I placed my mom at St. Andrews and I'm very pleased - the gorgeous historic building, chapel and grounds feel peaceful, rooms are comfortable, and meals/cleanliness are solid. The leadership and front-line staff (Joshua, the activities team and nurses) are professional, compassionate and family-minded, very receptive to family input, and keep residents engaged with daily activities and easy video calls. My loved one is safer, happier and well cared for here; I recommend it.
Loved one of resident
Jul 2026
Pricing
Prices shown are estimates and subject to change. Contact your senior living advisor for current pricing.
Schedule a Tour
Amenities
Healthcare services
Activities of daily living assistance
Assistance with bathing
Assistance with dressing
Assistance with transfers
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
4.24·(71)
Overall rating
5
4
3
2
1
Care
4.2
Staff
4.4
Meals
4.2
Amenities
4.2
Value
3.5
Pros
Historic, well-preserved architecture
On-site chapel and religious services
Attractive grounds and outdoor walking areas
Cottage-style dementia-care model with level-based grouping
Acceptance of Medicaid
Compassionate, family-oriented caregiving
Engaging, active activities program
Strong nursing and hospice collaboration
Rooms with natural light and cozy common areas
Organized admissions and informative tours
Secure environment and sense of safety
Clean, well-maintained hallways and public spaces
Pleasant meals and attentive dining staff
Smaller community feel and resident socialization
Cons
High staff turnover and inconsistent staffing
Gaps in family communication and billing transparency
Training deficiencies for caregivers and medication technicians
Medication management and PRN access
Inadequate memory-care staffing levels at times
Layout and multi-level design complicating supervision and outdoor access
Inconsistent cleanliness and sanitation issues in some areas
Weak supervision and fall-prevention practices
Management instability and frequent leadership changes
Gaps in end-of-life coordination and post-transition communication
Summary of reviews
St. Andrews Memory Care is consistently described as a visually distinctive, historic campus with preserved architectural details, an on-site chapel, and extensive outdoor space. Many families and visitors praise the grounds, natural light in rooms, cozy common areas and the sense of a smaller, community-focused environment. The facility operates a cottage-style dementia-care model that groups residents by cognitive level and accepts Medicaid; admissions and tours are frequently characterized as organized and informative.
Care quality and staff behavior are recurring focal points. Numerous accounts highlight compassionate, family-oriented caregiving, strong nursing and hospice collaboration, and staff who engage residents warmly. The activities program is repeatedly identified as a strength: an active calendar, enthusiastic activity leaders, and regular social opportunities that many families felt improved residents’ engagement. Dining is generally viewed positively, with several families noting satisfying meals and attentive dining staff.
At the same time, reviewers identify operational and clinical patterns that warrant attention. A high rate of staff turnover and frequent changes in management were cited as contributors to inconsistent staffing and supervision. Several comments point to training gaps for direct-care aides and medication technicians, and there are specific concerns about medication-management practices, including access to PRN medications and recent medication changes. These staffing and training issues are associated with reports of uneven supervision and fall-prevention practices.
The facility’s historic, multi-level layout is both an asset and a challenge. The chapel, preserved woodwork and building character create a distinctive setting, but multiple floors, long hallways and limited immediate outdoor access on some levels were described as complicating supervision and resident mobility. Cleanliness and sanitation were praised in many accounts, yet a number of notes referenced inconsistent upkeep in particular areas, suggesting variable housekeeping standards across units.
Communication and management practices show a mixed picture. Admissions and tour experiences are often positive, with helpful staff and clear orientation. However, families also describe gaps in routine communication, unclear billing or follow-up after a resident’s death, and variable responsiveness from leadership. Several reviews advise prospective families to ask specific questions about staffing consistency, medication protocols, end-of-life coordination, and housekeeping standards during visits.
Overall, St. Andrews appears well suited to families who prioritize a historic, homelike campus, a strong activities program, religious services, and compassionate bedside nursing/hospice collaboration. Prospective residents and their families seeking tighter clinical oversight, consistent caregiver assignments, single-level outdoor access, or robust documentation of medication and post-transition procedures should conduct targeted inquiries during tours and confirm current staffing and training practices before making a placement decision.
Reviews written on Mirador
We have no reviews to show about St. Andrews Memory Care.
Help other families by writing a review about your experience with this community.
Location
St. Andrews Memory Care is located at 7617 SE Main St, Portland, OR, 97215.
About St. Andrews Memory Care
St. Andrews Memory Care sits in southeast Portland and is built just for seniors living with Alzheimer's disease and other types of dementia, and you can see right away that every detail aims to help folks stay comfortable and safe. The community has 85 beds, all used for memory care, and you'll notice the property is fully secured with wandering prevention measures like bracelets that set off alarms if someone's going somewhere they shouldn't. The whole campus has recent updates with wide hallways, wheelchair accessible showers, accessible bathrooms, and big windows, and you'll see lots of elegant touches and lush, landscaped gardens where residents can relax or chat with visitors out in the fresh air. There's a friendly, home-like feeling inside, with cozy armchairs, pleasant artwork, and community areas filled with comfortable spots to gather, and it's the sort of place where families might come to visit and sit together for a while. Each resident gets to choose from several room layouts, like companion suites with two bedrooms or private studios with their own closet and bathroom, and all rooms have beds, easy chairs, and plenty of space for personal things.
The staff includes activity directors, certified nursing assistants, RNs, therapists, and full-time caregivers who know how to help people with different levels of memory loss, and the community stays busy with activities like art classes, music therapy, cooking classes, stretching, Qi Gong, chair yoga, gardening clubs, and trips to local places, plus intergenerational programs that bring younger folks in for visits. Services go beyond meals and housekeeping, and you'll find that people here get medication management, diabetes care including blood sugar monitoring and insulin when prescribed, help with nutrition, hygiene, and mobility, as well as extra care for folks with incontinence or at risk for wandering off. Transfers are handled with standby, one-person, two-person, or mechanical lift help, depending on what each resident needs, and staff are always present, day and night.
The whole property's designed for memory care, with safety and ease of movement in mind, and you'll see groups doing activities or sitting beside the piano or TV in one of the common areas, and it doesn't feel like a hospital-more like a big house. St. Andrews offers three levels of care-from lighter help for folks who mostly get around on their own, to heavier support for those with more complex needs, and this lets people stay in the same home even if their health changes. Meals are cooked on-site, with options for special diets like gluten-free, low sodium, low sugar, and vegetarian, so even people with strict medical diets can eat with everyone else, and there's a beautician too. Families can attend devotionals on site, and there's off-site transport available for appointments.
This community stands alone as a memory care facility and belongs to the Oregon Health Care Association, carrying multiple healthcare accreditations. The campus location is close to Providence St. Vincent Medical Center and is easy to reach using public transportation if relatives or friends want to visit. St. Andrews Memory Care works to reduce confusion and loneliness, giving residents a routine and environment that feels familiar and safe, and staff offer ongoing support and education for families trying to understand or manage their loved ones' memory problems. Costs for rooms average around $6,550 for a private studio and $5,050 for a semi-private suite, and everything from housing, therapy, meals, and activities is designed for people with memory impairments in mind.
Pacifica Senior Living, a division of Pacifica Companies (family-owned since 1978), was founded in 2008 and is headquartered in San Diego, California. Operating over 90 communities across 13-14 states with concentrations in California, Florida, and Arizona, Pacifica has grown to become the 13th largest overall senior care provider in the United States. The company ranks as the 5th largest memory care provider, 10th largest assisted living provider, and 21st largest independent living provider nationally, serving thousands of residents from coast to coast through their comprehensive care offerings.
Pacifica's mission centers on creating a lifestyle of independence, security, and peace of mind for each individual and their family. The company provides personalized, compassionate care services through their signature Heartland™ Assisted Living and Legacies™ Memory Care programs, which focus on the individual while offering customized care plans that respect each resident's needs, preferences, and privacy. Their philosophy emphasizes striking a balance between assistance and independence, providing dignified and compassionate retirement experiences in environments that feel like home. Each community is managed individually, allowing for tailored support of unique resident profiles and communal character, with everything from scheduling to dining menus designed around residents' preferences.
The company's specialized memory care programs demonstrate their expertise in dementia care. Their Legacies™ Memory Care program helps patients with Alzheimer's disease and other forms of memory loss feel safe and secure while providing memory-boosting activities. The innovative Amara Memory Support program creates welcoming and empowering environments that celebrate the essence of people rather than focusing on their diagnosis. Programming encompasses nine Focus Elements of Life: Recreation, Service, Spirituality, Movement, Sensory, Household Connection, Community, Exploration, and Creative Arts, delivered through stimulating activities including gardening, culinary adventures, musical experiences, creative artistic outlets, and mindfulness practices.
Pacifica offers a comprehensive continuum of care including independent living, assisted living, memory care, respite care, skilled nursing, and adult day care services. All communities focus on promoting well-being by meeting care needs while facilitating social interactions, activities, and wellness programs. Despite recent financial challenges leading to the bankruptcy of one management entity affecting approximately 20 California facilities, the majority of Pacifica's nearly 100 communities continue operating, maintaining their commitment to advancing senior living and providing peace of mind to residents and families through warm, family-like communities where each resident receives individualized attention while maintaining dignity and independence.
People often ask...
St. Andrews Memory Care offers competitive pricing, with rates starting at a cost of $6,656 per month.
St. Andrews Memory Care offers assisted living and memory care.
There are 53 photos of St. Andrews Memory Care on Mirador.
The full address for this community is 7617 SE Main St, Portland, OR 97215.
No, St. Andrews 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.
Deficiency—Resident Move-in & Evaluation: Res Evaluation
Deficiency—Service Plan: General
Deficiency—Change of Condition and Monitoring
Deficiency—Infection Prevention & Control
Deficiency—Systems: Treatment Orders
Deficiency—Systems: Medication Administration
Deficiency—Systems: Psychotropic Medication
Deficiency—Staffing Requirements and Training: Staffing
Deficiency—Acuity Based Staffing Tool - Updates & Staffing Plan
Deficiency—Training Within 30 Days of Hire – Direct Care Staff
Deficiency—Fire and Life Safety: Safety
Deficiency—Doors, Walls, Elevators, Odors
Deficiency—Resident Move-in & Evaluation: Res Evaluation
Deficiency—Staffing Requirements and Training – Pre-service
Deficiency—Administration Compliance
Deficiency—Staff Training Requirements
Deficiency—Compliance with Rules Health Care
Deficiency—Activities
25 Dec 2025Inspection
25 Dec 2025Inspection
Identified a safety deficiency for the absence of an exit door alarm or equivalent system to alert staff when a resident exited.
Licensing—Failed to maintain a safe physical environment
07 Oct 2025Inspection
07 Oct 2025Inspection
Investigated a claim of neglect for failing to add a newly prescribed narcotic to the medication administration record, resulting in unmanaged pain. Found violations related to medication administration and pain management.
Licensing—Failed to administer ordered medication
24 Jul 2025Abuse: Neglect
24 Jul 2025Abuse: Neglect
Investigated a medication administration failure; found an unsigned antibiotic order led to a five-day delay in treatment and patient discomfort due to an unsafe medication administration system.
Abuse—Failed to provide a safe medication administration system
24 Jul 2025Kitchen
24 Jul 2025Kitchen
Identified deficiencies in kitchen sanitation and administration compliance related to licensing rules.
Investigated a failure to provide a safe medication administration system that led to a missed antiseizure dose and a medical emergency.
Abuse—Failed to provide a safe medication administration system
12 Jun 2025Inspection
12 Jun 2025Inspection
Found that ABST evaluations were not completed, updated, or reviewed quarterly for each resident as required.
Licensing—Failed to use an ABST
12 Jun 2025Abuse: Neglect
12 Jun 2025Abuse: Neglect
Investigated and found deficiencies in the medication administration process that led to missed doses and harm.
Abuse—Failed to provide a safe medication administration system
05 May 2025Inspection
05 May 2025Inspection
Investigated the failure to complete or update quarterly ABST evaluations for every resident and concluded a violation of Oregon Administrative Rules.
Licensing—Failed to use an ABST
17 Apr 2025Inspection
17 Apr 2025Inspection
Found a violation for not administering medication as ordered, resulting in two patches on a person and potential harm; a $1,500 fine was assessed.
Licensing—Failed to administer medication as ordered
17 Apr 2025Abuse: Neglect
17 Apr 2025Abuse: Neglect
Investigated the allegation of neglect and abuse related to care and monitoring; observed inadequate follow-up for a skin injury that worsened and caused pain.
Abuse—Failed to provide service
03 Apr 2025Abuse: Neglect
03 Apr 2025Abuse: Neglect
Investigated and found failures in medication administration safety that left a resident without prescribed medication, causing harm.
Abuse—Failed to provide a safe medication administration system
03 Apr 2025Inspection
03 Apr 2025Inspection
Found that the facility failed to complete or update and review the Acuity-Based Staffing Tool evaluations quarterly.
Licensing—Failed to use an ABST
27 Mar 2025Inspection
27 Mar 2025Inspection
Identified failure to complete or update quarterly ABST evaluations for each resident.
Licensing—Failed to use an ABST
20 Mar 2025Inspection
20 Mar 2025Inspection
Investigated and identified a failure to complete, update, and review ABST evaluations quarterly for each resident.
Licensing—Failed to use an ABST
18 Mar 2025Abuse: Neglect
18 Mar 2025Abuse: Neglect
Investigated a feeding-related incident and found the care planning did not address known aspiration risk, resulting in abuse and neglect findings and a fine.
Abuse—Failed to properly plan care
22 Dec 2024Abuse: Neglect
22 Dec 2024Abuse: Neglect
Investigated and found neglect of care and abuse after a resident developed a Stage IV wound from a geri-sleeve incident; a $1125 fine was assessed.
Abuse—Failed to follow care plan
22 Nov 2024License Condition
22 Nov 2024License Condition
Found violations indicating an unsafe environment that placed residents at immediate jeopardy.
Regulatory Action—Failed to provide safe environment
15 Jul 2024Change of Owner
15 Jul 2024Change of Owner
Identified multiple deficiencies in resident care, safety, infection control, and privacy during a change of ownership review.
Deficiency—Staffing Requirements and Training: Staffing
Deficiency—Fire and Life Safety: Safety
Deficiency—Inspections and Investigation: Insp Interval
Deficiency—General Building Exterior
Deficiency—Doors, Walls, Elevators, Odors
Deficiency—Housekeeping and Laundry
Deficiency—Heating and Ventilation
Deficiency—Individual Rights Settings: Privacy, Dignity
Deficiency—Individual Privacy: Own Unit
Deficiency—Individual Door Locks: Key Access
Deficiency—Administration Compliance
Deficiency—Staff Training Requirements
Deficiency—Compliance With Rules Health Care
03 Jul 2024Licensure
03 Jul 2024Licensure
Determined substantial compliance with meal services requirements and related food sanitation rules.
Deficiency—Comment
17 Jun 2024Complaint
17 Jun 2024Complaint
Investigated identified multiple care deficiencies, including failure to report abuse, failure to implement services, poor coordination of health services, unsafe medication administration, and unsecured outdoor areas.
Deficiency—Res Hlth Srvc: On- and Off-Site Health Srvc
Deficiency—Systems: Medications and Treatments
Deficiency—Secure Outdoor Recreation Area
16 Jun 2024Inspection
16 Jun 2024Inspection
Found a violation for failing to provide a safe environment due to exterior courtyard doors being left unsecured multiple times.
Licensing—Failed to provide safe environment
18 Mar 2024Abuse: Neglect
18 Mar 2024Abuse: Neglect
Investigated and found a failure to provide a safe environment after observed inappropriate sexual contact, resulting in abuse and neglect.
Abuse—Failed to provide safe environment
22 Feb 2024Inspection
22 Feb 2024Inspection
Found that a service was not provided due to failure to coordinate care with off-site health services.
Licensing—Failed to provide service
18 Jan 2024Abuse: Neglect
18 Jan 2024Abuse: Neglect
Found inadequate fall interventions were planned, resulting in four falls and a compression fracture.
Abuse—Failed to properly plan care
07 Jan 2024Abuse: Neglect
07 Jan 2024Abuse: Neglect
Determined neglect and abuse due to failure to properly plan care, resulting in increased behaviors, falls, and injuries.
Abuse—Failed to properly plan care
03 Oct 2023Inspection
03 Oct 2023Inspection
Found that the allegation that a care plan was not followed led to an unsafe environment and abuse.
Licensing—Failed to provide safe environment
30 Sept 2023Abuse: Neglect
30 Sept 2023Abuse: Neglect
Determined that the care plan was not followed, leaving a scoop mattress on the bed and placing the resident at risk of harm.
Abuse—Failed to follow care plan
20 Sept 2023Abuse: Neglect
20 Sept 2023Abuse: Neglect
Investigated allegations of abuse and neglect due to failure to properly plan and monitor care, which led to injuries from wandering.
Abuse—Failed to properly plan care
15 Sept 2023Abuse: Neglect
15 Sept 2023Abuse: Neglect
Investigated a complaint of abuse and neglect; found that physical restraint and aggressive contact harmed a resident and violated rights and Oregon rules.
Abuse—Failed to protect resident from physical abuse
15 Sept 2023Inspection
15 Sept 2023Inspection
Investigated found that restraints were used in a forceful manner and staff did not report it, indicating systemic failure and abuse of a resident.
Licensing—Failed to assure resident rights
15 Sept 2023Inspection
15 Sept 2023Inspection
Found that an internal review was incomplete and a staff member who restrained residents was returned to work. A resident was held in a forceful restraint, creating an unsafe environment and risk of abuse.
Licensing—Failed to provide safe environment
02 Sept 2023Inspection
02 Sept 2023Inspection
Investigated and determined a violation for failing to have medication available and to ensure a safe medication administration system.
Licensing—Failed to have medication available
02 Sept 2023Abuse: Neglect
02 Sept 2023Abuse: Neglect
Investigated and found failure to provide one-on-one supervision per the care plan, resulting in an unwitnessed altercation and injury.
Abuse—Failed to follow care plan
01 Sept 2023Abuse: Neglect
01 Sept 2023Abuse: Neglect
Investigated the allegation of abuse/neglect. Findings showed staff restrained the resident on multiple occasions, causing physical and emotional distress, and mandatory reporting was not completed.
Abuse—Failed to protect resident from physical abuse
01 Sept 2023Inspection
01 Sept 2023Inspection
Found violations for failing to provide a safe environment and for using restraining or forceful handling during transfers of the alleged victim.
Licensing—Failed to provide safe environment
30 Aug 2023Abuse: Neglect
30 Aug 2023Abuse: Neglect
Investigated an abuse allegation found that restraints were used forcefully on a resident and that mandated reporting did not occur, revealing systemic oversight failures and a violation of resident rights.
Abuse—Failed to assure resident rights
30 Aug 2023Inspection
30 Aug 2023Inspection
Determined that a resident experienced physical abuse by a staff member and protections for the resident were not adequate.
Licensing—Failed to protect resident from physical abuse
25 Aug 2023Inspection
25 Aug 2023Inspection
Determined a failure to immediately notify local authorities about abuse or suspected abuse occurred. This finding identified a violation of reporting requirements.
Licensing—Failed to report potential or suspected abuse
30 Jul 2023Abuse: Neglect
30 Jul 2023Abuse: Neglect
Investigated found a failure to provide a safe environment for a resident, resulting in a fall and injury; this constitutes abuse.
Abuse—Failed to provide safe environment
25 Jul 2023License Condition
25 Jul 2023License Condition
Investigated the allegation and found failure to use an ABST.
Regulatory Action—Failed to use an ABST
25 Jul 2023License Condition
25 Jul 2023License Condition
Investigated the allegation of failing to report potential or suspected abuse and found a violation of the reporting rule.
Regulatory Action—Failed to report potential or suspected abuse
25 Jul 2023License Condition
25 Jul 2023License Condition
Found deficiencies in hygiene assistance, including failure to assist with bathing and washing hair. A resident reportedly had feces in their hair that had to be cut out.
Regulatory Action—Failed to provide or assist with hygiene
28 Jun 2023Abuse: Neglect
28 Jun 2023Abuse: Neglect
Investigated the allegation and found violations related to improper care planning and fall interventions. These deficiencies contributed to a fall resulting in a head injury.
Abuse—Failed to properly plan care
25 May 2023Inspection
25 May 2023Inspection
Found a deficiency due to lack of a pre-service orientation and training program for all direct care staff.
Licensing—Failed to provide inservice
25 May 2023Inspection
25 May 2023Inspection
Found that medications were not kept secure between setup and administration. The finding was substantiated.
Licensing—Failed to provide a safe medication administration system
25 May 2023Inspection
25 May 2023Inspection
Found that the required copy of the most current inspection report and license conditions was not posted in public view near the main entrance.
Licensing—Failed to provide safe environment
25 May 2023Inspection
25 May 2023Inspection
Found deficient oversight of the medication and treatment administration system, risking resident safety.
Licensing—Failed to provide safe environment
25 May 2023Inspection
25 May 2023Inspection
Found that required trainings for all staff were not completed.
Licensing—Failed to provide inservice
25 May 2023Inspection
25 May 2023Inspection
Found the outdoor recreation area lacked secured space and furniture of sufficient weight and stability to prevent injury or elopement.
Licensing—Failed to provide safe environment
25 May 2023Inspection
25 May 2023Inspection
Found that resident service plans were not readily available to staff and lacked clear guidance on service delivery, and that changes to the plans were not dated and initialed as required.
Licensing—Failed to provide safe environment
08 May 2023Abuse: Neglect
08 May 2023Abuse: Neglect
Found neglect and abuse due to failure to properly plan care, resulting in repeated falls and injuries.
Abuse—Failed to properly plan care
20 Apr 2023Complaint
20 Apr 2023Complaint
Identified multiple violations across governance, staffing, privacy, medication management, resident care, and facility safety, including improper supervision, inadequate training, and unsafe conditions.
Deficiency—Staffing Requirements and Training: Staffing
Deficiency—Acuity-Based Staffing Tool
Deficiency—Staffing Rqmt and Training: Training Rqmts
Deficiency—Staffing Requirements and Training – Pre-Serv
Deficiency—Training Within 30 Days: Direct Care Staff
Deficiency—Inspect and Investigations: Posting Surveys
Deficiency—Doors, Walls, Elevators, Odors
Deficiency—Staff Training Requirements
Deficiency—Secure Outdoor Recreation Area
16 Apr 2023Abuse: Neglect
16 Apr 2023Abuse: Neglect
Found a deficiency in safe medication administration that placed a resident at risk of serious harm. A $1,500 fine was assessed.
Abuse—Failed to provide a safe medication administration system
20 Mar 2023Inspection
20 Mar 2023Inspection
Investigated a complaint and found that a staff member failed to follow the resident's care plan for wheelchair transfers, resulting in a fall and discomfort and violating resident rights.
Licensing—Failed to assure resident was safe
06 Mar 2023Inspection
06 Mar 2023Inspection
Found that a resident did not have a safe and homelike environment, violating a rule.
Licensing—Failed to provide safe environment
06 Mar 2023Inspection
06 Mar 2023Inspection
Found that medication and treatment orders were not carried out as prescribed.
Licensing—Failed to provide a safe medication administration system
06 Mar 2023Inspection
06 Mar 2023Inspection
Found failure to provide assistance with toileting and bowel and bladder management, violating applicable rules.
Licensing—Failed to provide service
06 Mar 2023Inspection
06 Mar 2023Inspection
Found a deficiency for not documenting observation and evaluation of an individual's ability to perform safe medication administration unsupervised.
Licensing—Failed to provide a safe medication administration system
06 Mar 2023Inspection
06 Mar 2023Inspection
Found absence of a written policy prohibiting the falsification of records.
Licensing—Falsified records
06 Mar 2023Inspection
06 Mar 2023Inspection
Identified a failure to develop and implement a smoking policy in accordance with applicable rules.
Licensing—Failed to provide safe environment
06 Mar 2023Inspection
06 Mar 2023Inspection
Found a deficiency in supervision and training of staff, and in overall staff conduct when performing duties. This deficiency supported a licensing violation.
Licensing—Failed to provide safe environment
06 Mar 2023Inspection
06 Mar 2023Inspection
Identified insufficient qualified awake direct care staffing to meet 24-hour scheduled and unscheduled needs.
Licensing—Failed to provide service
06 Mar 2023Inspection
06 Mar 2023Inspection
Found interior and exterior surfaces were not kept clean. This violated the applicable rule.
Licensing—Failed to provide service
27 Feb 2023Abuse: Neglect
27 Feb 2023Abuse: Neglect
Found failures to plan care for falls, leading to several unwitnessed falls and ongoing discomfort; a $1500 fine was assessed.
Abuse—Failed to properly plan care
26 Feb 2023Abuse: Neglect
26 Feb 2023Abuse: Neglect
Investigated a resident abuse/neglect allegation; found the staff member's actions inconclusive for abuse, while there was a failure to protect the resident, resulting in neglect and abuse.
Abuse—Failed to protect resident from physical abuse
26 Jan 2023Abuse: Neglect
26 Jan 2023Abuse: Neglect
Found neglect due to failure to follow the care plan, resulting in pressure sores and ongoing discomfort. A subsequent lapse in care to address the pressure sore extended harm.
Abuse—Failed to follow care plan
23 Nov 2022Abuse: Neglect
23 Nov 2022Abuse: Neglect
Investigated the allegation and found inadequate care planning for wound care, resulting in new foot wounds and neglect/abuse.
Abuse—Failed to properly plan care
10 Oct 2022Abuse: Neglect
10 Oct 2022Abuse: Neglect
Found neglect and abuse due to failure to plan and monitor falls-related care, resulting in unwitnessed falls and discomfort.
Abuse—Failed to properly plan care
24 Aug 2022Abuse: Neglect
24 Aug 2022Abuse: Neglect
Determined that a failure to provide a safe environment led to abuse; a $250 fine was assessed.
Abuse—Failed to provide safe environment
17 Aug 2022Inspection
17 Aug 2022Inspection
Found a deficiency in oversight and reporting of changes in a resident's condition. Lacked a protocol and designated staff to determine actions and communicate changes to direct care staff.
Licensing—Failed to provide oversight and monitoring of change of condition
17 Aug 2022Inspection
17 Aug 2022Inspection
Investigated and identified a deficiency in training and competency documentation for direct care staff.
Licensing—Failed to provide inservice
17 Aug 2022Inspection
17 Aug 2022Inspection
Found that ABST was not fully implemented and related staffing levels did not align with ABST for 22 required ADLs.
Licensing—Failed to use an ABST
17 Aug 2022Inspection
17 Aug 2022Inspection
Found a failure to assist with toileting and bladder management, resulting in a substantiated licensing violation.
Licensing—Failed to provide service
02 Aug 2022Abuse: Neglect
02 Aug 2022Abuse: Neglect
Found a failure to follow a resident's care plan related to bed alarms, placing the resident at risk of harm; a fine was assessed.
Abuse—Failed to follow care plan
01 Jul 2022Inspection
01 Jul 2022Inspection
Found that medications were not administered as ordered, indicating a deficiency in the medication administration process.
Licensing—Failed to provide a safe medication administration system
01 Jul 2022Inspection
01 Jul 2022Inspection
Determined that a written policy prohibiting falsification of records was not developed or implemented.
Licensing—Failed to provide safe environment
01 Jul 2022Inspection
01 Jul 2022Inspection
Found that services were not provided in a manner that protects privacy and dignity.
Licensing—Failed to provide service
28 Jun 2022Abuse: Neglect
28 Jun 2022Abuse: Neglect
Found inadequate supervision that allowed a resident to elope from a secured area, creating risk of harm.
Abuse—Failed to provide safe environment
28 Jun 2022Abuse: Neglect
28 Jun 2022Abuse: Neglect
Found inadequate supervision leading to a resident eloping and at risk of harm; a fine of $188 was assessed.
Abuse—Failed to provide safe environment
23 Jun 2022Abuse: Neglect
23 Jun 2022Abuse: Neglect
Investigated a complaint and concluded that failure to properly plan and monitor care led to a resident's facial injury and hospital transfer. This constitutes abuse and neglect.
Abuse—Failed to properly plan care
06 May 2022Inspection
06 May 2022Inspection
Identified a deficient safe medication administration system that resulted in a resident receiving another resident's medication and being hospitalized in a sedated state.
Licensing—Failed to provide a safe medication administration system
02 May 2022Validation
02 May 2022Validation
Investigated findings identified widespread deficiencies across administration, resident care planning, health services, staffing, nutrition, activities, behavior, and safety, resulting in multiple citations.
Deficiency—Resident Move-In and Eval: Res Evaluation
Deficiency—Service Plan: General
Deficiency—Service Plan: Service Planning Team
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—Systems: Medications and Treatments
Deficiency—Systems: Treatment Orders
Deficiency—Systems: Medication Administration
Deficiency—Systems: Psychotropic Medication
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—Conditions
Deficiency—General Building Exterior
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—Behavior
02 May 2022Inspection
02 May 2022Inspection
Identified a deficiency for failing to submit timely or adequate staffing documentation.
Licensing—Failed to submit timely or adequate staffing documentation
18 Apr 2022Abuse: Neglect
18 Apr 2022Abuse: Neglect
Identified a neglect-related deficiency in the medication administration system that caused a resident to experience pain.
Abuse—Failed to provide a safe medication administration system
01 Apr 2022Inspection
01 Apr 2022Inspection
Found a violation for failing to submit timely staffing documentation and weekly vaccination reporting; assessed a $7,500 fine.
Licensing—Failed to submit timely or adequate staffing documentation
01 Mar 2022Inspection
01 Mar 2022Inspection
Found failure to submit timely weekly vaccination reporting for residents, staff, and vaccinated individuals for 27 days. This resulted in a licensing violation.
Licensing—Failed to submit timely or adequate staffing documentation
22 Feb 2022Abuse: Neglect
22 Feb 2022Abuse: Neglect
Investigated and found substantiated abuse and neglect due to failure to address resident behavior, resulting in injuries from resident-to-resident altercations. A $250 fine was assessed.
Abuse—Failed to address resident's behavior
12 Feb 2022Inspection
12 Feb 2022Inspection
Investigated and identified a records-retention deficiency. AV records were not kept for three years after the resident's passing, violating Oregon Administrative Rules.
Licensing—Failed to follow care plan
29 Dec 2021Abuse: Neglect
29 Dec 2021Abuse: Neglect
Found failures to follow the care plan and provide appropriate supervision, allowing a resident to wander into another resident's room and injure themselves, constituting abuse.
Abuse—Failed to provide safe environment
23 Aug 2021Abuse: Neglect
23 Aug 2021Abuse: Neglect
Investigated an incident and found a failure to provide a safe environment, resulting in violations and a $500 fine.
Abuse—Failed to provide safe environment
17 Aug 2021Abuse: Neglect
17 Aug 2021Abuse: Neglect
Investigated a complaint and found a failure to provide a safe environment, resulting in a physical altercation and injuries. Identified abuse and neglect.
Abuse—Failed to provide safe environment
04 Aug 2021Abuse: Neglect
04 Aug 2021Abuse: Neglect
Found that a staff member verbally abused a resident and that care planning and training were inadequate, constituting abuse and neglect. A 2,250 fine was assessed.
Abuse—Failed to protect resident from verbal abuse
04 Aug 2021Abuse: Neglect
04 Aug 2021Abuse: Neglect
Investigated a complaint and found a staff member physically abused a resident and the provider failed to protect and plan for the resident's behaviors, resulting in a fine.
Abuse—Failed to protect resident from physical abuse
30 Jul 2021Inspection
30 Jul 2021Inspection
Investigated a complaint about emotional abuse; found that inappropriate photos were taken of a resident and posted with demeaning comments, causing humiliation, and that an unsafe environment contributed to harm.
Licensing—Failed to protect resident from mental or emotional abuse
30 Jul 2021Inspection
30 Jul 2021Inspection
Determined that inappropriate videos were made and posted about a resident, constituting emotional abuse, and that a safe environment was not provided.
Licensing—Failed to protect resident from mental or emotional abuse
23 Jul 2021Inspection
23 Jul 2021Inspection
Determined that emotional abuse occurred and the environment was not safe.
Licensing—Failed to protect resident from mental or emotional abuse
13 Jul 2021Abuse: Neglect
13 Jul 2021Abuse: Neglect
Found neglect and failure to follow care plans that created an unsafe environment, with falls occurring during attempts to self-transfer.
Abuse—Failed to provide safe environment
04 Jul 2021Abuse: Neglect
04 Jul 2021Abuse: Neglect
Investigated a complaint and found a failure to provide a safe environment, with a resident at risk from unsafe self-transfers and sustaining a knee injury after a fall.
Abuse—Failed to provide safe environment
30 Jun 2021License Condition
30 Jun 2021License Condition
Found that a safe environment was not provided and terms of the license condition were not followed.
Regulatory Action—Failed to provide safe environment
30 Jun 2021License Condition
30 Jun 2021License Condition
Investigated the allegation and determined there was a failure to provide a safe environment, creating immediate jeopardy for current and future residents.
Regulatory Action—Failed to provide safe environment
14 Jun 2021Abuse: Neglect
14 Jun 2021Abuse: Neglect
Found a failure to provide a safe medication administration system, resulting in a resident receiving another resident's medications and potential for serious harm.
Abuse—Failed to provide a safe medication administration system
03 Jun 2021Abuse: Neglect
03 Jun 2021Abuse: Neglect
Investigated a complaint about resident rights and dentures; findings substantiated that staff failed to protect resident rights and dentures were lost, constituting abuse and neglect.
Abuse—Failed to assure resident rights
18 Apr 2021Abuse: Neglect
18 Apr 2021Abuse: Neglect
Found that the provider failed to provide a safe environment, resulting in abuse/neglect; a $500 fine was assessed.
Abuse—Failed to provide safe environment
26 Mar 2021Abuse: Neglect
26 Mar 2021Abuse: Neglect
Investigated a complaint and found a failure to provide a safe environment that constitutes abuse and neglect. It involved a resident-to-resident incident.
Abuse—Failed to provide safe environment
26 Mar 2021Abuse: Neglect
26 Mar 2021Abuse: Neglect
Found a failure to provide a safe environment that constitutes abuse and neglect. An altercation between residents occurred.
Abuse—Failed to provide safe environment
29 Dec 2020Inspection
29 Dec 2020Inspection
Identified violations related to unsafe medication administration. A resident received another resident's medication and was hospitalized, and a safe medication administration system was not provided.
Licensing—Failed to provide a safe medication administration system
22 Dec 2020Inspection
22 Dec 2020Inspection
Found a violation for failing to provide a safe environment that could threaten residents' health, safety, or welfare.
Licensing—Failed to provide safe environment
17 Dec 2020Inspection
17 Dec 2020Inspection
Investigated and identified a deficiency where a licensed nurse did not perform assessments during a resident's serious change of condition.
Licensing—Failed to obtain appropriate consultation
17 Dec 2020Inspection
17 Dec 2020Inspection
Investigated an allegation of unsanitary food service conditions and found a failure to provide sanitary conditions that may threaten residents' health and safety.
Licensing—Failed to provide sanitary food service conditions
13 Dec 2020Inspection
13 Dec 2020Inspection
Found that a staff member used threatening language toward a resident and the resident was not adequately protected from verbal abuse.
Licensing—Failed to protect resident from verbal abuse
13 Dec 2020Inspection
13 Dec 2020Inspection
Investigated and found that a resident suffered physical abuse and protections against abuse were not adequate.
Licensing—Failed to protect resident from physical abuse
13 Dec 2020Inspection
13 Dec 2020Inspection
Concluded that a resident was restrained for discipline and not protected from abuse.
Licensing—Failed to assure resident was safe
09 Dec 2020Abuse: Neglect
09 Dec 2020Abuse: Neglect
Found a violation of resident safety due to inadequate supervision, resulting in a fracture from a physical altercation; a $1,125 fine was assessed.
Abuse—Failed to provide safe environment
07 Dec 2020Abuse: Neglect
07 Dec 2020Abuse: Neglect
Found a failure to provide a safe medication administration system that led to risk of serious harm and constituted neglect and abuse.
Abuse—Failed to provide a safe medication administration system
29 Nov 2020Abuse: Neglect
29 Nov 2020Abuse: Neglect
Found violations related to oversight of a change in condition after a fall. The delay resulted in a hip fracture and a fine was assessed.
Abuse—Failed to provide oversight and monitoring of change of condition
06 Nov 2020Abuse: Neglect
06 Nov 2020Abuse: Neglect
Investigated failure to plan care for known fall history, resulting in multiple falls and ongoing discomfort; identified as neglect and abuse.
Abuse—Failed to properly plan care
02 Nov 2020Inspection
02 Nov 2020Inspection
Investigated the allegation and found a deficiency in incident and abuse reporting policies and procedures, and in timely reporting of a fall to a medical provider and APS.
Licensing—Failed to communicate necessary information
29 Oct 2020Abuse: Neglect
29 Oct 2020Abuse: Neglect
Found inadequate supervision led to a physical altercation causing discomfort, constituting neglect and abuse; a $375 fine was assessed.
Abuse—Failed to provide safe environment
09 Oct 2020Abuse: Neglect
09 Oct 2020Abuse: Neglect
Found neglect and abuse due to inadequate supervision, resulting in injury and discomfort to residents.
Abuse—Failed to provide safe environment
29 Sept 2020Abuse: Neglect
29 Sept 2020Abuse: Neglect
Found neglect and abuse due to failure to provide oral care and follow the care plan, leaving the resident without bottom dentures for about six months; a fine was assessed.
Abuse—Failed to assure resident rights
22 Sept 2020Abuse: Neglect
22 Sept 2020Abuse: Neglect
Found a failure to provide a safe environment and adequate supervision for an individual with a known elopement history, resulting in the person getting lost and returned by a community member, risking serious harm.
Abuse—Failed to provide safe environment
13 Sept 2020Abuse: Neglect
13 Sept 2020Abuse: Neglect
Found neglect and abuse due to inadequate supervision that led to a fight causing injury and discomfort; assessed a $375 fine.
Abuse—Failed to provide safe environment
13 Sept 2020Abuse: Neglect
13 Sept 2020Abuse: Neglect
Determined that inadequate supervision led to a physical altercation causing bruising and discomfort to a resident, constituting neglect and abuse.
Abuse—Failed to provide safe environment
13 Sept 2020Abuse: Neglect
13 Sept 2020Abuse: Neglect
Investigated allegations found inadequate supervision that led to a physical altercation and resident discomfort. This constitutes neglect and abuse.
Abuse—Failed to provide safe environment
11 Sept 2020Abuse: Neglect
11 Sept 2020Abuse: Neglect
Investigated and found that essential services were not provided, leading to a resident’s fall and injury due to a non-working room light. This constitutes neglect and abuse.
Abuse—Failed to provide service
24 Aug 2020Inspection
24 Aug 2020Inspection
Found failure to provide meaningful activities, resulting in a cited licensing violation.
Licensing—Failed to provide social services
24 Aug 2020Inspection
24 Aug 2020Inspection
Found that resident care equipment was not maintained in working order.
Licensing—Failed to provide or maintain resident care equipment
24 Aug 2020Inspection
24 Aug 2020Inspection
Found insufficient awake staff to meet residents' scheduled and unscheduled needs.
Licensing—Failed to provide appropriate staffing
24 Aug 2020Inspection
24 Aug 2020Inspection
Found a deficiency in ensuring fans are available during extreme heat when air conditioning is not provided.
Licensing—Failed to provide safe environment
24 Aug 2020Inspection
24 Aug 2020Inspection
Investigated an allegation of failure to intervene when a resident's condition changed and identified a violation for not updating change-of-condition interventions.
Licensing—Failed to intervene when resident's condition changed
22 Aug 2020Abuse: Neglect
22 Aug 2020Abuse: Neglect
Investigated a complaint and found neglect due to failure to provide appropriate services to a resident, causing unnecessary discomfort and loss of dignity.
Abuse—Failed to provide service
21 Aug 2020Abuse: Neglect
21 Aug 2020Abuse: Neglect
Investigated and found neglect due to a delayed medical assessment after a fall, resulting in prolonged pain and risk of serious harm to a resident. A $1,500 fine was assessed.
Abuse—Failed to perform adequate screening or assessment
21 Aug 2020Abuse: Neglect
21 Aug 2020Abuse: Neglect
Investigated and determined that interventions and care planning for known skin injuries were not properly implemented, resulting in another skin tear and neglect/abuse; a fine was assessed.
Abuse—Failed to properly plan care
12 Aug 2020Abuse: Neglect
12 Aug 2020Abuse: Neglect
Identified neglect and abuse due to failure to provide a safe environment, which led to a physical altercation and injury.
Abuse—Failed to provide safe environment
07 Aug 2020Abuse: Neglect
07 Aug 2020Abuse: Neglect
Found a failure to provide a safe environment and to follow a resident's care plan, resulting in a physical altercation and unnecessary discomfort.
Abuse—Failed to provide safe environment
07 Aug 2020Abuse: Neglect
07 Aug 2020Abuse: Neglect
Found failures to provide a safe environment resulting in abuse and neglect; a fine was assessed.
Abuse—Failed to provide safe environment
27 Jul 2020Abuse: Neglect
27 Jul 2020Abuse: Neglect
Found that the allegation of failing to provide a safe environment led to neglect and abuse due to inadequate supervision, causing a physical altercation and undue discomfort.
Abuse—Failed to provide safe environment
23 Jul 2020Abuse: Neglect
23 Jul 2020Abuse: Neglect
Found that improper transfers caused skin tears and violated resident rights, indicating abuse and neglect.
Abuse—Failed to properly plan care
17 Jul 2020Abuse: Neglect
17 Jul 2020Abuse: Neglect
Investigated alleged abuse/neglect due to failure to remove an aggressor from the alleged victim, resulting in a physical altercation and injury. A fine of $375 was assessed.
Abuse—Failed to provide safe environment
08 Jul 2020Abuse: Neglect
08 Jul 2020Abuse: Neglect
Cited violations for neglect and abuse due to failure to care plan and monitor a resident, resulting in a physical altercation and discomfort.
Abuse—Failed to provide safe environment
08 Jul 2020Abuse: Neglect
08 Jul 2020Abuse: Neglect
Investigated allegations of neglect and abuse; found a failure to care plan and monitor a resident according to known behavior, resulting in a physical altercation and unreasonable discomfort.
Abuse—Failed to provide safe environment
06 Jul 2020Inspection
06 Jul 2020Inspection
Found a deficiency in monitoring and updating the service plan after a significant change of condition for a resident.
Licensing—Failed to provide oversight and monitoring of change of condition
06 Jul 2020Abuse: Neglect
06 Jul 2020Abuse: Neglect
Investigated a complaint and found neglect and abuse due to failure to provide a safe environment, resulting in hospital transfer with injuries.
Abuse—Failed to provide safe environment
22 Jun 2020Abuse: Neglect
22 Jun 2020Abuse: Neglect
Investigated the complaint found a failure to provide stand-by ambulation assistance leading to injury; violation of resident rights and neglect/abuse, with a fine assessed.
Abuse—Failed to provide safe environment
20 Jun 2020Inspection
20 Jun 2020Inspection
Substantiated a deficiency for failing to provide a safe environment.
Licensing—Failed to provide safe environment
20 Jun 2020Inspection
20 Jun 2020Inspection
Investigated the allegation and found a failure to provide services to assist with Activities of Daily Living.
Licensing—Failed to provide service
20 Jun 2020Inspection
20 Jun 2020Inspection
Investigated the pest control allegation and found pest-entry prevention measures were not taken.
Licensing—Failed to control pests
20 Jun 2020Inspection
20 Jun 2020Inspection
Identified that interior and exterior materials, surfaces, and equipment were not maintained for residents' health, safety, and comfort.
Licensing—Failed to provide a homelike environment
20 Jun 2020Inspection
20 Jun 2020Inspection
Found a deficiency for not providing a homelike environment.
Licensing—Failed to provide a homelike environment
20 Jun 2020Inspection
20 Jun 2020Inspection
Investigated and found a failure to implement services outlined in the resident's service plan.
Licensing—Failed to provide service
17 Jun 2020Abuse: Neglect
17 Jun 2020Abuse: Neglect
Investigated a complaint and found failures to plan care and address known needs. This resulted in the resident's ongoing discomfort and constituted abuse.
Abuse—Failed to properly plan care
28 May 2020Abuse: Neglect
28 May 2020Abuse: Neglect
Investigated and found failures to protect a resident from inappropriate sexual contact due to ineffective interventions and care planning, resulting in abuse and neglect.
Abuse—Failed to protect resident from inappropriate sexual contact
18 May 2020Abuse: Neglect
18 May 2020Abuse: Neglect
Found abuse and neglect due to inadequate supervision that caused a physical altercation with injuries, and a fine was assessed.
Abuse—Failed to provide safe environment
09 May 2020Abuse: Neglect
09 May 2020Abuse: Neglect
Found neglect due to failure to properly plan care for a resident's fall history, resulting in multiple falls and head injuries; a fine was assessed.
Abuse—Failed to properly plan care
30 Apr 2020Abuse: Neglect
30 Apr 2020Abuse: Neglect
Found neglect and abuse due to failure to implement interventions and care plans for known behaviors, resulting in a physical altercation and discomfort to a resident. A $375 fine was assessed.
Abuse—Failed to provide safe environment
30 Apr 2020Abuse: Neglect
30 Apr 2020Abuse: Neglect
Found neglect and abuse violations for failing to provide a safe environment, resulting in an altercation and discomfort; a $375 fine was assessed.
Abuse—Failed to provide safe environment
24 Apr 2020Abuse: Neglect
24 Apr 2020Abuse: Neglect
Identified abuse and neglect due to failing to follow the alleged victim's care plan according to known fall history, resulting in multiple unwitnessed falls with injuries; a fine was assessed.
Abuse—Failed to properly plan care
19 Apr 2020Abuse: Neglect
19 Apr 2020Abuse: Neglect
Found failures to provide appropriate assessments, implement interventions, and develop an appropriate care plan for a resident's behavioral changes, resulting in risk of serious harm.
Abuse—Failed to properly plan care
07 Apr 2020Abuse: Neglect
07 Apr 2020Abuse: Neglect
Found violations of resident safety and rights due to failure to provide effective interventions, resulting in an injury from a physical altercation. A $500 fine was assessed.
Abuse—Failed to provide safe environment
04 Apr 2020Abuse: Neglect
04 Apr 2020Abuse: Neglect
Found neglect of care and abuse due to failure to implement effective interventions based on known behaviors, resulting in an altercation and injury.
Abuse—Failed to provide safe environment
17 Mar 2020Abuse: Neglect
17 Mar 2020Abuse: Neglect
Investigated and found a failure to supervise according to known behavior, which led to an injury during a physical altercation and constitutes abuse and neglect.
Abuse—Failed to provide safe environment
10 Mar 2020Abuse: Neglect
10 Mar 2020Abuse: Neglect
Found an unsafe environment due to furniture not being fastened, which led to a resident being found with a wardrobe on top of them and dying from injuries.
Abuse—Failed to provide safe environment
05 Mar 2020Inspection
05 Mar 2020Inspection
Investigated a safety deficiency after a complaint about wardrobes not anchored to the wall; the maintenance issue was confirmed.
Licensing—Failed to assure resident was safe
05 Mar 2020Inspection
05 Mar 2020Inspection
Found housekeeping deficiencies and substantiated the allegation.
Licensing—Failed to provide appropriate housekeeping services
02 Mar 2020Abuse: Neglect
02 Mar 2020Abuse: Neglect
Investigated a neglect allegation and found failures to plan and implement care for known skin concerns, resulting in injuries and resident discomfort.
Abuse—Failed to properly plan care
03 Feb 2020Abuse: Neglect
03 Feb 2020Abuse: Neglect
Found failure to provide a safe medication administration system, risking harm to a resident and constituting neglect and abuse. A $375 fine was assessed.
Abuse—Failed to provide a safe medication administration system
11 Jan 2020Abuse: Neglect
11 Jan 2020Abuse: Neglect
Found that care planning and interventions for a resident with a fall history were not properly implemented, resulting in an unwitnessed fall and hospital treatment.
Abuse—Failed to properly plan care
02 Jan 2020Abuse: Neglect
02 Jan 2020Abuse: Neglect
Found neglect and abuse due to failure to properly plan care for a resident with a fall history, resulting in multiple falls and discomfort.
Abuse—Failed to properly plan care
29 Dec 2019Abuse: Neglect
29 Dec 2019Abuse: Neglect
Investigated and found that staff failed to implement interventions and care plans for a resident's known behaviors, escalating risk of harm and constituting abuse.
Abuse—Failed to assure resident was safe
29 Dec 2019Abuse: Neglect
29 Dec 2019Abuse: Neglect
Found safety violations due to failing to protect a resident from elopement, creating risk of serious harm; assessed a $1,125 fine.
Abuse—Failed to assure resident was safe
29 Dec 2019Abuse: Neglect
29 Dec 2019Abuse: Neglect
Identified violations for failing to properly plan and implement care for a resident's skin injuries, leading to multiple injuries and unnecessary discomfort.
Abuse—Failed to properly plan care
12 Dec 2019Abuse: Neglect
12 Dec 2019Abuse: Neglect
Found failures to implement interventions and care planning for known behaviors, leading to a resident-to-resident physical altercation and violation of resident rights.
Abuse—Failed to provide safe environment
30 Oct 2019Abuse: Neglect
30 Oct 2019Abuse: Neglect
Found a failure to provide a safe environment that allowed an elopement and risk of serious harm; assessed a $375 fine.
Abuse—Failed to provide safe environment
23 Sept 2019Abuse: Neglect
23 Sept 2019Abuse: Neglect
Investigated an allegation of neglect that endangered a resident's health and safety. Found that basic services were not provided, creating a risk of serious harm.
Abuse—Failed to assure resident was safe
18 Sept 2019Abuse: Neglect
18 Sept 2019Abuse: Neglect
Found neglect that affected a resident's health and safety, resulting in a $375 fine.
Abuse—Failed to assure resident was safe
05 Aug 2019Abuse: Neglect
05 Aug 2019Abuse: Neglect
Found neglect due to the failure to provide basic care and services, resulting in physical harm to a resident. A fine was assessed.
Abuse—Failed to provide safe environment
31 Jul 2019Abuse: Neglect
31 Jul 2019Abuse: Neglect
Investigated the allegation and found neglect causing bruising due to failure to provide basic care and services to maintain health and safety.
Abuse—Failed to assure resident was safe
24 Jul 2019Abuse: Neglect
24 Jul 2019Abuse: Neglect
Identified neglect of basic care and safety that created a risk of serious harm; a fine was assessed.
Abuse—Failed to maintain a safe physical environment
24 Jul 2019Abuse: Neglect
24 Jul 2019Abuse: Neglect
Determined neglect occurred by failing to provide basic care and maintain a safe environment, creating risk of serious harm; assessed a $375 fine.
Abuse—Failed to maintain a safe physical environment
12 Jul 2019Abuse: Neglect
12 Jul 2019Abuse: Neglect
Found violations related to resident safety and rights due to an unsafe medication administration system and missing pills; a fine was assessed.
Abuse—Failed to protect resident from financial exploitation
03 Jul 2019Abuse: Neglect
03 Jul 2019Abuse: Neglect
Found neglect that risked a resident's health and safety.
Abuse—Failed to assure resident was safe
16 Jun 2019Abuse: Neglect
16 Jun 2019Abuse: Neglect
Investigated the complaint and found neglect due to failure to provide basic care and a safe environment, resulting in harm and risk. A $375 fine was assessed.
Abuse—Failed to provide safe environment
11 May 2019Abuse: Neglect
11 May 2019Abuse: Neglect
Investigated an allegation of neglect and found failure to provide a safe environment resulted in physical harm.
Abuse—Failed to provide safe environment
30 Apr 2019Abuse: Neglect
30 Apr 2019Abuse: Neglect
Investigated an allegation of neglect that resulted in risk of serious harm due to a failure to provide basic care and services to maintain health and safety. A fine was assessed.
Abuse—Failed to provide safe environment
28 Apr 2019Abuse: Neglect
28 Apr 2019Abuse: Neglect
Investigated an allegation of neglect and found inadequate supervision created a risk of serious harm; a fine was assessed.
Abuse—Failed to provide safe environment
28 Apr 2019Abuse: Neglect
28 Apr 2019Abuse: Neglect
Investigated and found neglect due to inadequate supervision, creating risk of serious harm to a resident.
Abuse—Failed to provide safe environment
20 Apr 2019Abuse: Neglect
20 Apr 2019Abuse: Neglect
Investigated an allegation of neglect related to falls and found that basic care and safety were not provided, creating risk of serious harm; a $375 fine was assessed.
Abuse—Failed to adequately care plan related to falls
18 Apr 2019Abuse: Neglect
18 Apr 2019Abuse: Neglect
Investigated an allegation of neglect and found a failure to follow the care plan that created an unsafe environment and risk of serious harm; a fine was assessed.
Abuse—Failed to follow care plan
17 Apr 2019Abuse: Neglect
17 Apr 2019Abuse: Neglect
Investigated a neglect finding that resulted in loss of personal dignity; a $375 fine was assessed.
Abuse—Failed to properly plan care
07 Mar 2019Inspection
07 Mar 2019Inspection
Identified a failure to report abuse of residents as required by state rules.
Licensing—Failed to report potential or suspected abuse
07 Mar 2019Inspection
07 Mar 2019Inspection
Found that residents were not assisted with dressing or grooming, including brushing teeth and denture care.
Licensing—Failed to assist with dressing or grooming
25 Jan 2019Inspection
25 Jan 2019Inspection
Identified a deficiency in maintaining a daytime temperature of at least 70°F in resident areas. Residents reported the building was too cold.
Licensing—Failed to provide or maintain resident care equipment
31 Dec 2018Abuse: Neglect
31 Dec 2018Abuse: Neglect
Identified neglect due to failure to provide timely medical treatment, resulting in an injury. A $500 fine was assessed.
Abuse—Failed to assure timely medical treatment
31 Dec 2018Abuse: Neglect
31 Dec 2018Abuse: Neglect
Investigated a complaint and found failure to assess and intervene after an injury of unknown origin, creating risk of serious harm.
Abuse—Failed to provide oversight and monitoring of change of condition
31 Dec 2018Inspection
31 Dec 2018Inspection
Found failure to report suspected abuse; a $750 fine was assessed.
Licensing—Failed to report potential or suspected abuse
17 Dec 2018Abuse: Physical Abuse
17 Dec 2018Abuse: Physical Abuse
Investigated an abuse allegation and found neglect due to inadequate supervision that resulted in physical harm to a resident.
Abuse—Failed to protect resident from rough treatment
12 Dec 2018Abuse: Neglect
12 Dec 2018Abuse: Neglect
Found neglect resulting in an unsafe environment and physical harm, with a fine assessed.
Abuse—Failed to assure resident was safe
26 Nov 2018Inspection
26 Nov 2018Inspection
Investigated allegation of inadequate housekeeping and found violation for failing to provide appropriate housekeeping services.
Licensing—Failed to provide appropriate housekeeping services
26 Nov 2018Inspection
26 Nov 2018Inspection
Investigated the allegation of inadequate staffing and found a staffing deficiency.
Licensing—Failed to provide appropriate staffing
26 Nov 2018Inspection
26 Nov 2018Inspection
Determined the allegation of failing to properly plan care to be supported by findings.
Licensing—Failed to properly plan care
26 Nov 2018Inspection
26 Nov 2018Inspection
Concluded that there was a failure to provide service.
Licensing—Failed to provide service
26 Nov 2018Inspection
26 Nov 2018Inspection
Determined that care planning failed to meet requirements.
Licensing—Failed to properly plan care
19 Nov 2018Abuse: Neglect
19 Nov 2018Abuse: Neglect
Found neglect that led to serious physical harm requiring hospitalization.
Abuse—Failed to perform adequate screening or assessment
01 Nov 2018Inspection
01 Nov 2018Inspection
Investigated the complaint and found a violation for failing to provide basic care, resulting in the loss of dentures and risk of serious harm.
Licensing—Failed to provide service
19 Apr 2018Inspection
19 Apr 2018Inspection
Investigated and found a staffing deficiency due to insufficient staff to meet residents' needs.
Licensing—Failed to provide appropriate staffing
14 Apr 2018Abuse: Neglect
14 Apr 2018Abuse: Neglect
Investigated a complaint and found a failure to provide a safe environment, resulting in a $188 fine.
Abuse—Failed to provide safe environment
11 Apr 2018Abuse: Neglect
11 Apr 2018Abuse: Neglect
Found that the care plan was not followed, creating a risk of minor harm.
Abuse—Failed to follow care plan
21 Nov 2017Inspection
21 Nov 2017Inspection
Investigated allegation found that a victim's medication was not administered as ordered, resulting in a substantiated licensing violation with a $250 fine.
Licensing—Failed to administer medication as ordered
17 Nov 2017Inspection
17 Nov 2017Inspection
Investigated and found that medication was not administered as ordered.
Licensing—Failed to administer medication as ordered
31 Oct 2017Inspection
31 Oct 2017Inspection
Found that the care plan was not followed, resulting in a substantiated licensing violation.
Licensing—Failed to provide safe environment
20 Oct 2017Inspection
20 Oct 2017Inspection
Determined that the reported victim was not properly dressed, resulting in loss of dignity.
Licensing—Failed to properly plan care
04 Aug 2017Inspection
04 Aug 2017Inspection
Determined the allegation of failing to provide or maintain resident care equipment was sustained.
Licensing—Failed to provide or maintain resident care equipment
13 Apr 2017Inspection
13 Apr 2017Inspection
Found a violation for failing to provide a safe and homelike environment.
Licensing—Failed to provide a homelike environment
11 Apr 2017Abuse: Neglect
11 Apr 2017Abuse: Neglect
Investigated the allegation and identified a failure to provide a safe medication administration system.
Abuse—Failed to provide a safe medication administration system
06 Apr 2017Abuse: Physical Abuse
06 Apr 2017Abuse: Physical Abuse
Concluded that an allegation of physical abuse occurred and that a safe environment was not provided to a resident.
Abuse—Failed to protect resident from rough treatment
05 Dec 2016Inspection
05 Dec 2016Inspection
Found a deficient medication system that posed a risk of harm to residents.
Licensing—Failed to provide a safe medication administration system
18 Nov 2016Condition
18 Nov 2016Condition
Investigated an allegation of failing to provide a safe environment and identified deficiencies.
Regulatory Action—Failed to provide safe environment
14 Nov 2016Inspection
14 Nov 2016Inspection
Found a failure to provide a safe medication administration system, and medication was not administered as ordered.
Licensing—Failed to provide a safe medication administration system
25 Oct 2016Abuse: Neglect
25 Oct 2016Abuse: Neglect
Investigated an allegation of neglect and found a failure to assess and intervene when a resident's condition changed.
Abuse—Failed to intervene when resident's condition changed
17 Oct 2016Inspection
17 Oct 2016Inspection
Found insufficient staffing.
Licensing—Failed to provide appropriate staffing
17 Oct 2016Inspection
17 Oct 2016Inspection
Investigated an allegation of failing to hire according to administrative rules and found a violation.
Licensing—Failed to hire according to administrative rules
16 Oct 2016Abuse: Neglect
16 Oct 2016Abuse: Neglect
Investigated the allegation and found a failure to assess and intervene when a resident's condition changed.
Abuse—Failed to intervene when resident's condition changed
10 Oct 2016Abuse: Neglect
10 Oct 2016Abuse: Neglect
Found a deficiency where a provider failed to protect a resident from eye injury.
Abuse—Failed to provide safe environment
04 Oct 2016Inspection
04 Oct 2016Inspection
Found a deficiency for failing to report injuries of unknown origin.
Licensing—Failed to investigate injury of unknown origin to rule out abuse
04 Oct 2016Inspection
04 Oct 2016Inspection
Found that resident records were not accessible and not maintained as complete, accurate, or preserved.
Licensing—Failed to make facility or resident records accessible
04 Oct 2016Inspection
04 Oct 2016Inspection
Investigated the allegation that a qualified caregiver was not present and substantiated a deficiency for not having an RN available for phone consult.
Licensing—Failed to assure that a qualified caregiver was present
04 Oct 2016Inspection
04 Oct 2016Inspection
Found a deficiency for failing to provide a move-out notice of less than 30 days under the rule. The finding noted that a resident was not allowed back after hospital admission.
Licensing—Failed to comply with move-out, transfer or discharge requirements
04 Oct 2016Inspection
04 Oct 2016Inspection
Found that Resident Health Services were not provided as required.
Licensing—Failed to provide service
03 Aug 2016Inspection
03 Aug 2016Inspection
Investigated an allegation of failing to cooperate with an investigation and failing to provide service plans; findings supported the allegation.
Licensing—Failed to cooperate with an investigation
03 Aug 2016Inspection
03 Aug 2016Inspection
Identified insufficient staffing levels that did not meet required staffing standards, including nighttime coverage.
Licensing—Failed to provide appropriate staffing
06 Apr 2016Abuse: Neglect
06 Apr 2016Abuse: Neglect
Investigated and identified a neglect-related failure to adequately assess and intervene regarding falls.
Abuse—Failed to adequately care plan related to falls
05 Feb 2016Inspection
05 Feb 2016Inspection
Found that the care plan for the reported victim and applicable protocol were not followed.
Licensing—Failed to follow care plan
28 Jan 2015Abuse: Neglect
28 Jan 2015Abuse: Neglect
Identified inadequate administrative oversight affecting residents' care and services.
Abuse—Failed to provide safe environment
28 Nov 2012Abuse: Financial abuse
28 Nov 2012Abuse: Financial abuse
Found failure to maintain a safe medication administration system.
Abuse—Failed to provide a safe medication administration system
13 Aug 2012Abuse: Physical Abuse
13 Aug 2012Abuse: Physical Abuse
Found that a resident was not protected from rough handling.
Abuse—Failed to protect resident from rough treatment
29 Jul 2012Abuse: Physical Abuse
29 Jul 2012Abuse: Physical Abuse
Investigated the allegation of physical abuse and found a failure to protect a resident from rough treatment.
Abuse—Failed to protect resident from rough treatment
24 Mar 2012Abuse: Neglect
24 Mar 2012Abuse: Neglect
Determined that care planning was inadequate and that a safe environment was not provided.
Abuse—Failed to properly plan care
27 Dec 2011Abuse: Physical Abuse
27 Dec 2011Abuse: Physical Abuse
Found a resident was not protected from rough handling. The incident involved physical abuse with minor harm or potential for moderate harm.
Abuse—Failed to protect resident from rough treatment
02 Sept 2011Inspection
02 Sept 2011Inspection
Found a safety deficiency due to failure to maintain a safe environment, posing potential for moderate harm.
Licensing—Failed to provide safe environment
20 Sept 2010Inspection
20 Sept 2010Inspection
Found a licensing violation for failing to protect a resident from inappropriate verbal comments.
Licensing—Failed to assure resident rights
08 Apr 2010Abuse: Neglect
08 Apr 2010Abuse: Neglect
Found neglect involving failure to provide appropriate care to a resident.
Abuse—Failed to provide service
25 Feb 2010Abuse: Neglect
25 Feb 2010Abuse: Neglect
Investigated a neglect allegation regarding oversight of change of condition and found deficiencies cited under multiple rules.
Abuse—Failed to provide oversight and monitoring of change of condition
12 Jan 2010Abuse: Neglect
12 Jan 2010Abuse: Neglect
Found failure to follow the care plan that had the potential for minor to moderate harm.
Abuse—Failed to follow care plan
Disclaimer
Mirador Living is not affiliated with the owner or operator(s) of St. Andrews Memory Care. The information above has not been verified or approved by the owner or operator. For exact information, please contact St. Andrews Memory Care directly. There is no cost for this service. We are compensated by the community you select.
Are you an owner or operator of this community?
Claim this listing to receive messages from prospective customers and manage your community page.
