separate dining areas for memory care and independent living
professional, compassionate caregiving staff
attentive med techs and direct caregivers
robust assisted-living and memory-care programming
varied social and recreational activities
responsive family communication and move-in support
hotel-like, upscale interior and common areas
pet-friendly community
long-tenured staff and family-oriented culture
Cons
inconsistent staffing levels and shift coverage
gaps in medication administration and clinical oversight
unreliable meal quality and service timing
variable housekeeping and sanitation in resident rooms
management instability and communication shortfalls
limited capacity for intensive one-to-one care
security and access-control weaknesses
variability in activities leadership and personalization
billing and pricing transparency issues
navigation and accessibility concerns for some units
Summary of reviews
Avamere at Bethany presents as an attractive, well-maintained community with many features families value. Reviewers consistently describe clean, bright interiors, spacious apartments (including multi-bedroom units with balconies), tasteful common areas, and thoughtfully maintained outdoor spaces connected to regional walking trails. On-site amenities such as a coffee shop, ice cream parlor and salon contribute to an upscale, hotel-like atmosphere. Many families highlight a warm, family-oriented culture created by long-tenured staff and note that the property feels welcoming and homelike.
Care and staffing receive mixed but specific feedback. Numerous comments praise professional, compassionate caregivers, attentive med techs, and strong assisted-living and memory-care teams who are engaged and familiar with residents. At the same time, there are recurring operational concerns: inconsistent staffing levels and shift coverage; gaps in medication administration and clinical oversight; and limited capacity to provide continuous one-on-one supervision for residents with high-acuity needs. These clinical and staffing issues have led some families to consider alternative settings for residents who require intensive medical attention.
Dining and activities are another area of divergence. Several families appreciate the dining rooms, pleasant meal presentation, and an active social calendar that includes exercise classes, games, outings and memory-focused programming. Others reported bland or inconsistent meal quality and occasional delays in meal service. Activity leadership appears to be in transition in some cases, producing variability in the regularity and individualization of programming; families who prioritize a highly active, personalized activity schedule may want to confirm current offerings during a tour.
Facility upkeep and operations show both strengths and weaknesses. The campus and many communal areas are kept clean and attractive, but housekeeping and sanitation in some resident rooms have been described as inconsistent. Reviewers also noted recent renovation and leadership responsiveness in certain instances, indicating that management has taken corrective steps. Conversely, there are patterns of management instability, including leadership turnover, communication gaps about pricing and billing, and concerns about billing transparency. Security and access-control lapses were mentioned, and at least one serious allegation regarding staff misconduct was raised; that allegation and other safety-related incidents suggest families should ask about incident response protocols, staff background checks, and security measures during tours.
Overall impression: Avamere at Bethany is often described as a pleasant, upscale community with caring staff, strong assisted-living and memory-care programming, and desirable amenities and grounds. It may be a good fit for independent or assisted-living residents who value environment, social opportunities, and family-oriented staff. Families with loved ones who require reliable, high-acuity medical oversight or continuous one-on-one supervision should carefully evaluate clinical staffing patterns, medication-management practices, housekeeping consistency, and management stability before deciding. Prospective residents and their families are advised to tour the community, speak with clinical leadership about current staffing and medication protocols, review recent incident and staffing records if available, and verify billing/price-change policies to ensure alignment with their care and financial expectations.
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Location
Avamere at Bethany is located at 16360 NW Avamere Ct, Portland, OR, 97229.
About Avamere at Bethany
Avamere at Bethany sits in Portland, Oregon, surrounded by lively greenery, offering senior living with independent living, assisted living, memory care, and respite care, and the whole place has 105 rooms and cottages, including 71 beds overall, and it features both private apartments and some smaller memory care units, with about 15 residents there at any time. Residents can expect services that fit their changing needs, so when someone starts off in independent living but needs more help later, things are set up for them to stay and get extra care if needed, with round-the-clock staff, wellness check-ins, emergency call systems, medication help, and personalized plans. There's always someone on staff, and the emergency call system works all day and night; the care team really does focus on things like helping with daily living, making sure health needs are checked, and supporting folks with Alzheimer's or other dementia in a small, quieter setting, and they use Dementia Live high-impact training for the staff working with memory care residents.
Residents enjoy a dining program that serves nutritious meals using good quality ingredients in a restaurant-style setting, and there's housekeeping and maintenance, so nobody has to worry about chores if they don't want to, and the facility has technology like Wi-Fi and a computer center. There are a lot of activities on the calendar, including fitness classes, small group gatherings, and sometimes individual activities when someone prefers things quieter, and a new activities director works on programs especially for memory care. Residents who bring pets will find the place pet-friendly, and living spaces get designed for comfort with both style and practical needs in mind, and the building comes with advanced security features and easy access for wheelchairs or people who need extra support getting around. Avamere at Bethany also offers in-house transportation, so residents can get out for appointments or outings.
The staff includes Senior Director of Sales and Outreach Cristal Ruvalcaba, Executive Director Matthew Mullen, Interim Executive Director Sara Sutherland, Operations Manager Cara Richard, Director of Community Relations Vicky Frazier, and Regional Director Mia Mullins (acting director), and the facility is managed by Areté Living. People can take a virtual tour or schedule a visit to see the place for themselves. The community supports aging in place, so someone doesn't have to move away if care needs change, whether in independent living, assisted living, or memory care. The setting is meant for active seniors as well as those who need more help, and the focus stays on keeping life comfortable and supportive, without making things too complicated or overwhelming. The website has more details for those who want to see more about the place.
Founded in 1995 by Rick Miller in Oregon, Avamere is headquartered in Wilsonville and operates skilled nursing and rehabilitation facilities across the Pacific Northwest. Originally growing to 33 facilities, the company spun off its senior living division (Arete Living) in 2022, refocusing on skilled nursing care.
People often ask...
Avamere at Bethany offers competitive pricing, with rates starting at a cost of $6,599 per month.
Avamere at Bethany offers independent living, assisted living, and memory care.
There are 69 photos of Avamere at Bethany on Mirador.
Yes, Avamere at Bethany allows residents to age in place and adjust their level of care as needed.
The full address for this community is 16360 NW Avamere Ct, Portland, OR 97229.
No, Avamere at Bethany 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.
Found that safeguards against elopement were not maintained, with doors and alarms failing to lock or alert consistently, which enabled an elopement.
Licensing—Failed to provide safe environment
07 Jul 2026Inspection
07 Jul 2026Inspection
Found a medication administration violation for one resident when lorazepam was given at 1 mg instead of 0.5 mg as ordered, with orders not followed as prescribed.
Licensing—Failed to provide a safe medication administration system
04 Jul 2026Inspection
04 Jul 2026Inspection
Investigated and found that the administrator failed to promptly report abuse to the local Department office or local AAA.
Licensing—Failed to report potential or suspected abuse
04 Jul 2026Inspection
04 Jul 2026Inspection
Found insufficient awake direct care staffing to meet 24-hour needs, with shifts not meeting the posted plan and a resident up all night unsupervised.
Licensing—Failed to staff as indicated by ABST
04 Jul 2026Inspection
04 Jul 2026Inspection
Investigated ABST evaluations were not completed or updated quarterly for all residents, with 5 of 21 residents lacking updates as of 07/04/26.
Licensing—Failed to use an ABST
04 Jul 2026Inspection
04 Jul 2026Inspection
Found that the facility failed to implement required services for a resident, creating safety concerns and risk of elopement.
Licensing—Failed to provide safe environment
26 Jun 2026Inspection
26 Jun 2026Inspection
Investigated an ABST-related allegation and found the Acuity-Based Staffing Tool did not accurately reflect residents and their needs. Inconsistencies between the roster, care plans, and ABST data, and staffing levels not aligned with scheduled and unscheduled resident needs were identified.
Licensing—Failed to use an ABST
20 Jun 2026Inspection
20 Jun 2026Inspection
Determined that records were not provided timely in response to a records request.
Licensing—Failed to submit timely or adequate staffing documentation
14 Jun 2026Inspection
14 Jun 2026Inspection
Found a deficiency in the medication administration system that did not ensure medications were administered as ordered.
Licensing—Failed to provide a safe medication administration system
10 Apr 2026Inspection
10 Apr 2026Inspection
Found that an updated ABST reflecting resident needs was not in place. Inconsistencies were identified between the roster, care plans, and the ABST data.
Licensing—Failed to use an ABST
08 Apr 2026Inspection
08 Apr 2026Inspection
Investigated and identified a deficiency involving an outdated ABST that did not accurately reflect resident needs. Inconsistencies were found between the resident roster, care plans, and ABST data.
Licensing—Failed to use an ABST
21 Feb 2026Inspection
21 Feb 2026Inspection
Found that records requested by the Department were not provided for staffing documentation as required.
Licensing—Failed to submit timely or adequate staffing documentation
10 Feb 2026Inspection
10 Feb 2026Inspection
Identified inconsistencies between the resident roster, care plans, and ABST data, and determined a violation of Oregon Administrative Rules.
Licensing—Failed to use an ABST
03 Dec 2025Inspection
03 Dec 2025Inspection
Investigated a records request allegation and found that the required documents were not provided by the due date. This violated Oregon Administrative Rules.
Licensing—Failed to cooperate with an investigation
22 Nov 2025Inspection
22 Nov 2025Inspection
Identified the failure to provide required records upon request, resulting in a license violation.
Licensing—Failed to provide safe environment
21 Nov 2025Abuse: Neglect
21 Nov 2025Abuse: Neglect
Investigated an allegation of neglect related to dietary safety and supervision. Found that a resident with a shellfish allergy was served shellfish and dietary restrictions were not adequately supervised during meals.
Abuse—Failed to assure food safety
17 Nov 2025Abuse: Neglect
17 Nov 2025Abuse: Neglect
Determined that supervision was inadequate, allowing a resident to elope and be at risk of harm; a fine was assessed.
Abuse—Failed to provide safe environment
21 Oct 2025Inspection
21 Oct 2025Inspection
Found failure to submit timely or adequate staffing documentation when requested.
Licensing—Failed to submit timely or adequate staffing documentation
10 Oct 2025Inspection
10 Oct 2025Inspection
Investigated an allegation that records were not provided upon request; found failure to provide records to the Department, violating state rules.
Licensing—Failed to make facility or resident records accessible
02 Sept 2025Abuse: Neglect
02 Sept 2025Abuse: Neglect
Found that failure to follow physician orders and maintain an accurate MAR delayed treatment and contributed to hospitalization; a $1500 fine was assessed.
Abuse—Failed to provide a safe medication administration system
23 May 2025Inspection
23 May 2025Inspection
Identified a records submission violation for failing to provide staffing records upon request.
Licensing—Failed to submit timely or adequate staffing documentation
06 Mar 2025Licensure
06 Mar 2025Licensure
Found multiple failures across move-in evaluations, service plans, change-of-condition processes, health services, and safety systems. Numerous deficiencies affected resident care planning, monitoring, and communication of outside provider recommendations.
Deficiency—Resident Move-in & Evaluation: Res Evaluation
Deficiency—Service Plan: General
Deficiency—Change of Condition and Monitoring
Deficiency—Resident Health Services
Deficiency—Res Hlth Srvc: On- and Off-Site Health Srvc
Deficiency—Systems: Treatment Orders
Deficiency—Restraints and Supportive Devices
Deficiency—Training Within 30 Days of Hire ? Direct Care Staff
Deficiency—Fire and Life Safety: Training for Residents
Deficiency—Call Sys, Exit Dr Alarm, Phones, TV, or Cable
Deficiency—Administration Compliance
Deficiency—Staff Training Requirements
Deficiency—Compliance with Rules Health Care
06 Mar 2025Licensure
06 Mar 2025Licensure
Investigated several deficiencies related to resident move-in evaluations, service planning, change-of-condition monitoring, health services, infection control, and facility operations, with numerous instances where plans and care did not reflect current resident needs or documented changes.
Deficiency—Resident Move-in & Evaluation: Res Evaluation
Deficiency—Service Plan: General
Deficiency—Change of Condition and Monitoring
Deficiency—Resident Health Services
Deficiency—Res Hlth Srvc: On- and Off-Site Health Srvc
Deficiency—Infection Prevention & Control
Deficiency—Systems: Treatment Orders
Deficiency—Systems: Resident Right to Refuse
Deficiency—Restraints and Supportive Devices
Deficiency—Staffing Requirements and Training ? Pre-service
Deficiency—Training Within 30 Days of Hire ? Direct Care Staff
Deficiency—Annual and Biennial Inservice for All Staff
Deficiency—Fire and Life Safety: Safety
Deficiency—Inspections and Investigation: Insp Interval
Deficiency—Staffing Requirements and Training ? Pre-service
02 Oct 2024Abuse: Neglect
02 Oct 2024Abuse: Neglect
Investigated and found a neglect/abuse violation where a resident was left without access to a call light for more than twelve hours while ill, with a cold room and no blanket.
Abuse—Failed to properly plan care
10 Aug 2024Abuse: Neglect
10 Aug 2024Abuse: Neglect
Investigated alleged neglect and abuse related to fall risk; found failure to identify a resident as a fall risk and to implement adequate fall interventions, resulting in a fracture and severe pain, and assessed a fine.
Abuse—Failed to properly plan care
10 Jul 2024Licensure
10 Jul 2024Licensure
Found extensive kitchen sanitation deficiencies across multiple visits; follow-up visits led to substantial compliance.
Deficiency—Inspections and Investigation: Insp Interval
Deficiency—Administration Compliance
10 Jul 2024Licensure
10 Jul 2024Licensure
Identified sanitation deficiencies in the kitchen and staff PPE during the initial survey, with follow-up visits showing substantial compliance for meals and food sanitation rules.
Deficiency—Inspections and Investigation: Insp Interval
09 Apr 2024Complaint
09 Apr 2024Complaint
Identified deficiencies related to medications and treatments, treatment orders, and acuity-based staffing, each with potential for moderate harm.
Deficiency—Systems: Medications and Treatments
Deficiency—Systems: Treatment Orders
Deficiency—Acuity-Based Staffing Tool
21 Jul 2023Abuse: Neglect
21 Jul 2023Abuse: Neglect
Investigated found a failure to provide a safe medication administration system, resulting in missed medications and harm to a resident. The resident experienced significant pain and anxiety due to the missed doses.
Abuse—Failed to provide a safe medication administration system
17 Jul 2023License Condition
17 Jul 2023License Condition
Found failure to use an ABST as required by the rule.
Regulatory Action—Failed to use an ABST
20 Jun 2023Licensure
20 Jun 2023Licensure
Observed deficiencies in kitchen cleanliness and glove-use practices; follow-up determined substantial compliance with food sanitation rules.
Identified deficiencies in kitchen cleanliness and glove use during the initial visit; subsequent follow-up showed substantial compliance for meals and food sanitation, with administration compliance also addressed.
Investigated a complaint and identified deficiencies in policy and procedure, service planning, treatment orders, acuity-based staffing, direct care staff training, and environmental controls.
Deficiency—Training Within 30 Days: Direct Care Staff
Deficiency—Doors, Walls, Elevators, Odors
21 Apr 2023Inspection
21 Apr 2023Inspection
Investigated a medication-error allegation and found that a trainee administered the wrong medication, causing discomfort; supervision during training was lacking and the medication administration system was unsafe.
Licensing—Failed to provide a safe medication administration system
17 Mar 2023Inspection
17 Mar 2023Inspection
Investigated an allegation of failing to provide medical treatment as ordered and found a violation related to unsafe medication and treatment administration systems.
Licensing—Failed to provide medical treatment as ordered
17 Mar 2023Inspection
17 Mar 2023Inspection
Investigated an allegation of failing to administer medication as ordered and determined that medication and treatment orders were not carried out as prescribed.
Licensing—Failed to administer medication as ordered
06 Mar 2023Inspection
06 Mar 2023Inspection
Found insufficient qualified awake direct care staff to meet residents' 24-hour needs, creating an unsafe environment.
Licensing—Failed to provide safe environment
06 Mar 2023Inspection
06 Mar 2023Inspection
Found a licensing violation for not documenting observation and evaluation of an individual's ability to safely perform medication and treatment administration unsupervised, indicating a deficient medication administration system.
Licensing—Failed to provide a safe medication administration system
28 Feb 2023Abuse: Neglect
28 Feb 2023Abuse: Neglect
Found a failure to provide a safe medication administration system, resulting in adverse effects and neglect/abuse; a $500 fine was assessed.
Abuse—Failed to provide a safe medication administration system
03 Feb 2023Inspection
03 Feb 2023Inspection
Investigated deficiencies in the Acuity-Based Staffing Tool (ABST) and related data, indicating a violation of Oregon Administrative Rules.
Licensing—Failed to use an ABST
01 Feb 2023Inspection
01 Feb 2023Inspection
Found a violation for failure to complete quarterly service plans.
Licensing—Failed to properly plan care
01 Feb 2023Inspection
01 Feb 2023Inspection
Found insufficient qualified awake direct care staff to meet residents' 24-hour needs, creating an unsafe environment.
Licensing—Failed to provide safe environment
19 Dec 2022Inspection
19 Dec 2022Inspection
Found that equipment was not kept in good repair, resulting in an unsafe environment.
Licensing—Failed to provide safe environment
19 Dec 2022Inspection
19 Dec 2022Inspection
Found a deficiency for failing to keep all interior and exterior surfaces clean, compromising a safe environment.
Licensing—Failed to provide safe environment
19 Dec 2022Inspection
19 Dec 2022Inspection
Investigated the allegation and found failure to respond to and resolve resident complaints, resulting in an unsafe environment.
Licensing—Failed to provide safe environment
19 Dec 2022Inspection
19 Dec 2022Inspection
Determined that there was a failure to document observation and evaluation of an individual’s ability to perform safe medication and treatment administration unsupervised.
Licensing—Failed to provide a safe medication administration system
06 Dec 2022Abuse: Neglect
06 Dec 2022Abuse: Neglect
Investigated the allegation and found that the care plan wasn't updated or followed, risking the resident's health due to meals oversight and monitoring lapses.
Abuse—Failed to follow care plan
05 Dec 2022Abuse: Neglect
05 Dec 2022Abuse: Neglect
Found failure to plan and maintain a comprehensive care plan for a resident requiring increased ADL assistance, which contributed to about 30 pounds of weight loss and related discomfort.
Abuse—Failed to properly plan care
16 Nov 2022Inspection
16 Nov 2022Inspection
Investigated a failure to provide a safe environment that allowed a non-consensual sexual relationship. Findings substantiated.
Licensing—Failed to provide safe environment
26 Oct 2022Abuse: Neglect
26 Oct 2022Abuse: Neglect
Investigated a complaint about medication administration and found a failure to provide a safe system, causing unnecessary discomfort and constituting neglect and abuse. A $250 fine was assessed.
Abuse—Failed to provide a safe medication administration system
08 Aug 2022Complaint
08 Aug 2022Complaint
Investigated the complaint and identified deficiencies related to reasonable precautions and safety-related areas, indicating potential for moderate harm.
Deficiency—Licensing Complaint Investigation
Deficiency—Reasonable Precautions
Deficiency—Doors, Walls, Elevators, Odors
08 Aug 2022Complaint
08 Aug 2022Complaint
Identified a deficiency related to reasonable precautions during the complaint investigation.
Deficiency—Licensing Complaint Investigation
Deficiency—Reasonable Precautions
05 Aug 2022Inspection
05 Aug 2022Inspection
Investigated the allegation of an unsafe environment and found that equipment was not kept in good repair.
Licensing—Failed to provide safe environment
05 Aug 2022Inspection
05 Aug 2022Inspection
Identified a deficiency related to infection control that could threaten residents' health and safety. Investigative findings indicated a violation of Oregon Administrative Rules.
Licensing—Failed to provide infection control
21 Jul 2022Inspection
21 Jul 2022Inspection
Identified a safety-related deficiency due to inadequate precautions against conditions that threaten residents' health, safety, or welfare.
Licensing—Failed to provide safe environment
02 May 2022Inspection
02 May 2022Inspection
Found a licensing violation for failing to submit timely weekly reporting on vaccinated individuals, residents, and staff. The noncompliance occurred during April 2022.
Licensing—Failed to submit timely or adequate staffing documentation
14 Mar 2022Validation
14 Mar 2022Validation
Investigations identified multiple deficiencies across care planning, health services, medication management, and safety. Several residents experienced incomplete evaluations, noncompliant service plans, and inadequate incident investigations.
Deficiency—Resident Move-In and Eval: Res Evaluation
Deficiency—Service Plan: General
Deficiency—Change of Condition and Monitoring
Deficiency—Res Hlth Srvc: On- and Off-Site Health Srvc
Deficiency—Systems: Treatment Orders
Deficiency—Systems: Medication Administration
Deficiency—Systems: Psychotropic Medication
Deficiency—Fire and Life Safety: Safety
Deficiency—Fire and Life Safety: Training For Residents
Deficiency—Doors, Walls, Elevators, Odors
Deficiency—Administration Compliance
Deficiency—Staff Training Requirements
Deficiency—Compliance With Rules Health Care
Deficiency—Activities
14 Mar 2022Validation
14 Mar 2022Validation
Identified deficiencies in pre-service orientation, competency within 30 days, annual in-service training, and fire safety documentation during the re-licensure survey; a later revisit found substantial compliance.
Deficiency—Comment
Deficiency—Staffing Requirements and Training – Pre-Serv
Deficiency—Training Within 30 Days: Direct Care Staff
Deficiency—Annual and Biennial Inservice For All Staff
Deficiency—Fire and Life Safety: Safety
Deficiency—Fire and Life Safety: Training For Residents
08 Feb 2022Abuse: Neglect
08 Feb 2022Abuse: Neglect
Found a failure to provide a safe medication administration system, resulting in harm to a resident; a fine was assessed.
Abuse—Failed to provide a safe medication administration system
03 Jan 2022Inspection
03 Jan 2022Inspection
Investigated and determined that there was a failure to provide a safe environment.
Licensing—Failed to provide safe environment
09 Dec 2021Abuse: Neglect
09 Dec 2021Abuse: Neglect
Found a failure to provide a safe environment, resulting in abuse and neglect; a fine was assessed.
Abuse—Failed to provide safe environment
03 Dec 2021Abuse: Neglect
03 Dec 2021Abuse: Neglect
Identified a deficiency in providing a safe medication administration system, resulting in neglect and abuse, with a $375 fine assessed.
Abuse—Failed to provide a safe medication administration system
03 Dec 2021Abuse: Neglect
03 Dec 2021Abuse: Neglect
Found a violation for failing to provide a safe medication administration system, resulting in neglect and abuse; a $375 fine was assessed.
Abuse—Failed to provide a safe medication administration system
30 Nov 2021Abuse: Neglect
30 Nov 2021Abuse: Neglect
Found a deficiency in the medication administration system due to failing to administer essential medications as ordered; a $375 fine was assessed.
Abuse—Failed to provide a safe medication administration system
05 Nov 2021Abuse: Neglect
05 Nov 2021Abuse: Neglect
Found a failure to provide a safe medication administration system, leading to missed doses and hospital observation for a resident. Missed dosages occurred on multiple dates in November 2021.
Abuse—Failed to provide a safe medication administration system
27 Sept 2021Inspection
27 Sept 2021Inspection
Verified the allegation that a call light was not answered promptly.
Licensing—Failed to answer call light in a timely manner
24 Sept 2021Inspection
24 Sept 2021Inspection
Investigated a staffing allegation and observed improper glove changes during incontinent care and lack of hand hygiene and aprons during meals.
Licensing—Failed to provide appropriate staffing
14 Sept 2021Inspection
14 Sept 2021Inspection
Investigated and found that call lights were not answered promptly.
Licensing—Failed to answer call light in a timely manner
24 Aug 2021Abuse: Neglect
24 Aug 2021Abuse: Neglect
Found failure to provide a safe environment after a resident eloped when a courtyard gate was left propped open, resulting in a substantiated abuse/neglect finding.
Abuse—Failed to provide safe environment
26 Jul 2021Inspection
26 Jul 2021Inspection
Investigated an allegation of unsafe medication administration and found a failure to provide a safe medication administration system.
Licensing—Failed to provide a safe medication administration system
10 Apr 2021Inspection
10 Apr 2021Inspection
Investigated a medication administration incident and found a violation related to unsafe medication practices after a resident received medications meant for another resident. A fine was assessed.
Licensing—Failed to provide a safe medication administration system
29 Nov 2020Abuse: Neglect
29 Nov 2020Abuse: Neglect
Investigated an incident where a staff member yelled at a resident during daily tasks, indicating verbal abuse; also found neglect due to failure to provide a safe environment.
Abuse—Failed to provide safe environment
29 Nov 2020Inspection
29 Nov 2020Inspection
Investigated a neglect allegation where an incontinence garment was left extremely soiled and not changed, and care was not completed as required.
Licensing—Failed to follow care plan
16 Nov 2020Inspection
16 Nov 2020Inspection
Found that meals were not provided as required. The finding verified a deficiency in meal provision.
Licensing—Failed to provide proper food/nutrition
21 Oct 2020Inspection
21 Oct 2020Inspection
Concluded that the allegation of failing to provide a safe environment was supported by findings that interior and exterior materials, surfaces, and all equipment were not kept clean and in good repair.
Licensing—Failed to provide safe environment
23 Sept 2020Inspection
23 Sept 2020Inspection
Found failure to implement service plans.
Licensing—Failed to follow care plan
23 Sept 2020Inspection
23 Sept 2020Inspection
Concluded that a resident's rights to consent to or refuse medications and treatments were not upheld.
Licensing—Failed to assure resident rights
23 Sept 2020Inspection
23 Sept 2020Inspection
Found failure to provide hygiene assistance after investigating an allegation of inadequate care, specifically bathing and washing hair.
Licensing—Failed to provide or assist with hygiene
11 Mar 2020Inspection
11 Mar 2020Inspection
Found that there was inadequate professional oversight of the medication administration system.
Licensing—Failed to provide a safe medication administration system
26 Feb 2020Abuse: Neglect
26 Feb 2020Abuse: Neglect
Investigated and found a failure to provide a safe environment. A resident was locked in his/her room for several hours, risking serious harm.
Abuse—Failed to provide safe environment
25 Feb 2020Abuse: Neglect
25 Feb 2020Abuse: Neglect
Investigated an allegation of neglect. Found staff failed to intervene when a resident's condition changed, resulting in a fall and injuries; a fine was assessed.
Abuse—Failed to intervene when resident's condition changed
18 Feb 2020Abuse: Neglect
18 Feb 2020Abuse: Neglect
Investigated and found failures to assess after a fall, update care plans, and respond to a change in condition, with injuries observed and a fine assessed.
Abuse—Failed to provide safe environment
08 Feb 2020Inspection
08 Feb 2020Inspection
Investigated an allegation that a prescribed medication was not administered; found a failure to administer as ordered.
Licensing—Failed to administer ordered medication
05 Feb 2020Inspection
05 Feb 2020Inspection
Found a deficiency for failing to maintain a safe physical environment that could threaten residents' health, safety, or welfare.
Licensing—Failed to maintain a safe physical environment
01 Oct 2019Inspection
01 Oct 2019Inspection
Investigated an allegation that a resident did not receive medications as ordered and found a deficiency in the medication administration system that created a risk of harm.
Licensing—Failed to administer medication as ordered
02 Sept 2019Abuse: Neglect
02 Sept 2019Abuse: Neglect
Found neglect due to failure to follow up with the resident's medical team and to document the injury timely, which created risk of harm; a fine was assessed.
Abuse—Failed to provide oversight and monitoring of change of condition
03 Aug 2019Abuse: Neglect
03 Aug 2019Abuse: Neglect
Investigated an allegation of neglect and found failure to follow the care plan led to an unsafe environment. A fine was assessed.
Abuse—Failed to follow care plan
30 Jun 2019Inspection
30 Jun 2019Inspection
Found a licensing violation due to failure to provide a safe medication administration system, creating risk of serious harm.
Licensing—Failed to provide a safe medication administration system
01 Jan 2019Abuse: Neglect
01 Jan 2019Abuse: Neglect
Investigated the complaint about delays in pain medications and found neglect related to unsafe medication administration and failure to follow ordering protocols, resulting in the resident going without prescribed medications.
Abuse—Failed to provide a safe medication administration system
14 Dec 2018Inspection
14 Dec 2018Inspection
Found failure to report suspected abuse; a $750 fine was assessed.
Licensing—Failed to report potential or suspected abuse
14 Dec 2018Abuse: Neglect
14 Dec 2018Abuse: Neglect
Found neglect due to failure to provide a safe environment and assessed a $250 fine.
Abuse—Failed to provide safe environment
01 Feb 2018Inspection
01 Feb 2018Inspection
Identified a deficiency in the medication administration system. It was categorized as a licensing violation.
Licensing—Failed to provide a safe medication administration system
10 Feb 2017Inspection
10 Feb 2017Inspection
Found that the care plan was not followed.
Licensing—Failed to follow care plan
23 Aug 2016Abuse: Financial abuse
23 Aug 2016Abuse: Financial abuse
Found residents were not protected from theft due to a system that failed to prevent theft or misuse of medications.
Abuse—Failure to provide a system that prevents theft or misuse of medication
27 Jun 2016Abuse: Neglect
27 Jun 2016Abuse: Neglect
Investigated the allegation of abuse/neglect and found failure to provide a safe environment.
Abuse—Failed to provide safe environment
27 Apr 2016Inspection
27 Apr 2016Inspection
Investigated a licensing allegation of unsafe medication administration and found the system not maintained.
Licensing—Failed to provide a safe medication administration system
02 Nov 2015Abuse: Neglect
02 Nov 2015Abuse: Neglect
Found that a safe environment was not provided, resulting in injury.
Abuse—Failed to address resident's behavior
12 Feb 2014Inspection
12 Feb 2014Inspection
Found failure to follow the resident's plan of care.
Licensing—Failed to follow care plan
14 Aug 2013Abuse: Neglect
14 Aug 2013Abuse: Neglect
Found an inadequate medication management system and assessed a $300 fine.
Abuse—Failed to provide a safe medication administration system
24 Jul 2013Inspection
24 Jul 2013Inspection
Investigated an allegation of failing to provide a safe environment and found emotional abuse occurred.
Licensing—Failed to provide safe environment
09 Jun 2013Abuse: Physical Abuse
09 Jun 2013Abuse: Physical Abuse
Investigated a physical abuse allegation and identified a failure to provide a safe environment.
Abuse—Failed to protect resident from rough treatment
30 May 2013Abuse: Neglect
30 May 2013Abuse: Neglect
Found deficient care and services and assessed a $300 fine.
Abuse—Failed to follow care plan
25 May 2013Inspection
25 May 2013Inspection
Found a lack of a safe environment after a resident-to-resident altercation caused injury.
Licensing—Failed to provide safe environment
23 Dec 2012Inspection
23 Dec 2012Inspection
Investigated the allegation and found a failure to provide a safe environment.
Licensing—Failed to provide safe environment
06 Apr 2012Abuse: Neglect
06 Apr 2012Abuse: Neglect
Investigated a neglect allegation related to toileting assistance and found inadequate care. This could cause minor harm or risk of moderate harm.
Abuse—Failed to assist with toileting
05 Apr 2012Inspection
05 Apr 2012Inspection
Found that the medication administration system was not adequately maintained.
Licensing—Failed to keep medication record current or accurate
20 Sept 2011Abuse: Neglect
20 Sept 2011Abuse: Neglect
Found failure to follow the care plan, indicating neglect with potential for harm.
Abuse—Failed to follow care plan
13 Aug 2011Inspection
13 Aug 2011Inspection
Investigated an allegation and substantiated a deficiency related to medication records. Found a failure to provide a safe environment.
Licensing—Failed to keep medication record current or accurate
11 Jan 2011Inspection
11 Jan 2011Inspection
Found a deficiency in providing a safe environment.
Licensing—Failed to address resident's behavior
25 Feb 2010Inspection
25 Feb 2010Inspection
Found that the facility failed to provide a safe environment.
Licensing—Failed to follow care plan
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