I moved my mom here and I'm grateful - the staff (Liz Graves especially) are genuine, patient and clearly trained in memory care, and the on-site medical team and attentive caregivers give me real confidence. The bright, home-like community with spacious rooms, lovely gardens and secure walking paths, good food and a lively activities program (piano, Name That Tune, crafts, outings) has brought my mom back to smiling. Communication is proactive and transparent, administrators listen, and overall it feels warm, well-run and gives our family peace of mind.
Loved one of resident
Jul 2026
Pricing
Prices shown are estimates and subject to change. Contact your senior living advisor for current pricing.
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Amenities
Healthcare services
Activities of daily living assistance
Assistance with bathing
Assistance with dressing
Assistance with transfers
Coordination with health care providers
Hospice waiver
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
Dementia waiver
Mild cognitive impairment
Specialized memory care programming
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
3.46·(39)
Overall rating
5
4
3
2
1
Care
3.7
Staff
3.8
Meals
3.4
Amenities
4.3
Value
1.7
Pros
Compassionate memory-care staff
Engaging music and arts programming
Varied recreational activities and outings
Spacious, well‑lit common areas
Secure outdoor courtyard and walking paths
Clean, well‑maintained facility interior
Balanced, well‑rounded dining options and snacks
On‑site clinical nursing and medical oversight
Long‑tenured, knowledgeable staff in select roles
Proactive family communication and daily updates
Home‑like atmosphere with garden views
Strong infection‑control practices during COVID‑19
Welcoming front‑desk and admissions team
Cons
High staff turnover and reliance on agency personnel
Inconsistent caregiver availability and staffing ratios
Gaps in staff training and competency consistency
Medication‑management controls and errors
Unreliable meal‑service continuity and dietary accommodation
Inconsistent activity delivery and program continuity
Cleanliness and sanitation inconsistencies in care tasks
Weak incident oversight and delayed family communication
Billing and charge‑transparency problems
Clinical leadership instability and managerial turnover
Allegations of financial misconduct and serious staff‑conduct concerns
Summary of reviews
Maple Grove Memory Care presents as a facility with clear strengths in environment and programmatic offerings alongside persistent operational challenges. Physically, the community is generally described as spacious, well maintained, and bright, with large common areas, garden spaces, and secure outdoor walking paths that support a pleasant, home‑like atmosphere. Many families cite specific program highlights — music, piano sessions, crafts, visiting animals, bus outings, exercise classes, and other dementia‑focused activities — that contribute to resident engagement and moments of joy.
Clinical and day‑to‑day care feedback is mixed. Positive accounts reference on‑site nursing support, compassionate caregivers, end‑of‑life support, and improved family communication with daily updates. Conversely, other families describe inconsistent caregiving continuity, delayed assistance, and episodic lapses in sanitation and personal‑care tasks. There are also substantive concerns about medication management practices and occasional medication errors. A number of reviewers link these care inconsistencies to staffing patterns; specifically, high turnover and reliance on outside agency staff appear to affect continuity and staff competency in some units.
Dining and nutrition receive both praise and criticism. The facility is credited with a varied, balanced menu, snacks throughout the day, and improvement in resident weight for some individuals. At the same time, there are operational weaknesses around meal‑service continuity and adherence to dietary restrictions for certain residents. Prospective families should verify current practices for special diets and mealtime assistance during visits.
Activity programming is a visible strength when staffing and coordination are present: structured music programs, interactive games, crafts, and outings are frequently mentioned. However, activity delivery is described as inconsistent at times, with periods of minimal engagement tied to limited staff availability. This variability suggests programs may depend heavily on current staffing levels rather than on a robust, consistently staffed schedule.
Management and communication show signs of improvement alongside areas requiring attention. Several families report that administrators have become more responsive, communication has improved, and the facility has implemented positive changes. Other comments indicate managerial instability, with turnover among clinical managers and intermittent lapses in incident oversight and billing transparency. There are also serious, singular claims — including allegations of financial misconduct and concerns following a resident's death — that warrant careful inquiry and, if relevant, review of regulatory records.
Overall pattern: Maple Grove offers many elements families seek in memory care — a pleasant physical setting, engaging programming, and pockets of experienced, caring staff. However, operational inconsistencies (notably staffing continuity, medication controls, meal delivery, and incident oversight) create a polarized set of experiences. Recommended due diligence for prospective families includes observing staffing levels at different times of day, asking for staffing ratio and agency‑staffing policies, reviewing recent incident logs and corrective actions, confirming medication‑administration protocols, and checking billing practices and clinical leadership tenure before making a placement decision.
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Location
Maple Grove Memory Care is located at 17309 NE Glisan St, Portland, OR, 97230.
About Maple Grove Memory Care
Pacific Gardens Alzheimer’s Special Care Center is a senior living community dedicated to providing specialized support for individuals facing Alzheimer’s disease and other forms of memory loss. The center is operated by Sinceri Senior Living, an organization that has developed expertise in serving seniors with dementia needs through tailored programs and a compassionate approach to care. Nestled in a neighborhood within Portland, the center provides a safe and nurturing environment where residents can enjoy both comfort and dignity as their needs evolve.
The community at Pacific Gardens is designed around the unique challenges and opportunities associated with memory care. Residents are surrounded by thoughtful architecture and secure settings that promote independence while ensuring safety. The team at Pacific Gardens utilizes specialized dementia care techniques, focusing on activities and engagements that bring joy and mental stimulation, while also offering gentle support for daily living needs. Skilled caregivers work closely with each resident, customizing the level of care and engagement to match individual abilities and preferences, helping to foster a sense of purpose and routine.
Meals at Pacific Gardens Alzheimer’s Special Care Center are created to be both nutritious and appealing, with attention given to dietary needs and preferences. Residents participate in a variety of daily activities, ranging from guided group sessions to individualized interactions, encouraging social connections and cognitive engagement. The community fosters a warm, supportive atmosphere not only for those who live there but also for visiting family and friends, who are seen as essential partners in residents’ well-being.
Management and staff at Pacific Gardens are selected for both their professional experience and their heartfelt commitment to enriching the lives of people with memory impairments. Team members are continuously trained to uphold best practices in memory care, creating an environment where residents feel valued, respected, and understood. Through personalized care plans, meaningful activities, and a focus on holistic well-being, Pacific Gardens Alzheimer’s Special Care Center is dedicated to offering peace of mind and quality of life for seniors facing the challenges of Alzheimer’s and related conditions.
Sinceri Senior Living is a premier senior living management company founded in 1986 by Jerry Erwin and headquartered in Vancouver, Washington. Originally operating under the name JEA Senior Living, the company has grown substantially over its nearly four decades of operation to become a major player in the senior care industry. Today, Sinceri operates 83 communities across 21 states, serving approximately 5,330 seniors nationwide with a comprehensive range of living options designed to meet diverse care needs and lifestyle preferences.
The company offers three distinct levels of senior care: independent living, assisted living, and specialized memory care through their signature "Meaningful Moments" program. Their assisted living services include 24-hour licensed supervision, medication management, nutritious dining programs, and their exclusive "Elevate" Life Enrichment Program, which addresses four key wellness dimensions - physical, emotional, social, and intellectual aspects. The Meaningful Moments memory care program takes a unique person-centered approach, focusing on each resident's individual history, passions, and interests to create meaningful connections and engagement opportunities for those affected by Alzheimer's and related dementia conditions.
Sinceri's philosophy centers on treating residents like family and fostering genuine bonds between those who live and serve in their communities. Their mission emphasizes honoring the aging process while providing exceptional, person-centered care that empowers residents to maintain their independence and live their best lives regardless of care needs. The company believes that everyone deserves dignity, respect, and opportunities for joy and meaningful experiences, which drives their holistic approach to senior care that goes beyond basic safety and comfort to create truly enriching living environments.
The company has earned significant industry recognition, including certification as a Great Place to Work for seven consecutive years and multiple Forbes honors, including ranking as #78 among America's Best Midsize Employers in 2021 and recognition as one of America's Best Employers by State for Washington. In recent years, Sinceri has experienced substantial growth through strategic partnerships with major healthcare REITs including National Health Investors and Ventas, adding multiple properties in 2024 while maintaining strong operational performance with seven consecutive quarters of NOI growth and achieving pre-pandemic occupancy levels across their stabilized portfolio.
People often ask...
Maple Grove Memory Care offers competitive pricing, with rates starting at a cost of $6,011 per month.
Maple Grove Memory Care offers assisted living and memory care.
There are 24 photos of Maple Grove Memory Care on Mirador.
The full address for this community is 17309 NE Glisan St, Portland, OR 97230.
No, Maple Grove Memory Care 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 an allegation of verbal/emotional abuse; concluded that a staff member threatened to throw water at a resident and failed to protect them from abuse.
Licensing—Failed to protect resident from verbal abuse
25 Feb 2025Kitchen
25 Feb 2025Kitchen
Identified deficiencies in kitchen cleanliness and administration compliance related to food sanitation rules. Noted extensive cleanliness issues and licensing-rule noncompliance observed.
Investigated a complaint and found neglect and abuse due to failure to provide medications and appropriate care, resulting in skin breakdown and lung issues for a resident. A $1,500 fine was assessed.
Abuse—Failed to provide service
17 Jan 2025Abuse: Neglect
17 Jan 2025Abuse: Neglect
Investigated the incident and found a failure to provide a safe environment that resulted in a finding of abuse/neglect.
Abuse—Failed to provide safe environment
09 Jan 2025Inspection
09 Jan 2025Inspection
Identified deficiencies in the Acuity-Based Staffing Tool and staffing levels. Inconsistencies between the resident roster, care plans, and ABST data showed staffing did not meet residents' scheduled and unscheduled needs.
Licensing—Failed to staff as indicated by ABST
07 Jan 2025Inspection
07 Jan 2025Inspection
Identified deficiencies in the use of an acuity-based staffing tool, with inconsistencies between the resident roster, care plans, and ABST data, and staffing not aligned with resident needs.
Licensing—Failed to use an ABST
07 Jan 2025Abuse: Neglect
07 Jan 2025Abuse: Neglect
Found neglect related to failing to maintain a safe medication administration system, resulting in missed doses and unreasonable discomfort.
Abuse—Failed to provide a safe medication administration system
07 Jan 2025Abuse: Neglect
07 Jan 2025Abuse: Neglect
Found neglect due to failing to maintain an available supply of diabetes medications and related administration supplies, resulting in a missed dose and risk of serious harm.
Abuse—Failed to have medication available
23 Dec 2024Inspection
23 Dec 2024Inspection
Identified deficiencies in acuity-based staffing. The ABST did not reflect resident needs and ADLs, and staffing levels did not meet the needs indicated by the ABST.
Licensing—Failed to staff as indicated by ABST
17 Dec 2024Abuse: Neglect
17 Dec 2024Abuse: Neglect
Investigated a medication administration issue and found that a prescribed medication was unavailable because it was not ordered timely, risking harm to a resident.
Abuse—Failed to provide a safe medication administration system
16 Dec 2024Inspection
16 Dec 2024Inspection
Investigated the allegation and found a violation of medication administration observation requirements. Staff failed to visually confirm ingestion of medication unless the prescriber allowed otherwise.
Licensing—Failed to administer medication as ordered
13 Dec 2024Inspection
13 Dec 2024Inspection
Investigated and determined that ordered medications were not administered as prescribed.
Licensing—Failed to administer ordered medication
05 Dec 2024Inspection
05 Dec 2024Inspection
Investigated and identified a violation due to an outdated acuity-based staffing tool that did not reflect resident needs, with inconsistencies between the roster, care plans, and ABST data.
Licensing—Failed to use an ABST
05 Dec 2024Abuse: Neglect
05 Dec 2024Abuse: Neglect
Investigated found a lapse in medication administration after a new order wasn't implemented before discontinuing the old one, resulting in a three-day gap in a needed dose and a finding of abuse and neglect with a fine assessed.
Abuse—Failed to provide a safe medication administration system
05 Dec 2024Monitoring
05 Dec 2024Monitoring
Identified health and safety violations tied to fire code compliance and licensing rules that put residents at risk.
Deficiency—Reasonable Precautions
Deficiency—Administration Compliance
04 Dec 2024Inspection
04 Dec 2024Inspection
Found deficiencies in updating the ABST to reflect resident needs, with inconsistencies between the roster, care plans, and ABST data.
Licensing—Failed to use an ABST
04 Dec 2024Inspection
04 Dec 2024Inspection
Identified inconsistencies between the resident roster, care plans, and ABST data, and found the Acuity-Based Staffing Tool was not updated to reflect resident care needs.
Licensing—Failed to use an ABST
01 Dec 2024Inspection
01 Dec 2024Inspection
Found that medication and treatment orders were not carried out as prescribed.
Licensing—Failed to have medication available
29 Nov 2024Abuse: Neglect
29 Nov 2024Abuse: Neglect
Found that a safe environment was not provided for a resident, with two residents engaging in physical altercations, resulting in an abuse finding. A $375 fine was assessed.
Abuse—Failed to provide safe environment
29 Nov 2024Abuse: Neglect
29 Nov 2024Abuse: Neglect
Investigated and found a failure to provide a safe environment, constituting abuse and neglect.
Abuse—Failed to provide safe environment
27 Nov 2024License Condition
27 Nov 2024License Condition
Concluded that residents were at risk due to failure to provide a safe environment.
Regulatory Action—Failed to provide safe environment
15 Nov 2024License Condition
15 Nov 2024License Condition
Investigated the allegation of failing to provide daily living assistance. Found deficiencies in ADL support and in maintaining a safe environment.
Regulatory Action—Failed to provide service
15 Nov 2024Abuse: Neglect
15 Nov 2024Abuse: Neglect
Investigated an allegation of abuse and neglect involving inappropriate sexual contact and found that interventions and a safe care plan were not provided.
Abuse—Failed to protect resident from inappropriate sexual contact
15 Nov 2024License Condition
15 Nov 2024License Condition
Investigated the allegation of failing to provide service and found a failure to provide service due to insufficient precautions against health hazards.
Regulatory Action—Failed to provide service
15 Nov 2024Inspection
15 Nov 2024Inspection
Investigated and found that the ABST was not updated to reflect residents' care needs, with inconsistencies between the roster, care plans, and ABST data.
Licensing—Failed to use an ABST
15 Nov 2024License Condition
15 Nov 2024License Condition
Found that an acuity-based staffing tool was not used as required.
Regulatory Action—Failed to use an ABST
05 Nov 2024Inspection
05 Nov 2024Inspection
Found that an acuity-based staffing tool was not fully implemented or updated as required.
Licensing—Failed to use an ABST
05 Nov 2024Inspection
05 Nov 2024Inspection
Found failure to fully implement and update an acuity-based staffing tool for one of three sampled residents. This posed minor harm or potential for moderate harm.
Licensing—Failed to use an ABST
22 Oct 2024Inspection
22 Oct 2024Inspection
Investigated allegation found a deficiency in the Acuity-Based Staffing Tool accuracy and inconsistencies between roster, care plans, and ABST data.
Licensing—Failed to use an ABST
22 Oct 2024Inspection
22 Oct 2024Inspection
Found a deficiency in carrying out medication orders as prescribed, indicating an unsafe medication administration system.
Licensing—Failed to provide a safe medication administration system
21 Oct 2024Abuse: Neglect
21 Oct 2024Abuse: Neglect
Investigated and found neglect and abuse due to failure to provide a safe environment for a resident. A $375 fine was assessed.
Abuse—Failed to provide safe environment
21 Oct 2024Inspection
21 Oct 2024Inspection
Investigated and identified a deficiency in updating the Acuity-Based Staffing Tool to reflect resident needs. Inconsistencies were found between the roster, care plans, and ABST data.
Licensing—Failed to use an ABST
18 Oct 2024Inspection
18 Oct 2024Inspection
Investigated the allegation of failing to administer prescribed medication and found that medication orders were not carried out as prescribed. This constitutes a violation of state rules.
Licensing—Failed to administer ordered medication
17 Oct 2024Inspection
17 Oct 2024Inspection
Determined that medication orders were not carried out as prescribed.
Licensing—Failed to administer medication as ordered
14 Oct 2024Inspection
14 Oct 2024Inspection
Investigated a housekeeping issue and determined unpleasant odors were present.
Licensing—Failed to provide appropriate housekeeping services
14 Oct 2024Complaint
14 Oct 2024Complaint
Investigated a complaint and found deficiencies in meal service, medication/treatment orders, and acuity-based staffing.
Deficiency—Staffing Requirements and Training: Staffing
Deficiency—Acuity Based Staffing Tool - Abst Time
Deficiency—Acuity Based Staffing Tool - Updates & Plan
13 Oct 2024Abuse: Neglect
13 Oct 2024Abuse: Neglect
Investigated found that bathing assistance per the care plan was not followed, leaving the resident to bathe without help and with no monitoring, risking harm.
Abuse—Failed to follow care plan
04 Oct 2024Abuse: Neglect
04 Oct 2024Abuse: Neglect
Investigated found a failure to provide a safe environment when a resident accessed a secure kitchen area through a broken door, obtained a knife, and threatened staff, placing the resident at risk.
Abuse—Failed to provide safe environment
05 Sept 2024Inspection
05 Sept 2024Inspection
Investigated an allegation of insufficient staffing and found staffing levels did not align with ABST indications, with inconsistencies between the schedule and ABST data.
Licensing—Failed to staff as indicated by ABST
05 Sept 2024Abuse: Neglect
05 Sept 2024Abuse: Neglect
Investigated and found neglect and abuse due to failure to provide a safe environment, resulting in an unwitnessed physical altercation causing discomfort to a resident.
Abuse—Failed to provide safe environment
03 Sept 2024Inspection
03 Sept 2024Inspection
Found that the provider failed to maintain an accurate Acuity-Based Staffing Tool reflecting resident needs and ADLs, with inconsistencies among roster, care plans, and ABST data, resulting in staffing levels not aligned with needs.
Licensing—Failed to use an ABST
03 Sept 2024Inspection
03 Sept 2024Inspection
Found deficiencies in ABST data with inconsistencies between resident roster, care plans, and ABST, and staffing not aligned to resident needs.
Licensing—Failed to use an ABST
03 Sept 2024Abuse: Neglect
03 Sept 2024Abuse: Neglect
Found violations for failing to provide a safe environment and follow care plans, leading to a physical altercation between residents. A $375.00 fine was assessed.
Abuse—Failed to provide safe environment
03 Sept 2024Abuse: Neglect
03 Sept 2024Abuse: Neglect
Found neglect and abuse due to failure to follow care plans, resulting in a physical altercation between residents.
Abuse—Failed to provide safe environment
31 Aug 2024Abuse: Neglect
31 Aug 2024Abuse: Neglect
Found that a resident was involved in altercations resulting in a head contusion due to a failure to provide a safe environment, constituting abuse and neglect.
Abuse—Failed to provide safe environment
31 Aug 2024Inspection
31 Aug 2024Inspection
Found that the acuity-based staffing tool did not accurately reflect resident needs or required ADLs, with inconsistencies between the roster, care plans, and ABST data. Staffing levels did not align with the ABST to meet scheduled and unscheduled resident needs.
Licensing—Failed to use an ABST
24 Aug 2024Abuse: Neglect
24 Aug 2024Abuse: Neglect
Investigated and found a failure to provide a safe environment, resulting in neglect and abuse.
Abuse—Failed to provide safe environment
13 Aug 2024Enhanced Oversight and Supervision
13 Aug 2024Enhanced Oversight and Supervision
Investigated the allegation of failing to provide a safe environment. Found that a safe environment was not provided.
Regulatory Action—Failed to provide safe environment
07 Aug 2024Abuse: Neglect
07 Aug 2024Abuse: Neglect
Investigated the allegation of a failure to provide a safe environment and found abuse and neglect that caused serious harm.
Abuse—Failed to provide safe environment
06 Aug 2024Inspection
06 Aug 2024Inspection
Found a deficiency in safe medication administration due to failure to carry out prescribed orders for one resident.
Licensing—Failed to provide a safe medication administration system
01 Aug 2024Inspection
01 Aug 2024Inspection
Investigated and found that a caregiver failed to follow the resident's care plan during feeding, causing a choking episode and neglect/abuse.
Licensing—Failed to follow care plan
31 Jul 2024Inspection
31 Jul 2024Inspection
Found failure to provide three daily nutritious meals with snacks available seven days a week as required by rule.
Licensing—Failed to provide service
28 Jul 2024Abuse: Neglect
28 Jul 2024Abuse: Neglect
Investigated a safety concern and found a resident at risk after being located outside a locked area near a busy road; determined a safe environment was not provided.
Abuse—Failed to provide safe environment
26 Jul 2024Abuse: Neglect
26 Jul 2024Abuse: Neglect
Found neglect related to unsafe medication administration and untimely medication orders that led to hospitalization for a blood sugar crisis. The findings cited multiple regulatory requirements.
Abuse—Failed to provide a safe medication administration system
25 Jul 2024Inspection
25 Jul 2024Inspection
Investigated a complaint and found a violation related to medication administration that could cause harm by not following prescribed orders.
Licensing—Failed to provide a safe medication administration system
25 Jul 2024Inspection
25 Jul 2024Inspection
Found a failure to provide a safe medication administration system and to carry out medication and treatment orders as prescribed.
Licensing—Failed to provide a safe medication administration system
15 Jul 2024Inspection
15 Jul 2024Inspection
Investigated the allegation and found a deficiency in staffing, specifically a shortage of qualified awake direct care staff to meet residents' 24-hour needs.
Licensing—Failed to provide service
12 Jul 2024Inspection
12 Jul 2024Inspection
Found a safety lapse left a resident at risk by not ensuring doors closed and locked, exposing them to a nearby road.
Licensing—Failed to provide safe environment
11 Jul 2024Abuse: Neglect
11 Jul 2024Abuse: Neglect
Found a failure to provide a safe environment that harmed a resident, constituting abuse and neglect. A fine was assessed.
Abuse—Failed to provide safe environment
11 Jul 2024Abuse: Neglect
11 Jul 2024Abuse: Neglect
Investigated and found a failure to provide a safe environment, constituting abuse and neglect. A $375 fine was assessed.
Abuse—Failed to provide safe environment
28 Jun 2024Inspection
28 Jun 2024Inspection
Found service plans did not reflect resident needs.
Licensing—Failed to care plan in accordance with assessment
28 Jun 2024Inspection
28 Jun 2024Inspection
Found a violation of medication administration procedures due to the same person not preparing and documenting medications who administers them.
Licensing—Failed to provide a safe medication administration system
28 Jun 2024Inspection
28 Jun 2024Inspection
Found a deficiency for failing to keep accurate medication administration records for residents.
Licensing—Failed to keep medication record current or accurate
25 Jun 2024Complaint
25 Jun 2024Complaint
Investigation found multiple deficiencies in care planning, monitoring of changes in condition, staffing, and medication management, including service plans not reflecting resident needs and failure to follow physician orders.
Deficiency—Service Plan: General
Deficiency—Change of Condition and Monitoring
Deficiency—Systems: Medications and Treatments
Deficiency—Systems: Medication Administration
Deficiency—Systems: Treatment Orders
Deficiency—Systems: Medication Administration
Deficiency—Staffing Requirements and Training: Staffing
Deficiency—Acuity-Based Staffing Tool
16 Jun 2024Inspection
16 Jun 2024Inspection
Investigated the allegation and found a medication administration violation involving failure to follow prescribed orders.
Licensing—Failed to administer medication as ordered
13 Jun 2024Inspection
13 Jun 2024Inspection
Determined that medication orders were not carried out as prescribed.
Licensing—Failed to administer medication as ordered
12 Jun 2024Abuse: Neglect
12 Jun 2024Abuse: Neglect
Found failures to plan and implement safety interventions for a resident with a history of falls, resulting in neglect and abuse findings.
Abuse—Failed to properly plan care
02 Jun 2024Inspection
02 Jun 2024Inspection
Identified insufficient qualified awake direct care staffing to meet residents' 24-hour needs.
Licensing—Failed to meet the scheduled and unscheduled needs of residents
01 Jun 2024Abuse: Neglect
01 Jun 2024Abuse: Neglect
Investigated and identified violations for failing to plan and implement adequate falls prevention, resulting in neglect and abuse findings.
Abuse—Failed to properly plan care
29 May 2024Inspection
29 May 2024Inspection
Investigated an allegation of not administering medication as ordered and found a violation.
Licensing—Failed to administer medication as ordered
23 May 2024Inspection
23 May 2024Inspection
Found failure to carry out medication and treatment orders as prescribed. This constitutes a licensing violation under Oregon Administrative Rules.
Licensing—Failed to administer medication as ordered
22 May 2024Inspection
22 May 2024Inspection
Found a deficiency that the service plan did not reflect the resident's needs.
Licensing—Failed to follow care plan
22 May 2024Inspection
22 May 2024Inspection
Found failure to implement required services, resulting in a licensing violation.
Licensing—Failed to provide service
21 May 2024Abuse: Neglect
21 May 2024Abuse: Neglect
Concluded that abuse and neglect occurred, harming a resident; a fine was assessed.
Abuse—Failed to provide safe environment
16 May 2024Abuse: Neglect
16 May 2024Abuse: Neglect
Found neglect and abuse due to failure to implement interventions and provide a safe environment, causing repeated discomfort.
Abuse—Failed to provide safe environment
16 May 2024Inspection
16 May 2024Inspection
Found an Acuity-Based Staffing Tool that did not accurately reflect resident needs, with inconsistencies between the roster, care plans, and ABST data.
Licensing—Failed to use an ABST
13 May 2024Inspection
13 May 2024Inspection
Found a violation for failing to administer medication as ordered.
Licensing—Failed to administer medication as ordered
12 May 2024Inspection
12 May 2024Inspection
Identified that medication orders were not carried out as prescribed. This constitutes a level 2 violation with potential for moderate harm.
Licensing—Failed to administer medication as ordered
12 May 2024Inspection
12 May 2024Inspection
Identified a deficiency in providing hygiene assistance and ensuring implementation of services.
Licensing—Failed to provide or assist with hygiene
11 May 2024Abuse: Neglect
11 May 2024Abuse: Neglect
Found deficiencies related to safety and resident rights, with repeated aggressive incidents causing injuries due to failure to implement appropriate care and interventions.
Abuse—Failed to provide safe environment
07 May 2024Abuse: Neglect
07 May 2024Abuse: Neglect
Investigated a complaint about a high fall risk resident and found failures to provide needed services and supervision, resulting in unwitnessed falls and neglect.
Abuse—Failed to provide service
07 May 2024Abuse: Neglect
07 May 2024Abuse: Neglect
Investigated a resident fall incident and found failure to implement fall-prevention interventions, resulting in a subsequent fall with head injury and a $1,500 fine.
Abuse—Failed to properly plan care
06 May 2024Abuse: Neglect
06 May 2024Abuse: Neglect
Found deficiencies in fall risk management and care planning that left an Alleged Victim at risk and led to unwitnessed falls and injuries.
Abuse—Failed to properly plan care
03 May 2024Inspection
03 May 2024Inspection
Concluded that a deficiency occurred due to failure to determine and document the required action when a resident's condition changed.
Licensing—Failed to intervene when resident's condition changed
03 May 2024Abuse: Neglect
03 May 2024Abuse: Neglect
Identified violations for failing to provide a safe environment, resulting in abuse and neglect.
Abuse—Failed to provide safe environment
03 May 2024Abuse: Neglect
03 May 2024Abuse: Neglect
Investigated an allegation of neglect and abuse and found a failure to provide a safe environment, resulting in harm when aggression was not adequately monitored.
Abuse—Failed to provide safe environment
03 May 2024Inspection
03 May 2024Inspection
Determined that staffing levels were insufficient to meet residents' scheduled and unscheduled needs.
Licensing—Failed to meet the scheduled and unscheduled needs of residents
30 Apr 2024Abuse: Neglect
30 Apr 2024Abuse: Neglect
Found a safety deficiency when a secured door was not watched during a fire drill, briefly allowing a resident to exit to the parking lot before staff retrieved them.
Abuse—Failed to provide safe environment
16 Apr 2024Inspection
16 Apr 2024Inspection
Investigated and found failure to carry out medication and treatment orders as prescribed.
Licensing—Failed to administer medication as ordered
06 Apr 2024Abuse: Neglect
06 Apr 2024Abuse: Neglect
Found a failure to provide a safe environment that resulted in serious harm. A $2,500 fine was assessed.
Abuse—Failed to provide safe environment
05 Apr 2024License Condition
05 Apr 2024License Condition
Identified deficiencies for failing to provide a safe environment.
Regulatory Action—Failed to provide safe environment
03 Apr 2024Abuse: Neglect
03 Apr 2024Abuse: Neglect
Identified neglect and abuse due to failure to follow a care plan, causing emotional distress to a resident; a fine was assessed.
Abuse—Failed to provide safe environment
02 Apr 2024Inspection
02 Apr 2024Inspection
Concluded that medication and treatment orders were not carried out as prescribed, exposing residents to potential harm.
Licensing—Failed to administer medication as ordered
02 Apr 2024Inspection
02 Apr 2024Inspection
Investigated and determined that qualified awake direct care staff were insufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident.
Licensing—Failed to meet the scheduled and unscheduled needs of residents
31 Mar 2024Inspection
31 Mar 2024Inspection
Identified insufficient qualified awake direct care staffing to meet 24-hour scheduled and unscheduled needs, resulting in a violation of state rules.
Licensing—Failed to provide appropriate staffing
31 Mar 2024Inspection
31 Mar 2024Inspection
Investigated an allegation of failing to administer ordered medication. Found that medication orders were not carried out as prescribed.
Licensing—Failed to administer ordered medication
25 Mar 2024Abuse: Neglect
25 Mar 2024Abuse: Neglect
Investigated and found staff failed to provide a safe environment, resulting in abuse and neglect of a resident; a $375 fine was assessed.
Abuse—Failed to provide safe environment
24 Mar 2024Abuse: Neglect
24 Mar 2024Abuse: Neglect
Investigated and found violations of resident rights due to abuse and neglect, with a fine assessed.
Abuse—Failed to provide safe environment
23 Mar 2024Abuse: Neglect
23 Mar 2024Abuse: Neglect
Investigated and found that safety measures and care planning for residents with known aggressive behaviors were not adequately implemented, resulting in injuries and substantiated abuse/neglect. A fine was assessed.
Abuse—Failed to provide safe environment
23 Mar 2024Abuse: Neglect
23 Mar 2024Abuse: Neglect
Investigated and found violations of resident rights related to neglect and abuse due to failure to address known behaviors and provide a safe environment, resulting in a $375 fine.
Abuse—Failed to address resident's behavior
21 Mar 2024Inspection
21 Mar 2024Inspection
Concluded that the Acuity-Based Staffing Tool failed to reflect the resident population and their care needs, violating Oregon Administrative Rules.
Licensing—Failed to use an ABST
18 Mar 2024Validation
18 Mar 2024Validation
Identified extensive deficiencies across administration, resident rights, health services, medications, infection prevention, nutrition, activities, and safety; corrective actions were implemented and substantial compliance was reached after follow-up.
Deficiency—Comment
Deficiency—Facility Administration: Operation
Deficiency—Resident Rights and Protection - General
Deficiency—Resident Move-In and Eval: Res Evaluation
Deficiency—Service Plan: General
Deficiency—Change of Condition and Monitoring
Deficiency—Resident Health Services
Deficiency—Rn Delegation and Teaching
Deficiency—Res Hlth Srvc: On- and Off-Site Health Srvc
Deficiency—Infection Prevention & Control
Deficiency—Systems: Medications and Treatments
Deficiency—Systems: Tracking Control Substances
Deficiency—Systems: Treatment Orders
Deficiency—Systems: Resident Right to Refuse
Deficiency—Systems: Medication Administration
Deficiency—Restraints and Supportive Devices
Deficiency—Acuity-Based Staffing Tool
Deficiency—Training Within 30 Days: Direct Care Staff
Deficiency—Fire and Life Safety: Safety
Deficiency—Fire and Life Safety: Training For Residents
Deficiency—Inspections and Investigation: Insp Interval
Deficiency—Doors, Walls, Elevators, Odors
Deficiency—Administration Compliance
Deficiency—Staff Training Requirements
Deficiency—Compliance With Rules Health Care
Deficiency—Nutrition and Hydration
Deficiency—Activities
Deficiency—Resident Rooms
11 Mar 2024Inspection
11 Mar 2024Inspection
Found a violation of care plan implementation. The finding notes failure to ensure the implementation of services.
Licensing—Failed to follow care plan
11 Mar 2024Complaint
11 Mar 2024Complaint
Investigated and found multiple deficiencies: failed to implement a resident's service plan, breached infection control protocols during a COVID outbreak, and widely failed to carry out medication orders due to staffing shortages.
Deficiency—Service Plan: General
Deficiency—Infection Prevention & Control
Deficiency—Systems: Treatment Orders
Deficiency—Staffing Requirements and Training: Staffing
Deficiency—Staffing Requirements and Training – Pre-Serv
Deficiency—Resident Rooms
11 Mar 2024Inspection
11 Mar 2024Inspection
Investigated an allegation that medication orders were not administered as ordered. Found that medication orders were not carried out as prescribed.
Licensing—Failed to administer medication as ordered
11 Mar 2024Inspection
11 Mar 2024Inspection
Investigated the allegation and found that medication and treatment orders were not carried out as prescribed.
Licensing—Failed to administer medication as ordered
11 Mar 2024Inspection
11 Mar 2024Inspection
Found a failure to ensure the implementation of services.
Licensing—Failed to provide service
11 Mar 2024Inspection
11 Mar 2024Inspection
Determined that staffing was insufficient to meet residents' scheduled and unscheduled needs, causing unmet needs and delays in care.
Licensing—Failed to meet the scheduled and unscheduled needs of residents
07 Mar 2024Abuse: Neglect
07 Mar 2024Abuse: Neglect
Concluded that neglect occurred due to inadequate supervision of medication administration, resulting in maladministered medications and discomfort.
Abuse—Failed to provide a safe medication administration system
01 Mar 2024Abuse: Neglect
01 Mar 2024Abuse: Neglect
Identified failure to provide a safe medication administration system, resulting in missed doses and constituting neglect and abuse; a $375 fine was assessed.
Abuse—Failed to provide a safe medication administration system
24 Feb 2024Abuse: Neglect
24 Feb 2024Abuse: Neglect
Investigated a complaint and found neglect related to an unsafe medication administration system due to inadequate staffing and on-call issues, resulting in improper timely administration and resident discomfort.
Abuse—Failed to provide a safe medication administration system
24 Feb 2024Inspection
24 Feb 2024Inspection
Investigated and found that staff were not provided with an orientation to the resident, including the service plan. The finding indicates a violation of Oregon rules.
Licensing—Failed to provide inservice
24 Feb 2024Abuse: Neglect
24 Feb 2024Abuse: Neglect
Determined neglect due to insufficient staffing, a nonfunctional on-call system, and failure to administer medications as prescribed, which caused resident discomfort.
Abuse—Failed to provide a safe medication administration system
24 Feb 2024Inspection
24 Feb 2024Inspection
Found that residents could be locked out of or inside their rooms at any time, affecting resident rights.
Licensing—Failed to assure resident rights
24 Feb 2024Inspection
24 Feb 2024Inspection
Investigated a medication administration allegation and found a violation for not carrying out ordered medications.
Licensing—Failed to administer ordered medication
20 Feb 2024Licensure
20 Feb 2024Licensure
Found no deficiencies. Substantial compliance with the applicable rules was noted.
Deficiency—Comment
17 Feb 2024Abuse: Neglect
17 Feb 2024Abuse: Neglect
Found neglect due to failure to follow care plan, which placed a resident at risk of serious harm; assessed a $375 fine.
Abuse—Failed to follow care plan
05 Feb 2024Inspection
05 Feb 2024Inspection
Found a deficiency for failing to provide a safe medication administration system.
Licensing—Failed to provide a safe medication administration system
04 Feb 2024Abuse: Neglect
04 Feb 2024Abuse: Neglect
Found neglect and abuse due to failure to provide a safe environment for a resident.
Abuse—Failed to provide safe environment
26 Jan 2024Abuse: Neglect
26 Jan 2024Abuse: Neglect
Investigated the allegation that a resident was not protected from inappropriate sexual contact and found abuse and neglect with repeated safety failures, and a $1,500 fine was assessed.
Abuse—Failed to protect resident from inappropriate sexual contact
12 Jan 2024Abuse: Neglect
12 Jan 2024Abuse: Neglect
Found neglect and abuse due to inadequate oversight that allowed a resident-to-resident altercation resulting in a skin tear.
Abuse—Failed to provide safe environment
09 Jan 2024Inspection
09 Jan 2024Inspection
Investigated the allegation and found a failure to establish and maintain infection prevention and control protocols.
Licensing—Failed to provide infection control
06 Jan 2024Inspection
06 Jan 2024Inspection
Found violations of resident rights, neglect, wrongful restraint, and verbal abuse, and a failure to maintain a safe environment.
Licensing—Failed to provide safe environment
06 Jan 2024Inspection
06 Jan 2024Inspection
Found that a safe environment was not provided, with a resident experiencing neglect, wrongful restraint, and verbal/emotional abuse.
Licensing—Failed to provide safe environment
06 Jan 2024Inspection
06 Jan 2024Inspection
Found that a staff member restrained and verbally abused a resident, violating rights and safety rules.
Licensing—Failed to protect resident from mental or emotional abuse
30 Dec 2023Abuse: Neglect
30 Dec 2023Abuse: Neglect
Found neglect of care and abuse from not properly responding to a resident's behaviors, causing repeated falls and delayed healing; a $1,500 fine was assessed.
Abuse—Failed to provide service
27 Dec 2023Abuse: Neglect
27 Dec 2023Abuse: Neglect
Found neglect and abuse due to failure to provide a safe environment and adequate care, resulting in a fall with head injury.
Abuse—Failed to provide safe environment
26 Dec 2023Abuse: Neglect
26 Dec 2023Abuse: Neglect
Investigated an allegation of neglect and abuse and found that the care plan was not followed, putting a resident at risk; a fine was assessed.
Abuse—Failed to follow care plan
24 Dec 2023Abuse: Neglect
24 Dec 2023Abuse: Neglect
Investigated an allegation of abuse and neglect related to inadequate care planning, which led to an unwitnessed fall and fractured hip.
Abuse—Failed to properly plan care
21 Dec 2023Abuse: Neglect
21 Dec 2023Abuse: Neglect
Found neglect and abuse for failing to follow a temporary one-to-one care plan, putting a resident at risk of serious harm; a fine was assessed.
Abuse—Failed to follow care plan
18 Dec 2023Abuse: Neglect
18 Dec 2023Abuse: Neglect
Investigated an allegation of an unsafe environment that caused harm; found neglect and abuse and assessed a $500 fine.
Abuse—Failed to provide safe environment
14 Dec 2023Abuse: Neglect
14 Dec 2023Abuse: Neglect
Found neglect of care due to failure to monitor a fall-risk resident per the care plan, leading to an unwitnessed fall and finger injury; a $500 fine was assessed.
Abuse—Failed to provide safe environment
27 Nov 2023Abuse: Neglect
27 Nov 2023Abuse: Neglect
Found that a resident was not provided a safe environment, resulting in abuse and neglect.
Abuse—Failed to provide safe environment
26 Nov 2023Abuse: Neglect
26 Nov 2023Abuse: Neglect
Found a failure to provide a safe environment and to implement appropriate care for known behaviors, resulting in abuse and neglect.
Abuse—Failed to provide safe environment
25 Nov 2023Abuse: Neglect
25 Nov 2023Abuse: Neglect
Found that care planning failed for a resident with escalating behaviors, resulting in an unsafe environment and abuse.
Abuse—Failed to provide safe environment
16 Oct 2023Complaint
16 Oct 2023Complaint
Investigated and found deficiencies in safety precautions, staffing tool implementation, and access to outdoor recreation.
Deficiency—Reasonable Precautions
Deficiency—Acuity-Based Staffing Tool
Deficiency—General Building Exterior
14 Oct 2023Inspection
14 Oct 2023Inspection
Found that the facility failed to provide three daily nutritious, palatable meals with snacks available seven days a week.
Licensing—Failed to provide service
06 Oct 2023Inspection
06 Oct 2023Inspection
Found deficiencies in the medication administration process due to late dosing and missed passes.
Licensing—Failed to provide a safe medication administration system
25 Sept 2023Inspection
25 Sept 2023Inspection
Found that an accessible outdoor recreation area was not provided.
Licensing—Failed to provide service
22 Sept 2023Abuse: Neglect
22 Sept 2023Abuse: Neglect
Investigated found neglect and abuse due to failing to provide a safe environment, resulting in physical harm; a fine was assessed.
Abuse—Failed to provide safe environment
22 Sept 2023Abuse: Neglect
22 Sept 2023Abuse: Neglect
Investigated a report of abuse/neglect and found failures to follow the care plan and provide a safe environment, resulting in distress to a resident.
Abuse—Failed to provide safe environment
20 Sept 2023Abuse: Neglect
20 Sept 2023Abuse: Neglect
Found failures to provide a safe environment and to follow care plans, resulting in injuries to an Alleged Victim.
Abuse—Failed to provide safe environment
01 Sept 2023Inspection
01 Sept 2023Inspection
Investigated a complaint and found that the facility failed to carry out medication orders as prescribed for one resident, indicating a deficiency in the medication administration system.
Licensing—Failed to provide a safe medication administration system
28 Aug 2023Abuse: Neglect
28 Aug 2023Abuse: Neglect
Investigated allegations found the provider failed to ensure a safe environment and to implement appropriate interventions for known behaviors, resulting in injuries from multiple altercations.
Abuse—Failed to provide safe environment
19 Aug 2023Abuse: Neglect
19 Aug 2023Abuse: Neglect
Investigated and found abuse and neglect due to inappropriate sexual contact between residents and a failure to follow a care plan, resulting in distress and loss of personal dignity.
Abuse—Failed to protect resident from inappropriate sexual contact
13 Jul 2023Abuse: Neglect
13 Jul 2023Abuse: Neglect
Found that the resident did not receive adequate services and care. This led to unkempt appearance, inappropriate clothing, and a room with urine odor and waste, causing discomfort and loss of dignity.
Abuse—Failed to provide service
27 Jun 2023Abuse: Neglect
27 Jun 2023Abuse: Neglect
Investigated a narcotics administration issue and found a failure to provide a safe medication administration system, with a fine assessed.
Abuse—Failed to provide a safe medication administration system
19 Jun 2023Abuse: Neglect
19 Jun 2023Abuse: Neglect
Found a failure to provide a safe medication administration system resulting in abuse and neglect, and assessed a $500 fine.
Abuse—Failed to provide a safe medication administration system
31 May 2023Inspection
31 May 2023Inspection
Identified a housekeeping deficiency causing interior odors.
Licensing—Failed to provide appropriate housekeeping services
05 Apr 2023Abuse: Neglect
05 Apr 2023Abuse: Neglect
Identified failures to implement interventions and update the care plan for a resident's known behaviors, which led to an assault and an unsafe environment. A fine was assessed.
Abuse—Failed to provide safe environment
02 Apr 2023Abuse: Neglect
02 Apr 2023Abuse: Neglect
Found failures to plan and implement care for a known fall risk, leading to multiple falls and injuries; a $500 fine was assessed.
Abuse—Failed to properly plan care
23 Mar 2023License Condition
23 Mar 2023License Condition
Investigated the allegation of inadequate direct care staffing and found that sufficient staff were not provided to meet residents' scheduled and unscheduled needs.
Regulatory Action—Failed to meet the scheduled and unscheduled needs of residents
23 Mar 2023License Condition
23 Mar 2023License Condition
Investigated an allegation and found deficiencies in ABST usage, specifically failing to fully implement and update the Acuity Based Staffing Tool in accordance with the rule.
Regulatory Action—Failed to use an ABST
12 Mar 2023Abuse: Neglect
12 Mar 2023Abuse: Neglect
Investigated a resident abuse/neglect case and found that timely medical treatment was not provided after an injury, resulting in hospital treatment and multiple broken ribs.
Abuse—Failed to assure timely medical treatment
22 Feb 2023Abuse: Neglect
22 Feb 2023Abuse: Neglect
Found neglect and abuse after staff failed to follow the care plan, resulting in a resident being punched.
Abuse—Failed to follow care plan
22 Feb 2023Abuse: Neglect
22 Feb 2023Abuse: Neglect
Found that failure to provide 1:1 supervision allowed a resident to be choked while sleeping, creating an unsafe environment and violating resident rights. A $500 fine was assessed.
Abuse—Failed to provide safe environment
21 Feb 2023Abuse: Neglect
21 Feb 2023Abuse: Neglect
Identified violations for failing to provide required 1:1 monitoring, resulting in a resident being harmed and discomfort due to staffing shortages.
Abuse—Failed to provide safe environment
15 Feb 2023Abuse: Neglect
15 Feb 2023Abuse: Neglect
Found neglect and abuse related to pain management; a $500 fine assessed.
Abuse—Failed to provide a safe medication administration system
04 Feb 2023Abuse: Neglect
04 Feb 2023Abuse: Neglect
Investigated an allegation of neglect and abuse and found the resident did not receive necessary care as conditions worsened, resulting in multiple falls with injuries and no documented follow-up evaluations.
Abuse—Failed to provide service
01 Feb 2023Abuse: Neglect
01 Feb 2023Abuse: Neglect
Investigated and found neglect of care and abuse due to failure to follow the care plan, with a $1,125 fine assessed.
Abuse—Failed to follow care plan
01 Feb 2023Inspection
01 Feb 2023Inspection
Investigated the allegation and determined no licensing violation occurred.
Licensing—Failed to provide appropriate housekeeping services
31 Jan 2023Licensure
31 Jan 2023Licensure
Determined substantial compliance with meal-related requirements and sanitation rules.
Deficiency—Comment
24 Jan 2023Abuse: Neglect
24 Jan 2023Abuse: Neglect
Investigated a report of abuse and neglect and found failure to implement interventions and care plans for the resident's change in condition. The resident did not eat or move from bed and died shortly after.
Abuse—Failed to provide service
24 Jan 2023Abuse: Neglect
24 Jan 2023Abuse: Neglect
Found a resident at risk of falls was not provided a safe environment and care plans were not updated after falls.
Abuse—Failed to provide safe environment
25 Dec 2022Inspection
25 Dec 2022Inspection
Found that ten narcotic pills were stolen from a resident due to failure to protect medications from theft.
Licensing—Failed to protect resident from financial exploitation
25 Dec 2022Inspection
25 Dec 2022Inspection
Investigated an instance of financial exploitation and found that narcotic pain medications were stolen by an unknown perpetrator and protections for medications were inadequate.
Licensing—Failed to protect resident from financial exploitation
21 Dec 2022Abuse: Neglect
21 Dec 2022Abuse: Neglect
Concluded that abuse and neglect occurred due to failure to provide a safe environment, resulting in resident harm. A $375 fine was assessed.
Abuse—Failed to provide safe environment
08 Dec 2022Complaint
08 Dec 2022Complaint
Found deficiencies in bathing assistance, staffing adequacy, and the use of an acuity-based staffing tool. These findings indicate gaps in resident care and staffing oversight.
Deficiency—Licensing Complaint Investigation
Deficiency—Resident Services: Adls
Deficiency—Staffing Requirements and Training: Staffing
Deficiency—Acuity-Based Staffing Tool
01 Dec 2022Inspection
01 Dec 2022Inspection
Found failure to submit timely weekly reporting of vaccinated individuals, residents, and staff for November 2022.
Licensing—Failed to submit timely or adequate staffing documentation
29 Nov 2022Abuse: Neglect
29 Nov 2022Abuse: Neglect
Investigated and found neglect and abuse due to failing to follow the resident's catheter care plan, causing pain and hospital transfer.
Abuse—Failed to follow care plan
22 Nov 2022Inspection
22 Nov 2022Inspection
Investigated an allegation of inadequate hygiene assistance and found that bathing and hair washing assistance was not provided.
Licensing—Failed to provide or assist with hygiene
16 Nov 2022Abuse: Neglect
16 Nov 2022Abuse: Neglect
Investigated and found a failure to provide a safe environment and follow the care plan, resulting in a resident's discomfort; a fine was assessed.
Abuse—Failed to provide safe environment
01 Nov 2022Inspection
01 Nov 2022Inspection
Found that weekly reporting of vaccinated individuals, residents, and staff was not submitted to the proper authority for 30 days, occurring from Oct 1 to Oct 31, 2022.
Licensing—Failed to submit timely or adequate staffing documentation
17 Oct 2022Abuse: Neglect
17 Oct 2022Abuse: Neglect
Investigated a complaint found the resident was left in soiled briefs with skin breakdown and discomfort, and medications were not consistently administered as ordered.
Abuse—Failed to provide service
13 Oct 2022Abuse: Neglect
13 Oct 2022Abuse: Neglect
Investigated and found a failure to provide a safe environment resulting in inappropriate sexual contact between residents and loss of personal dignity.
Abuse—Failed to provide safe environment
12 Oct 2022Abuse: Neglect
12 Oct 2022Abuse: Neglect
Found neglect and abuse occurred when a resident was exposed to inappropriate sexual contact by another resident in a common area, harming dignity; a fine was assessed.
Abuse—Failed to protect resident from inappropriate sexual contact
11 Oct 2022Abuse: Neglect
11 Oct 2022Abuse: Neglect
Found that the provider failed to provide a safe environment for a resident, with multiple altercations causing distress. A $1,350 fine was assessed.
Abuse—Failed to provide safe environment
26 Sept 2022Abuse: Neglect
26 Sept 2022Abuse: Neglect
Identified violations for failing to protect a resident from inappropriate contact and for not providing a safe environment, resulting in abuse and neglect. A monetary fine was assessed.
Abuse—Failed to protect resident from inappropriate sexual contact
07 Sept 2022Complaint
07 Sept 2022Complaint
Found deficiencies in medication order administration and staffing levels, indicating medications were not given as prescribed and staffing was insufficient to meet resident needs.
Deficiency—Licensing Complaint Investigation
Deficiency—Systems: Treatment Orders
Deficiency—Staffing Requirements and Training: Staffing
07 Sept 2022Inspection
07 Sept 2022Inspection
Found insufficient staff to meet scheduled and unscheduled needs and licensing conditions, compromising safety.
Licensing—Failed to provide safe environment
03 Sept 2022Abuse: Neglect
03 Sept 2022Abuse: Neglect
Found a deficiency in the safe medication administration system affecting a resident; one neglect allegation was upheld, another not upheld.
Abuse—Failed to provide a safe medication administration system
01 Sept 2022Abuse: Neglect
01 Sept 2022Abuse: Neglect
Found inadequate staffing and failure to implement fall-prevention measures that endangered a known fall risk resident. A $500 fine was assessed.
Abuse—Failed to properly plan care
30 Aug 2022Inspection
30 Aug 2022Inspection
Investigated the concern and found a deficiency due to insufficient staff that could affect residents' safety.
Licensing—Failed to provide safe environment
30 Aug 2022Inspection
30 Aug 2022Inspection
Investigated an allegation that medication was not administered as ordered. Found that medication orders were not carried out as prescribed.
Licensing—Failed to administer medication as ordered
28 Aug 2022Inspection
28 Aug 2022Inspection
Found insufficient staff to meet scheduled and unscheduled needs, compromising resident safety.
Licensing—Failed to provide safe environment
21 Aug 2022Inspection
21 Aug 2022Inspection
Found insufficient staffing to meet scheduled and unscheduled resident needs and licensing condition requirements.
Licensing—Failed to provide safe environment
15 Aug 2022Inspection
15 Aug 2022Inspection
Found insufficient staff to meet residents' scheduled and unscheduled needs and licensing condition requirements.
Licensing—Failed to provide safe environment
10 Aug 2022Abuse: Neglect
10 Aug 2022Abuse: Neglect
Investigated found violations for verbal abuse and neglect of a resident, and a fine was assessed.
Abuse—Failed to protect resident from verbal abuse
10 Aug 2022Abuse: Neglect
10 Aug 2022Abuse: Neglect
Found neglect and abuse due to untrained staff swatting at a resident and failing to implement person-centered care plans, resulting in a fine.
Abuse—Failed to properly plan care
10 Aug 2022Abuse: Neglect
10 Aug 2022Abuse: Neglect
Found violations of resident rights due to untrained staff restraining a resident during care, with lacking person-centered care plans and resulting in abuse.
Abuse—Failed to assure resident rights
07 Aug 2022Abuse: Neglect
07 Aug 2022Abuse: Neglect
Determined that the provider failed to implement interventions or care plans for known behaviors, resulting in a physical altercation and findings of neglect and abuse; a fine was assessed.
Abuse—Failed to properly plan care
04 Aug 2022Abuse: Neglect
04 Aug 2022Abuse: Neglect
Investigated a resident-to-resident altercation and found neglect and abuse due to failure to plan for known behaviors and ensure resident safety. The incident left a resident at risk for serious harm.
Abuse—Failed to properly plan care
12 Jul 2022Inspection
12 Jul 2022Inspection
Identified insufficient staffing that failed to meet scheduled and unscheduled resident needs and licensing conditions, creating a safety risk.
Licensing—Failed to provide safe environment
26 Jun 2022Abuse: Neglect
26 Jun 2022Abuse: Neglect
Investigated a report of abuse and neglect due to failure to follow a care plan for wandering, which led to a resident-to-resident altercation and injuries.
Abuse—Failed to follow care plan
07 Jun 2022Abuse: Neglect
07 Jun 2022Abuse: Neglect
Investigated an allegation of failing to plan care for a resident with known fall risk; found insufficient interventions to mitigate increasing fall risk, resulting in injuries and a finding of neglect.
Abuse—Failed to properly plan care
07 Jun 2022Inspection
07 Jun 2022Inspection
Investigated a complaint and found a failure to provide a safe medication administration system, creating potential for moderate harm.
Licensing—Failed to provide a safe medication administration system
31 May 2022Inspection
31 May 2022Inspection
Verified failure to administer prescribed medication per order.
Licensing—Failed to administer ordered medication
20 May 2022Inspection
20 May 2022Inspection
Investigated a housekeeping-related allegation and found deficiencies in keeping interior and exterior materials, surfaces, and equipment clean and in good repair; verified a bowel movement left in the toilet for 3 days.
Licensing—Failed to provide appropriate housekeeping services
20 May 2022Inspection
20 May 2022Inspection
Verified failure to carry out medication orders as prescribed, including crushing medications without a physician’s order and not providing Boost.
Licensing—Failed to administer medication as ordered
10 May 2022Abuse: Neglect
10 May 2022Abuse: Neglect
Investigated a safety complaint and found that a resident was found outside locked doors on multiple occasions, with no additional safeguards; a $500 fine was assessed.
Abuse—Failed to provide safe environment
05 May 2022Inspection
05 May 2022Inspection
Investigated the complaint and verified that residents were not assisted with bathing and toileting. This finding showed violations of required care standards.
Licensing—Failed to assist with toileting
05 May 2022Inspection
05 May 2022Inspection
Investigated a staffing deficiency due to insufficient staff to meet residents' needs, including bathing and toileting.
Licensing—Failed to provide appropriate staffing
05 May 2022Inspection
05 May 2022Inspection
Found a deficiency for not including policies and procedures on medical emergency response for all shifts, related to how emergencies and falls are handled.
Licensing—Failed to properly plan care
05 May 2022Inspection
05 May 2022Inspection
Investigated the allegation of cleanliness issues. Found failure to keep all interior materials and surfaces clean.
Licensing—Failed to provide safe environment
05 May 2022Inspection
05 May 2022Inspection
Investigated a complaint and found quarterly service plans were not updated.
Licensing—Failed to keep resident record current or accurate
03 May 2022Abuse: Neglect
03 May 2022Abuse: Neglect
Investigated and found a failure to provide a safe environment, placing a resident at risk by being found outside near a busy road; a fine was assessed.
Abuse—Failed to provide safe environment
26 Apr 2022Inspection
26 Apr 2022Inspection
Investigated found that a staff member failed to follow a resident’s care plan, yelled at the resident, pulled them by the arm, and used body weight to push them forward, risking harm and violating rights.
Licensing—Failed to follow care plan
16 Apr 2022Abuse: Neglect
16 Apr 2022Abuse: Neglect
Found failure to provide necessary services as ordered, resulting in repeated constipation and discomfort for the resident.
Abuse—Failed to provide service
31 Mar 2022Inspection
31 Mar 2022Inspection
Investigated and found a violation of providing a safe and homelike environment; verified that a resident was made to sleep in a wheelchair instead of their bed.
Licensing—Failed to provide safe environment
25 Mar 2022Inspection
25 Mar 2022Inspection
Investigated the allegation of an unsafe environment and found that stairways, halls, doorways, passageways, and exits were obstructed.
Licensing—Failed to provide safe environment
25 Mar 2022License Condition
25 Mar 2022License Condition
Determined that residents were at risk due to an unsafe environment.
Regulatory Action—Failed to provide safe environment
25 Mar 2022Inspection
25 Mar 2022Inspection
Identified a failure to ensure immediate notification to the local SPD office of any incident of abuse or suspected abuse. Found a violation of reporting requirements regarding abuse notifications.
Licensing—Failed to provide safe environment
25 Mar 2022Inspection
25 Mar 2022Inspection
Found failure to provide a safe environment for residents.
Licensing—Failed to provide safe environment
25 Mar 2022Inspection
25 Mar 2022Inspection
Found that health services were not provided and there were no adequate systems to respond to 24-hour care needs.
Licensing—Failed to provide safe environment
25 Mar 2022Inspection
25 Mar 2022Inspection
Determined that outdoor lighting did not meet the minimum level of five foot candles, indicating a deficiency in providing a safe environment.
Licensing—Failed to provide safe environment
25 Mar 2022Inspection
25 Mar 2022Inspection
Found that required postings were not posted in a routinely accessible and conspicuous location.
Licensing—Failed to provide safe environment
25 Mar 2022Inspection
25 Mar 2022Inspection
Determined staffing was inadequate, creating potential safety concerns for residents.
Licensing—Failed to provide safe environment
25 Mar 2022Inspection
25 Mar 2022Inspection
Found that exit doors lacked alarms or an alert system to notify staff when a resident exits.
Licensing—Failed to provide safe environment
25 Mar 2022Inspection
25 Mar 2022Inspection
Found a deficiency in the safe medication administration system. The finding noted a failure to provide a safe medication administration system.
Licensing—Failed to provide a safe medication administration system
24 Mar 2022Abuse: Neglect
24 Mar 2022Abuse: Neglect
Found neglect and abuse involving a resident left in a wheelchair at night, resulting in a pressure ulcer due to not following the care plan.
Abuse—Failed to follow care plan
23 Mar 2022Inspection
23 Mar 2022Inspection
Concluded that the complaint alleging inadequate housekeeping supplies was verified, noting lack of paper towels and garbage bags for storing soiled items.
Licensing—Failed to provide appropriate housekeeping services
23 Mar 2022Inspection
23 Mar 2022Inspection
Investigated and found a violation of nursing delegation requirements related to not carrying out medication and treatment orders.
Licensing—Failed to comply with nursing delegation requirement
21 Mar 2022Inspection
21 Mar 2022Inspection
Investigated a staffing training allegation and found that there was no program to determine direct care staff competency, with new staff not being trained.
Licensing—Failed to provide appropriate staffing
21 Mar 2022Inspection
21 Mar 2022Inspection
Found that staff failed to assist with toileting and bowel/bladder management.
Licensing—Failed to assist with toileting
21 Mar 2022Inspection
21 Mar 2022Inspection
Investigated and verified that medication orders were not followed, causing two days of missed doses.
Licensing—Failed to administer medication as ordered
21 Mar 2022Inspection
21 Mar 2022Inspection
Found inadequate awake direct care staffing to meet residents' 24-hour needs, with late or missing assistance and medication administration.
Licensing—Failed to provide service
21 Mar 2022Inspection
21 Mar 2022Inspection
Investigated and found a failure to implement services per the care plan, including assisting the resident with hearing aids.
Licensing—Failed to follow care plan
21 Mar 2022Inspection
21 Mar 2022Inspection
Investigated an allegation that medication orders were not carried out; found that about 17 residents missed their morning medications on 3/21/2022.
Licensing—Failed to administer ordered medication
20 Mar 2022Abuse: Neglect
20 Mar 2022Abuse: Neglect
Found a failure to provide a safe medication administration system, resulting in missed medication doses and unnecessary discomfort; a $250 fine was assessed.
Abuse—Failed to provide a safe medication administration system
20 Mar 2022Inspection
20 Mar 2022Inspection
Investigated and verified insufficient qualified awake direct care staff to meet residents' 24-hour needs. Residents left through a back gate and did not receive appropriate mobility and medication assistance.
Licensing—Failed to assure resident was safe
20 Mar 2022Inspection
20 Mar 2022Inspection
Investigated a complaint and found that interior and exterior materials and surfaces and equipment were not kept clean or in good repair. A resident banged on tall metal exit gates until they could exit.
Licensing—Failed to provide safe environment
20 Mar 2022Inspection
20 Mar 2022Inspection
Investigated the medication administration allegation and found that orders were not carried out as prescribed, resulting in a resident not receiving medications on 3/20/2022.
Licensing—Failed to administer medication as ordered
15 Mar 2022Inspection
15 Mar 2022Inspection
Investigated and verified that background checks were not obtained for all subject individuals per OAR 411-054-0025(1)(d).
Licensing—Failed to provide safe environment
15 Mar 2022Inspection
15 Mar 2022Inspection
Investigated the allegation and identified a staffing deficiency related to awake direct care, with insufficient staffing to meet 24-hour needs and evidence of clocking in and leaving during the night shift requiring visitors to assist residents.
Licensing—Failed to provide service
15 Mar 2022Inspection
15 Mar 2022Inspection
Investigated an allegation of unsafe environment and found a substantiated violation for failing to notify about abuse incidents.
Licensing—Failed to provide safe environment
12 Mar 2022Abuse: Neglect
12 Mar 2022Abuse: Neglect
Found a failure to provide a safe environment that placed a resident at risk for serious harm.
Abuse—Failed to provide safe environment
09 Mar 2022Inspection
09 Mar 2022Inspection
Investigated and found that medication orders were not carried out as prescribed, and morning medications were not given as directed.
Licensing—Failed to administer medication as ordered
09 Mar 2022Inspection
09 Mar 2022Inspection
Investigated a complaint and found violations related to not promptly providing records and failing to maintain a safe, homelike environment.
Licensing—Failed to provide safe environment
09 Mar 2022Inspection
09 Mar 2022Inspection
Found insufficient staff to meet scheduled and unscheduled resident needs, including timely medication administration.
Licensing—Failed to provide appropriate staffing
09 Mar 2022Inspection
09 Mar 2022Inspection
Investigated the staffing allegation and found insufficient staff to meet residents' scheduled and unscheduled needs, including a cottage with no caregivers and meals not provided.
Licensing—Failed to provide appropriate staffing
05 Mar 2022Abuse: Neglect
05 Mar 2022Abuse: Neglect
Investigated a complaint and found bed alarms were not used and the care plan was not followed, resulting in a fall and injury. A fine was assessed.
Abuse—Failed to follow care plan
05 Mar 2022Abuse: Neglect
05 Mar 2022Abuse: Neglect
Found failure to provide a safe environment for a resident, resulting in neglect and abuse; a $500 fine was assessed.
Abuse—Failed to provide safe environment
04 Mar 2022Abuse: Neglect
04 Mar 2022Abuse: Neglect
Investigated a claim that care planning for a known fall risk was inadequate; found that interventions to mitigate falling were not implemented, leading to multiple falls and injuries.
Abuse—Failed to properly plan care
02 Mar 2022Abuse: Neglect
02 Mar 2022Abuse: Neglect
Investigated allegations found failures to implement interventions for a known fall risk, leading to multiple falls and injuries; substantiated neglect and abuse.
Abuse—Failed to properly plan care
01 Mar 2022Inspection
01 Mar 2022Inspection
Identified noncompliance with weekly reporting requirements for vaccinated individuals, residents, and staff for February 1–28, 2022.
Licensing—Failed to submit timely or adequate staffing documentation
01 Mar 2022Inspection
01 Mar 2022Inspection
Investigated the staffing allegation and found insufficient staff to meet scheduled and unscheduled resident needs, including toileting and eating assistance.
Licensing—Failed to provide appropriate staffing
28 Feb 2022Abuse: Neglect
28 Feb 2022Abuse: Neglect
Found neglect and abuse due to failure to follow the care plan, resulting in a resident fall and medical evaluation; a $750 fine was assessed.
Abuse—Failed to follow care plan
28 Feb 2022Abuse: Neglect
28 Feb 2022Abuse: Neglect
Investigated and found a staffing deficiency led to a resident not receiving a PRN medication, resulting in neglect and abuse.
Abuse—Failed to provide appropriate staffing
25 Feb 2022Inspection
25 Feb 2022Inspection
Investigated and found that RN delegations were not provided or documented as required, and insulin was administered without proper delegation.
Licensing—Failed to administer medication as ordered
25 Feb 2022Inspection
25 Feb 2022Inspection
Found insufficient staffing to meet scheduled and unscheduled resident needs.
Licensing—Failed to provide appropriate staffing
25 Feb 2022Inspection
25 Feb 2022Inspection
Investigated and verified that medication orders were not carried out as prescribed and that blood sugar checks were performed late or not at all as ordered.
Licensing—Failed to follow care plan
23 Feb 2022Abuse: Neglect
23 Feb 2022Abuse: Neglect
Investigated and found neglect due to failure to provide ordered PRN pain medication, resulting in a $450 fine.
Abuse—Failed to provide appropriate pain control
22 Feb 2022Abuse: Neglect
22 Feb 2022Abuse: Neglect
Found deficiencies in fall-risk care planning and failure to implement interventions, leading to injuries; a $1,500 fine was assessed.
Abuse—Failed to properly plan care
22 Feb 2022Inspection
22 Feb 2022Inspection
Found insufficient staff to meet residents' scheduled and unscheduled needs, including bathing, ambulation, and meals.
Licensing—Failed to assist with toileting
22 Feb 2022Abuse: Neglect
22 Feb 2022Abuse: Neglect
Found that a safe medication administration system was not maintained, with multiple doses delayed or omitted for a resident, risking serious harm.
Abuse—Failed to provide a safe medication administration system
22 Feb 2022Abuse: Neglect
22 Feb 2022Abuse: Neglect
Found a failure to provide a safe medication administration system, with multiple doses for a blood sugar disorder administered late or not at all, risking serious harm; a $1,500 fine was assessed.
Abuse—Failed to provide a safe medication administration system
21 Feb 2022Inspection
21 Feb 2022Inspection
Found insufficient staff to meet residents' scheduled and unscheduled needs, including bathing, housekeeping, and laundry.
Licensing—Failed to provide appropriate staffing
21 Feb 2022Inspection
21 Feb 2022Inspection
Verified the allegation that evening medications were not administered as ordered.
Licensing—Failed to provide medical treatment as ordered
21 Feb 2022Inspection
21 Feb 2022Inspection
Investigated and found that exit doors to the common area were not locked after dark and staff were not aware when residents exited to go out in the dark.
Licensing—Failed to provide service
21 Feb 2022Inspection
21 Feb 2022Inspection
Investigated an allegation of inadequate staffing training and verified that a training program to determine direct care staff competency was lacking, with new med tech staff left to work alone without guidance.
Licensing—Failed to provide appropriate staffing
19 Feb 2022Abuse: Neglect
19 Feb 2022Abuse: Neglect
Investigated found a resident left unattended in a supply closet with an opened bottle of body wash, resulting in vomiting and discomfort; a safe environment and adherence to the care plan were not maintained, and a fine was assessed.
Abuse—Failed to provide safe environment
18 Feb 2022Complaint
18 Feb 2022Complaint
Found insufficient staff to meet scheduled and unscheduled resident needs, including night med tech shortages and medication administration delays, with doors locked and areas restricted that left residents unsupervised and at risk.
Deficiency—Staffing Requirements and Training: Staffing
17 Feb 2022Abuse: Neglect
17 Feb 2022Abuse: Neglect
Found neglect and abuse due to failure to provide services and timely medical treatment after falls, resulting in a fractured hip; a $1,500 fine was assessed.
Abuse—Failed to provide service
16 Feb 2022Inspection
16 Feb 2022Inspection
Determined that medication and treatment orders were not carried out as prescribed.
Licensing—Failed to administer medication as ordered
16 Feb 2022Inspection
16 Feb 2022Inspection
Investigated and found a staffing deficiency that left residents without basic care, medications, and treatments.
Licensing—Failed to provide appropriate staffing
16 Feb 2022Inspection
16 Feb 2022Inspection
Found insufficient awake direct care staffing to meet residents' scheduled and unscheduled needs, with families having to assist with showers and bedmaking.
Licensing—Failed to provide appropriate housekeeping services
15 Feb 2022Inspection
15 Feb 2022Inspection
Found insufficient staff to meet residents' scheduled and unscheduled needs, including med techs and caregivers.
Licensing—Failed to assure a qualified caregiver was present
15 Feb 2022Inspection
15 Feb 2022Inspection
Investigated and found a violation for failing to administer medications as ordered by a physician, with missed and late doses verified.
Licensing—Failed to administer medication as ordered
12 Feb 2022Inspection
12 Feb 2022Inspection
Found staffing shortages that did not meet scheduled and unscheduled resident care needs.
Licensing—Failed to provide appropriate staffing
12 Feb 2022Abuse: Neglect
12 Feb 2022Abuse: Neglect
Investigated the allegation and found neglect and abuse due to failure to follow the care plan and assist with toileting, leaving a resident in urine-soaked clothes and at risk of serious harm.
Abuse—Failed to follow care plan
08 Feb 2022Abuse: Neglect
08 Feb 2022Abuse: Neglect
Found neglect due to failure to provide a safe environment after a resident was found about half a mile from the care setting.
Abuse—Failed to provide safe environment
05 Feb 2022Abuse: Neglect
05 Feb 2022Abuse: Neglect
Investigated the allegation and found violations for failing to implement interventions and care planning for a known fall risk. This led to multiple falls with injuries and a $1,800 fine.
Abuse—Failed to properly plan care
31 Jan 2022Abuse: Neglect
31 Jan 2022Abuse: Neglect
Investigated and found a failure to follow the dietary care plan, causing gastric distress; a $500 fine was assessed.
Abuse—Failed to follow care plan
27 Jan 2022Abuse: Neglect
27 Jan 2022Abuse: Neglect
Found failures in the medication administration system that allowed unsafe handling of medications and led to missed doses; a $500 fine was assessed.
Abuse—Failed to provide a safe medication administration system
10 Jan 2022Inspection
10 Jan 2022Inspection
Investigated the complaint and found a deficiency in a policy addressing residents' possessions; the finding verified that residents were dressed in another resident's clothing.
Licensing—Failed to protect resident from financial exploitation
04 Dec 2021Abuse: Neglect
04 Dec 2021Abuse: Neglect
Identified violations for neglect and abuse due to failure to provide a safe environment, with a fine assessed.
Abuse—Failed to provide safe environment
29 Oct 2021Abuse: Neglect
29 Oct 2021Abuse: Neglect
Investigated and found a failure to provide a safe environment, resulting in a resident being hit by another resident.
Abuse—Failed to provide safe environment
14 Oct 2021Abuse: Neglect
14 Oct 2021Abuse: Neglect
Found a failure to provide a safe environment that resulted in an unwitnessed fall with an eye abrasion and discomfort. A $250 fine was assessed.
Abuse—Failed to provide safe environment
15 Aug 2021Abuse: Neglect
15 Aug 2021Abuse: Neglect
Investigated a safety complaint and determined a failure to provide a safe environment that constitutes abuse; a fine of $375 was assessed.
Abuse—Failed to provide safe environment
25 May 2021Inspection
25 May 2021Inspection
Investigated an allegation that hygiene was not provided or assisted with for a resident; the allegation was verified.
Licensing—Failed to provide or assist with hygiene
25 May 2021Inspection
25 May 2021Inspection
Found failure to provide appropriate staffing. The allegation was confirmed.
Licensing—Failed to provide appropriate staffing
12 May 2021Abuse: Neglect
12 May 2021Abuse: Neglect
Determined that staff failed to follow the resident's care plan for refusing care, resulting in neglect and abuse. A $563 fine was assessed.
Abuse—Failed to follow care plan
11 May 2021Abuse: Neglect
11 May 2021Abuse: Neglect
Investigated a resident-to-resident altercation and found inadequate supervision creating an unsafe environment, indicating abuse and neglect with a fine assessed.
Abuse—Failed to provide safe environment
22 Mar 2021Abuse: Neglect
22 Mar 2021Abuse: Neglect
Determined there was a violation for failing to provide a safe environment, leading to a $375 fine.
Abuse—Failed to provide safe environment
22 Mar 2021Abuse: Neglect
22 Mar 2021Abuse: Neglect
Investigated a resident-to-resident incident resulting in an injury; found a failure to provide a safe environment that constitutes abuse and neglect.
Abuse—Failed to provide safe environment
24 Feb 2021Inspection
24 Feb 2021Inspection
Investigated the staffing allegation and verified insufficient staffing.
Licensing—Failed to provide appropriate staffing
16 Jan 2021Abuse: Neglect
16 Jan 2021Abuse: Neglect
Found a violation for failing to provide a safe environment by lacking an effective system to report injuries, creating potential risk of harm.
Abuse—Failed to provide safe environment
07 Aug 2020Inspection
07 Aug 2020Inspection
Found that a safe environment was not provided, resulting in a licensing violation and a $375 fine.
Licensing—Failed to provide safe environment
12 May 2020Inspection
12 May 2020Inspection
Investigated found a staff member physically abused a resident during a shower and inappropriate verbal comments toward a resident were not prevented.
Licensing—Failed to provide safe environment
03 May 2020Abuse: Neglect
03 May 2020Abuse: Neglect
Concluded that the care plan was not followed, resulting in neglect and risk of harm; a fine was assessed.
Abuse—Failed to follow care plan
25 Apr 2020Inspection
25 Apr 2020Inspection
Investigated and found that hazardous materials were not secured, leading to a resident ingesting chemicals, and staff provided milk instead of following Poison Control guidance.
Licensing—Failed to maintain a safe physical environment
22 Mar 2020Abuse: Neglect
22 Mar 2020Abuse: Neglect
Investigated found that an altercation occurred and staff failed to follow the care plan and supervision requirements, resulting in injury and neglect/abuse.
Abuse—Failed to follow care plan
09 Mar 2020Inspection
09 Mar 2020Inspection
Determined that a safety violation occurred and that staff verbally abused the resident.
Licensing—Failed to provide safe environment
19 Feb 2020Inspection
19 Feb 2020Inspection
Found failure to maintain resident care equipment in good repair.
Licensing—Failed to provide or maintain resident care equipment
19 Feb 2020Inspection
19 Feb 2020Inspection
Investigated the allegation and verified a deficiency in heating to maintain 70°F in resident areas.
Licensing—Failed to maintain a safe physical environment
30 Sept 2019Abuse: Neglect
30 Sept 2019Abuse: Neglect
Investigated and found a violation for failing to provide a safe environment, creating risk when a resident wandered out of a locked setting.
Abuse—Failed to provide safe environment
30 Sept 2019Inspection
30 Sept 2019Inspection
Found failure to report suspected abuse; a $750 fine was assessed.
Licensing—Failed to report potential or suspected abuse
07 Aug 2019Abuse: Neglect
07 Aug 2019Abuse: Neglect
Found neglect that caused physical harm to a resident and a $1,500 fine was assessed.
Abuse—Failed to properly plan care
13 Apr 2019Abuse: Neglect
13 Apr 2019Abuse: Neglect
Found neglect of a resident for failing to follow the care plan, resulting in physical harm and unreasonable discomfort, with a $375 fine assessed.
Abuse—Failed to follow care plan
11 Mar 2019Abuse: Neglect
11 Mar 2019Abuse: Neglect
Determined neglect occurred due to failure to maintain an adequate medication system, creating risk of serious harm to a resident.
Abuse—Failed to administer medication as ordered
11 Dec 2018Abuse: Neglect
11 Dec 2018Abuse: Neglect
Found neglect by failing to assess and intervene, causing discomfort to a resident.
Abuse—Failed to assure timely medical treatment
24 Aug 2018Inspection
24 Aug 2018Inspection
Investigated and found inadequate staffing, leaving residents alone in common areas.
Licensing—Failed to provide appropriate staffing
15 Aug 2018Abuse: Sexual abuse
15 Aug 2018Abuse: Sexual abuse
Identified neglect of residents and an allegation of failure to protect a resident from inappropriate sexual contact; a fine was assessed.
Abuse—Failed to protect resident from inappropriate sexual contact
02 Jun 2018Inspection
02 Jun 2018Inspection
Investigated an allegation of failing to follow the care plan. Found a failure to provide a safe environment.
Licensing—Failed to follow care plan
08 May 2017Inspection
08 May 2017Inspection
Investigated an allegation of nursing delegation noncompliance and found a violation.
Licensing—Failed to comply with nursing delegation requirement
08 May 2017Inspection
08 May 2017Inspection
Concluded that there was a licensing violation for failure to oversee and monitor change of condition.
Licensing—Failed to provide oversight and monitoring of change of condition
08 May 2017Inspection
08 May 2017Inspection
Investigated an allegation that a resident record was not kept current or accurate. Determined that the allegation was true.
Licensing—Failed to keep resident record current or accurate
08 May 2017Inspection
08 May 2017Inspection
Concluded that the allegation of failing to provide or maintain resident care equipment was supported.
Licensing—Failed to provide or maintain resident care equipment
08 May 2017Inspection
08 May 2017Inspection
Investigated an allegation and found that a qualified caregiver was not present.
Licensing—Failed to assure that a qualified caregiver was present
02 May 2017Inspection
02 May 2017Inspection
Investigated the allegation of failing to provide a safe environment and found that victims were not protected from inappropriate comment and actions.
Licensing—Failed to provide safe environment
19 Apr 2017Inspection
19 Apr 2017Inspection
Investigated the allegation of failing to provide appropriate activities and identified a deficiency.
Licensing—Failed to provide appropriate activities
24 Mar 2017Inspection
24 Mar 2017Inspection
Determined that the staffing allegation of inadequate staffing was supported by the findings.
Licensing—Failed to provide appropriate staffing
24 Mar 2017Inspection
24 Mar 2017Inspection
Investigated and found a violation related to hiring according to administrative rules.
Licensing—Failed to hire according to administrative rules
15 Mar 2017Inspection
15 Mar 2017Inspection
Investigated the allegation that a reported victim's care plan was not followed. Found noncompliance with the care plan.
Licensing—Failed to follow care plan
01 Nov 2016Inspection
01 Nov 2016Inspection
Investigated a medication management issue and found that an adequate medication system was not maintained.
Licensing—Failed to provide a safe medication administration system
24 Oct 2016Abuse: Neglect
24 Oct 2016Abuse: Neglect
Investigated and found a failure to assess and intervene. Findings supported this deficiency.
Abuse—Failed to provide safe environment
21 Sept 2016Condition
21 Sept 2016Condition
Found violations involving failure to provide a safe environment and inadequate administrative oversight.
Regulatory Action—Failed to provide safe environment
30 Jan 2016Abuse: Financial abuse
30 Jan 2016Abuse: Financial abuse
Found a resident was not protected from theft related to financial exploitation.
Abuse—Failed to protect resident from financial exploitation
08 Dec 2015Abuse: Neglect
08 Dec 2015Abuse: Neglect
Found that a safe environment was not provided.
Abuse—Failed to provide safe environment
10 Oct 2015Abuse: Neglect
10 Oct 2015Abuse: Neglect
Investigated an allegation of failing to follow the care plan and found that appropriate care was not provided.
Abuse—Failed to follow care plan
29 Aug 2015Inspection
29 Aug 2015Inspection
Found that the care plan was not followed. This created potential for harm.
Licensing—Failed to follow care plan
11 Apr 2015Inspection
11 Apr 2015Inspection
Found a failure to administer medication as ordered and to maintain an adequate medication system.
Licensing—Failed to administer medication as ordered
08 Apr 2015Inspection
08 Apr 2015Inspection
Found that medication was not administered as ordered. This resulted in a Level 2 licensing violation.
Licensing—Failed to administer medication as ordered
07 Apr 2015Inspection
07 Apr 2015Inspection
Determined that there was an inadequate medication system and that medications were not administered as ordered.
Licensing—Failed to administer medication as ordered
06 Apr 2015Inspection
06 Apr 2015Inspection
Found a medication administration violation for failing to administer medication as ordered.
Licensing—Failed to administer medication as ordered
02 Apr 2015Inspection
02 Apr 2015Inspection
Found a medication administration deficiency.
Licensing—Failed to administer medication as ordered
01 Apr 2015Inspection
01 Apr 2015Inspection
Found the medication system was inadequate and medications were not administered as ordered.
Licensing—Failed to administer medication as ordered
19 Mar 2015Abuse: Neglect
19 Mar 2015Abuse: Neglect
Investigated an allegation of failing to administer medication as ordered and identified a deficient medication administration system.
Abuse—Failed to administer medication as ordered
15 Mar 2015Inspection
15 Mar 2015Inspection
Found an inadequate medication system and confirmed failure to administer medication as ordered.
Licensing—Failed to administer medication as ordered
14 Mar 2015Inspection
14 Mar 2015Inspection
Found a deficiency in medication administration where the reported victim's medication was not given as ordered.
Licensing—Failed to provide a safe medication administration system
11 Mar 2015Inspection
11 Mar 2015Inspection
Found a deficient safe medication system. Investigated an allegation of failing to administer medications as ordered.
Licensing—Failed to administer medication as ordered
05 Mar 2015Inspection
05 Mar 2015Inspection
Found a failure to provide a safe medication administration system.
Licensing—Failed to provide a safe medication administration system
25 Feb 2015Inspection
25 Feb 2015Inspection
Found failure to administer medication as ordered.
Licensing—Failed to administer medication as ordered
06 Feb 2015Inspection
06 Feb 2015Inspection
Investigated an allegation of unsafe medication administration and found medications were not administered as ordered.
Licensing—Failed to provide a safe medication administration system
28 Jan 2015Inspection
28 Jan 2015Inspection
Investigated allegations found a failure to provide a safe medication administration system. The violation was substantiated and a $300 fine was assessed.
Licensing—Failed to provide a safe medication administration system
09 Jan 2015Inspection
09 Jan 2015Inspection
Found a deficiency in safe medication administration; medications were not administered as ordered.
Licensing—Failed to provide a safe medication administration system
07 Jan 2015Inspection
07 Jan 2015Inspection
Identified a deficiency in medication recordkeeping and safe medication administration. The finding indicated that a safe medication administration system was not maintained.
Licensing—Failed to keep medication record current or accurate
01 Jan 2015Inspection
01 Jan 2015Inspection
Found that one medication was not administered as ordered.
Licensing—Failed to administer medication as ordered
26 Dec 2014Inspection
26 Dec 2014Inspection
Found that a medication was not administered as ordered to residents RV1 and RV2.
Licensing—Failed to administer medication as ordered
17 Dec 2014Inspection
17 Dec 2014Inspection
Investigated an allegation of failing to provide a safe medication administration system and identified an inadequate medication system.
Licensing—Failed to provide a safe medication administration system
30 Nov 2014Abuse: Financial abuse
30 Nov 2014Abuse: Financial abuse
Investigated an allegation of financial abuse and found that a secure environment was not maintained.
Abuse—Failed to provide safe environment
16 Nov 2014Inspection
16 Nov 2014Inspection
Determined that a medication was not provided as ordered, resulting in a licensing violation being substantiated.
Licensing—Failed to provide medical treatment as ordered
13 Oct 2014Inspection
13 Oct 2014Inspection
Identified deficiencies in maintaining a safe medication administration system with potential for harm to residents.
Licensing—Failed to provide a safe medication administration system
24 Jun 2014Inspection
24 Jun 2014Inspection
Found a hygiene care deficiency with potential for harm.
Licensing—Failed to provide or assist with hygiene
09 Jun 2014Abuse: Neglect
09 Jun 2014Abuse: Neglect
Investigated the allegation of neglect and found a failure to protect a resident from an injury.
Abuse—Failed to provide safe environment
13 May 2014Abuse: Neglect
13 May 2014Abuse: Neglect
Found neglect due to failure to provide peri care to a resident.
Abuse—Failed to provide peri care
10 Apr 2013Abuse: Financial abuse
10 Apr 2013Abuse: Financial abuse
Concluded the financial abuse allegation to be substantiated and that personal belongings were not protected from theft.
Abuse—Failed to provide safe environment
20 Jan 2013Abuse: Neglect
20 Jan 2013Abuse: Neglect
Investigated an allegation of abuse/neglect and found failure to assess and intervene. A $300 fine was assessed.
Abuse—Failed to perform adequate screening or assessment
11 May 2012Abuse: Neglect
11 May 2012Abuse: Neglect
Investigated the allegation of failing to obtain appropriate consultation and found that appropriate care was not provided.
Abuse—Failed to obtain appropriate consultation
12 Feb 2011Abuse: Neglect
12 Feb 2011Abuse: Neglect
Determined that a resident safety failure occurred due to failure to assess and intervene.
Abuse—Failed to assure resident was safe
Disclaimer
Mirador Living is not affiliated with the owner or operator(s) of Maple Grove Memory Care. The information above has not been verified or approved by the owner or operator. For exact information, please contact Maple Grove Memory Care directly. There is no cost for this service. We are compensated by the community you select.
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