Pricing ranges from
    $6,582 – 8,556/month

    Sunnyside Meadows Memory Care

    12195 SE 117th Ave, Portland, OR 97086
    • Assisted Living
    • Memory Care

    Beautiful, clean community; caring staff

    Overall I'm very pleased with this beautiful, brand-new community - clean, spacious, stylish and smelling fresh with a lovely patio and well-kept common areas. The staff are caring, attentive and professional, providing dignified memory care and peaceful hospice transitions, engaging daily activities, and reliable on-site medical, shuttle and video visit services, which gives me real 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
    • Medication management
    • Mental wellness program

    Healthcare staffing

    • 12-16 hour nursing
    • 24-hour call system
    • 24-hour supervision

    Meals and dining

    • Diabetes diet
    • Meal preparation and service
    • Restaurant-style dining
    • Special dietary restrictions

    Room

    • Air-conditioning
    • Cable
    • Fully furnished
    • Housekeeping and linen services
    • Kitchenettes
    • Private bathrooms
    • Telephone
    • Wifi

    Memory care community services

    • Mild cognitive impairment
    • Specialized memory care programming

    Transportation

    • Community operated transportation
    • Transportation arrangement
    • Transportation arrangement (non-medical)

    Common areas

    • Beauty salon
    • Computer center
    • Dining room
    • Fitness room
    • Gaming room
    • Garden
    • Outdoor space
    • Small library
    • Wellness center

    Community services

    • Concierge services
    • Fitness programs
    • Move-in coordination

    Activities

    • Community-sponsored activities
    • Planned day trips
    • Resident-run activities
    • Scheduled daily activities

    Reviews

    3.64·(28)

    Overall rating

    1. 5
    2. 4
    3. 3
    4. 2
    5. 1
    • Care

      3.9
    • Staff

      3.7
    • Meals

      5.0
    • Amenities

      4.7
    • Value

      1.0

    Pros

    • Clean, bright, well-maintained environment
    • Brand-new, modern facility design
    • Secure access and dedicated memory-care unit
    • Private and spacious resident rooms
    • Inviting outdoor courtyard and patio
    • On-site clinical integration (PACE and medical visits)
    • Attentive nursing leadership
    • Dependable administrative and reception staff
    • Caring and accommodating direct-care staff
    • Personalized, dignity-focused care routines
    • Active activity program and daily memory-care offerings
    • Regular community outings and shuttle service
    • Salon and step-in bathing facilities
    • Varied dining options and daily menus
    • Family-friendly events and facilitated visitation
    • Cleanliness and good odor control in many areas
    • Timely communication and responsiveness from some staff

    Cons

    • Inconsistent staffing levels and assignment continuity
    • Gaps in clinical oversight and variable responsiveness
    • Communication gaps between management and families
    • Allegations of theft and property mismanagement
    • Sanitation concerns in isolated instances
    • Staff professionalism and conduct
    • Perceived management emphasis on financial priorities
    • Hospitality-style atmosphere that may feel impersonal for some residents
    • Staff compensation and retention challenges

    Summary of reviews

    Sunnyside Meadows Memory Care is frequently described as a new, well‑maintained memory‑care community with modern finishes, private rooms, secure access, and pleasant outdoor spaces. Many families and visitors comment positively on the facility’s cleanliness, bright common areas, and amenities such as a salon, step‑in bathing room, library, snack bar/cafeteria, and a secure courtyard. On-site clinical integration (including PACE services and regular on-site medical visits) and shuttle transportation are notable operational strengths that many families found reassuring.

    Staffing and direct care receive mixed but detailed praise. Several accounts highlight attentive nursing leadership, caring direct‑care staff, a supportive administrative team, and personalized routines that treat residents with dignity. Positive experiences include effective hospice transitions, timely clinical responses in some emergencies, and staff who facilitate family involvement and visits. At the same time, there are consistent operational concerns about staffing consistency—caregiver assignments can be variable and staff levels may fluctuate—creating risk for delays in care and uneven continuity.

    Dining and activities are generally well regarded. Reviewers mention varied menus, daily meals, celebratory events (for example holiday gatherings and birthday participation), daily crafts, music, movement classes, and frequent outings. The activity calendar is active and includes twice‑weekly excursions for some residents; that said, activity fit is individualized, and some residents or families felt the social programming did not match their loved one’s preferences.

    Facility‑level safety and housekeeping are strengths in many reports, but a subset of accounts raises sanitation and property‑security concerns. While many families describe the environment as safe and well cared for, isolated instances describe lapses in personal‑care responsiveness and concerns about missing belongings; these are serious operational issues that warrant follow‑up. Clinical oversight is uneven in some reports—families should seek clear documentation on staffing ratios, assignment practices, incident reporting, and emergency protocols.

    Management and culture display both positive and negative patterns. Several families praise an accommodating executive director and dependable front‑line administration; others describe turnover or management changes that coincided with declines in communication, professionalism, or perceived prioritization of financial targets over resident needs. There are also mentions of staff compensation and retention problems that can affect continuity of care.

    Bottom line: Sunnyside Meadows offers many of the physical and programmatic elements families expect in a modern memory‑care community—clean facilities, medical integration, active programming, and compassionate staff leadership in many cases. Prospective residents and families should verify current staffing practices, ask for examples of staff assignment continuity, review security and property‑management protocols, and request recent incident and staffing metrics to ensure the operational concerns highlighted by some families have been addressed.

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    Location

    Map showing location of Sunnyside Meadows Memory Care

    Sunnyside Meadows Memory Care is located at 12195 SE 117th Ave, Portland, OR, 97086.

    About Sunnyside Meadows Memory Care

    Sunnyside Meadows Memory Care, located in Happy Valley, offers specialized senior living options for individuals with memory loss due to Alzheimer’s and dementia. Situated close to public parks, medical care providers, and other daily life necessities, residents have easy access to a range of conveniences. Additionally, Clackamas Town Center is nearby, providing added convenience for shopping and entertainment.

    The facility offers a variety of activities to engage residents and promote social interaction and mental stimulation. From exercise and walking clubs to weekly book clubs and social events like movies and happy hour, there is something for everyone. Residents can also enjoy music programs, cards and board games, cooking and art classes, as well as nondenominational worship services. Each neighborhood within Sunnyside Meadows has its own spacious kitchen and dining room area, creating a homely and communal atmosphere for residents to enjoy meals together.

    One of the highlights of Sunnyside Meadows Memory Care is the dining experience. The chef and cooks take pride in using from-scratch cooking techniques, in-season fruits and vegetables, and natural herbs and spices to create delicious and well-balanced meals. Residents can look forward to enjoying comfort foods and family-favorite recipes, as the chef often seeks input from residents and family members to ensure meal preferences are accommodated. Special dietary restrictions are also accommodated, with a focus on promoting brain health and overall wellness through the food choices offered.

    Overall, Sunnyside Meadows Memory Care prioritizes providing a comfortable and engaging environment for residents with memory loss. With a range of activities, personalized dining options, and compassionate care from the staff, residents can feel at home and enjoy a high quality of life.

    People often ask...

    Sunnyside Meadows Memory Care offers competitive pricing, with rates starting at a cost of $6,582 per month.

    Sunnyside Meadows Memory Care offers assisted living and memory care.

    There are 20 photos of Sunnyside Meadows Memory Care on Mirador.

    The full address for this community is 12195 SE 117th Ave, Portland, OR 97086.

    No, Sunnyside Meadows 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.

    License number50R443
    StatusActive
    Facility typeResidential Care Facility
    Capacity72 residents
    LicenseeOregon MC Operations, LLC
    EffectiveDecember 14th, 2016
    Special certificationMemory Care
    View the official license record

    Inspection Reports

    219

    Reports

    0

    Type A Citations

    0

    Type B Citations

    5

    Complaints

    10

    Years

    13 Nov 2025Licensure
    Identified multiple deficiencies in acuity-based staffing documentation, staff training, building exterior chemical storage, and adherence to health care and memory care licensing rules.
    • DeficiencyAcuity Based Staffing Tool - ABST Time
    • DeficiencyTraining Within 30 Days of Hire – Direct Care Staff
    • DeficiencyGeneral Building Exterior
    • DeficiencyAdministration Compliance
    • DeficiencyStaff Training Requirements
    • DeficiencyCompliance with Rules Health Care
    13 Nov 2025FEOS
    Investigated deficiencies in acuity-based staffing; ABST did not accurately capture care time and care elements for three sampled residents.
    • DeficiencyAcuity Based Staffing Tool - ABST Time
    01 Nov 2025Abuse: Neglect
    Identified abuse and neglect due to failure to revise the care plan and protect a resident from known risk behaviors. The resident experienced unreasonable discomfort as a result.
    • AbuseFailed to properly plan care
    21 Jul 2025Abuse: Neglect
    Investigated a fall risk care plan deficiency and found that insufficient fall prevention led to an unwitnessed fall with fractures and hospitalization, resulting in abuse and neglect findings.
    • AbuseFailed to properly plan care
    25 Jun 2025Abuse: Neglect
    Found failure to provide a safe environment, resulting in a resident's fall and discomfort, which constitutes abuse and neglect.
    • AbuseFailed to provide safe environment
    11 Jun 2025Abuse: Neglect
    Determined that dietary orders weren’t followed, exposing a resident to allergenic sausage and causing breathing difficulties and swelling. A fine was assessed.
    • AbuseFailed to follow care plan
    10 May 2025Inspection
    Found violations in medication administration safety, including missed doses of prescribed thyroid medication.
    • LicensingFailed to provide a safe medication administration system
    26 Apr 2025Abuse: Neglect
    Investigated a complaint about care that left a resident with a worsening condition due to lack of a proper care plan and wound care.
    • AbuseFailed to properly plan care
    17 Apr 2025Inspection
    Investigated a care plan violation where restricted food was given, causing a resident to choke and suffer harm. Found neglect and abuse, with a $1,500 fine assessed.
    • LicensingFailed to follow care plan
    14 Apr 2025Inspection
    Found a violation for failing to provide a safe medication administration system, leading to prolonged incorrect administration of diabetic medication with no negative outcome. No corrective actions described here.
    • LicensingFailed to provide a safe medication administration system
    08 Apr 2025Inspection
    Found a violation for failing to provide a safe medication administration system, which could lead to harm from incorrect medication handling.
    • LicensingFailed to provide a safe medication administration system
    08 Apr 2025Inspection
    Identified a deficiency for failing to provide a safe environment for residents. The finding indicates risk to health, safety, or welfare.
    • LicensingFailed to provide safe environment
    08 Apr 2025Inspection
    Investigated a complaint and found deficiencies in psychotropic medication use. The findings showed medications were used without proper consultation and without documenting non-pharmacological interventions.
    • LicensingFailed to provide service
    08 Apr 2025Inspection
    Investigated the allegation and concluded that medication and treatment orders were not carried out as prescribed.
    • LicensingFailed to provide service
    08 Apr 2025Inspection
    Investigated a complaint and found that inadequate administrative oversight of operations, including supervision and training of staff, posed a risk to resident safety.
    • LicensingFailed to provide service
    08 Apr 2025Inspection
    Investigated and found that the service plan did not reflect the resident's needs and implementation of services was not ensured.
    • LicensingFailed to follow care plan
    08 Apr 2025Inspection
    Found a failure to provide records when requested during an investigation. The finding documented that records were not made available to the Department.
    • LicensingFailed to cooperate with an investigation
    08 Apr 2025Inspection
    Identified a deficiency in care planning related to evaluating a resident and updating the service plan.
    • LicensingFailed to properly plan care
    08 Apr 2025Inspection
    Identified failure to have an emergency preparedness plan for a sampled resident.
    • LicensingFailed to provide safe environment
    08 Apr 2025Inspection
    Found failure to assess all residents with a significant change of condition, posing an immediate jeopardy to residents' health and safety.
    • LicensingFailed to provide oversight and monitoring of change of condition
    07 Apr 2025License Condition
    Determined that the facility failed to provide a safe environment and posed immediate jeopardy to residents, resulting in a license condition restricting admissions.
    • Regulatory ActionFailed to provide safe environment
    06 Apr 2025Inspection
    Identified a licensing violation for failing to provide records to the Department upon request. This presented minor harm potential.
    • LicensingFailed to provide safe environment
    06 Apr 2025Abuse: Neglect
    Investigated a sexual abuse/neglect case where delayed alerts and insufficient supervision allowed inappropriate contact between residents, causing emotional harm; a fine was assessed.
    • AbuseFailed to provide safe environment
    06 Apr 2025Inspection
    Found failure to provide and document RN delegation and teaching for sampled residents, creating an immediate jeopardy to health, safety, and welfare.
    • LicensingFailed to provide service
    03 Apr 2025Inspection
    Found deficiencies in an acuity-based staffing tool and related staffing levels, with inconsistencies among the resident roster, care plans, and ABST data that did not meet residents' needs.
    • LicensingFailed to use an ABST
    03 Apr 2025Inspection
    Identified a deficient safe medication administration system after a missed insulin dose; a $500 fine was assessed.
    • LicensingFailed to provide a safe medication administration system
    02 Apr 2025Inspection
    Determined that records were not provided when requested, violating administrative rules.
    • LicensingFailed to provide safe environment
    02 Apr 2025Inspection
    Identified deficiencies in ABST accuracy and staffing levels to meet resident needs.
    • LicensingFailed to use an ABST
    01 Apr 2025Inspection
    Found a deficiency due to an outdated ABST not reflecting resident needs, with inconsistencies among the roster, care plans, and ABST data. Determined that this violated Oregon Administrative Rules.
    • LicensingFailed to use an ABST
    30 Mar 2025Inspection
    Investigated identified an issue with the Acuity-Based Staffing Tool not reflecting residents’ care needs. Inconsistencies existed between the resident roster, care plans, and ABST.
    • LicensingFailed to use an ABST
    29 Mar 2025Inspection
    Found insufficient direct care staff to meet residents' needs, with understaffing on all shifts due to walk-outs.
    • LicensingFailed to use an ABST
    29 Mar 2025Inspection
    Investigated and found a failure to document that staff can safely administer medications unsupervised, and identified inadequate staff training and supervision due to staffing shortages.
    • LicensingFailed to provide a safe medication administration system
    29 Mar 2025Inspection
    Investigated a complaint and found a deficiency in documenting observation and evaluation of safe medication and treatment administration unsupervised. Staff were reportedly not properly trained and were working unsupervised on the floor due to staffing shortages.
    • LicensingFailed to use an ABST
    28 Mar 2025Inspection
    Investigated and found a failure to immediately notify the local Department office or local AAA of abuse or suspected abuse, and that multiple resident incidents were not reported.
    • LicensingFailed to communicate necessary information
    24 Mar 2025Inspection
    Identified a deficiency for failing to provide records upon request.
    • LicensingFailed to provide safe environment
    10 Mar 2025Inspection
    Investigated found that an updated Acuity-Based Staffing Tool was not in place and did not reflect resident needs. Inconsistencies with the roster and care plans led to a determination of a violation of Oregon Administrative Rules.
    • LicensingFailed to use an ABST
    06 Mar 2025Inspection
    Found that records were not made available upon request during an offsite review.
    • LicensingFailed to cooperate with an investigation
    06 Mar 2025Inspection
    Found that requested records were not provided when asked by the department. The missing records included the staffing plan, staff roster, resident roster with room numbers, and the direct care schedule for 01/19/25.
    • LicensingFailed to provide safe environment
    06 Mar 2025Inspection
    Investigated an allegation that the provider failed to cooperate by not providing requested information to the Department; findings indicate information was not provided.
    • LicensingFailed to cooperate with an investigation
    06 Mar 2025Inspection
    Determined that records were not provided to Department personnel upon request. Missing items included the staffing plan, staff roster with titles, resident roster with room numbers, and the direct care staff schedule for 01/11/25.
    • LicensingFailed to provide safe environment
    27 Feb 2025Inspection
    Found a violation for failing to provide records requested by the Department.
    • LicensingFailed to provide safe environment
    22 Feb 2025Inspection
    Identified deficiencies in the ABST's accuracy, with inconsistencies between the resident roster, care plans, and ABST data.
    • LicensingFailed to use an ABST
    18 Feb 2025Abuse: Neglect
    Found failures to plan and supervise falls-related care for a resident with a history of falls, resulting in an unwitnessed fall and injury. A $1,125 fine was assessed.
    • AbuseFailed to properly plan care
    18 Feb 2025Inspection
    Investigated allegation of failing to provide documentation upon request and found a violation.
    • LicensingFailed to cooperate with an investigation
    18 Feb 2025Inspection
    Investigated the allegation of failing to cooperate with an investigation and determined a violation of Oregon Administrative Rules for not providing requested documentation.
    • LicensingFailed to cooperate with an investigation
    14 Feb 2025Inspection
    Found a violation for failing to provide records to the Department upon request.
    • LicensingFailed to provide safe environment
    13 Feb 2025Abuse: Neglect
    Found staffing gaps and insufficient interventions allowed a resident to inappropriately touch another resident.
    • AbuseFailed to properly plan care
    13 Feb 2025Inspection
    Found that records were not provided to the Department upon request.
    • LicensingFailed to provide safe environment
    13 Feb 2025Abuse: Neglect
    Found that staff failed to provide a safe environment and to adequately address sexually inappropriate behaviors, resulting in a resident experiencing discomfort and pain from an incident.
    • AbuseFailed to provide safe environment
    13 Feb 2025Inspection
    Found that records were not provided as requested, violating state rules.
    • LicensingFailed to provide safe environment
    03 Feb 2025Inspection
    Found that records were not provided to the Department upon request. This violated Oregon Administrative Rules.
    • LicensingFailed to provide safe environment
    03 Feb 2025Abuse: Neglect
    Investigated abuse and neglect due to failure to follow a care plan for transfers, resulting in injuries to the resident. The violations included missing signature on the service plan and noncompliance with the care plan.
    • AbuseFailed to follow care plan
    02 Feb 2025Inspection
    Found a failure to provide records upon request, violating Oregon Administrative Rules.
    • LicensingFailed to submit timely or adequate staffing documentation
    29 Jan 2025Inspection
    Investigated and found a failure to implement a service plan reflecting residents' needs. The finding was based on observation, interviews, and record review during a site visit.
    • LicensingFailed to properly plan care
    26 Jan 2025Inspection
    Investigated a staffing records issue and substantiated a deficiency for failing to provide records upon request.
    • LicensingFailed to submit timely or adequate staffing documentation
    08 Jan 2025Inspection
    Investigated found that the acuity-based staffing tool was not updated to reflect resident needs. Inconsistencies existed between the resident roster, care plans, and ABST data, violating Oregon Administrative Rules.
    • LicensingFailed to use an ABST
    06 Jan 2025Inspection
    Identified inconsistencies between the resident roster, care plans, and ABST data, showing the ABST was not updated to reflect residents' care needs.
    • LicensingFailed to use an ABST
    02 Jan 2025Inspection
    Identified a deficiency in the Acuity-Based Staffing Tool reflecting resident care needs. Inconsistencies between the resident roster, care plans, and ABST data violated Oregon Administrative Rules.
    • LicensingFailed to use an ABST
    01 Jan 2025Inspection
    Investigated the allegation and identified a deficiency in the Acuity-Based Staffing Tool (ABST) that failed to reflect resident care needs, with inconsistencies between the roster, care plans, and ABST data.
    • LicensingFailed to use an ABST
    16 Dec 2024Inspection
    Identified an outdated ABST not reflecting residents' care needs, with inconsistencies between the roster, care plans, and ABST data.
    • LicensingFailed to use an ABST
    15 Dec 2024Inspection
    Identified deficiencies in the Acuity-Based Staffing Tool that failed to reflect residents’ needs. Found inconsistencies between the roster, care plans, and ABST entries, in violation of Oregon Administrative Rules.
    • LicensingFailed to use an ABST
    13 Dec 2024Inspection
    Found that the Acuity-Based Staffing Tool was not updated to reflect resident care needs, with inconsistencies between the roster, care plans, and ABST data.
    • LicensingFailed to use an ABST
    11 Dec 2024Inspection
    Determined that an updated ABST reflecting resident population and care needs was not maintained, with inconsistencies between the roster, care plans, and ABST data.
    • LicensingFailed to use an ABST
    10 Dec 2024Inspection
    Investigated and found that an updated ABST reflecting resident care needs was not maintained, with inconsistencies between the roster, care plans, and ABST.
    • LicensingFailed to use an ABST
    10 Dec 2024Inspection
    Identified inconsistencies between ABST data, the resident roster, and care plans, resulting in a licensing violation.
    • LicensingFailed to use an ABST
    09 Dec 2024Inspection
    Investigated and found a deficiency in updating the Acuity-Based Staffing Tool to reflect resident care needs and related data inconsistencies.
    • LicensingFailed to use an ABST
    06 Dec 2024Inspection
    Identified inconsistencies between the resident roster, care plans, and ABST data, with an updated staffing tool not reflected, resulting in a licensing violation.
    • LicensingFailed to use an ABST
    03 Dec 2024Inspection
    Identified a deficiency in the Acuity-Based Staffing Tool that did not accurately reflect resident care needs, with inconsistencies among the roster, care plans, and ABST data.
    • LicensingFailed to use an ABST
    29 Nov 2024Inspection
    Investigated and found deficiencies in updating the Acuity-Based Staffing Tool to accurately reflect resident care needs.
    • LicensingFailed to use an ABST
    24 Nov 2024Inspection
    Investigated and determined that an updated Acuity-Based Staffing Tool reflecting resident needs was not maintained, with inconsistencies between the roster, care plans, and ABST data.
    • LicensingFailed to use an ABST
    21 Nov 2024Abuse: Neglect
    Found failure to properly plan care resulting in neglect and abuse related to skin care; assessed a $500 fine.
    • AbuseFailed to properly plan care
    14 Nov 2024Inspection
    Found an outdated ABST not reflecting resident needs, with inconsistencies among the roster, care plans, and ABST data.
    • LicensingFailed to use an ABST
    09 Nov 2024Inspection
    Investigated the allegation and concluded staffing did not meet residents' scheduled and unscheduled needs.
    • LicensingFailed to meet the scheduled and unscheduled needs of residents
    09 Nov 2024Inspection
    Determined that staffing levels did not align with ABST indications and resident needs. Inconsistencies were found among the resident roster, care plans, and ABST data.
    • LicensingFailed to staff as indicated by ABST
    30 Oct 2024Abuse: Neglect
    Found that a safe environment was not provided, resulting in abuse and neglect findings; a $500 fine was assessed.
    • AbuseFailed to provide safe environment
    28 Oct 2024Abuse: Neglect
    Investigated and found a failure to provide a safe medication administration system, resulting in resident discomfort and neglect. A $375 fine was assessed.
    • AbuseFailed to provide a safe medication administration system
    19 Oct 2024Inspection
    Found that medication and treatment orders were not carried out as prescribed. This represented a violation of Oregon Administrative Rules.
    • LicensingFailed to administer medication as ordered
    01 Oct 2024Inspection
    Investigated and identified deficiencies in care planning and interventions for a known fall risk, leading to repeated falls; a $250 fine was assessed.
    • LicensingFailed to properly plan care
    27 Sept 2024Abuse: Neglect
    Found that care around a resident's known history of falls was not properly planned, leading to abuse and neglect findings and a fine.
    • AbuseFailed to properly plan care
    18 Sept 2024Inspection
    Investigated and found a deficiency in the Acuity-Based Staffing Tool that did not reflect resident needs, violating Oregon Administrative Rules.
    • LicensingFailed to use an ABST
    18 Sept 2024Complaint
    Investigated and found Acuity-Based Staffing Tool not fully implemented, with evening shifts understaffed relative to posted staffing plans on multiple dates.
    • DeficiencyAcuity-Based Staffing Tool
    17 Sept 2024Inspection
    Investigated determined a failure to provide a safe medication administration system and incomplete staff training, leading to the resident not receiving medications as ordered.
    • LicensingFailed to provide a safe medication administration system
    17 Sept 2024Inspection
    Investigated and found that a staff member did not complete required medication administration training and was assigned to pass medications, resulting in a resident missing a scheduled blood pressure dose. The provider failed to provide a safe medication administration system.
    • LicensingFailed to provide a safe medication administration system
    17 Sept 2024Inspection
    Found a deficiency in the medication administration system due to incomplete staff training and placing an inadequately trained staff member on duty, resulting in a scheduled medication not being administered.
    • LicensingFailed to provide a safe medication administration system
    17 Sept 2024Inspection
    Found a failure to provide a safe medication administration system and inadequate staff training, resulting in a scheduled medication not given as ordered.
    • LicensingFailed to provide a safe medication administration system
    11 Sept 2024Abuse: Neglect
    Found failure to follow the nail care component of the care plan, leading to a skin tear and neglect/abuse; a $500 fine was assessed.
    • AbuseFailed to follow care plan
    15 Aug 2024Inspection
    Found a licensing violation for failing to maintain an updated ABST that accurately reflects resident population and care needs.
    • LicensingFailed to use an ABST
    22 Jul 2024Inspection
    Found a failure to provide a safe environment that led to a resident fall and injury.
    • LicensingFailed to provide safe environment
    02 Jul 2024Abuse: Neglect
    Investigated found abuse and neglect due to ants in a resident's room and delayed treatment; a $500 fine was assessed.
    • AbuseFailed to provide service
    25 May 2024Inspection
    Investigated a complaint and found a violation for failing to provide a safe medication administration system with potential for harm.
    • LicensingFailed to provide a safe medication administration system
    14 May 2024Inspection
    Investigated failure to report suspected abuse promptly, resulting in a finding of a reportable incident under abuse notification rules.
    • LicensingFailed to report potential or suspected abuse
    13 May 2024Inspection
    Found that the resident's service plan did not reflect mobility needs and was not properly implemented. A wheelchair used for transport was not addressed in the plan, and the resident fell after sitting in an unlocked wheelchair.
    • LicensingFailed to properly plan care
    13 May 2024Complaint
    Investigated found multiple deficiencies related to abuse reporting, service planning, resident monitoring, medication administration, and interior maintenance.
    • DeficiencyReporting & Investigating Abuse-Other Action
    • DeficiencyService Plan: General
    • DeficiencyChange of Condition and Monitoring
    • DeficiencySystems: Treatment Orders
    • DeficiencyAcuity-Based Staffing Tool
    • DeficiencyDoors, Walls, Elevators, Odors
    13 May 2024Inspection
    Investigated the allegation of failing to provide a safe environment and concluded there was a safety deficiency, including a loose rubber threshold between carpeted and linoleum areas that created a tripping hazard.
    • LicensingFailed to provide safe environment
    13 May 2024Inspection
    Identified a deficiency for not maintaining an updated ABST that reflects residents' care needs.
    • LicensingFailed to use an ABST
    30 Apr 2024Inspection
    Found that service plans were not readily available to staff and did not provide clear direction for delivering services. Violated Oregon Administrative Rules.
    • LicensingFailed to communicate necessary information
    29 Apr 2024Abuse: Neglect
    Investigated found the care provider failed to plan and provide appropriate care for the resident, resulting in bruising, skin tears, and discomfort.
    • AbuseFailed to properly plan care
    28 Apr 2024Abuse: Neglect
    Investigated found a resident fell twice after being left alone, resulting in injuries. Staff lacked care plans to guide care, creating an unsafe environment.
    • AbuseFailed to provide safe environment
    26 Apr 2024Inspection
    Investigated an allegation that oversight and monitoring of a resident's change of condition wasn't provided; found no documented written communication of the change of condition or required interventions for direct care staff on each shift.
    • LicensingFailed to provide oversight and monitoring of change of condition
    22 Mar 2024Inspection
    Investigated a narcotics count discrepancy and found a violation related to safe medication administration. The investigation also found no abuse in relation to alleged financial exploitation.
    • LicensingFailed to provide a safe medication administration system
    21 Mar 2024Inspection
    Found that medication orders were not carried out as prescribed, resulting in a missed dose on March 21, 2024 for Levothyroid.
    • LicensingFailed to provide a safe medication administration system
    14 Mar 2024Abuse: Neglect
    Found neglect and abuse occurred when a resident was slapped after inadequate monitoring of a resident's known behavior, causing redness and discomfort.
    • AbuseFailed to provide safe environment
    14 Mar 2024Inspection
    Identified deficiencies in an Acuity-Based Staffing Tool that did not accurately reflect resident needs and ADLs, with inconsistencies among the roster, care plans, and ABST data.
    • LicensingFailed to use an ABST
    29 Feb 2024Abuse: Neglect
    Investigated a groping incident and found inadequate supervision of a resident with known inappropriate sexualized behavior, resulting in emotional harm to a resident.
    • AbuseFailed to provide safe environment
    20 Feb 2024Abuse: Neglect
    Investigated found the care plan was not followed and lights were off, resulting in a resident fall and discomfort.
    • AbuseFailed to follow care plan
    14 Feb 2024Inspection
    Found that medications were not administered as prescribed to a resident, including a missed dose on February 12, 2024.
    • LicensingFailed to provide a safe medication administration system
    03 Feb 2024Inspection
    Determined that medication orders were not carried out as prescribed, with a missed dose on February 2, 2024.
    • LicensingFailed to provide a safe medication administration system
    31 Jan 2024Abuse: Neglect
    Investigated an allegation of neglect and abuse related to care planning. Found that care planning failed to address fall risk and the fall mat was moved, contributing to an unwitnessed fall and discomfort.
    • AbuseFailed to properly plan care
    25 Jan 2024Inspection
    Investigated an allegation of abuse and found that a caregiver used physical force on a resident, did not follow the care plan, causing a fall and creating an unsafe environment.
    • LicensingFailed to provide safe environment
    23 Jan 2024Abuse: Neglect
    Investigated and found that inadequate interventions and care planning related to a resident's fall history led to an unwitnessed fall and hospital transfer with head injuries.
    • AbuseFailed to provide safe environment
    15 Jan 2024Inspection
    Investigated a failure to follow physician orders for a chest x-ray and oxygen; the ordered services were not provided as requested.
    • LicensingFailed to provide medical treatment as ordered
    28 Dec 2023Licensure
    Identified sanitation and administration deficiencies; a follow-up found substantial compliance.
    • DeficiencyComment
    • DeficiencyResident Services Meals, Food Sanitation Rule
    • DeficiencyAdministration Compliance
    18 Dec 2023Inspection
    Identified a failure to provide a safe medication administration system and to carry out medication orders as prescribed.
    • LicensingFailed to provide a safe medication administration system
    18 Dec 2023Complaint
    Investigated identified deficiencies in reporting abuse, medication administration, staffing, training documentation, record-keeping, and odor control. Found multiple violations cited.
    • DeficiencyLicensing Complaint Investigation
    • DeficiencyReporting & Investigating Abuse-Other Action
    • DeficiencySystems: Treatment Orders
    • DeficiencyStaffing Requirements and Training: Staffing
    • DeficiencyTraining Within 30 Days: Direct Care Staff
    • DeficiencyInspections and Investigations
    • DeficiencyDoors, Walls, Elevators, Odors
    18 Dec 2023Inspection
    Found a deficiency for failing to keep the indoor environment free from unpleasant odors.
    • LicensingFailed to provide safe environment
    04 Dec 2023Inspection
    Found a failure to provide a safe medication administration system. This involved improper administration of medications and posed a safety risk.
    • LicensingFailed to provide a safe medication administration system
    04 Dec 2023Inspection
    Investigated an allegation of failing to provide a safe environment and identified deficiencies in medication administration and the medication administration system.
    • LicensingFailed to provide safe environment
    28 Nov 2023Inspection
    Identified a failure to administer hypertension and dementia medications as ordered, with five days of missed doses in November 2023.
    • LicensingFailed to provide a safe medication administration system
    20 Nov 2023Inspection
    Identified insufficient awake direct care staffing to meet 24-hour needs, with no staff visible and reports of sick calls reducing coverage.
    • LicensingFailed to provide appropriate staffing
    05 Nov 2023Abuse: Neglect
    Found violations of resident rights due to neglect and abuse, with a fine assessed.
    • AbuseFailed to provide safe environment
    21 Oct 2023Inspection
    Investigated the staffing complaint and found insufficient qualified awake direct care staff to meet 24-hour needs, resulting in a substantiated violation.
    • LicensingFailed to provide appropriate staffing
    18 Oct 2023Inspection
    Found that a safe environment was not provided when an elopement-risk individual exited the premises without assistance.
    • LicensingFailed to provide safe environment
    09 Oct 2023Abuse: Neglect
    Found that staff failed to follow the care plan, leading to a resident fall and head injury; a $1500 fine was assessed.
    • AbuseFailed to follow care plan
    30 Sept 2023Abuse: Neglect
    Investigated fall-risk care planning failures that led to a resident fall and injury; a $2,500 fine was assessed.
    • AbuseFailed to properly plan care
    26 Sept 2023Inspection
    Found a deficiency in documenting that observed and evaluated an individual's ability to perform safe medication and treatment administration unsupervised.
    • LicensingFailed to provide a safe medication administration system
    24 Sept 2023Abuse: Neglect
    Found failures in care planning and staff training that led to an unwitnessed fall with injury.
    • AbuseFailed to properly plan care
    24 Sept 2023Abuse: Neglect
    Investigated a fall-related incident and found failures to monitor changing condition and prevent falls, leading to an unwitnessed fall and hospital treatment.
    • AbuseFailed to provide oversight and monitoring of change of condition
    21 Sept 2023License Condition
    Investigated the allegation of a failure to provide a safe environment and found noncompliance with Oregon Administrative Rules, placing residents at risk.
    • Regulatory ActionFailed to provide safe environment
    14 Sept 2023Abuse: Neglect
    Found that the resident did not receive basic care promptly after a fall, resulting in a broken wrist and unnecessary discomfort.
    • AbuseFailed to provide service
    08 Sept 2023Abuse: Neglect
    Found neglect due to failure to monitor a resident's change of condition, leading to injury and hospitalization.
    • AbuseFailed to provide oversight and monitoring of change of condition
    06 Sept 2023Inspection
    Investigated a narcotics administration allegation and identified a failure to provide a safe medication administration system. Found a deficiency related to the medication administration system.
    • LicensingFailed to provide a safe medication administration system
    05 Sept 2023Validation
    Identified widespread noncompliance across resident rights, abuse reporting, service planning, health services, medications, infection control, safety, and operations. Multiple deficiencies were cited during the re-licensure process and follow-up visits, with one area noted as immediate jeopardy prior to correction.
    • DeficiencyComment
    • DeficiencyResident Rights and Protection - General
    • DeficiencyReporting & Investigating Abuse-Other Action
    • DeficiencyResident Move-In and Eval: Res Evaluation
    • DeficiencyService Plan: General
    • DeficiencyService Plan: Service Planning Team
    • DeficiencyChange of Condition and Monitoring
    • DeficiencyResident Health Services
    • DeficiencyRes Hlth Srvc: On- and Off-Site Health Srvc
    • DeficiencyInfection Prevention & Control
    • DeficiencySystems: Medications and Treatments
    • DeficiencySystems: Tracking Control Substances
    • DeficiencySystems: Treatment Orders
    • DeficiencySystems: Medication Administration
    • DeficiencySystems: Psychotropic Medication
    • DeficiencyRestraints and Supportive Devices
    • DeficiencyAcuity-Based Staffing Tool
    • DeficiencyTraining Within 30 Days: Direct Care Staff
    • DeficiencyFire and Life Safety: Safety
    • DeficiencyFire and Life Safety: Training For Residents
    • DeficiencyInspections and Investigation: Insp Interval
    • DeficiencyGeneral Building Exterior
    • DeficiencyHousekeeping and Laundry
    • DeficiencyCall Sys, Exit Dr Alarm, Phones, Tv, Or Cable
    • DeficiencyIndividual Rights Settings: Privacy, Dignity
    • DeficiencyIndividual Privacy: Own Unit
    • DeficiencyAdministration Responsibilities
    • DeficiencyAdministration Compliance
    • DeficiencyStaff Training Requirements
    • DeficiencyCompliance With Rules Health Care
    • DeficiencyNutrition and Hydration
    • DeficiencyActivities
    • DeficiencyBehavior
    • DeficiencySecure Outdoor Recreation Area
    • DeficiencyExit Doors
    01 Sept 2023Inspection
    Investigated the allegation of neglect and found that a staff member gave AV a cold, rough bed bath, causing pain and discomfort, and failed to provide a safe environment.
    • LicensingFailed to provide safe environment
    30 Aug 2023Complaint
    Found multiple deficiencies in abuse reporting, service planning, medication orders, staffing, acuity-based staffing, and staff pre-service training.
    • DeficiencyLicensing Complaint Investigation
    • DeficiencyReporting & Investigating Abuse-Other Action
    • DeficiencyService Plan: General
    • DeficiencySystems: Treatment Orders
    • DeficiencyStaffing Requirements and Training: Staffing
    • DeficiencyAcuity-Based Staffing Tool
    • DeficiencyStaffing Requirements and Training – Pre-Serv
    25 Aug 2023Inspection
    Investigated a complaint and determined that neglect occurred, leaving a resident standing unattended during toileting, which led to a fall and injury.
    • LicensingFailed to provide safe environment
    21 Aug 2023Inspection
    Identified a failure to provide a safe environment due to unsatisfactory staff performance verification and improper turning/positioning of residents.
    • LicensingFailed to provide safe environment
    14 Aug 2023Abuse: Neglect
    Found violations for failure to plan adequate care, resulting in skin breakdown and discomfort for a resident. A $500 fine was assessed.
    • AbuseFailed to properly plan care
    14 Aug 2023Abuse: Neglect
    Investigated an abuse and neglect case and found that care left a resident in urine-soaked briefs, causing discomfort.
    • AbuseFailed to follow care plan
    04 Aug 2023Inspection
    Investigated and identified a failure to develop a service plan reflecting resident needs and to implement behavior interventions.
    • LicensingFailed to properly plan care
    04 Aug 2023Inspection
    Determined that there was a failure to provide a safe environment and to investigate and report abuse incidents.
    • LicensingFailed to provide safe environment
    27 Jul 2023Abuse: Neglect
    Found the provider failed to provide adequate care, with an ant infestation causing unreasonable discomfort to a resident. A $1500 fine was assessed.
    • AbuseFailed to provide safe environment
    17 Jul 2023Abuse: Neglect
    Identified a failure to provide a safe medication administration system, resulting in a resident not receiving prescribed blood pressure medication and suffering a stroke.
    • AbuseFailed to provide a safe medication administration system
    07 Jul 2023Abuse: Neglect
    Investigated an incident of resident-to-resident sexual misconduct and found neglect and abuse due to failure to provide basic care, supervision, and proper care planning.
    • AbuseFailed to properly plan care
    03 Jul 2023Abuse: Neglect
    Found inadequate interventions and care planning for known resident behaviors, leading to risk of harm and neglect/abuse. A $500 fine was assessed.
    • AbuseFailed to properly plan care
    26 Jun 2023Inspection
    Identified a staffing deficiency due to insufficient qualified awake direct care staff to meet 24-hour needs, compromising resident safety.
    • LicensingFailed to provide appropriate staffing
    19 Jun 2023Inspection
    Found a violation of safe medication administration practices due to failing to carry out prescribed medication orders. The issue affected a resident between 2023-06-19 and 2023-07-05.
    • LicensingFailed to provide a safe medication administration system
    11 Jun 2023Abuse: Neglect
    Investigated the allegation and found neglect due to inadequate supervision, which led to a resident fall and injuries; a $1,000 fine was assessed.
    • AbuseFailed to properly plan care
    11 Jun 2023Abuse: Neglect
    Investigated and determined supervision and care planning failed for a resident with a known history of falls, resulting in a fall with injury.
    • AbuseFailed to properly plan care
    19 May 2023Inspection
    Investigated an allegation of unsafe medication administration and determined that an antibiotic prescribed for AV was not administered because it was not entered correctly on the MAR.
    • LicensingFailed to provide a safe medication administration system
    25 Apr 2023Inspection
    Found insufficient awake direct care staff to meet 24-hour needs, with delayed responses to call lights creating an unsafe environment.
    • LicensingFailed to provide safe environment
    15 Feb 2023Inspection
    Investigated and found that the ABST was not updated to reflect residents' needs, with inconsistencies among the resident roster, care plans, posted staffing plan, and ABST data. The finding noted a violation of Oregon Administrative Rules.
    • LicensingFailed to use an ABST
    10 Feb 2023Abuse: Neglect
    Investigated and found a failure to provide a safe environment, constituting abuse and neglect. A $375.00 fine was assessed.
    • AbuseFailed to provide safe environment
    12 Jan 2023Complaint
    Identified deficiencies in abuse investigation, service planning, infection control, and staffing, including inadequate investigations, outdated service plans, poor masking, and insufficient awake staff.
    • DeficiencyLicensing Complaint Investigation
    • DeficiencyReporting & Investigating Abuse-Other Action
    • DeficiencyService Plan: General
    • DeficiencyInfection Prevention & Control
    • DeficiencyStaffing Requirements and Training: Staffing
    • DeficiencyAcuity-Based Staffing Tool
    06 Jan 2023Inspection
    Found that an acuity-based staffing tool was not adopted or fully implemented.
    • LicensingFailed to use an ABST
    06 Jan 2023Inspection
    Found a staffing deficiency due to insufficient qualified awake direct care staff to meet 24-hour scheduled and unscheduled needs.
    • LicensingFailed to meet the scheduled and unscheduled needs of residents
    06 Jan 2023Inspection
    Determined that masking requirements were not followed.
    • LicensingFailed to provide infection control
    06 Jan 2023Inspection
    Investigated the allegation and found a failure to update service plans as required by rule.
    • LicensingFailed to care plan in accordance with assessment
    01 Jan 2023Abuse: Neglect
    Investigated a complaint and found neglect of care and abuse for failing to follow the care plan, resulting in an eye injury and a bruise from not wearing proper footwear. A $188 fine was assessed.
    • AbuseFailed to follow care plan
    28 Dec 2022Abuse: Neglect
    Investigated and found that the facility failed to provide a safe environment, resulting in harm to a resident and a $500 fine assessed.
    • AbuseFailed to provide safe environment
    15 Dec 2022Inspection
    Found that the service plan did not reflect residents' needs, a deficiency with potential for minor to moderate harm due to inadequate care planning.
    • LicensingFailed to properly plan care
    15 Dec 2022Inspection
    Investigated and determined a safety violation due to failing to promptly investigate abuse reports and protect residents.
    • LicensingFailed to provide safe environment
    12 Dec 2022Abuse: Neglect
    Investigated a complaint and found a failure to provide a safe environment, resulting in a resident injury from a resident-to-resident altercation.
    • AbuseFailed to provide safe environment
    12 Dec 2022Abuse: Neglect
    Found that a resident experienced multiple unwitnessed falls and did not receive appropriate services for changing condition, resulting in ongoing discomfort. A fine was assessed.
    • AbuseFailed to provide service
    08 Dec 2022Licensure
    Found improper food storage and sanitation in the kitchen during the initial visit; a follow-up determined substantial compliance with applicable rules.
    • DeficiencyComment
    • DeficiencyResident Services Meals, Food Sanitation Rule
    • DeficiencyAdministration Compliance
    01 Dec 2022Abuse: Neglect
    Investigated an allegation that a staff member with a history of sexually inappropriate behavior touched a resident, causing discomfort and loss of dignity. Found a failure to provide a safe environment by not protecting the resident from the staff member's behavior.
    • AbuseFailed to provide safe environment
    25 Nov 2022Abuse: Neglect
    Found neglect and abuse due to failure to provide a safe environment. This resulted in a resident-to-resident altercation.
    • AbuseFailed to provide safe environment
    21 Nov 2022Abuse: Neglect
    Investigated and found that there was a failure to plan care for wandering behavior, leading to a resident entering another resident's room and causing a scratch; a $250 fine was assessed.
    • AbuseFailed to properly plan care
    01 Nov 2022Inspection
    Found violations for failing to submit timely weekly vaccination reporting to the proper authority for 30 days.
    • LicensingFailed to submit timely or adequate staffing documentation
    18 Apr 2022Inspection
    Found that there were no policies and procedures to prevent and respond to incidents, resulting in a failure to provide a safe environment.
    • LicensingFailed to provide safe environment
    07 Aug 2021Abuse: Neglect
    Investigated an allegation of neglect and abuse and found that the care plan was not updated after a significant change in condition, contributing to an injury. A fine was assessed.
    • AbuseFailed to properly plan care
    14 Jul 2021Abuse: Neglect
    Investigated found a failure to provide a safe environment, leading to a resident being found outside unsupervised.
    • AbuseFailed to provide safe environment
    27 May 2021Abuse: Neglect
    Determined that a safe environment was not provided, resulting in substantiated abuse/neglect.
    • AbuseFailed to provide safe environment
    29 Mar 2021Abuse: Neglect
    Found a substantiated violation for failing to provide a safe environment during an outing, resulting in a $500 fine assessed.
    • AbuseFailed to provide safe environment
    02 Feb 2021Abuse: Neglect
    Found inadequate care planning for a resident at risk of falls. The resident fell, was hospitalized, and required staples to the head.
    • AbuseFailed to properly plan care
    25 Jan 2021Abuse: Neglect
    Investigated an allegation of neglect and found that failing to follow the care plan led to a fall with minor injury.
    • AbuseFailed to follow care plan
    22 Jan 2021Abuse: Neglect
    Investigated an allegation of abuse and neglect; found failure to properly plan care led to a fall with injury, including a clavicle fracture and a skin laceration. A fine was assessed.
    • AbuseFailed to properly plan care
    01 Jan 2021Inspection
    Investigated the allegation of failing to administer medication as ordered and found that medication and treatment orders were not carried out.
    • LicensingFailed to administer medication as ordered
    28 Oct 2020Abuse: Neglect
    Found inadequate care planning for fall risk, with injuries observed as a result, constituting neglect and abuse. A fine was assessed.
    • AbuseFailed to properly plan care
    19 Aug 2020Inspection
    Investigated the allegation and found failure to exercise reasonable precautions that may threaten residents' health, safety, or welfare.
    • LicensingFailed to assure resident was safe
    17 Aug 2020Inspection
    Determined that residents did not have a safe and homelike environment.
    • LicensingFailed to provide a homelike environment
    13 Aug 2020Inspection
    Found that direct care staff performance verification was not ensured.
    • LicensingFailed to provide appropriate staffing
    21 Jun 2020Abuse: Neglect
    Concluded that a safe environment was not provided, resulting in a skin injury and constituting abuse and neglect.
    • AbuseFailed to provide safe environment
    05 May 2020Abuse: Neglect
    Found neglect due to insufficient supervision of fall risks, exposing a resident to potential harm; a $500 fine was assessed.
    • AbuseFailed to provide safe environment
    04 May 2020Inspection
    Identified a deficiency where the service plan did not reflect the resident's needs.
    • LicensingFailed to properly plan care
    30 Apr 2020Abuse: Neglect
    Found deficiencies in supervision and staff support related to known behaviors, resulting in injury; a fine was assessed.
    • AbuseFailed to provide safe environment
    16 Apr 2020Abuse: Neglect
    Investigated and found neglect for failing to provide a safe environment, with bruises observed and delayed staff notification; a fine was assessed.
    • AbuseFailed to provide safe environment
    30 Jan 2020Abuse: Neglect
    Investigated and found that a staff member transferred a resident inappropriately without proper training, placing residents at risk for harm; a $338 fine was assessed.
    • AbuseFailed to provide safe environment
    28 Jan 2020Inspection
    Investigated and found failure to immediately report abuse and to promptly investigate all abuse reports.
    • LicensingFailed to report potential or suspected abuse
    13 Jan 2020Abuse: Neglect
    Investigated a neglect allegation for failing to follow the care plan with 30‑minute safety checks, leading to an unwitnessed fall and head injury; a $1,500 fine was assessed.
    • AbuseFailed to follow care plan
    09 Jan 2020Abuse: Neglect
    Found that the resident’s care plan to use Geri sleeves was not followed, leading to skin tears and bruising on the forearms. This constitutes neglect and abuse.
    • AbuseFailed to follow care plan
    08 Jan 2020Abuse: Neglect
    Found deficiencies related to unsafe environment and inadequate staff transfer training. The transfer of a resident was performed inappropriately by pulling up with hands, causing bruising, and staff lacked training to transfer safely.
    • AbuseFailed to provide safe environment
    06 Jan 2020Abuse: Neglect
    Identified neglect and physical abuse violations tied to how a resident was assisted with showering, and a $225 fine was assessed. Also noted a failure to provide a care plan for staff to guide showering.
    • AbuseFailed to protect resident from physical abuse
    03 Jan 2020Inspection
    Found violations involving protection from abuse after investigating a staff member grabbing a resident's arm to keep him/her from leaving, causing distress and a red mark.
    • LicensingFailed to protect resident from physical abuse
    02 Jan 2020Inspection
    Determined the care plan wasn't followed during a transfer, causing injury to a resident.
    • LicensingFailed to follow care plan
    11 Dec 2019Inspection
    Identified a chemical restraint involving medication administration that endangered a resident.
    • LicensingFailure to provide a system that prevents theft or misuse of medication
    11 Dec 2019Abuse: Neglect
    Found neglect and abuse due to failure to follow a resident's care plan and to protect arms and hands during glove washing, resulting in bruises; a fine was assessed.
    • AbuseFailed to follow care plan
    04 Dec 2019Abuse: Neglect
    Investigated and determined violations of resident rights due to neglect and abuse related to shower supervision and failure to investigate a prior incident.
    • AbuseFailed to investigate injury of unknown origin to rule out abuse
    21 Nov 2019Abuse: Neglect
    Found violations related to medication administration safety and resident rights after a staff member administered end-of-life medication and soon after gave pain medication, leading to a fall with injuries.
    • AbuseFailed to provide a safe medication administration system
    21 Nov 2019Abuse: Neglect
    Concluded that staff failed to timely seek medical treatment after a resident's fall, placing the resident at risk for serious harm and constituting abuse and neglect.
    • AbuseFailed to assure timely medical treatment
    18 Nov 2019Abuse: Neglect
    Found that the care plan requiring a two-person transfer was not followed, with staff unaware of the two-person transfer requirement, placing the resident at risk of serious harm.
    • AbuseFailed to follow care plan
    17 Nov 2019Inspection
    Determined that a staff member used force on a resident to board an activity bus, prevented use of a walker during ambulation, and did not follow the resident's care plan, constituting physical abuse and neglect.
    • LicensingFailed to protect resident from physical abuse
    17 Nov 2019Abuse: Neglect
    Found failure to follow the resident care plan left a resident in a soiled and soaked brief, risking skin breakdown. The finding identified neglect and abuse and a fine was assessed.
    • AbuseFailed to follow care plan
    14 Nov 2019Abuse: Neglect
    Investigated a complaint of neglect; found the care plan for an air mattress wasn't followed, causing the resident discomfort.
    • AbuseFailed to follow care plan
    10 Nov 2019Abuse: Neglect
    Investigated a complaint and found improper transfer techniques due to inadequate training led to bruising and an unsafe environment. A $169 fine was assessed.
    • AbuseFailed to provide safe environment
    11 Aug 2019Abuse: Neglect
    Investigated the allegation of neglect and found a failure to provide a safe environment. A fine was assessed.
    • AbuseFailed to provide safe environment
    17 Apr 2019Abuse: Neglect
    Found neglect by failing to provide basic care necessary to maintain health and safety, resulting in harm or risk of harm; a fine was assessed.
    • AbuseFailed to provide safe environment
    17 Apr 2019Abuse: Neglect
    Found neglect and failure to provide a safe environment, resulting in harm and risk of harm to an adult; a fine was assessed.
    • AbuseFailed to provide safe environment
    24 Nov 2018Abuse: Neglect
    Found neglect to provide basic care and services, resulting in a fall and risk of serious harm to a resident.
    • AbuseFailed to provide safe environment
    24 Nov 2018Abuse: Neglect
    Investigated a neglect allegation and found that basic care and services were not provided, creating a risk of serious harm.
    • AbuseFailed to administer medication as ordered
    19 Jun 2018Inspection
    Found that staff failed to properly assess and intervene, leading to a resident-to-resident altercation.
    • LicensingFailed to provide safe environment
    26 Feb 2018Inspection
    Investigated a resident records allegation and found that entries in service plans were not properly initialed and dated.
    • LicensingFailed to keep resident record current or accurate
    09 Jan 2018Inspection
    Concluded that failure to report potential or suspected abuse occurred, resulting in a civil penalty.
    • LicensingFailed to report potential or suspected abuse
    09 Jan 2018Abuse: Neglect
    Found a failure to administer medication as ordered, resulting in an inadequate medication system and a $500 fine.
    • AbuseFailed to administer medication as ordered
    30 Dec 2017Abuse: Neglect
    Concluded that a safe environment was not provided, resulting in a resident-to-resident altercation.
    • AbuseFailed to provide safe environment
    24 Dec 2017Abuse: Neglect
    Investigated allegations of neglect and improper care planning; found a failure to provide a safe environment that led to a resident to resident altercation.
    • AbuseFailed to properly plan care
    14 Dec 2017Abuse: Neglect
    Found failure to provide a safe environment resulting in an RV fall with injury; a $300 fine was assessed.
    • AbuseFailed to provide safe environment
    04 Nov 2017Abuse: Neglect
    Found that medication was not administered as ordered, resulting in physical harm.
    • AbuseFailed to administer medication as ordered
    04 Jan 2017Inspection
    Investigated an allegation of an unsafe environment. Found that a resident was not prevented from falling out of bed.
    • LicensingFailed to provide safe environment
    29 Dec 2016Inspection
    Found violations for failing to follow the care plan and for an unsafe environment that caused an injury.
    • LicensingFailed to follow care plan

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