Atrium at Mc Loughlin Place

    1153 Molalla Ave, Oregon City, OR 97045
    • Assisted Living
    • Memory Care

    Compassionate staff and welcoming community

    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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    Tour Type

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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

    1. 5
    2. 4
    3. 3
    4. 2
    5. 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
    • Uneven housekeeping and room maintenance
    • Activity programming skewed toward female residents
    • 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

    Map showing location of Atrium at Mc Loughlin Place

    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.

    License number70M059
    StatusActive
    Facility typeAssisted Living Facility
    Capacity74 residents
    LicenseeVOP Mcloughlin Place, LLC
    EffectiveMarch 30th, 1997
    View the official license record

    Inspection Reports

    223

    Reports

    0

    Type A Citations

    0

    Type B Citations

    6

    Complaints

    16

    Years

    30 Oct 2025Inspection
    Investigated a complaint about care planning and found service plans did not reflect residents' needs or preferences.
    • LicensingFailed to properly plan care
    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.
    • LicensingFailed to provide a safe medication administration system
    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.
    • AbuseFailed to provide service
    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.
    • AbuseFailed to provide service
    16 Jun 2025Inspection
    Found that a service plan was not developed by the required Service Planning Team.
    • LicensingFailed to properly plan care
    10 Jun 2025License Condition
    Found that qualified awake direct care staffing was insufficient to meet residents' 24-hour needs.
    • Regulatory ActionFailed to use an ABST
    06 Jun 2025Inspection
    Identified a records access deficiency due to failure to provide records upon request.
    • LicensingFailed to provide safe environment
    27 May 2025Licensure
    Identified widespread deficiencies across administration, resident rights, safety, staffing, and medication management with multiple risks to residents’ health and safety.
    • DeficiencyFacility Administration: Operation
    • DeficiencyFacility Administration: Policy & Procedure
    • DeficiencyFacility Administration: Quality Improvement
    • DeficiencyReasonable Precautions
    • DeficiencyResident Rights and Protection - General
    • DeficiencyReporting & Investigating Abuse-Other Action
    • DeficiencyResident Move-in & Evaluation: Res Evaluation
    • DeficiencyService Plan: General
    • DeficiencyService Plan: Service Planning Team
    • DeficiencyChange of Condition and Monitoring
    • DeficiencySystems: Medications and Treatments
    • DeficiencySystems: Medication Administration
    • DeficiencySystems: Tracking Control Substances
    • DeficiencySystems: Treatment Orders
    • DeficiencySystems: Resident Right to Refuse
    • DeficiencyStaffing Requirements and Training: Staffing
    • DeficiencyAcuity Based Staffing Tool - ABST Time
    • DeficiencyAcuity Based Staffing Tool - Updates & Staffing Plan
    • DeficiencyTraining Within 30 Days of Hire – 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
    • DeficiencyGeneral Building: Doors-Walls, Cleanable
    • DeficiencyCall System
    • DeficiencyIndividual Rights Settings: Privacy, Dignity
    • DeficiencyIndividual freedom & Support: Activities
    • DeficiencyResident Move-in & Evaluation: Res Evaluation
    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.
    • AbuseFailed to protect resident from inappropriate sexual contact
    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.
    • AbuseFailed to properly plan care
    21 May 2025Abuse: Neglect
    Found abuse by neglect for failing to protect a resident from inappropriate sexual contact; a $1500 fine was assessed.
    • AbuseFailed to protect resident from inappropriate sexual contact
    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.
    • AbuseFailed to provide a safe medication administration system
    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.
    • AbuseFailed to properly plan care
    13 May 2025Kitchen
    Found deficiencies in food sanitation practices and administration compliance, including extensive unsanitary kitchen conditions and sanitizer levels below guidelines.
    • DeficiencyResident Services Meals, Food Sanitation Rule
    • DeficiencyAdministration Compliance
    13 May 2025Kitchen
    Identified significant kitchen sanitation deficiencies and improper food handling, indicating noncompliance with food sanitation rules.
    • DeficiencyResident Services Meals, Food Sanitation Rule
    13 May 2025Abuse: Neglect
    Found a violation of a safe medication administration system and assessed a $500 fine.
    • AbuseFailed to provide a safe medication administration system
    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.
    • AbuseFailed to properly plan care
    25 Apr 2025License Condition
    Identified multiple rule violations related to providing a safe environment.
    • Regulatory ActionFailed to provide safe environment
    24 Apr 2025Inspection
    Found that records were not made available to the Department upon request.
    • LicensingFailed to provide safe environment
    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.
    • LicensingFailed to provide safe environment
    17 Apr 2025Inspection
    Found a deficiency for not having written policies to ensure a 24-hour resident monitoring and reporting system.
    • LicensingFailed to provide safe environment
    17 Apr 2025Inspection
    Investigated the allegation of failing to properly plan care and found the service plan did not reflect residents' needs.
    • LicensingFailed to properly plan care
    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.
    • LicensingFailed to use an ABST
    15 Apr 2025Inspection
    Found that an acuity-based staffing tool was not developed, maintained, or implemented as required.
    • LicensingFailed to use an ABST
    12 Apr 2025Abuse: Neglect
    Found abuse by neglect due to failure to provide a safe environment, resulting in resident altercations.
    • AbuseFailed to provide safe environment
    03 Apr 2025Abuse: Neglect
    Found neglect-related deficiencies in medication administration. A $375 fine was assessed.
    • AbuseFailed to provide a safe medication administration system
    01 Apr 2025Abuse: Neglect
    Investigated and found a safety failure led to abuse and neglect of a resident. A $250 fine was assessed.
    • AbuseFailed to provide safe environment
    24 Feb 2025Abuse: Neglect
    Identified neglect for failing to provide a safe environment, leading to elopement and discovery on another floor.
    • AbuseFailed to provide safe environment
    08 Jan 2025Abuse: Neglect
    Found abuse by neglect due to lack of staff monitoring during meals, allowing inappropriate contact between residents.
    • AbuseFailed to protect resident from inappropriate sexual contact
    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.
    • AbuseFailed to provide a safe medication administration system
    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.
    • AbuseFailed to provide safe environment
    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.
    • AbuseFailed to provide safe environment
    07 May 2024License Condition
    Found deficiencies related to providing a safe environment across multiple rules.
    • Regulatory ActionFailed to provide safe environment
    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.
    • AbuseFailed to follow care plan
    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.
    • AbuseFailed to provide a safe medication administration system
    12 Nov 2023Abuse: Neglect
    Identified a failure to provide a safe environment resulting in bruising; a fine was assessed.
    • AbuseFailed to provide safe environment
    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.
    • AbuseFailed to provide safe environment
    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.
    • AbuseFailed to follow care plan
    09 Oct 2023Validation
    Investigated multiple deficiencies across care, safety, infection control, and operations; later determined substantial compliance.
    • DeficiencyComment
    • DeficiencyResident Services Meals, Food Sanitation Rule
    • DeficiencyResident Move-In and Eval: Res Evaluation
    • DeficiencyChange of Condition and Monitoring
    • DeficiencyInfection Prevention & Control
    • DeficiencySystems: Tracking Control Substances
    • DeficiencySystems: Treatment Orders
    • DeficiencyAcuity-Based Staffing Tool
    • DeficiencyTraining Within 30 Days: Direct Care Staff
    • DeficiencyFire and Life Safety: Safety
    • DeficiencyFire and Life Safety: Training For Residents
    • DeficiencyInspections and Investigation: Insp Interval
    • DeficiencyDoors, Walls, Elevators, Odors
    • DeficiencyHousekeeping and Laundry
    • DeficiencyAdministration Compliance
    • DeficiencyStaff Training Requirements
    • DeficiencyCompliance With Rules Health Care
    09 Oct 2023Validation
    Identified widespread deficiencies across administration, resident care, health services, infection control, and safety systems with multiple regulatory citations.
    • DeficiencyComment
    • DeficiencyFacility Administration: Required Postings
    • DeficiencyResident Rights and Protection - General
    • DeficiencyReporting & Investigating Abuse-Other Action
    • DeficiencyResident Services Meals, Food Sanitation Rule
    • DeficiencyResident Move-In and Eval: Res Evaluation
    • DeficiencyService Plan: General
    • DeficiencyService Plan: Service Planning Team
    • DeficiencyChange of Condition and Monitoring
    • DeficiencyResident Health Services
    • DeficiencyRes Hlth Srvc: On- and Off-Site Health Srvc
    • DeficiencyInfection Prevention & Control
    • DeficiencySystems: Tracking Control Substances
    • DeficiencySystems: Medication Administration
    • DeficiencySystems: Self-Administration of Meds
    • DeficiencyAdministrator Qualification and Requirements
    • DeficiencyAcuity-Based Staffing Tool
    • 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
    • DeficiencyGeneral Building Exterior
    • DeficiencyGeneral Building: Doors-Walls, Cleanable
    • DeficiencyHouse Keeping and Sanitation
    • DeficiencyCall System
    28 Sept 2023Abuse: Neglect
    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.
    • AbuseFailed to provide service
    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.
    • AbuseFailed to follow care plan
    05 Sept 2023Abuse: Neglect
    Found failure to properly plan care and provide timely supervision, resulting in neglect and abuse.
    • AbuseFailed to properly plan care
    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.
    • AbuseFailed to properly plan care
    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.
    • AbuseFailed to follow care plan
    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.
    • AbuseFailed to properly plan care
    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.
    • AbuseFailed to provide safe environment
    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.
    • AbuseFailed to follow care plan
    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.
    • AbuseFailed to follow care plan
    01 Jun 2023Complaint
    Found staffing deficiencies and delayed call-light responses due to insufficient qualified awake direct care staff to meet 24-hour needs.
    • DeficiencyLicensing Complaint Investigation
    • DeficiencyService Plan: General
    • DeficiencyStaffing Requirements and Training: Staffing
    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.
    • DeficiencyLicensing Complaint Investigation
    • DeficiencyService Plan: General
    25 May 2023Inspection
    Investigated an allegation that care was not properly planned and found the service plan did not reflect residents' needs.
    • LicensingFailed to properly plan care
    25 May 2023Inspection
    Found insufficient awake direct care staffing to meet residents' 24-hour needs, with a substantiated staffing deficiency.
    • LicensingFailed to provide appropriate staffing
    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.
    • AbuseFailed to provide safe environment
    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.
    • AbuseFailed to provide safe environment
    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.
    • AbuseFailed to properly plan care
    20 Apr 2023Inspection
    Identified failure to update service plans quarterly, a licensing violation with potential for harm.
    • LicensingFailed to properly plan care
    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.
    • AbuseFailed to provide a safe medication administration system
    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.
    • DeficiencyComment
    • DeficiencyReporting & Investigating Abuse-Other Action
    • DeficiencyService Plan: General
    • DeficiencyChange of Condition and Monitoring
    • DeficiencyResident Health Services
    • DeficiencyRes Hlth Srvc: On- and Off-Site Health Srvc
    • DeficiencySystems: Treatment Orders
    • DeficiencySystems: Resident Right to Refuse
    • DeficiencySystems: Medication Administration
    • DeficiencySystems: Psychotropic Medication
    • DeficiencyStaffing Requirements and Training: Staffing
    • DeficiencyFire and Life Safety: Safety
    • DeficiencyGeneral Building Exterior
    • DeficiencyDoors, Walls, Elevators, Odors
    • DeficiencyHousekeeping and Laundry
    • DeficiencyCall Sys, Exit Dr Alarm, Phones, Tv, Or Cable
    • DeficiencyAdministration Responsibilities
    • DeficiencyAdministration Compliance
    • DeficiencyStaff Training Requirements
    • DeficiencyCompliance With Rules Health Care
    • DeficiencyNutrition and Hydration
    • DeficiencyActivities
    • DeficiencyBehavior
    05 Feb 2023Abuse: Neglect
    Investigated and found failure to oversee and monitor a resident's change of condition, leading to injuries and falls.
    • AbuseFailed to provide oversight and monitoring of change of condition
    02 Feb 2023License Condition
    Found non-compliance with the acuity-based staffing tool requirement to determine appropriate staffing levels.
    • Regulatory ActionFailed to use an ABST
    15 Jan 2023Abuse: Neglect
    Investigated a near-physical confrontation and found an unsafe environment that constitutes neglect and abuse, with a fine assessed.
    • AbuseFailed to provide safe environment
    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.
    • LicensingFailed to provide a safe medication administration system
    13 Nov 2022Abuse: Neglect
    Found a failure to plan care for exit-seeking behavior, leading to a missing resident and safety concerns.
    • AbuseFailed to properly plan care
    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.
    • LicensingFailed to administer medication as ordered
    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.
    • AbuseFailed to provide safe environment
    25 Oct 2022License Condition
    Found that an acuity-based staffing tool was not used to determine appropriate staffing levels.
    • Regulatory ActionFailed to use an ABST
    20 Oct 2022Complaint
    Investigated a complaint and identified deficiencies in regulatory compliance.
    • DeficiencyDefinitions
    • DeficiencyAcuity-Based Staffing Tool
    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.
    • DeficiencyComment
    • DeficiencyResident Services Meals, Food Sanitation Rule
    • DeficiencyAdministration Compliance
    14 Sept 2022Licensure
    Identified a kitchen cleanliness deficiency on the initial visit; a follow-up concluded substantial compliance with meal service and sanitation rules.
    • DeficiencyComment
    • DeficiencyResident Services Meals, Food Sanitation Rule
    07 Sept 2022Abuse: Neglect
    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.
    • AbuseFailed to protect resident from physical abuse
    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.
    • AbuseFailed to properly plan care
    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.
    • AbuseFailed to assure resident rights
    24 Aug 2022Abuse: Neglect
    Investigated allegation of abuse and neglect and found failures to plan care and mitigate fall risk.
    • AbuseFailed to properly plan care
    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.
    • AbuseFailed to properly plan care
    04 Aug 2022Complaint
    Found deficiencies in safe medication administration and tracking of controlled substances.
    • DeficiencySystems: Medications and Treatments
    • DeficiencySystems: Tracking Control Substances
    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.
    • DeficiencyAcuity-Based Staffing Tool
    04 Aug 2022Complaint
    Investigated the complaint and found no deficiencies.
    • DeficiencyDefinitions
    24 Jul 2022Abuse: Neglect
    Found a lack of a safe medication administration system, resulting in missed doses of several medications.
    • AbuseFailed to provide a safe medication administration system
    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.
    • AbuseFailed to provide safe environment
    23 Jun 2022Inspection
    Found that the service plan did not reflect the resident's needs identified in the evaluation.
    • LicensingFailed to properly plan care
    17 Jun 2022Inspection
    Investigated and identified a failure to have a policy to safeguard residents' possessions, resulting in a licensing violation.
    • LicensingFailed to provide a homelike environment
    08 May 2022Abuse: Neglect
    Found a safety violation due to failure to provide a safe environment, leading to multiple unwitnessed falls and injuries.
    • AbuseFailed to provide safe environment
    31 Mar 2022Inspection
    Found that individuals acting as administrator did not have full administrator licenses, violating Oregon Administrative Rules.
    • LicensingFailed to keep medication record current or accurate
    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.
    • AbuseFailed to assure resident was safe
    24 Jan 2022Inspection
    Found a deficiency in the safe medication and treatment system related to failing to provide a safe medication administration system.
    • LicensingFailed to provide a safe medication administration system
    24 Jan 2022Inspection
    Found a deficiency for failing to document observation and evaluation of safe medication and treatment administration unsupervised.
    • LicensingFailed to provide a safe medication administration system
    24 Jan 2022Inspection
    Determined that resident rights were violated by failing to treat residents with dignity and respect.
    • LicensingFailed to assure resident rights
    24 Jan 2022Inspection
    Identified a deficiency for not providing pre-service orientation to employees before they began their job responsibilities.
    • LicensingFailed to provide safe environment
    24 Jan 2022Inspection
    Investigated and identified a deficiency in tracking controlled substances due to absence of an approved system.
    • LicensingFailed to provide a safe medication administration system
    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.
    • AbuseFailed to protect resident from involuntary seclusion
    09 Nov 2021Inspection
    Found cleanliness deficiencies related to interior materials and surfaces, including floors, rugs, and the kitchen.
    • LicensingFailed to provide safe environment
    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.
    • AbuseFailed to assure resident was safe
    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.
    • AbuseFailed to provide safe environment
    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.
    • LicensingFailed to properly plan care
    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.
    • AbuseFailed to follow care plan
    27 Sept 2021Inspection
    Found a failure to provide a safe environment due to furniture obstructing a doorway, constituting abuse.
    • LicensingFailed to provide safe environment
    27 Sept 2021Abuse: Neglect
    Concluded that the care plan was not followed to ensure resident safety, resulting in abuse and neglect after an altercation.
    • AbuseFailed to follow care plan
    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.
    • LicensingFailed to provide safe environment
    14 Aug 2021Inspection
    Found that a resident was not protected from financial exploitation and protections failed, with potential harm.
    • LicensingFailed to protect resident from financial exploitation
    20 Jul 2021Abuse: Neglect
    Investigated and found a transportation failure to arrange medical or social transportation, causing missed appointments and indicating neglect and abuse.
    • AbuseFailed to provide transportation for medical or social purposes
    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.
    • AbuseFailed to assure timely medical treatment
    08 Jul 2021Inspection
    Investigated and verified that a safe physical environment was not maintained.
    • LicensingFailed to maintain a safe physical environment
    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.
    • AbuseFailed to provide a safe medication administration system
    05 Jun 2021Abuse: Neglect
    Found neglect and abuse for failing to protect a resident from financial exploitation, with a $500 fine assessed.
    • AbuseFailed to protect resident from financial exploitation
    18 May 2021Abuse: Neglect
    Found a violation for failing to provide a safe environment, resulting in abuse and neglect.
    • AbuseFailed to provide safe environment
    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.
    • AbuseFailed to provide safe environment
    06 Apr 2021Abuse: Neglect
    Found that a safe environment was not provided, resulting in a resident fall and injury.
    • AbuseFailed to provide safe environment
    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.
    • AbuseFailed to follow care plan
    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.
    • AbuseFailed to properly plan care
    26 Feb 2021Abuse: Neglect
    Found neglect of care and abuse for failing to treat a pressure sore, leaving the resident at risk for harm.
    • AbuseFailed to provide service
    23 Feb 2021Inspection
    Found a safe medication administration system was not provided, resulting in incorrect medication dosing.
    • LicensingFailed to provide a safe medication administration system
    11 Feb 2021Inspection
    Determined that a resident experienced physical abuse and that protections against abuse were inadequate. The incident led to hospital transport.
    • LicensingFailed to protect resident from physical abuse
    09 Feb 2021Abuse: Neglect
    Found staff failed to follow the resident's care plan, resulting in abuse/neglect; a fine was assessed.
    • AbuseFailed to follow care plan
    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.
    • AbuseFailed to follow care plan
    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.
    • AbuseFailed to provide a safe medication administration system
    20 Nov 2020Abuse: Neglect
    Found an unsafe medication administration system and unaccounted fentanyl patches, indicating abuse and neglect.
    • AbuseFailed to provide a safe medication administration system
    20 Nov 2020Abuse: Neglect
    Found a failure to provide a safe medication administration system, resulting in missing narcotics and no audit of narcotic records.
    • AbuseFailed to provide a safe medication administration system
    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.
    • AbuseFailed to provide a safe medication administration system
    20 Nov 2020Abuse: Neglect
    Found a violation for failing to provide a safe medication administration system. Assessed a $500 fine.
    • AbuseFailed to provide a safe medication administration system
    20 Nov 2020Abuse: Neglect
    Found a deficient safe medication administration system and assessed a $500 fine for the deficiency.
    • AbuseFailed to provide a safe medication administration system
    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.
    • AbuseFailed to properly secure or store medication
    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.
    • AbuseFailure to provide a system that prevents theft or misuse of medication
    18 Nov 2020Abuse: Neglect
    Found unsafe medication administration practices and a lack of narcotics auditing, resulting in unaccounted medication.
    • AbuseFailed to provide a safe medication administration system
    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.
    • AbuseFailed to provide a safe medication administration system
    18 Nov 2020Abuse: Neglect
    Determined that a safe medication administration system was not provided, leading to unaccounted narcotics and related abuse.
    • AbuseFailed to provide a safe medication administration system
    18 Nov 2020Abuse: Neglect
    Found a violation for an unsafe medication administration system that left opioids unaccounted for. A $500 fine was assessed.
    • AbuseFailed to provide a safe medication administration system
    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.
    • AbuseFailed to provide a safe medication administration system
    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.
    • AbuseFailed to provide a safe medication administration system
    14 Nov 2020Abuse: Neglect
    Found violations for failing to maintain a safe medication administration system, including unaccounted narcotics, and assessed a $1,500 fine.
    • AbuseFailed to provide a safe medication administration system
    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.
    • AbuseFailed to provide a safe medication administration system
    05 Nov 2020Abuse: Neglect
    Found a violation for failing to provide a safe environment, constituting abuse.
    • AbuseFailed to provide safe environment
    14 Sept 2020Inspection
    Investigated the allegation and found that medication and treatment orders were not carried out as prescribed.
    • LicensingFailed to administer medication as ordered
    14 Sept 2020Inspection
    Investigated the staffing documentation allegation and verified that training records for employees were not maintained.
    • LicensingFailed to submit timely or adequate staffing documentation
    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.
    • LicensingFailed to report potential or suspected abuse
    24 Aug 2020Inspection
    Found that medication orders were not carried out as prescribed.
    • LicensingFailed to administer ordered medication
    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.
    • AbuseFailed to provide a safe medication administration system
    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.
    • AbuseFailed to provide a safe medication administration system
    06 Jul 2020License Condition
    Investigated infection control and found practices were not consistently followed, putting staff and residents at risk.
    • Regulatory ActionFailed to provide infection control
    30 Jun 2020Inspection
    Investigated and found that a resident's pill organizer was taken by a staff member, constituting financial exploitation and abuse.
    • LicensingFailed to protect resident from financial exploitation
    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.
    • LicensingFailed to protect resident from financial exploitation
    29 Jun 2020Inspection
    Investigated and found that resident service plans failed to provide clear direction to staff.
    • LicensingFailed to follow care plan
    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.
    • AbuseFailed to provide a safe medication administration system
    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.
    • AbuseFailed to follow care plan
    09 Jun 2020Inspection
    Investigated found a violation involving failure to protect a resident from financial exploitation and inconsistent narcotics documentation surrounding oxycodone administration.
    • LicensingFailed to protect resident from financial exploitation
    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.
    • LicensingFailed to protect resident from financial exploitation
    29 May 2020Inspection
    Identified deficiencies in resident telephone access, including inadequate telephones and restricted private use.
    • LicensingFailed to provide service
    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.
    • LicensingFailed to provide safe environment
    29 May 2020Inspection
    Found insufficient staffing to meet scheduled and unscheduled resident needs.
    • LicensingFailed to provide appropriate staffing
    12 May 2020Abuse: Neglect
    Investigated a medication safety issue and found a deficient medication administration system, with missing oxycodone and conflicting administration records.
    • AbuseFailed to provide a safe medication administration system
    28 Mar 2020Abuse: Neglect
    Investigated a complaint and found violations related to improper readmission, resulting in harm to a resident.
    • AbuseFailed to properly admit or re-admit
    03 Mar 2020Inspection
    Verified that ordered medication was not administered as prescribed.
    • LicensingFailed to administer ordered medication
    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
    Investigated an allegation of failing to assure resident rights and found records were not kept confidential as required by law.
    • LicensingFailed to assure resident rights
    14 Feb 2020Inspection
    Found insufficient professional oversight of the medication and treatment administration system.
    • LicensingFailed to provide a safe medication administration system
    14 Feb 2020Inspection
    Investigated and found a licensing violation for failing to administer medication as ordered.
    • LicensingFailed to administer medication as ordered
    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.
    • AbuseFailed to protect resident from financial exploitation
    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.
    • AbuseFailed to administer medication as ordered
    16 Dec 2019Inspection
    Confirmed insufficient staffing to meet residents' needs.
    • LicensingFailed to provide appropriate staffing
    16 Dec 2019Inspection
    Determined that the provider failed to provide assistance with bathing, dressing, and toileting.
    • LicensingFailed to provide or assist with hygiene
    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.
    • AbuseFailed to perform adequate screening or assessment
    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.
    • AbuseFailed to provide safe environment
    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.
    • AbuseFailed to administer ordered medication
    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.
    • AbuseFailed to provide a safe medication administration system
    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.
    • AbuseFailed to provide safe environment
    20 Jun 2019Inspection
    Found a failure to provide a safe medication administration system.
    • LicensingFailed to provide a safe medication administration system
    21 May 2019Abuse: Neglect
    Concluded neglect led to harm from failing to provide necessary services to maintain health and safety.
    • AbuseFailed to properly plan care
    21 May 2019Inspection
    Investigated a report of potential abuse and identified a failure to report suspected abuse.
    • LicensingFailed to report potential or suspected abuse
    08 May 2019Inspection
    Found that the Service Planning Team was not included in developing the resident's service plan.
    • LicensingFailed to properly plan care
    04 May 2019Abuse: Neglect
    Determined that neglect occurred, resulting in a resident-to-resident altercation with injury. A $188 fine was assessed.
    • AbuseFailed to provide safe environment
    23 Apr 2019Inspection
    Identified insufficient direct care staff to meet residents' scheduled and unscheduled needs. This left residents' shower and laundry needs unmet.
    • LicensingFailed to provide or assist with hygiene
    26 Jan 2019Abuse: Neglect
    Investigated the allegation of neglect and assessed a $500 fine.
    • AbuseFailed to provide a safe medication administration system
    26 Jan 2019Inspection
    Investigated and found a failure to report suspected abuse; a $1,000 fine was assessed.
    • LicensingFailed to report potential or suspected abuse
    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.
    • LicensingFailed to properly plan care
    07 Sept 2018Inspection
    Found direct care staffing insufficient to meet residents' needs, including not following the posted staffing plan.
    • LicensingFailed to provide appropriate staffing
    04 Jun 2018Abuse: Neglect
    Identified a neglect violation for failing to administer medication as ordered, which led to hospitalization. A $500 fine was assessed.
    • AbuseFailed to administer medication as ordered
    04 Jun 2018Inspection
    Found failure to report suspected abuse and assessed a $750 fine.
    • LicensingFailed to report potential or suspected abuse
    08 May 2018Inspection
    Found that quarterly service plans were not completed; a resident had not received an updated service plan since 2017.
    • LicensingFailed to properly plan care
    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.
    • LicensingFailed to properly plan care
    23 Mar 2018Inspection
    Found a deficiency for failing to control pests, with residents having head lice.
    • LicensingFailed to control pests
    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.
    • LicensingFailed to provide appropriate housekeeping services
    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.
    • AbuseFailed to provide safe environment
    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.
    • LicensingFailed to assure that a qualified caregiver was present
    12 Mar 2018Inspection
    Investigated the allegation that staffing was inadequate and found a deficiency due to insufficient staff for unscheduled needs.
    • LicensingFailed to provide appropriate staffing
    12 Mar 2018Inspection
    Investigated and substantiated a failure to investigate an unknown-origin injury and report incidents to Adult Protective Services.
    • LicensingFailed to investigate injury of unknown origin to rule out abuse
    21 Nov 2017Inspection
    Investigated an allegation of failing to provide a safe environment; identified a licensing violation and assessed a $200 fine.
    • LicensingFailed to provide safe environment
    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.
    • AbuseFailed to protect resident from financial exploitation
    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.
    • AbuseFailed to intervene when resident's condition changed
    15 Jun 2017Abuse: Neglect
    Investigated an allegation of improper care planning and found a safety deficiency resulting in three resident-to-resident altercations.
    • AbuseFailed to properly plan care
    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.
    • AbuseFailed to adequately care plan related to falls
    01 May 2016Abuse: Neglect
    Found a failure to provide a safe environment. A $300 fine was assessed.
    • AbuseFailed to address resident's behavior
    01 May 2016Abuse: Neglect
    Found violations related to unsafe environment.
    • AbuseFailed to address resident's behavior
    13 Apr 2016Abuse: Neglect
    Found a failure to provide a secure environment.
    • AbuseFailed to provide safe environment
    05 Feb 2016Inspection
    Found a deficiency in active supervision of a staff member with a preliminary criminal history check.
    • LicensingFailed to assure that a qualified caregiver was present
    21 Jan 2016Abuse: Neglect
    Found the care plan was not followed, with potential for moderate harm.
    • AbuseFailed to follow care plan
    02 Jan 2015Abuse: Neglect
    Determined there was a failure to provide a safe environment.
    • AbuseFailed to provide safe environment
    01 Jan 2015Abuse: Neglect
    Investigated the neglect allegation and found a failure to provide a safe environment.
    • AbuseFailed to address resident's behavior
    26 Dec 2014Inspection
    Investigated a complaint and found failure to assess and intervene, creating a potential unsafe environment.
    • LicensingFailed to provide safe environment
    08 Nov 2014Abuse: Neglect
    Investigated an allegation of failing to assure timely medical treatment and found that appropriate care was not provided.
    • AbuseFailed to assure timely medical treatment
    01 Nov 2014Abuse: Neglect
    Found a failure to follow a safe medication administration system and assessed a $300 fine.
    • AbuseFailed to provide a safe medication administration system
    05 May 2014Abuse: Neglect
    Investigated a neglect allegation and found a failure to follow the agreed service plan.
    • AbuseFailed to follow care plan
    05 May 2014Abuse: Neglect
    Investigated a neglect allegation and found failure to provide needed services; a $300 fine assessed.
    • AbuseFailed to properly plan care
    12 Apr 2014Inspection
    Investigated a complaint and identified a violation for failing to prevent a resident-to-resident altercation.
    • LicensingFailed to address resident's behavior
    25 Feb 2014Inspection
    Found a violation of resident rights and care standards; a resident was forced to shower due to inadequate care.
    • LicensingFailed to assure resident rights
    25 Feb 2014Inspection
    Investigated a failure to have a safe medication administration system, which led to missed doses of medication.
    • LicensingFailed to provide a safe medication administration system
    30 Dec 2013Abuse: Neglect
    Found a deficiency in care planning that led to a fall with injury.
    • AbuseFailed to properly plan care
    02 Jul 2013Abuse: Neglect
    Investigated an abuse/neglect allegation of moderate harm. Found violations; a civil penalty was assessed.
    • AbuseFailed to provide service
    26 May 2013Inspection
    Investigated and found a deficiency in assessing and intervening with resident behavior, which led to a resident altercation.
    • LicensingFailed to address resident's behavior
    23 Jan 2013Inspection
    Investigated an allegation that staff failed to address resident behavior, resulting in a resident-to-resident altercation; violations were cited.
    • LicensingFailed to address resident's behavior
    08 Jan 2013Inspection
    Investigated an allegation of unsafe medication administration and found a failure to have a safe medication administration system.
    • LicensingFailed to provide a safe medication administration system
    07 Jan 2013Inspection
    Identified a deficiency in the safe medication administration system. The finding indicated potential for harm due to unsafe medication practices.
    • LicensingFailed to provide a safe medication administration system
    26 Dec 2012Abuse: Neglect
    Determined that basic care was not provided. Violations were identified.
    • AbuseFailed to provide service
    12 Sept 2012Inspection
    Investigated an allegation of failing to administer medication as ordered; found a lack of a safe medication administration system.
    • LicensingFailed to administer medication as ordered
    31 Aug 2012Inspection
    Investigated an allegation of failing to assist with eating and found that a resident was not treated with dignity and respect.
    • LicensingFailed to assist with eating
    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.
    • AbuseFailed to administer medication as ordered
    01 May 2012Abuse: Neglect
    Investigated an allegation of not administering medication as ordered and identified violations for not following doctors' orders.
    • AbuseFailed to administer medication as ordered
    17 Apr 2012Abuse: Financial abuse
    Determined there was no safe medication administration system, which allowed theft of medications. A $300 fine was assessed.
    • AbuseFailure to provide a system that prevents theft or misuse of medication
    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.
    • AbuseFailed to provide safe environment
    13 Aug 2011Abuse: Neglect
    Found that the care plan was not followed, resulting in a fall with injury.
    • AbuseFailed to follow care plan
    18 Jul 2011Abuse: Neglect
    Determined that neglect occurred due to failing to seek timely medical attention when a resident's condition changed.
    • AbuseFailed to intervene when resident's condition changed
    28 Apr 2011Abuse: Neglect
    Investigated an abuse/neglect allegation of inadequate screening or assessment that led to a resident-to-resident altercation with injury.
    • AbuseFailed to perform adequate screening or assessment
    23 Dec 2010Abuse: Neglect
    Found failures to maintain an adequate medication system.
    • AbuseFailed to provide a safe medication administration system
    23 Dec 2010Inspection
    Identified a deficiency for failing to appropriately assess and intervene when a resident's condition changed.
    • LicensingFailed to intervene when resident's condition changed

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