012Abuse: Neglect
Found deficiencies in the medication administration system that could affect safe delivery of medications. The deficiency involved not administering medications as ordered.
Abuse—Failed to administer medication as ordered
01 May 2012Abuse: Neglect
01 May 2012Abuse: Neglect
Investigated an allegation of not administering medication as ordered and identified violations for not following doctors' orders.
Abuse—Failed to administer medication as ordered
17 Apr 2012Abuse: Financial abuse
17 Apr 2012Abuse: Financial abuse
Determined there was no safe medication administration system, which allowed theft of medications. A $300 fine was assessed.
Abuse—Failure to provide a system that prevents theft or misuse of medication
15 Mar 2012Abuse: Neglect
15 Mar 2012Abuse: Neglect
Identified a substantiated neglect allegation due to failure to provide a safe environment. Found continued noncompliance with Oregon Administrative Rules since 02/25/11, evidenced by relicensure survey and four subsequent revisit surveys.
Abuse—Failed to provide safe environment
13 Aug 2011Abuse: Neglect
13 Aug 2011Abuse: Neglect
Found that the care plan was not followed, resulting in a fall with injury.
Abuse—Failed to follow care plan
18 Jul 2011Abuse: Neglect
18 Jul 2011Abuse: Neglect
Determined that neglect occurred due to failing to seek timely medical attention when a resident's condition changed.
Abuse—Failed to intervene when resident's condition changed
28 Apr 2011Abuse: Neglect
28 Apr 2011Abuse: Neglect
Investigated an abuse/neglect allegation of inadequate screening or assessment that led to a resident-to-resident altercation with injury.
Abuse—Failed to perform adequate screening or assessment
23 Dec 2010Abuse: Neglect
23 Dec 2010Abuse: Neglect
Found failures to maintain an adequate medication system.
Abuse—Failed to provide a safe medication administration system
23 Dec 2010Inspection
23 Dec 2010Inspection
Identified a deficiency for failing to appropriately assess and intervene when a resident's condition changed.
Licensing—Failed to intervene when resident's condition changed
Disclaimer
Mirador Living is not affiliated with the owner or operator(s) of Atrium at Mc Loughlin Place. The information above has not been verified or approved by the owner or operator. For exact information, please contact Atrium at Mc Loughlin Place directly. There is no cost for this service. We are compensated by the community you select.
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