My grandma loves living here - the staff are consistently friendly, respectful, and go the extra mile (special thanks to Nicole and Johnathan), even helping with an oxygen provider transition. The building is clean, bright, and homey with large rooms, good food, planned activities and a welcoming community space. Management is responsive, meds are handled, and overall we're very pleased and would recommend it.
Loved one of resident
Jul 2026
Pricing
Prices shown are estimates and subject to change. Contact your senior living advisor for current pricing.
Schedule a Tour
Amenities
Healthcare services
Activities of daily living assistance
Assistance with bathing
Assistance with dressing
Assistance with transfers
Medication management
Mental wellness program
Healthcare staffing
12-16 hour nursing
24-hour call system
24-hour supervision
Meals and dining
Diabetes diet
Meal preparation and service
Restaurant-style dining
Special dietary restrictions
Room
Air-conditioning
Cable
Fully furnished
Housekeeping and linen services
Kitchenettes
Private bathrooms
Telephone
Wifi
Memory care community services
Mild cognitive impairment
Specialized memory care programming
Transportation
Community operated transportation
Transportation arrangement
Transportation arrangement (non-medical)
Common areas
Beauty salon
Computer center
Dining room
Fitness room
Gaming room
Garden
Outdoor space
Small library
Wellness center
Community services
Concierge services
Fitness programs
Move-in coordination
Activities
Community-sponsored activities
Planned day trips
Resident-run activities
Scheduled daily activities
Reviews
3.44·(70)
Overall rating
5
4
3
2
1
Care
2.3
Staff
3.1
Meals
1.9
Amenities
2.6
Value
1.0
Pros
Friendly, compassionate direct-care staff
Clean, well-maintained common areas
Bright, open layout with large community and dining rooms
Planned activities and social programming
Memory-care option available
Informative, helpful admission tours
Family-oriented, small-community atmosphere
Occasional strengths in care transitions and coordination
Cons
Chronic understaffing and high staff turnover
Inconsistent medication administration and clinical follow-through
Delayed response to resident call signals and family notifications
Gaps in supervision and elopement-prevention practices
Inconsistent personal-care scheduling (bathing, linen and clothing changes)
Sanitation and odor concerns in some rooms and common areas
Pest-control concerns
Inconsistent meal quality and untimely meal service
Weak infection-control and outbreak management
Poor communication and incident reporting to families
Difficulties with transfers, admissions, and billing transparency
Staff conduct and responsiveness
Summary of reviews
Firwood Gardens elicits a strongly mixed set of impressions. Many families and visitors describe a bright, well-maintained environment with active communal spaces, scheduled programming, and a memory-care option; several accounts praise individual caregivers for being attentive, friendly, and helpful during admissions or transitions. These positive experiences frequently highlight clean common areas, large dining and activity rooms, and staff members who create a welcoming, community-oriented atmosphere.
At the same time, reviews reveal recurring operational concerns that affect clinical care and daily living. Staffing shortages and turnover are common themes and are linked to inconsistent delivery of basic services: missed medication doses, missed therapy sessions, delayed assistance with personal care, and irregular bathing and linen-change schedules. Multiple accounts describe delayed responses to call signals and slow family notification after incidents, which families identify as a key area of risk and frustration.
Safety and supervision are additional areas of concern. Several reviews describe incidents of residents leaving the building or wandering, sometimes resulting in injuries and involvement of outside authorities; these point to gaps in supervision and elopement-prevention procedures. Reviewers also raise sanitation and pest-control concerns in certain rooms and corridors, alongside inconsistent infection-control practices during outbreaks. These issues combine with reports of inconsistent food quality and late meal service to create variability in the everyday resident experience.
Staff conduct and communication are described in polarized terms. While some staff are characterized as going above and beyond, other accounts note rudeness, inattentiveness (including use of personal devices while on duty), and poor tone in family interactions. Management impressions are similarly mixed: there are reports of responsive leadership and helpful managers, but also frequent turnover, perceived money-focused decision-making, and difficulty with transfers, admissions, and billing transparency.
Taken together, the pattern suggests the facility has structural strengths—layout, communal programming, and dedicated individual caregivers—but operational weaknesses that can substantially affect resident safety and quality of life when staffing or systems fail. Prospective residents and families should ask direct questions about current staffing levels and ratios, medication-administration and incident-notification protocols, elopement-prevention measures, pest-control and sanitation practices, infection-control policies, and the specifics of transfer/billing procedures before making placement decisions.
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Location
Firwood Gardens is located at 819 NE 122nd Ave, Portland, OR, 97230.
About Firwood Gardens
Sapphire at Firwood Gardens is a locally owned adult residential care and memory care community dedicated to fostering a tradition of quality care, hospitality, and genuine compassion. Nestled in Northeast Portland, this community is designed to offer a warm and inviting atmosphere, where professional staff members are committed to providing personalized care tailored to the individual needs of each resident. The environment is modern and thoughtfully maintained, ensuring every resident enjoys their living space and experiences daily comfort and safety.
Within Sapphire at Firwood Gardens, there are nearly eighty private apartments, providing a range of options from cozy studios to spacious deluxe suites. Each residence is equipped with essential amenities, and residents benefit from three delicious meals a day, prepared to support both nutrition and enjoyment. The community grounds are beautifully landscaped, encouraging residents to enjoy the outdoors, whether taking a stroll, enjoying time in the greenhouse, or practicing on the putting green. Indoors, cozy community spaces, a full-service hair salon, and spacious dining rooms offer plenty of options for relaxation and socialization.
A hallmark of life at Sapphire at Firwood Gardens is the robust spectrum of personal care and support services, thoughtfully designed to empower residents to maintain independence while receiving needed support. Assistance with daily living tasks such as medication management, bathing, dressing, personal hygiene, and help to and from the dining areas is provided around the clock by attentive staff members. These care services are supported by a state-of-the-art electronic health records system, enabling real-time communication among team members for seamless service and oversight.
Community life is further enriched by the presence of life engagement counselors who ensure residents have access to a diverse schedule of recreational, educational, and social activities. Designed to engage minds and foster connection, activities range from arts and crafts, outings for shopping, and exploring the outdoors, to events that take place within the community itself. The entire campus is equipped with fully accessible WiFi, supporting residents who want to stay connected with family, friends, or personal interests online.
Sapphire at Firwood Gardens is committed to promoting dignity and independence for every individual, offering both general residential care as well as specialized memory care for seniors coping with memory loss. The staff focuses on creating a serene, secure, and supportive environment where each resident’s unique preferences and abilities are honored. Ultimately, the mission of Sapphire at Firwood Gardens is to promote the highest quality of life not only for its residents, but also for the staff and surrounding community, treating everyone with the utmost consideration and respect. The combination of modern amenities, compassionate staffing, and a person-centered approach makes Sapphire at Firwood Gardens a trusted and welcoming choice for senior residential and memory care in the Portland area.
People often ask...
Firwood Gardens offers competitive pricing, with rates starting at a cost of $5,856 per month.
Firwood Gardens offers assisted living and memory care.
There are 28 photos of Firwood Gardens on Mirador.
The full address for this community is 819 NE 122nd Ave, Portland, OR 97230.
No, Firwood Gardens 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 a resident did not receive a safe environment or care, resulting in neglect; a $375 fine was assessed.
Abuse—Failed to provide safe environment
28 Oct 2025Inspection
28 Oct 2025Inspection
Found that a staff member made inappropriate sexual comments to a resident, causing significant emotional harm, and the provider failed to protect the resident from mental or emotional abuse.
Licensing—Failed to protect resident from mental or emotional abuse
06 Oct 2025Inspection
06 Oct 2025Inspection
Investigated and identified non-compliance with an acuity-based staffing requirement.
Licensing—Failed to use an ABST
28 Sept 2025Abuse: Neglect
28 Sept 2025Abuse: Neglect
Investigated the allegation and found a failure to provide a safe environment, constituting neglect and abuse; a fine was assessed.
Abuse—Failed to provide safe environment
28 Aug 2025Inspection
28 Aug 2025Inspection
Investigated a licensing allegation and identified a deficiency in developing, maintaining, and implementing an acuity-based staffing tool.
Licensing—Failed to use an ABST
13 Aug 2025License Condition
13 Aug 2025License Condition
Found failure to provide services as required by the rule.
Regulatory Action—Failed to provide service
13 Aug 2025License Condition
13 Aug 2025License Condition
Found failure to use an Acuity Based Staffing Tool in accordance with the applicable rule.
Regulatory Action—Failed to use an ABST
22 Jul 2025Kitchen
22 Jul 2025Kitchen
Identified deficiencies in kitchen sanitation and administration compliance. Noted widespread cleaning issues and improper food handling that did not meet requirements.
Identified a deficiency in oversight and monitoring of residents' short-term changes in condition, with weekly progress not documented until resolved.
Licensing—Failed to provide oversight and monitoring of change of condition
08 Jul 2025Inspection
08 Jul 2025Inspection
Found that records were not provided to the Department when requested, violating a state administrative rule.
Licensing—Failed to make facility or resident records accessible
27 Jun 2025Inspection
27 Jun 2025Inspection
Found that an Acuity Based Staffing Tool was not developed, maintained, or implemented as required.
Licensing—Failed to use an ABST
30 May 2025Abuse: Neglect
30 May 2025Abuse: Neglect
Investigated and found violations related to providing a safe environment and adequate hydration, which led to dehydration and kidney injury.
Abuse—Failed to provide safe environment
28 May 2025Inspection
28 May 2025Inspection
Identified a deficiency that the provider did not develop, maintain, or implement an Acuity Based Staffing Tool, violating a state administrative rule.
Licensing—Failed to use an ABST
28 May 2025Abuse: Neglect
28 May 2025Abuse: Neglect
Investigated and found a failure to provide a safe environment, resulting in a resident leaving the facility and being taken to the hospital; a fine was assessed.
Abuse—Failed to assure resident was safe
21 May 2025Inspection
21 May 2025Inspection
Found that records were not provided upon request, violating state administrative rule.
Licensing—Failed to make facility or resident records accessible
01 May 2025Licensure
01 May 2025Licensure
Identified widespread deficiencies affecting infection prevention, staffing training, fire safety, administration, exterior conditions, and plumbing.
Deficiency—Infection Prevention & Control
Deficiency—Staffing Requirements and Training – Pre-service
Deficiency—Fire and Life Safety: Safety
Deficiency—Inspections and Investigation: Insp Interval
Deficiency—General Building Exterior
Deficiency—Plumbing Systems
Deficiency—Administration Compliance
Deficiency—Staff Training Requirements
24 Apr 2025Complaint
24 Apr 2025Complaint
Found deficiencies in implementing services per the resident's plan and in maintaining the acuity-based staffing system, leading to inadequate staffing and unmet care needs. Specifically, care needs and transfer requirements weren't accurately reflected, and ABST data wasn't updated quarterly.
Deficiency—Service Plan: General
Deficiency—Staffing Requirements and Training: Staffing
Deficiency—Acuity Based Staffing Tool - Abst Time
Deficiency—Acuity Based Staffing Tool - Updates & Plan
27 Mar 2025Inspection
27 Mar 2025Inspection
Investigated the staffing allegation and found insufficient qualified awake direct care staff to meet residents' 24-hour needs, with under-staffing on two shifts.
Licensing—Failed to meet the scheduled and unscheduled needs of residents
17 Feb 2025Inspection
17 Feb 2025Inspection
Investigated and identified deficiencies in documenting care time and care elements for residents, with one sampled resident lacking time assignments in the service plan and ABST profile.
Licensing—Failed to meet the scheduled and unscheduled needs of residents
17 Feb 2025Inspection
17 Feb 2025Inspection
Investigated a staffing issue and found insufficient qualified awake direct care staff to meet residents' 24-hour needs. The findings showed violations of state staffing requirements.
Licensing—Failed to staff as indicated by ABST
28 Nov 2024Abuse: Neglect
28 Nov 2024Abuse: Neglect
Found a failure to provide a safe environment that placed a resident at risk. A $188 fine was assessed.
Abuse—Failed to provide safe environment
13 Nov 2024Inspection
13 Nov 2024Inspection
Investigated a complaint of verbal abuse toward a resident; found staff verbalized abuse, causing distress and violating resident rights, and the provider failed to protect the resident from verbal abuse.
Licensing—Failed to protect resident from verbal abuse
12 Sept 2024Inspection
12 Sept 2024Inspection
Identified a violation for not fully implementing an acuity-based staffing tool.
Licensing—Failed to staff as indicated by ABST
15 Aug 2024Abuse: Neglect
15 Aug 2024Abuse: Neglect
Investigated a claim of neglect for failing to provide a safe environment; found a second resident-to-resident incident occurred with staff not following a temporary plan, indicating safety failures.
Abuse—Failed to provide safe environment
11 Jun 2024Abuse: Neglect
11 Jun 2024Abuse: Neglect
Investigated and found that safety supervision was not provided, placing a dependent resident at risk after an elopement. A $375 fine was assessed for the violation.
Abuse—Failed to provide safe environment
10 Jun 2024Abuse: Neglect
10 Jun 2024Abuse: Neglect
Found safety violations due to failure to supervise and provide a safe environment, including an elopement through an unlocked courtyard gate by a dependent resident; a fine was assessed.
Abuse—Failed to provide safe environment
06 Jun 2024Inspection
06 Jun 2024Inspection
Found safety deficiencies due to staff neglect that allowed a resident to exit a secured area and risk harm; a $375 fine was assessed.
Licensing—Failed to provide safe environment
24 Apr 2024Licensure
24 Apr 2024Licensure
Identified deficiencies in kitchen sanitation and administration compliance. Issues included uncovered desserts transported between floors, dirty areas around the dishwashing area, dusty vents, grease buildup, and improper glove use.
Found that a resident was financially exploited and the licensee failed to protect the resident from financial abuse.
Licensing—Failed to protect resident from financial exploitation
24 Aug 2023Abuse: Neglect
24 Aug 2023Abuse: Neglect
Investigated a neglect allegation and found staff failed to follow the resident's care plan by not redirecting away from doors, risking harm; a fine was assessed.
Abuse—Failed to follow care plan
13 Aug 2023Abuse: Neglect
13 Aug 2023Abuse: Neglect
Investigated found that a safe environment wasn't provided because of two elopements and a malfunctioning door lock, risking serious harm; a fine was assessed.
Abuse—Failed to provide safe environment
12 Aug 2023Abuse: Neglect
12 Aug 2023Abuse: Neglect
Investigated a complaint and found a safety failure that allowed a resident to leave the premises and be injured; a $375 fine was assessed.
Abuse—Failed to provide safe environment
22 Jul 2023Inspection
22 Jul 2023Inspection
Investigated an allegation of verbal abuse toward a resident and found a violation of resident rights and failure to protect the resident from verbal abuse.
Licensing—Failed to protect resident from verbal abuse
22 Jul 2023Inspection
22 Jul 2023Inspection
Investigated a complaint of physical abuse and neglect. Found that a staff member hit a resident, causing a red mark and loss of dignity, and that protection against abuse was not provided.
Licensing—Failed to protect resident from physical abuse
22 Jul 2023Inspection
22 Jul 2023Inspection
Found that a staff member blocked a resident from moving and communicating, which constituted involuntary seclusion and violated resident rights.
Licensing—Failed to protect resident from involuntary seclusion
01 Jun 2023Licensure
01 Jun 2023Licensure
Identified deficiencies in kitchen food sanitation practices and administration compliance; a follow-up determined substantial compliance.
Investigated and found a failure to provide a safe environment that placed an individual at risk for serious harm.
Abuse—Failed to provide safe environment
22 Mar 2023Abuse: Neglect
22 Mar 2023Abuse: Neglect
Found a failure to provide a safe environment with a known elopement risk and an unsecured entrance door. The individual was found outside near garbage cans, placing them at risk for harm.
Abuse—Failed to provide safe environment
18 Aug 2022Abuse: Neglect
18 Aug 2022Abuse: Neglect
Found neglect and abuse due to failure to follow the care plan and provide appropriate services, causing discomfort and loss of dignity. A fine was assessed.
Abuse—Failed to provide service
11 Aug 2022Complaint
11 Aug 2022Complaint
Found staffing shortages and misaligned acuity data, including unfilled shifts and mismatches between residents' needs and the Acuity-Based Staffing Tool.
Deficiency—Licensing Complaint Investigation
Deficiency—Staffing Requirements and Training: Staffing
Deficiency—Acuity-Based Staffing Tool
19 Jul 2022Inspection
19 Jul 2022Inspection
Investigated a staffing-related allegation and found direct care staffing insufficient to meet residents' scheduled and unscheduled needs; later confirmed back in compliance.
Licensing—Failed to meet the scheduled and unscheduled needs of residents
19 Jul 2022Inspection
19 Jul 2022Inspection
Identified inconsistencies between the resident roster, care plans, and ABST data, with staffing not reflecting needs; later confirmed back in compliance.
Licensing—Failed to use an ABST
18 Jul 2022Abuse: Neglect
18 Jul 2022Abuse: Neglect
Found that appropriate services were not provided according to resident needs, including delayed response to call lights and care plan noncompliance, resulting in discomfort and loss of dignity.
Abuse—Failed to provide service
12 Jul 2022Inspection
12 Jul 2022Inspection
Found direct care staffing insufficient on weekends to meet residents' scheduled and unscheduled needs.
Licensing—Failed to meet the scheduled and unscheduled needs of residents
01 Jul 2022Abuse: Neglect
01 Jul 2022Abuse: Neglect
Investigated found that the call light system failed, preventing the resident from calling for help or requesting pain medication on multiple occasions, resulting in increased pain and neglect/abuse.
Abuse—Failed to provide service
23 Jun 2022Abuse: Neglect
23 Jun 2022Abuse: Neglect
Investigated and found that the care plan was not followed, allowing an at-risk resident to leave the premises unsupervised and at risk of harm. A fine was assessed for this abuse/neglect finding.
Abuse—Failed to follow care plan
01 Jun 2022Abuse: Neglect
01 Jun 2022Abuse: Neglect
Investigated and found failure to follow the care plan for a resident, resulting in abuse/neglect.
Abuse—Failed to follow care plan
27 Apr 2022Abuse: Neglect
27 Apr 2022Abuse: Neglect
Investigated an allegation of money being stolen and found failures to respond, investigate, and safeguard belongings, resulting in a violation of resident rights and constituting abuse and neglect.
Abuse—Failed to assure resident rights
04 Jan 2022Validation
04 Jan 2022Validation
Identified widespread deficiencies across abuse reporting, resident planning, medications, nutrition, safety, and staff training. Substantial compliance was determined on follow-up.
Deficiency—Resident Move-In and Eval: Res Evaluation
Deficiency—Service Plan: General
Deficiency—Change of Condition and Monitoring
Deficiency—Systems: Treatment Orders
Deficiency—Systems: Resident Right to Refuse
Deficiency—Systems: Medication Administration
Deficiency—Systems: Treatment Administration
Deficiency—Systems: Self-Administration of Meds
Deficiency—Staffing Requirements and Training – Pre-Serv
Deficiency—Training Within 30 Days: Direct Care Staff
Deficiency—Fire and Life Safety: Safety
Deficiency—Fire and Life Safety: Training For Residents
Deficiency—Doors, Walls, Elevators, Odors
Deficiency—Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable
Deficiency—Administration Compliance
Deficiency—Compliance With Rules Health Care
Deficiency—Nutrition and Hydration
Deficiency—Activities
Deficiency—Resident Rooms
30 Dec 2021Abuse: Neglect
30 Dec 2021Abuse: Neglect
Found that a staff member diverted a resident's narcotic pain medication, constituting abuse and financial exploitation. Determined the facility failed to provide a safe medication administration system, leading to theft of the medication.
Abuse—Failed to provide a safe medication administration system
13 Dec 2021Abuse: Neglect
13 Dec 2021Abuse: Neglect
Investigated allegations of abuse and neglect involving medication handling, and found that a staff member diverted a resident's narcotic pain medication, indicating a failure in a safe medication administration system and resulting in abuse and neglect.
Abuse—Failed to provide a safe medication administration system
06 Dec 2021Abuse: Neglect
06 Dec 2021Abuse: Neglect
Concluded that a staff member used an unauthorized rice sock to relieve a resident's abdominal pain, causing a burn, and that care planning and supervision were insufficient, resulting in neglect and abuse.
Abuse—Failed to properly plan care
15 Nov 2021Inspection
15 Nov 2021Inspection
Determined there was no policy to safekeep residents' possessions, indicating a lapse related to protecting residents from financial exploitation.
Licensing—Failed to protect resident from financial exploitation
15 Nov 2021Inspection
15 Nov 2021Inspection
Investigated the allegation of failing to assist with toileting and found insufficient staff to meet scheduled and unscheduled needs.
Licensing—Failed to assist with toileting
15 Nov 2021Inspection
15 Nov 2021Inspection
Investigated and found a deficiency for failing to assist with toileting.
Licensing—Failed to assist with toileting
08 Nov 2021Inspection
08 Nov 2021Inspection
Found that medication was not administered as ordered by the physician. This was a violation of Oregon Administrative Rules.
Licensing—Failed to administer medication as ordered
08 Nov 2021Inspection
08 Nov 2021Inspection
Investigated an allegation of inadequate staffing and found insufficient staff to meet scheduled and unscheduled needs.
Licensing—Failed to provide appropriate staffing
08 Nov 2021Inspection
08 Nov 2021Inspection
Concluded that no licensing violation occurred after investigating a toileting assistance allegation.
Licensing—Failed to assist with toileting
05 Nov 2021Abuse: Neglect
05 Nov 2021Abuse: Neglect
Investigated a complaint and found that a staff member wrongfully restrained a resident, creating an unsafe environment and constituting abuse and neglect. A $450 fine was assessed.
Abuse—Failed to provide safe environment
01 Oct 2021Abuse: Neglect
01 Oct 2021Abuse: Neglect
Found a violation for failing to provide a safe environment, resulting in an injury, and assessed a $225 fine.
Abuse—Failed to provide safe environment
20 Sept 2021Abuse: Neglect
20 Sept 2021Abuse: Neglect
Investigated found inadequate care planning for nighttime care needs, leading to care refusals and a finding of neglect/abuse; a $450 fine was assessed. Investigations into verbal abuse and involuntary seclusion were inconclusive or found no wrongdoing.
Abuse—Failed to properly plan care
08 Sept 2021Inspection
08 Sept 2021Inspection
Investigated and verified a confidentiality violation involving disclosure of another resident's records without consent.
Licensing—Failed to assure resident rights
07 Jun 2021Inspection
07 Jun 2021Inspection
Found that there was no training program to determine competency of direct care staff.
Licensing—Failed to assure resident rights
07 Jun 2021Inspection
07 Jun 2021Inspection
Investigated the allegation of failing to protect resident rights and found a deficiency in safeguarding residents' health, safety, or welfare.
Licensing—Failed to assure resident rights
07 Jun 2021Inspection
07 Jun 2021Inspection
Investigated and determined a staffing deficiency left residents' scheduled and unscheduled needs unmet.
Licensing—Failed to meet the scheduled and unscheduled needs of residents
07 Jun 2021Inspection
07 Jun 2021Inspection
Found a deficiency in medication administration safety due to not carrying out orders as prescribed.
Licensing—Failed to provide a safe medication administration system
07 Jun 2021Inspection
07 Jun 2021Inspection
Investigated the allegation and found a deficiency in toileting assistance for residents. The finding violated Oregon Administrative Rules.
Licensing—Failed to assist with toileting
22 Apr 2021Abuse: Neglect
22 Apr 2021Abuse: Neglect
Found violations related to inadequate basic care and failure to provide podiatry care, resulting in neglect and abuse.
Abuse—Failed to provide service
14 Apr 2021Inspection
14 Apr 2021Inspection
Investigated a complaint alleging failure to assure resident rights and found a deficiency in safeguarding residents' possessions.
Licensing—Failed to assure resident rights
23 Mar 2021Abuse: Neglect
23 Mar 2021Abuse: Neglect
Found neglect and abuse due to failure to provide basic care, resulting in health and safety risks for a resident, including inadequate incontinence care, frequent falls, improper nasal cannula use, and unmonitored room temperature; a fine was assessed.
Abuse—Failed to provide service
23 Mar 2021Inspection
23 Mar 2021Inspection
Investigated an allegation of financial exploitation where a resident's debit card was used for about $2,400 in unauthorized purchases and protections against exploitation were insufficient.
Licensing—Failed to protect resident from financial exploitation
21 Mar 2021Inspection
21 Mar 2021Inspection
Investigated and found insufficient staff to meet residents' scheduled and unscheduled needs.
Licensing—Failed to meet the scheduled and unscheduled needs of residents
21 Mar 2021Inspection
21 Mar 2021Inspection
Investigated and found a violation involving toileting assistance.
Licensing—Failed to assist with toileting
08 Mar 2021Abuse: Neglect
08 Mar 2021Abuse: Neglect
Determined that basic care and services necessary to maintain health and safety were not provided in a timely manner, resulting in neglect and abuse.
Abuse—Failed to provide service
16 Nov 2020Abuse: Neglect
16 Nov 2020Abuse: Neglect
Investigated and found neglect and abuse due to failure to provide basic care, resulting in a resident's hospitalization and a severe skin condition.
Abuse—Failed to properly plan care
13 Nov 2020Inspection
13 Nov 2020Inspection
Investigated the allegation that medication orders were not carried out as prescribed and found a deficiency in medication administration.
Licensing—Failed to provide a safe medication administration system
04 Nov 2020Abuse: Neglect
04 Nov 2020Abuse: Neglect
Investigated and found neglect and abuse due to failing to provide basic care and to follow medical orders, causing discomfort; a fine was assessed.
Abuse—Failed to provide service
23 Oct 2020Inspection
23 Oct 2020Inspection
Investigated an allegation of inadequate oversight of change of condition and failure to provide bathing and washing hair assistance; findings supported these concerns.
Licensing—Failed to provide oversight and monitoring of change of condition
23 Oct 2020Inspection
23 Oct 2020Inspection
Investigated the allegation that personal hygiene assistance and dressing/undressing were not provided; findings were verified.
Licensing—Failed to provide service
23 Oct 2020Inspection
23 Oct 2020Inspection
Investigated the allegation and found a deficiency in meal provision, failing to provide three daily nutritious meals with snacks seven days a week in line with USDA guidelines.
Licensing—Failed to provide proper food/nutrition
23 Oct 2020Inspection
23 Oct 2020Inspection
Investigated the allegation of failing to provide reasonable precautions against conditions that may threaten residents' health, safety or welfare and found a deficiency.
Licensing—Failed to provide safe environment
23 Oct 2020Inspection
23 Oct 2020Inspection
Found that the grounds were not kept orderly and free of litter and refuse.
Licensing—Failed to provide safe environment
23 Oct 2020Inspection
23 Oct 2020Inspection
Found insufficient awake qualified direct care staffing to meet scheduled and unscheduled resident needs.
Licensing—Failed to provide appropriate staffing
23 Oct 2020Inspection
23 Oct 2020Inspection
Concluded that assistance with ADLs including toileting and bowel and bladder management was not provided.
Licensing—Failed to assist with toileting
15 Oct 2020Inspection
15 Oct 2020Inspection
Investigated allegations of financial exploitation involving unauthorized credit card charges to an alleged victim and identified an unsafe environment for the victim.
Licensing—Failed to provide safe environment
21 Sept 2020Inspection
21 Sept 2020Inspection
Investigated and concluded that a resident's personal property was stolen and protections against theft were inadequate, constituting abuse.
Licensing—Failed to provide safe environment
10 Jun 2020Inspection
10 Jun 2020Inspection
Identified inadequate professional oversight of the medication administration system.
Licensing—Failed to provide a safe medication administration system
10 Jun 2020Inspection
10 Jun 2020Inspection
Confirmed the failure to provide and document delegations. A licensing violation involving nursing delegation was substantiated.
Licensing—Failed to comply with nursing delegation requirement
10 Jun 2020Inspection
10 Jun 2020Inspection
Investigated the allegation that resident records were not kept current or accurate and identified inaccurate treatment records for residents.
Licensing—Failed to keep resident record current or accurate
10 Jun 2020Inspection
10 Jun 2020Inspection
Investigated the allegation that medication administration records were not kept current or accurate; found the records inaccurate.
Licensing—Failed to keep medication record current or accurate
25 May 2020Abuse: Neglect
25 May 2020Abuse: Neglect
Identified violations of the toileting care plan, leaving the resident in urine overnight and traumatized.
Abuse—Failed to follow care plan
25 May 2020Inspection
25 May 2020Inspection
Found a deficiency in the medication administration process where medications were not set up or poured and documented by the same person who administers them.
Licensing—Failed to provide a safe medication administration system
25 May 2020Inspection
25 May 2020Inspection
Determined that direct care staffing was insufficient to meet residents' scheduled and unscheduled needs.
Licensing—Failed to provide appropriate staffing
25 May 2020Inspection
25 May 2020Inspection
Investigated and verified the allegation that medication was not administered as ordered.
Licensing—Failed to administer medication as ordered
25 May 2020Inspection
25 May 2020Inspection
Found a deficiency that there was no training program with methods to determine staff competency through evaluation, observation, or written testing.
Licensing—Failed to provide appropriate staffing
25 May 2020Abuse: Neglect
25 May 2020Abuse: Neglect
Found neglect and an unsafe environment due to failure to provide basic care, leaving the resident in discomfort.
Abuse—Failed to provide safe environment
25 May 2020Inspection
25 May 2020Inspection
Verified the allegation that the service plan was not completed after quarterly evaluations and that service plans must be readily available to staff with clear directions for service delivery.
Licensing—Failed to care plan in accordance with assessment
25 May 2020Abuse: Neglect
25 May 2020Abuse: Neglect
Found that a staff member failed to follow the resident's care plan, resulting in physical harm and discomfort. A $250 fine was assessed.
Abuse—Failed to follow care plan
25 May 2020Inspection
25 May 2020Inspection
Investigated a licensing allegation and found that there was no written policy prohibiting the falsification of records.
Licensing—Falsified records
13 Apr 2020Inspection
13 Apr 2020Inspection
Found inadequate housekeeping practices that left interior surfaces dusty and not properly cleaned.
Licensing—Failed to provide appropriate housekeeping services
13 Apr 2020Inspection
13 Apr 2020Inspection
Found that resident's medical and other records were not kept confidential.
Licensing—Failed to assure resident rights
05 Mar 2020Inspection
05 Mar 2020Inspection
Identified insufficient direct care staffing to meet 24-hour scheduled and unscheduled needs. This finding was confirmed.
Licensing—Failed to provide appropriate staffing
08 Aug 2018Inspection
08 Aug 2018Inspection
Investigated a licensing violation alleging failure to provide a safe environment, which led to a resident altercation with minor injury.
Licensing—Failed to provide safe environment
07 Jun 2018Abuse: Neglect
07 Jun 2018Abuse: Neglect
Determined that neglect occurred due to failure to provide oversight and monitoring after a fall, creating a serious risk of harm, and assessed a $1500 fine.
Abuse—Failed to provide oversight and monitoring of change of condition
07 Jun 2018Inspection
07 Jun 2018Inspection
Investigated an allegation of failing to report potential abuse; the finding confirmed the failure and a $750 fine was assessed.
Licensing—Failed to report potential or suspected abuse
19 Jan 2018Inspection
19 Jan 2018Inspection
Concluded that the allegation of failing to provide appropriate housekeeping services was substantiated. Found a Level 1 violation related to housekeeping services.
Licensing—Failed to provide appropriate housekeeping services
10 Jan 2018Inspection
10 Jan 2018Inspection
Investigated a licensing violation for failing to administer medications as ordered.
Licensing—Failed to provide a safe medication administration system
01 Aug 2016Abuse: Financial abuse
01 Aug 2016Abuse: Financial abuse
Found a safety deficiency that allowed theft from a reported victim.
Abuse—Failed to provide safe environment
06 Jul 2016Abuse: Financial abuse
06 Jul 2016Abuse: Financial abuse
Investigated the allegation of financial abuse and found a failure to prevent property loss.
Abuse—Failed to provide safe environment
06 Nov 2015Inspection
06 Nov 2015Inspection
Investigated an allegation of inadequate housekeeping. Found an odor problem that was substantiated.
Licensing—Failed to provide appropriate housekeeping services
06 Nov 2015Inspection
06 Nov 2015Inspection
Found that service plans did not reflect residents' current care needs and were not updated timely.
Licensing—Failed to properly plan care
06 Nov 2015Inspection
06 Nov 2015Inspection
Found a deficiency in responding to and resolving resident complaints as required by the rule.
Licensing—Failed to provide service
14 Jan 2015Inspection
14 Jan 2015Inspection
Investigated the allegation and determined that medications were not administered as ordered.
Licensing—Failed to administer medication as ordered
29 Jun 2013Abuse: Verbal/Mental abuse
29 Jun 2013Abuse: Verbal/Mental abuse
Investigated and found a failure to protect a resident from verbal abuse.
Abuse—Failed to protect resident from verbal abuse
15 Mar 2011Abuse: Financial abuse
15 Mar 2011Abuse: Financial abuse
Found a failure to maintain a safe medication system.
Abuse—Failed to provide a safe medication administration system
01 Jul 2010Abuse: Financial abuse
01 Jul 2010Abuse: Financial abuse
Found substantiated that a resident was exposed to financial exploitation due to inadequate safeguards.
Abuse—Failed to provide safe environment
30 Jun 2010Inspection
30 Jun 2010Inspection
Investigated the allegation of an unsafe medication administration system and found an inadequate medication system.
Licensing—Failed to provide a safe medication administration system
03 Feb 2010Inspection
03 Feb 2010Inspection
Investigated the allegation of failing to protect resident rights, and found a resident was not protected from threats of harm and intimidation by another resident.
Licensing—Failed to assure resident rights
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Mirador Living is not affiliated with the owner or operator(s) of Firwood Gardens. The information above has not been verified or approved by the owner or operator. For exact information, please contact Firwood Gardens directly. There is no cost for this service. We are compensated by the community you select.
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