I placed my mother here and have been very pleased - staff are caring, professional and responsive 24/7 (call buttons answered quickly), apartments are private, clean and bright, and the community feels peaceful and family-like. Activities are engaging, the food is good, and the organized, collaborative care and management team (Jessica included) made the move-in smooth and welcoming.
Loved one of resident
Jul 2026
Pricing
Prices shown are estimates and subject to change. Contact your senior living advisor for current pricing.
Schedule a Tour
Amenities
Healthcare services
Activities of daily living assistance
Assistance with bathing
Assistance with dressing
Assistance with transfers
Coordination with health care providers
Medication management
Mental wellness program
Healthcare staffing
12-16 hour nursing
24-hour call system
24-hour supervision
Meals and dining
Diabetes diet
Meal preparation and service
Restaurant-style dining
Special dietary restrictions
Room
Air-conditioning
Cable
Fully furnished
Housekeeping and linen services
Kitchenettes
Private bathrooms
Spa
Telephone
Wifi
Transportation
Community operated transportation
Transportation arrangement
Transportation arrangement (medical)
Transportation arrangement (non-medical)
Transportation to doctors appointments
Common areas
Beauty salon
Computer center
Dining room
Fitness room
Gaming room
Garden
Outdoor space
Small library
Wellness center
Community services
Concierge services
Fitness programs
Move-in coordination
Activities
Community-sponsored activities
Planned day trips
Resident-run activities
Scheduled daily activities
Reviews
4.33·(27)
Overall rating
5
4
3
2
1
Care
4.0
Staff
4.0
Meals
4.0
Amenities
3.0
Value
4.3
Pros
Rapid response to call-buttons
Cohesive health-services team
Organized, dedicated care staff
Effective cross-department collaboration
Holistic approach to resident well-being
Inclusive culture and celebration of diversity
Approachable, helpful staff
24/7 staff availability
Private, clean and bright apartments
Responsive maintenance and smooth move-in support
Engaging, varied activities program
Pleasant, peaceful campus and good views
Satisfying dining options
Warm, family-like community atmosphere
Attentive executive leadership and proactive staff
Cons
Staffing shortages and burnout
Gaps in management oversight of staff conduct
Inconsistent medication-management practices
Sanitation concerns in some resident areas
Security and asset-control weaknesses
Challenges in Medicaid placement and billing coordination
Connectivity and Wi‑Fi reliability issues
Tension in workplace culture and staff morale problems
Inconsistent admissions and application processes
Gaps in clinical-incident response and family communication
Summary of reviews
Reviews reflect a facility with many operational strengths alongside several significant operational concerns. Positive feedback centers on day-to-day care delivery: staff are frequently described as responsive, organized, and available around the clock, with a cohesive health-services team and strong cross-department collaboration. Families and residents highlight a holistic approach to resident well-being that includes attention to physical, emotional, social, and mental needs. The community is often called welcoming and family-like, with private, bright apartments, a pleasant campus, and responsive maintenance that facilitates smooth move-ins.
Clinical and safety observations are mixed. Strengths include prompt call-button responses, coordinated care teams, and proactive COVID monitoring. At the same time, reviewers raised serious operational concerns that affect safety and confidence: inconsistent medication-management practices, sanitation concerns in some resident areas, and gaps in management oversight of staff conduct. In a limited number of accounts, there were serious criminal-related allegations involving a caregiver; these specific claims heighten the importance of careful staff vetting and supervisory processes. Families should ask directly about incident reporting, staff background checks, and recent regulatory findings when evaluating the facility.
Staff culture and management receive both praise and criticism. Several accounts commend an attentive executive director and named staff for problem-solving and compassionate care; others describe staffing shortages, burnout, and a tense workplace environment that can interfere with consistency of care. Communication also varies — some families report clear, receptive interactions and helpful transition support, while others describe frustrating application or admissions experiences and delayed communication following incidents. This pattern suggests variability in leadership responsiveness year-to-year or shift-to-shift.
Residents and visitors generally report positive lifestyle elements: good food, an active calendar of engaging activities, and a warm community atmosphere that keeps residents socially engaged. Facilities are often described as clean and well-maintained, with prompt resolution of maintenance issues, though connectivity problems (unreliable Wi‑Fi) and localized sanitation concerns were noted and should be verified during a visit.
Practical takeaways: prospective residents and families will see many strengths in everyday care, social programming, and leadership presence, yet should also probe operational risk areas during a tour. Recommended questions include staffing ratios by shift, medication-administration protocols, recent staffing turnover, processes for handling and communicating clinical incidents, sanitation schedules, security/asset controls, Wi‑Fi reliability, and how the facility manages Medicaid placement and billing coordination. An on-site visit that observes mealtime, activity participation, staff–resident interactions, and cleanliness in common and private areas will help reconcile the mixed patterns apparent in these reviews.
Reviews written on Mirador
We have no reviews to show about Gilman Grove.
Help other families by writing a review about your experience with this community.
Location
Gilman Grove is located at 2205 Gilman Dr, Oregon City, OR, 97045.
About Gilman Grove
Gilman Grove sits in a quiet Oregon City neighborhood, close to places like Providence Medical Group, Walgreens, Oregon City Brewing Company, and local parks, so residents don't have far to go for doctor's visits or errands, and they can get out to enjoy the community if they want to. The building includes advanced safety features, with an emergency call system spread throughout the community and staff who are on-site and available at all hours, including licensed nurses and resident care coordinators. There's scheduled transportation for appointments, errands, and social events, and both residents and guests can find parking without much trouble. People who enjoy keeping busy have many activities to choose from, like music sessions, games, book clubs, group exercise, gardening, arts and crafts, and trips off-site, while hobbies and fitness programs give folks a chance to stay active and meet others. Pets are welcome, and visitors can enjoy guest meals and parking when they come by.
The rooms are spacious, include their own kitchenettes, and you can get room service if you prefer a meal in private, or you can join others for restaurant-style dining prepared by an executive chef, with snacks always around if you get hungry outside of mealtimes. Housekeeping, laundry, and linen changes are regular, and the staff provides ongoing help with things like medication reminders and extra support when needed, as well as making sure things stay clean and comfortable. Physical therapy, rehabilitation, and fitness programs are available, and the beauty and barber shop helps everyone look and feel their best. Residents have Wi-Fi and pleasant common areas for socializing or joining group programs, and if you want a quiet spot outside, the garden is there for you. Gilman Grove aims to give folks a good balance between independence and support, providing personalized care that fits each person's needs, and residents' opinions are heard and respected, so they can feel at home in a place that tries for a family-like atmosphere, where openness and trust matter.
Gilman Grove has a licensed capacity for 101 residents, is ADA accessible, and is licensed under state number 009412. Financing options include Medicaid, checks, and credit cards, and new residents are welcomed with a one-time entry fee. Virtual tours are available every day by appointment, making it a little easier to see what the community is like before making a decision. Whether someone needs a little help with daily activities or more focused services, Gilman Grove offers assisted living and a range of health-related services, with continuing care and memory care options available as health needs change over time.
Frontier Management is a leading senior living provider in the United States, operating over 120 communities across 19 states. Headquartered in Durham, Oregon, Frontier offers a range of senior living options, including independent living, assisted living, and memory care. Founded in 2000, Frontier has grown significantly and has been recognized for its excellence in senior care, earning multiple prestigious industry awards.
One of Frontier's hallmark programs is the Spark program, rooted in Montessori-style practices, which promotes purpose and engagement among residents. Initially designed for memory care, this program has been expanded to other types of care within Frontier's communities. The Spark program empowers residents to have an active role in their community, enhancing their daily lives through meaningful activities.
Frontier is also known for its dedication to resident health and well-being. Their communities offer comprehensive services tailored to individual needs, including customized healthcare plans through the Frontier Advantage Network, which aims to extend residents' stay by keeping them healthier for longer periods.
The company has undergone significant changes and growth in recent years, including a rebranding effort to refresh its image and enhance its services. Frontier's communities are spread across various states including Arizona, California, Florida, Georgia, Idaho, Illinois, Indiana, Iowa, Louisiana, Massachusetts, Mississippi, Missouri, Montana, Nebraska, Nevada, Oregon, Tennessee, Texas, Utah, Washington, and Wisconsin.
Frontier Management's commitment to quality care, innovative programs, and extensive service options makes it a prominent name in senior living, continually striving to meet the evolving needs of its residents.
People often ask...
Gilman Grove offers competitive pricing, with rates starting at a cost of $4,989 per month.
Gilman Grove offers independent living and assisted living.
There are 32 photos of Gilman Grove on Mirador.
The full address for this community is 2205 Gilman Dr, Oregon City, OR 97045.
No, Gilman Grove 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 deficiencies in ABST accuracy and staffing levels, with inconsistencies between the resident roster, care plans, and ABST data leading to insufficient staffing.
Licensing—Failed to use an ABST
04 Jul 2025Inspection
04 Jul 2025Inspection
Identified inconsistencies between ABST data and resident-related records, and found staffing levels not aligned with ABST-indicated needs.
Licensing—Failed to use an ABST
02 May 2025Inspection
02 May 2025Inspection
Identified a deficiency for not updating the ABST to accurately reflect residents and their care needs, with inconsistencies between the roster, care plans, and ABST data.
Licensing—Failed to use an ABST
02 May 2025Inspection
02 May 2025Inspection
Investigated a complaint of physical abuse and neglect; found that a helper caused neck injuries to the resident, and protection from abuse failed, violating resident rights.
Licensing—Failed to protect resident from physical abuse
23 Apr 2025Inspection
23 Apr 2025Inspection
Investigated and found a deficiency relating to an outdated ABST that did not reflect resident needs, with inconsistencies among the roster, care plans, and ABST data.
Licensing—Failed to use an ABST
05 Apr 2025Inspection
05 Apr 2025Inspection
Found a violation due to failing to maintain an updated ABST that accurately reflects resident needs, with inconsistencies between the roster, care plans, and ABST data.
Licensing—Failed to use an ABST
05 Apr 2025Inspection
05 Apr 2025Inspection
Determined that a staff member failed to administer medications as ordered, causing adverse reactions and hospitalization. Found that a safe medication administration system was not provided.
Licensing—Failed to provide a safe medication administration system
03 Apr 2025Inspection
03 Apr 2025Inspection
Identified inconsistencies between the resident roster, care plans, and the ABST, and cited a licensing violation.
Licensing—Failed to use an ABST
03 Apr 2025Abuse: Neglect
03 Apr 2025Abuse: Neglect
Found failure to provide a safe medication administration system, resulting in missed doses of a blood thinner for a resident with atrial fibrillation.
Abuse—Failed to provide a safe medication administration system
01 Apr 2025Inspection
01 Apr 2025Inspection
Identified inconsistencies between the resident roster, care plans, and ABST data, indicating the ABST did not accurately reflect resident care needs.
Licensing—Failed to use an ABST
20 Mar 2025Inspection
20 Mar 2025Inspection
Found that staff failed to administer a prescribed antidepressant for 14 days, indicating an unsafe medication administration system.
Licensing—Failed to provide a safe medication administration system
17 Jan 2025License Condition
17 Jan 2025License Condition
Found violations for failing to provide a safe environment.
Regulatory Action—Failed to provide safe environment
29 Sept 2024Inspection
29 Sept 2024Inspection
Investigated a failure-to-follow-care-plan allegation that led to a resident fall and injury; violations of resident rights and neglect/abuse were found.
Licensing—Failed to follow care plan
05 Aug 2024Change of Owner
05 Aug 2024Change of Owner
Identified widespread deficiencies across administration, resident rights, care planning, monitoring of changes in condition, health services, infection control, medication systems, and facility maintenance. The findings show noncompliance with multiple state requirements.
Deficiency—Comment
Deficiency—Facility Administration: Operation
Deficiency—Resident Rights and Protection - General
Deficiency—Resident Move-In and Eval: Res Evaluation
Investigated safety concerns after a resident fall occurred without documented care needs or a move-in assessment, indicating neglect and abuse.
Abuse—Failed to provide safe environment
27 Dec 2023Licensure
27 Dec 2023Licensure
Determined substantial compliance with meal service and food sanitation rules.
Deficiency—Comment
07 Oct 2023Abuse: Neglect
07 Oct 2023Abuse: Neglect
Investigated and concluded that a resident was not kept safe, resulting in abuse and neglect.
Abuse—Failed to provide safe environment
27 Sept 2023Abuse: Neglect
27 Sept 2023Abuse: Neglect
Investigated a neglect/abuse finding where a resident with dementia left unsupervised and was found off-site; elopement risk was not addressed in the care plan.
Abuse—Failed to provide safe environment
25 Sept 2023Abuse: Neglect
25 Sept 2023Abuse: Neglect
Investigated a complaint alleging neglect and abuse and found a failure to implement interventions to address a resident's falls, leaving them at risk for harm.
Abuse—Failed to properly plan care
25 Aug 2023Abuse: Neglect
25 Aug 2023Abuse: Neglect
Found that a resident's funds were not protected, with $300 missing, indicating neglect and abuse.
Abuse—Failed to protect resident from financial exploitation
07 Aug 2023Abuse: Neglect
07 Aug 2023Abuse: Neglect
Investigated and found a failure to provide a safe environment after an incident where a resident grabbed another's arm and twisted it, leaving a red mark. A fine was assessed for the violation.
Abuse—Failed to provide safe environment
27 Jul 2023Inspection
27 Jul 2023Inspection
Investigated and found that a resident's debit card was used without authorization, resulting in over $5,000 withdrawn over nine months, constituting financial abuse and neglect of resident rights.
Licensing—Failed to protect resident from financial exploitation
15 Jun 2023Inspection
15 Jun 2023Inspection
Investigated the allegation and found a failure to protect a resident from financial exploitation.
Licensing—Failed to protect resident from financial exploitation
26 Mar 2023Abuse: Neglect
26 Mar 2023Abuse: Neglect
Investigated and found that a staff member requested massages and back scratches from a resident, admitted to receiving the contact, and was allowed to continue working, resulting in neglect and abuse and placing residents at risk.
Abuse—Failed to provide safe environment
21 Mar 2023Abuse: Neglect
21 Mar 2023Abuse: Neglect
Investigated a complaint and found a resident's room flooded with sewage, leaving the resident wet and distressed; staff failed to provide a safe environment.
Abuse—Failed to provide safe environment
17 Mar 2023Inspection
17 Mar 2023Inspection
Investigated a medication incident found that a staff member administered another resident's medication due to distraction, causing discomfort, and identified a failure to provide a safe medication administration system.
Licensing—Failed to provide a safe medication administration system
15 Mar 2023License Condition
15 Mar 2023License Condition
Found direct care staffing was insufficient to meet residents' scheduled and unscheduled needs.
Regulatory Action—Failed to provide appropriate staffing
15 Mar 2023License Condition
15 Mar 2023License Condition
Found ABST was not fully implemented and updated as required. Identified a violation of the applicable rule.
Regulatory Action—Failed to use an ABST
13 Mar 2023Abuse: Neglect
13 Mar 2023Abuse: Neglect
Investigated an allegation of neglect and abuse; found improper wound care caused an infected wound and pain, with a $500 fine assessed.
Abuse—Failed to provide appropriate skin care
07 Feb 2023Inspection
07 Feb 2023Inspection
Found that a resident's rings went missing and were taken by an unidentified staff member, constituting financial abuse; the provider failed to protect the resident from financial exploitation.
Licensing—Failed to protect resident from financial exploitation
01 Feb 2023Abuse: Neglect
01 Feb 2023Abuse: Neglect
Found abuse and neglect violations involving inappropriate sexual contact by staff with a resident, and a failure to protect residents.
Abuse—Failed to protect resident from inappropriate sexual contact
05 Jan 2023Complaint
05 Jan 2023Complaint
Investigated and found multiple deficiencies related to grievance handling, service plans, medication administration, staffing, training, and facility upkeep.
Identified deficiencies related to staffing requirements and the acuity-based staffing tool.
Deficiency—Licensing Complaint Investigation
Deficiency—Staffing Requirements and Training: Staffing
Deficiency—Acuity-Based Staffing Tool
05 Jan 2023Complaint
05 Jan 2023Complaint
Investigated deficiencies in ADLs support, medications and treatments, and staffing with a widespread scope and potential for harm.
Deficiency—Resident Services: Adls
Deficiency—Systems: Medications and Treatments
Deficiency—Staffing Requirements and Training: Staffing
25 Dec 2022Inspection
25 Dec 2022Inspection
Investigated a complaint and found a failure to provide a safe medication administration system, resulting in a resident receiving another resident’s medication and a fall requiring hospital evaluation.
Licensing—Failed to provide a safe medication administration system
01 Nov 2022Inspection
01 Nov 2022Inspection
Identified a violation for failing to submit timely or adequate staffing documentation and weekly vaccination reporting for residents and staff for 30 days in October 2022.
Licensing—Failed to submit timely or adequate staffing documentation
31 Oct 2022Inspection
31 Oct 2022Inspection
Found insufficient direct care staffing to meet scheduled and unscheduled resident needs, violating staffing requirements.
Licensing—Failed to provide appropriate staffing
31 Oct 2022Inspection
31 Oct 2022Inspection
Negated the allegation about meeting residents' needs due to a prior investigation.
Licensing—Failed to meet the scheduled and unscheduled needs of residents
15 Oct 2022Inspection
15 Oct 2022Inspection
Identified a violation of safe medication administration due to failure to carry out medication and treatment orders as prescribed.
Licensing—Failed to provide a safe medication administration system
15 Oct 2022Inspection
15 Oct 2022Inspection
Investigated an allegation about using an acuity-based staffing tool and found it was not fully implemented or updated per the rule. The allegation was negated because a condition was based on a prior investigation.
Licensing—Failed to use an ABST
01 Oct 2022Inspection
01 Oct 2022Inspection
Found a licensing violation for failing to submit timely staffing documentation and weekly vaccination reporting; assessed a $7,500 fine.
Licensing—Failed to submit timely or adequate staffing documentation
13 Sept 2022Licensure
13 Sept 2022Licensure
Found significant cleanliness deficiencies in the kitchen during the first visit; follow-up indicated substantial compliance.
Found violations of resident rights involving involuntary seclusion after a resident's call pendant was left out of reach. The pendant should have been kept near the resident, and staff failed to ensure access to call for assistance.
Licensing—Failed to protect resident from involuntary seclusion
20 Aug 2022Inspection
20 Aug 2022Inspection
Found failure to verify direct care staff have demonstrated satisfactory performance in any duty they are assigned.
Licensing—Failed to provide service
20 Aug 2022Inspection
20 Aug 2022Inspection
Found a violation for not providing a homelike environment, including unpleasant odors and dirty interior surfaces.
Licensing—Failed to provide a homelike environment
17 Aug 2022Abuse: Neglect
17 Aug 2022Abuse: Neglect
Investigated a complaint and found neglect and abuse for delaying toenail care for a bed-bound diabetic resident with thick, overgrown nails.
Abuse—Failed to assist with dressing or grooming
09 Aug 2022Inspection
09 Aug 2022Inspection
Found a deficiency in responding to and resolving resident complaints.
Licensing—Failed to assure resident rights
20 Jun 2022Abuse: Neglect
20 Jun 2022Abuse: Neglect
Investigated and found a failure to provide a safe environment after an aggressive resident harmed a resident.
Abuse—Failed to provide safe environment
17 Jun 2022Inspection
17 Jun 2022Inspection
Found a deficiency in developing and implementing effective methods to respond to and resolve resident complaints.
Licensing—Failed to provide safe environment
17 Jun 2022Inspection
17 Jun 2022Inspection
Observed deficiencies in maintaining interior and exterior materials, surfaces, and equipment, including black mold in the ceiling and an unrepaired hole.
Licensing—Failed to provide a homelike environment
19 May 2022Inspection
19 May 2022Inspection
Investigated the allegation and substantiated that necessary information was not communicated.
Licensing—Failed to communicate necessary information
19 May 2022Inspection
19 May 2022Inspection
Found insufficient staffing to meet residents' scheduled and unscheduled needs.
Licensing—Failed to provide appropriate staffing
17 May 2022Inspection
17 May 2022Inspection
Found insufficient staffing to meet the scheduled and unscheduled needs of residents.
Licensing—Failed to provide appropriate staffing
17 May 2022Inspection
17 May 2022Inspection
Identified a violation for failing to carry out medication orders as prescribed.
Licensing—Failed to provide a safe medication administration system
11 May 2022Inspection
11 May 2022Inspection
Found that a safe environment was not provided, indicating a safety deficiency affecting residents' health or welfare.
Licensing—Failed to provide safe environment
10 May 2022Inspection
10 May 2022Inspection
Found a deficiency in medication administration due to failing to carry out medication and treatment orders as prescribed.
Licensing—Failed to provide a safe medication administration system
10 May 2022Inspection
10 May 2022Inspection
Found residents were not assisted with toileting as required.
Licensing—Failed to provide service
10 May 2022Inspection
10 May 2022Inspection
Investigated the allegation of inadequate staffing and found insufficient staff to meet residents' needs.
Licensing—Failed to provide appropriate staffing
09 May 2022Abuse: Neglect
09 May 2022Abuse: Neglect
Investigated an allegation of failing to provide a safe environment and found neglect and abuse.
Abuse—Failed to provide safe environment
28 Apr 2022Inspection
28 Apr 2022Inspection
Identified a deficiency in keeping interior and exterior materials, surfaces, and equipment clean and in good repair for residents' health and safety.
Licensing—Failed to provide safe environment
28 Apr 2022Inspection
28 Apr 2022Inspection
Found deficiencies in responding to and resolving resident complaints, violating Oregon Administrative Rules.
Licensing—Failed to assure resident rights
09 Mar 2022Inspection
09 Mar 2022Inspection
Found a deficiency in medication administration records where records were signed by staff other than the person who administered the medications.
Licensing—Failed to provide a safe medication administration system
09 Mar 2022Inspection
09 Mar 2022Inspection
Found that quarterly service plans were not completed, violating Oregon Administrative Rules.
Licensing—Failed to properly plan care
04 Feb 2022Inspection
04 Feb 2022Inspection
Investigated and concluded that a resident was not protected from financial exploitation by an unknown individual who took a ring. The finding showed neglect and financial abuse.
Licensing—Failed to protect resident from financial exploitation
23 Nov 2021Abuse: Neglect
23 Nov 2021Abuse: Neglect
Investigated a complaint about a resident's call light being ignored for over an hour, causing soiling and discomfort in November 2021; found violations of resident rights and neglect/abuse.
Abuse—Failed to answer call light in a timely manner
22 Oct 2021Inspection
22 Oct 2021Inspection
Found a deficiency in infection control that could threaten residents' health, safety, or welfare.
Licensing—Failed to provide infection control
22 Oct 2021Inspection
22 Oct 2021Inspection
Investigated a staffing allegation and found insufficient qualified awake direct care staff to meet 24-hour needs.
Licensing—Failed to provide appropriate staffing
13 Oct 2021Abuse: Neglect
13 Oct 2021Abuse: Neglect
Found insufficient staffing led to the resident not receiving a planned shower, risking harm.
Abuse—Failed to provide appropriate staffing
21 Sept 2021Inspection
21 Sept 2021Inspection
Found insufficient staff to meet residents' scheduled and unscheduled needs.
Licensing—Failed to provide appropriate staffing
12 Aug 2021Inspection
12 Aug 2021Inspection
Found insufficient staff to meet residents' scheduled and unscheduled needs.
Licensing—Failed to provide appropriate staffing
12 Aug 2021Inspection
12 Aug 2021Inspection
Found a deficiency for failing to assist residents with toileting.
Licensing—Failed to assist with toileting
07 Aug 2021Inspection
07 Aug 2021Inspection
Investigated found insufficient direct care staff to meet residents' scheduled and unscheduled needs.
Licensing—Failed to provide appropriate staffing
05 Aug 2021Inspection
05 Aug 2021Inspection
Found insufficient staffing to meet scheduled and unscheduled resident needs.
Licensing—Failed to provide appropriate staffing
05 Aug 2021Inspection
05 Aug 2021Inspection
Found that background checks were not obtained for all subject individuals.
Licensing—Failed to hire according to administrative rules
05 Aug 2021Abuse: Neglect
05 Aug 2021Abuse: Neglect
Found that a staff member verbally harassed a resident, causing emotional harm, and the provider failed to protect the resident from emotional harm; a $250 fine was assessed.
Abuse—Failed to provide safe environment
28 Jun 2021Inspection
28 Jun 2021Inspection
Investigated and found that a staff member diluted morphine, stole medication, caused discomfort, and compromised medication safety.
Licensing—Failure to provide a system that prevents theft or misuse of medication
07 Jun 2021Abuse: Neglect
07 Jun 2021Abuse: Neglect
Found violations for failing to report a positive COVID-19 case to the department and public health, with a sanction imposed.
Abuse—Failed to provide infection control
12 May 2021Abuse: Neglect
12 May 2021Abuse: Neglect
Found neglect and abuse occurred when incontinence supplies ran out and a too-small substitute caused an allergic reaction and discomfort.
Abuse—Failed to provide service
12 May 2021Inspection
12 May 2021Inspection
Investigated and found that a resident was financially exploited due to a failure to protect from exploitation, resulting in a violation and a $250 fine.
Licensing—Failed to protect resident from financial exploitation
26 Apr 2021Inspection
26 Apr 2021Inspection
Investigated a staffing allegation and found insufficient qualified awake direct care staff to meet 24-hour scheduled and unscheduled needs.
Licensing—Failed to provide appropriate staffing
25 Apr 2021Abuse: Neglect
25 Apr 2021Abuse: Neglect
Found that pain medications were not administered as ordered due to unpacking delays, resulting in several missed doses and neglect.
Abuse—Failed to have medication available
16 Apr 2021Abuse: Neglect
16 Apr 2021Abuse: Neglect
Found a violation of resident rights due to neglect and abuse related to wound care that left the resident at risk and in discomfort. A $375 fine was assessed.
Abuse—Failed to provide service
09 Feb 2021Abuse: Neglect
09 Feb 2021Abuse: Neglect
Investigated and found violations related to inadequate care planning and delivery, resulting in discomfort and risk of harm to a resident.
Abuse—Failed to properly plan care
05 Feb 2021Abuse: Neglect
05 Feb 2021Abuse: Neglect
Found a failure to provide a safe medication administration system and assessed a $1,000 fine.
Abuse—Failed to provide a safe medication administration system
04 Feb 2021Abuse: Neglect
04 Feb 2021Abuse: Neglect
Found that a resident with diminished capacity was allowed to go to the emergency department unaccompanied, resulting in a failure to provide a safe environment and constitutes abuse; a $1,000 fine was assessed.
Abuse—Failed to provide safe environment
22 Dec 2020Inspection
22 Dec 2020Inspection
Found deficiencies in menu planning, substitutions, and advance notice of menu changes.
Licensing—Failed to provide proper food/nutrition
22 Dec 2020Inspection
22 Dec 2020Inspection
Determined that there were deficiencies in responding to and resolving resident complaints, indicating a failure to assure resident rights.
Licensing—Failed to assure resident rights
18 Dec 2020Abuse: Neglect
18 Dec 2020Abuse: Neglect
Investigated and found a failure to implement a change in medication administration, causing the Alleged Victim undue discomfort and indicating a deficient medication administration system.
Abuse—Failed to provide a safe medication administration system
12 Dec 2020Abuse: Neglect
12 Dec 2020Abuse: Neglect
Investigated found that staff failed to have medication available for an Alleged Victim, leading to dehydration and a urinary tract infection; a $500 fine was assessed.
Abuse—Failed to have medication available
02 Nov 2020Inspection
02 Nov 2020Inspection
Verified insufficient qualified awake direct care staffing to meet 24-hour needs.
Licensing—Failed to provide appropriate staffing
23 Oct 2020Inspection
23 Oct 2020Inspection
Found insufficient direct care staffing to meet residents' scheduled and unscheduled needs.
Licensing—Failed to provide appropriate staffing
22 Oct 2020Abuse: Neglect
22 Oct 2020Abuse: Neglect
Identified neglect for failing to follow the care plan, which caused skin breakdown around a catheter site; a $500 fine was assessed.
Abuse—Failed to follow care plan
20 Oct 2020Inspection
20 Oct 2020Inspection
Investigated and found insufficient awake qualified direct care staffing to meet residents' scheduled and unscheduled needs.
Licensing—Failed to provide appropriate staffing
16 Oct 2020Abuse: Neglect
16 Oct 2020Abuse: Neglect
Found a failure to provide timely testing and treatment for a suspected UTI, resulting in unnecessary pain.
Abuse—Failed to assure timely medical treatment
01 Oct 2020Abuse: Neglect
01 Oct 2020Abuse: Neglect
Determined a failure to provide a safe medication administration system by not checking the resident's blood sugar before insulin, risking harm.
Abuse—Failed to provide a safe medication administration system
30 Sept 2020Abuse: Neglect
30 Sept 2020Abuse: Neglect
Investigated a medication administration failure that led to withdrawal symptoms and hospital treatment.
Abuse—Failed to administer medication as ordered
10 Sept 2020Abuse: Neglect
10 Sept 2020Abuse: Neglect
Found that the resident's CPAP machine was not provided during evacuation, risking oxygen safety and resulting in abuse/neglect findings with a fine issued.
Abuse—Failed to provide service
10 Sept 2020Abuse: Neglect
10 Sept 2020Abuse: Neglect
Investigated a medication administration allegation; found a missed dose that placed a resident at risk for harm and constituted neglect and abuse.
Abuse—Failed to administer medication as ordered
20 Aug 2020Abuse: Neglect
20 Aug 2020Abuse: Neglect
Found that prescribed medications were not provided as ordered for several months and the physician was not notified, risking serious harm; identified neglect and abuse.
Abuse—Failed to administer medication as ordered
16 Aug 2020Inspection
16 Aug 2020Inspection
Found that a safe medication administration system was not provided. This constitutes a licensing violation with potential for harm.
Licensing—Failed to provide a safe medication administration system
12 Aug 2020Inspection
12 Aug 2020Inspection
Found insufficient direct care staff to meet residents' scheduled and unscheduled needs.
Licensing—Failed to provide appropriate staffing
12 Aug 2020Abuse: Neglect
12 Aug 2020Abuse: Neglect
Found that a safe medication administration system was not provided, causing a resident to miss a prescribed blood thinner for three days and risk serious harm.
Abuse—Failed to provide a safe medication administration system
12 Aug 2020Abuse: Neglect
12 Aug 2020Abuse: Neglect
Investigated a care plan violation where a resident was not helped into night clothes or into bed. This led to neglect and the resident being transported to the hospital.
Abuse—Failed to follow care plan
12 Aug 2020Inspection
12 Aug 2020Inspection
Found a deficiency in the medication system due to the lack of a safe medication administration system.
Licensing—Failed to provide a safe medication administration system
09 Aug 2020Inspection
09 Aug 2020Inspection
Investigated and found that a staff member failed to properly administer pain medication for three days, leaving the resident in discomfort, and identified a failure to maintain a safe medication administration system.
Licensing—Failed to provide a safe medication administration system
28 Jul 2020Inspection
28 Jul 2020Inspection
Identified that medication orders were not carried out as prescribed. The finding noted a failure to reorder medications timely.
Licensing—Failed to administer medication as ordered
28 Jul 2020Inspection
28 Jul 2020Inspection
Investigated the nursing delegation allegation and found a lack of a training program to determine direct care staff competency.
Licensing—Failed to comply with nursing delegation requirement
28 Jul 2020Inspection
28 Jul 2020Inspection
Found insufficient staff to meet residents' scheduled and unscheduled needs.
Licensing—Failed to provide appropriate staffing
28 Jul 2020Inspection
28 Jul 2020Inspection
Investigated the allegation that a resident was not safe and substantiated that reasonable precautions were not exercised.
Licensing—Failed to assure resident was safe
20 Jun 2020Abuse: Neglect
20 Jun 2020Abuse: Neglect
Investigated a complaint and found neglect and abuse due to failure to protect a resident's belongings after money went missing.
Abuse—Failed to provide safe environment
15 Jun 2020Inspection
15 Jun 2020Inspection
Determined there was insufficient staff to meet residents' scheduled and unscheduled needs.
Licensing—Failed to provide appropriate staffing
15 Jun 2020Inspection
15 Jun 2020Inspection
Found a failure to maintain a safe environment and inconsistent PPE use by staff to prevent COVID-19 transmission.
Licensing—Failed to maintain a safe physical environment
14 May 2020Abuse: Neglect
14 May 2020Abuse: Neglect
Investigated a medication-management incident and found a failure to provide a safe medication administration system, placing a resident at risk of harm.
Abuse—Failed to provide a safe medication administration system
13 Mar 2020Inspection
13 Mar 2020Inspection
Investigated the staffing allegation and found insufficient staffing to meet residents' needs.
Licensing—Failed to provide appropriate staffing
10 Mar 2020Inspection
10 Mar 2020Inspection
Investigated the staffing allegation and determined there were not enough qualified awake direct care staff to meet residents' 24-hour needs.
Licensing—Failed to provide appropriate staffing
10 Mar 2020Inspection
10 Mar 2020Inspection
Investigated an allegation about staffing verification; found that direct care staff performance verification was not properly demonstrated.
Licensing—Failed to provide appropriate staffing
23 Feb 2020Inspection
23 Feb 2020Inspection
Investigated an allegation of physical abuse and found that a staff member punished a resident by throwing water and failed to protect them, violating rules.
Licensing—Failed to protect resident from physical abuse
11 Feb 2020Inspection
11 Feb 2020Inspection
Found a failure to provide a safe medication administration system and an instance of incorrect medication given, creating a potential for harm. Violations were substantiated.
Licensing—Failed to provide a safe medication administration system
04 Feb 2020Inspection
04 Feb 2020Inspection
Found that medication administration according to physician orders was not carried out and follow-up with the primary care physician was delayed.
Licensing—Failed to administer medication as ordered
04 Feb 2020Inspection
04 Feb 2020Inspection
Investigated the allegation and found that medication orders were not administered as prescribed, resulting in a cited violation.
Licensing—Failed to administer medication as ordered
29 Jan 2020Abuse: Neglect
29 Jan 2020Abuse: Neglect
Found a failure to provide a safe environment, leaving a resident at risk due to an inaccessible call pendant; a fine was assessed.
Abuse—Failed to provide safe environment
21 Jan 2020Inspection
21 Jan 2020Inspection
Found deficiencies in medication administration, including failure to carry out prescribed orders and to reorder pain medications or provide eye treatments.
Licensing—
20 Jan 2020Abuse: Neglect
20 Jan 2020Abuse: Neglect
Investigated a neglect allegation found failure to assess and intervene after a fall, resulting in delayed evaluation and injury; a fine was assessed.
Abuse—Failed to assure timely medical treatment
12 Jan 2020Inspection
12 Jan 2020Inspection
Investigated a case where a staff member was rough with a resident during personal care, resulting in a bruise, and concluded there was a failure to provide a safe environment.
Licensing—Failed to provide safe environment
11 Jan 2020Abuse: Neglect
11 Jan 2020Abuse: Neglect
Determined that an unsafe environment and failure to follow the care plan led to elopement and injury; a fine was assessed. Violations were cited.
Abuse—Failed to provide safe environment
16 Dec 2019Abuse: Neglect
16 Dec 2019Abuse: Neglect
Found a failure to provide a safe medication administration system, resulting in a resident going without a prescribed blood thinner despite the medication arriving the prior day. A $1,000 fine was assessed.
Abuse—Failed to provide a safe medication administration system
16 Dec 2019Abuse: Neglect
16 Dec 2019Abuse: Neglect
Investigated the complaint and found neglect and abuse due to a delayed response to a resident's call light, leaving the resident in a restroom for over 20 minutes.
Abuse—Failed to answer call light in a timely manner
11 Dec 2019Inspection
11 Dec 2019Inspection
Investigated a complaint and determined that a resident's money was stolen by an unknown individual and that the resident's property was not protected from theft, constituting financial exploitation.
Licensing—Failed to protect resident from financial exploitation
25 Sept 2019Abuse: Neglect
25 Sept 2019Abuse: Neglect
Investigated a complaint and found the provider failed to protect residents from financial exploitation, with funds missing from residents' personal incidental accounts and insufficient staff training.
Abuse—Failed to protect resident from financial exploitation
25 Sept 2019Abuse: Neglect
25 Sept 2019Abuse: Neglect
Found that residents' personal funds were not protected from exploitation, with funds missing and increasing from about $370 to $505 by September 2019, and the licensee ultimately responsible for the funds.
Abuse—Failed to protect resident from financial exploitation
25 Sept 2019Abuse: Neglect
25 Sept 2019Abuse: Neglect
Found that funds in residents' personal accounts were not protected and money went missing; a fine was assessed.
Abuse—Failed to protect resident from financial exploitation
25 Sept 2019Abuse: Neglect
25 Sept 2019Abuse: Neglect
Investigated found that residents' funds were not protected from financial exploitation, with several hundred dollars missing over a few months. Determined that training gaps and access to funds by multiple staff allowed exploitation, and a $4,500 fine was assessed.
Abuse—Failed to protect resident from financial exploitation
25 Sept 2019Abuse: Neglect
25 Sept 2019Abuse: Neglect
Found that residents' personal funds were not protected from financial exploitation, with missing funds totaling about $505.
Abuse—Failed to protect resident from financial exploitation
25 Sept 2019Abuse: Neglect
25 Sept 2019Abuse: Neglect
Identified failure to protect residents' funds from exploitation, with funds missing and a financial abuse finding; a $4,500 fine assessed.
Abuse—Failed to protect resident from financial exploitation
25 Sept 2019Abuse: Neglect
25 Sept 2019Abuse: Neglect
Found that the facility failed to protect residents from financial exploitation, resulting in missing funds and a $4,500 fine.
Abuse—Failed to protect resident from financial exploitation
25 Sept 2019Abuse: Neglect
25 Sept 2019Abuse: Neglect
Found failure to protect residents' funds from exploitation, with funds missing and a $4500 fine assessed.
Abuse—Failed to protect resident from financial exploitation
25 Sept 2019Abuse: Neglect
25 Sept 2019Abuse: Neglect
Investigated and found that residents were not protected from financial exploitation and funds went missing; a fine was assessed.
Abuse—Failed to protect resident from financial exploitation
22 Sept 2019Abuse: Neglect
22 Sept 2019Abuse: Neglect
Investigated a complaint and found neglect and abuse due to failure to provide bathing assistance per the resident's care plan, with documentation gaps, resulting in a $500 fine.
Abuse—Failed to provide or assist with hygiene
22 Sept 2019Abuse: Neglect
22 Sept 2019Abuse: Neglect
Found deficiencies in catheter care training that could affect residents' care, with a $500 fine assessed.
Abuse—Failed to assure a qualified caregiver was present
01 Aug 2019Inspection
01 Aug 2019Inspection
Investigated a theft of medications by an unknown person and found a failure to protect medications from theft. The finding identified violations of state administrative rules.
Licensing—Failure to provide a system that prevents theft or misuse of medication
31 Jul 2019Inspection
31 Jul 2019Inspection
Found that a resident's pain medications were stolen by an unknown person, showing failure to protect from financial exploitation. The findings indicated a violation of state rules.
Licensing—Failed to protect resident from financial exploitation
11 Jun 2019Abuse: Neglect
11 Jun 2019Abuse: Neglect
Found neglect by failing to implement established care plan tasks, resulting in a resident injury fall.
Abuse—Failed to follow care plan
07 May 2019Inspection
07 May 2019Inspection
Investigated the allegation of failing to provide a safe environment and found a violation.
Licensing—Failed to provide safe environment
16 Mar 2019Abuse: Neglect
16 Mar 2019Abuse: Neglect
Investigated a neglect allegation related to medication administration and found that basic care was not provided as ordered, resulting in harm and risk of serious harm.
Abuse—Failed to administer medication as ordered
11 Feb 2019Abuse: Neglect
11 Feb 2019Abuse: Neglect
Found a failure to provide a safe environment that resulted in harm, with a $1,500 fine assessed.
Abuse—Failed to provide safe environment
11 Feb 2019Inspection
11 Feb 2019Inspection
Investigated and found a failure to report suspected abuse, resulting in a $1,000 fine.
Licensing—Failed to report potential or suspected abuse
21 Jan 2019Inspection
21 Jan 2019Inspection
Concluded a failure to report suspected abuse occurred. A $1,000 fine was assessed.
Licensing—Failed to report potential or suspected abuse
21 Jan 2019Abuse: Neglect
21 Jan 2019Abuse: Neglect
Found neglect substantiated for failing to provide timely medical treatment, risking harm to the individual. A $500 fine was assessed.
Abuse—Failed to assure timely medical treatment
18 Jan 2019Abuse: Neglect
18 Jan 2019Abuse: Neglect
Investigated and found neglect in administering medications as ordered, causing discomfort and risk of serious harm.
Abuse—Failed to provide a safe medication administration system
16 Jan 2019Abuse: Neglect
16 Jan 2019Abuse: Neglect
Found neglect by failing to provide basic care or services necessary to maintain health and safety, resulting in a $375 fine.
Abuse—Failed to provide safe environment
27 Dec 2018Abuse: Neglect
27 Dec 2018Abuse: Neglect
Found neglect of a resident resulting in harm. A $500 fine was assessed.
Abuse—Failed to intervene when resident's condition changed
27 Dec 2018Inspection
27 Dec 2018Inspection
Found a licensing violation for failing to report suspected abuse. A $1,000 fine was assessed.
Licensing—Failed to report potential or suspected abuse
14 Dec 2018Abuse: Neglect
14 Dec 2018Abuse: Neglect
Found neglect of a resident during transit on the transport bus, with a $188 fine assessed.
Abuse—Failed to provide safe environment
13 Dec 2018Inspection
13 Dec 2018Inspection
Investigated a medication administration issue and found failure to administer medication as ordered.
Licensing—Failed to administer medication as ordered
08 Dec 2018Abuse: Financial abuse
08 Dec 2018Abuse: Financial abuse
Investigated a financial exploitation allegation and found a theft of $500 from a resident's locked closet was not prevented, resulting in a $188 fine.
Abuse—Failed to protect resident from financial exploitation
06 Dec 2018Inspection
06 Dec 2018Inspection
Found a deficiency for failing to respond to call lights promptly, with residents waiting up to two hours.
Licensing—Failed to answer call light in a timely manner
11 Nov 2018Abuse: Neglect
11 Nov 2018Abuse: Neglect
Found neglect for failing to administer medications as ordered, which caused discomfort, and assessed a fine.
Abuse—Failed to provide service
09 Nov 2018Abuse: Neglect
09 Nov 2018Abuse: Neglect
Investigated a complaint of neglect and found that basic care was not provided, putting an adult at risk of serious harm; a $250 fine was assessed.
Abuse—Failed to answer call light in a timely manner
09 Nov 2018Inspection
09 Nov 2018Inspection
Found failure to report suspected abuse.
Licensing—Failed to report potential or suspected abuse
07 Nov 2018Abuse: Neglect
07 Nov 2018Abuse: Neglect
Found neglect for not using an assistive device to transfer an adult, resulting in harm and unreasonable discomfort.
Abuse—Failed to provide safe environment
01 Nov 2018Abuse: Neglect
01 Nov 2018Abuse: Neglect
Found neglect for failing to administer ordered medication and provide basic care, and assessed a $375 fine.
Abuse—Failed to administer ordered medication
25 Oct 2018Inspection
25 Oct 2018Inspection
Found staffing deficiencies due to untimely response to call lights, indicating noncompliance with required staffing practices.
Licensing—Failed to answer call light in a timely manner
21 Oct 2018Abuse: Neglect
21 Oct 2018Abuse: Neglect
Investigated an allegation of neglect and found failure to provide a safe environment, risking physical harm to an adult resident.
Abuse—Failed to provide safe environment
11 Oct 2018Abuse: Physical Abuse
11 Oct 2018Abuse: Physical Abuse
Investigated an allegation of physical abuse and found neglect for failing to protect a resident from rough treatment, resulting in injury.
Abuse—Failed to protect resident from rough treatment
21 Aug 2018Abuse: Neglect
21 Aug 2018Abuse: Neglect
Investigated a neglect allegation and concluded safety was not maintained, with multiple violations cited.
Abuse—Failed to provide safe environment
02 Aug 2018Inspection
02 Aug 2018Inspection
Identified deficiencies showing equipment necessary for residents' health and safety was not maintained in working order, with plumbing issues and many light bulbs out.
Licensing—Failed to provide or maintain resident care equipment
02 Aug 2018Inspection
02 Aug 2018Inspection
Investigated a staffing complaint and identified insufficient staffing to meet residents' scheduled and unscheduled needs.
Licensing—Failed to provide appropriate staffing
20 Jul 2018Inspection
20 Jul 2018Inspection
Found inadequate staffing levels that risk delays in resident assistance, with residents waiting more than 40 minutes for help.
Licensing—Failed to provide appropriate staffing
08 Jun 2018Abuse: Neglect
08 Jun 2018Abuse: Neglect
Found that the care plan was not followed, resulting in a fall with injury, and a $500 fine was assessed.
Abuse—Failed to follow care plan
08 Jun 2018Inspection
08 Jun 2018Inspection
Investigated an allegation of failing to report potential or suspected abuse; found failure to self-report and assessed a $750 fine.
Licensing—Failed to report potential or suspected abuse
09 May 2018Inspection
09 May 2018Inspection
Investigated a resident-complaints issue and found ineffective methods for responding to and resolving complaints, including a report that residents were told exercise equipment would be replaced.
Licensing—Failed to provide service
09 May 2018Inspection
09 May 2018Inspection
Found that required weekend care staff were not provided.
Licensing—Failed to provide appropriate staffing
03 Apr 2018Inspection
03 Apr 2018Inspection
Investigated the allegation that medication was not administered as ordered and found a failure to follow safe medication administration practices as required by the rule.
Licensing—Failed to administer medication as ordered
15 Feb 2018Inspection
15 Feb 2018Inspection
Investigated an allegation about housekeeping services and found that appropriate housekeeping was not provided.
Licensing—Failed to provide appropriate housekeeping services
14 Feb 2018Inspection
14 Feb 2018Inspection
Found that staff failed to answer call light in a timely manner.
Licensing—Failed to answer call light in a timely manner
14 Feb 2018Inspection
14 Feb 2018Inspection
Investigated an allegation that records were not accessible and found it substantiated.
Licensing—Failed to make facility or resident records accessible
31 Jan 2018Inspection
31 Jan 2018Inspection
Found failure to adequately assess and plan care for falls, resulting in falls with injury.
Licensing—Failed to adequately care plan related to falls
05 Jan 2018Inspection
05 Jan 2018Inspection
Investigated allegation of inadequate staffing. Determined there was evidence to support it.
Licensing—Failed to provide appropriate staffing
05 Jan 2018Inspection
05 Jan 2018Inspection
Investigated a licensing allegation and concluded the licensee failed to communicate necessary information.
Licensing—Failed to communicate necessary information
05 Jan 2018Inspection
05 Jan 2018Inspection
Investigated the complaint and found a deficiency in the medication administration system.
Licensing—Failed to provide a safe medication administration system
05 Jan 2018Inspection
05 Jan 2018Inspection
Investigated an allegation that a homelike environment was not provided. Found the allegation supported.
Licensing—Failed to provide a homelike environment
05 Jan 2018Inspection
05 Jan 2018Inspection
Investigated an allegation of failing to provide appropriate housekeeping services. Found a licensing violation related to housekeeping.
Licensing—Failed to provide appropriate housekeeping services
01 Dec 2017Abuse: Neglect
01 Dec 2017Abuse: Neglect
Determined a deficiency in medication management that resulted in a resident running out of narcotic pain medication and being in pain.
Abuse—Failed to administer medication as ordered
08 Sept 2017Inspection
08 Sept 2017Inspection
Investigated a complaint alleging failure to provide medication and treatment as ordered. Found violations related to carrying out medication and treatment orders.
Licensing—Failed to provide medical treatment as ordered
08 Sept 2017Abuse: Neglect
08 Sept 2017Abuse: Neglect
Found deficiencies in the medication administration system that led to orders not being followed.
Abuse—Failed to provide a safe medication administration system
08 Sept 2017Inspection
08 Sept 2017Inspection
Found that the training program lacked a method to determine performance capability through a demonstration and evaluation, related to a complaint that Medication Aides were not trained.
Licensing—Failed to assure that a qualified caregiver was present
21 Jun 2017Inspection
21 Jun 2017Inspection
Substantiated the staffing allegation. The finding noted failure to provide appropriate staffing.
Licensing—Failed to provide appropriate staffing
09 Jan 2017Inspection
09 Jan 2017Inspection
Investigated the allegation of insufficient staffing and found that appropriate staffing was not provided.
Licensing—Failed to provide appropriate staffing
22 Dec 2016Inspection
22 Dec 2016Inspection
Investigated an allegation that hygiene was not provided or assisted. Found a deficiency related to hygiene.
Licensing—Failed to provide or assist with hygiene
03 Dec 2016Inspection
03 Dec 2016Inspection
Found deficiencies in medication administration safety; the allegation that the wrong medication was administered was supported by findings.
Licensing—Failed to provide a safe medication administration system
21 Oct 2016Abuse: Financial abuse
21 Oct 2016Abuse: Financial abuse
Investigated and found a failure to protect a resident from theft, with a related financial abuse allegation.
Abuse—Failed to provide safe environment
08 Oct 2016Inspection
08 Oct 2016Inspection
Investigated and found that a call light was not properly responded to, leaving a resident sitting unassisted in the bathroom for an extended period.
Licensing—Failed to assist with toileting
10 Sept 2016Abuse: Financial abuse
10 Sept 2016Abuse: Financial abuse
Investigated a financial abuse allegation and identified a safety deficiency in protecting a resident from theft.
Abuse—Failed to provide safe environment
17 Aug 2016Inspection
17 Aug 2016Inspection
Found insufficient in-number care staff to meet the 24hour schedule and unscheduled needs of residents.
Licensing—Failed to provide appropriate staffing
17 Aug 2016Inspection
17 Aug 2016Inspection
Found a deficiency for failing to provide a call system that connects resident units to staff.
Licensing—Failed to maintain functional door alarm or call system
31 Jul 2016Inspection
31 Jul 2016Inspection
Investigated the allegation and identified a failure to provide a safe environment to protect residents from self-harm.
Licensing—Failed to provide safe environment
20 May 2016Abuse: Neglect
20 May 2016Abuse: Neglect
Investigated the complaint and found neglect due to inadequate pain management causing unreasonable discomfort.
Abuse—Failed to provide appropriate pain control
14 May 2016Abuse: Financial abuse
14 May 2016Abuse: Financial abuse
Investigated the complaint and found a safety failure that left a resident vulnerable to theft.
Abuse—Failed to provide safe environment
02 May 2016Inspection
02 May 2016Inspection
Identified insufficient staffing to meet residents' scheduled and unscheduled needs.
Licensing—Failed to provide appropriate staffing
02 May 2016Inspection
02 May 2016Inspection
Identified a deficiency in the call system that connects resident units to the staff center. The finding relates to a rule requiring such connectivity.
Licensing—Failed to assure adequate supply or equipment
02 May 2016Inspection
02 May 2016Inspection
Investigated a complaint and found that residents did not receive necessary assistance with daily living activities.
Licensing—Failed to provide service
21 Mar 2016Inspection
21 Mar 2016Inspection
Found deficiencies related to meal preparation and nutrition.
Licensing—Failed to provide proper food/nutrition
09 Dec 2015Inspection
09 Dec 2015Inspection
Identified a violation of the move-out notice requirement due to failure to provide the required less-than-30-day notice for involuntary moveouts.
Licensing—Failed to comply with move-out, transfer or discharge requirements
15 May 2015Abuse: Neglect
15 May 2015Abuse: Neglect
Identified a deficiency for failing to provide a safe environment.
Abuse—Failed to provide safe environment
24 Dec 2014Inspection
24 Dec 2014Inspection
Found deficiencies in the medication administration system due to failure to provide medication as ordered.
Licensing—Failed to provide a safe medication administration system
22 Jan 2014Abuse: Neglect
22 Jan 2014Abuse: Neglect
Investigated abuse/neglect allegation and found that medications were not administered as prescribed.
Abuse—Failed to provide a safe medication administration system
05 Aug 2011Abuse: Financial abuse
05 Aug 2011Abuse: Financial abuse
Investigated the financial abuse allegation and found a failure to provide a secure environment.
Abuse—Failed to provide safe environment
Disclaimer
Mirador Living is not affiliated with the owner or operator(s) of Gilman Grove. The information above has not been verified or approved by the owner or operator. For exact information, please contact Gilman Grove directly. There is no cost for this service. We are compensated by the community you select.
Are you an owner or operator of this community?
Claim this listing to receive messages from prospective customers and manage your community page.
