Cedar Village by Cogir

    4452 Lancaster Dr NE, Salem, OR 97305
    • Independent Living
    • Assisted Living
    • Memory Care

    Kind attentive staff; happy grandma

    I placed my mom at Cedar Village and I'm very pleased. The staff are kind, attentive and professional-caregivers go above and beyond and families feel supported. The community is clean, well-maintained and welcoming, with comfortable rooms, good dining and plenty of activities; our grandma is happy and I recommend a tour.

    Loved one of resident
    Jul 2026

    Pricing

    Prices shown are estimates and subject to change. Contact your senior living advisor for current pricing.

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    Amenities

    Healthcare services

    • Activities of daily living assistance
    • Assistance with bathing
    • Assistance with dressing
    • Assistance with transfers
    • Coordination with health care providers
    • Hospice waiver
    • Medication management
    • Mental wellness program

    Healthcare staffing

    • 24-hour call system
    • 24-hour supervision

    Meals and dining

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

    Room

    • Cable
    • Fully furnished
    • Housekeeping and linen services
    • Kitchenettes
    • Spa
    • Telephone
    • Wifi

    Memory care community services

    • Dementia waiver
    • Mild cognitive impairment
    • Specialized memory care programming

    Transportation

    • Transportation arrangement (medical)
    • Transportation to doctors appointments

    Common areas

    • Beauty salon
    • Dining room
    • Garden
    • Outdoor space
    • Small library

    Community services

    • Move-in coordination

    Activities

    • Community-sponsored activities
    • Resident-run activities
    • Scheduled daily activities

    Reviews

    4.26·(106)

    Overall rating

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

      3.9
    • Staff

      4.3
    • Meals

      3.5
    • Amenities

      3.5
    • Value

      2.3

    Pros

    • Compassionate and attentive caregiving
    • Strong personal connections between staff and residents
    • High staff-to-resident ratio at times
    • Engaging activity program and social opportunities
    • Therapy animals and diverse programmed events
    • Restaurant-style dining presentation
    • Varied menu with multiple entree options
    • On-site chef and printed menus
    • Clean, bright, and well-maintained common areas
    • Spacious, well-lit floor plans and private rooms
    • Accessible apartment features (kitchenettes, walk-in showers)
    • Secure memory-care unit and routine safety checks
    • Convenient location near hospital and services
    • Helpful admissions and appointment coordination
    • Quick maintenance response for repairs and updates
    • Low staff turnover in some periods
    • Strong social community and family-like atmosphere
    • Pet-friendly policy (outside memory care)
    • Regular transportation and outings offered

    Cons

    • Inconsistent medication management and privacy procedures
    • Variable food quality and meal-temperature control
    • Uneven staffing levels and periodic high turnover
    • Inconsistent housekeeping and sanitation practices
    • Variable activity-program quality and scheduling reliability
    • Inconsistent adherence to individual care plans and follow-through
    • Management responsiveness and communication variability
    • Price and cost-transparency concerns
    • Gaps in clinical oversight and medication knowledge among aides
    • Security-procedure inconsistencies in memory care access
    • Maintenance and daily-living task lapses
    • Odor concerns in some common areas and memory-care wing
    • Allegations of medication mishandling and regulatory scrutiny

    Summary of reviews

    Overall impression: Cedar Village presents as a well-appointed, bright community with many families experiencing strong, personalized caregiving and an active social environment. Reviewers frequently cite compassionate staff, restaurant-style dining presentation, a varied menu, and a broad activity calendar that includes therapy animals and frequent events. The facility’s physical plant—spacious floor plans, private apartments with kitchenettes and walk-in showers, a two-level layout, and proximity to medical services—receives consistent praise. Several families described the community as clean, welcoming, and well maintained, with staff who create meaningful social opportunities and a family-like atmosphere.

    Care and clinical oversight: Clinical experiences are mixed. Positive accounts emphasize attentive nursing checks, hydration and weight monitoring, and staff who follow care plans and support independence. However, a recurring concern centers on medication management and privacy during administration: reviewers described practices that lack discretion, limited aide familiarity with specific medications, and instances that led to questions about controlled-substance handling. These concerns have been significant enough in some cases to prompt Ombudsman involvement and allegations, indicating an area families should evaluate closely during a tour.

    Staffing and management: Staff warmth and engagement are often highlighted, with many families naming individual caregivers and lifestyle staff as strengths. Conversely, other reports point to variable staffing levels, periods of high turnover, caregiver fatigue, and instances of delayed responses to call lights. Management performance appears inconsistent across accounts: some reviews praise responsive administration, quick resolution of issues, and effective admissions support; others cite unresponsiveness, poor follow-through on service requests, and communication gaps. Leadership transitions were specifically mentioned as a factor that correlated with perceived declines in consistency.

    Dining and housekeeping: Dining impressions range from highly favorable (chef-driven meals, appealing presentation, printed menus on tables) to critical (inconsistent quality, overcooked vegetables, dry entrees, and cold food on delivery). Memory-care dining and snack availability were singled out as less reliable in several accounts. Housekeeping and sanitation are generally described as good in many areas, but intermittent lapses—missed trash pick-up, inconsistent room cleaning, reused cleaning rags, and odor concerns in some common spaces—were also reported. Prospective families should ask about meal-service timing, kitchen oversight, and housekeeping schedules.

    Activities and community life: Activity programming is a clear strength for many residents: daily schedules with multiple options, strong lifestyle staff, outings, and social events create an engaged community for those who participate. At the same time, a portion of reviews characterize the programming as limited or overly dependent on bingo and describe canceled activities. This suggests variability in program delivery and an uneven resident experience depending on timing and staff availability.

    Facilities and safety: The community’s design and amenities receive frequent praise—bright common spaces, roomy apartments, security measures for memory care, and proximity to local services. Noted weaknesses include traffic noise affecting the dementia wing and some outdoor spaces that are not consistently restful. Maintenance responsiveness is often highlighted positively, though occasional lapses such as closet doors off tracks or delayed small repairs were reported.

    Notable patterns and guidance: Reviews show a pronounced split between families who find Cedar Village exceptional and those who have experienced operational lapses. The most actionable concerns center on medication practices, consistency of housekeeping and dining, and administrative follow-through. Prospective residents and family members should observe medication administration routines, ask about staff training and turnover, request sample menus and meal observation, confirm housekeeping and bathing schedules, and clarify pricing and contract fine print. Verifying any regulatory or Ombudsman history and asking how leadership addresses identified issues will provide additional context for decision-making.

    In summary, Cedar Village offers many features that appeal to families seeking an active, well-appointed community with attentive caregivers and robust programming. At the same time, variability in operational consistency—particularly around medication management, dining, housekeeping, and management responsiveness—warrants careful, specific inquiry during a tour and before moving a loved one in.

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    Location

    Map showing location of Cedar Village by Cogir

    Cedar Village by Cogir is located at 4452 Lancaster Dr NE, Salem, OR, 97305.

    About Cedar Village by Cogir

    Cedar Village Assisted Living & Memory Care offers an inviting and supportive environment for seniors seeking both Assisted Living and Memory Care services in the Salem area. This community extends its warm and attentive care to residents from neighboring towns including Aumsville, Jefferson, Mt. Angel, Woodburn, and throughout Marion and Polk counties. Designed with comfort and style in mind, Cedar Village features elegant interiors and thoughtfully planned floorplans, fostering a sense of home and tranquility for all who live there. Whether new to the area or a local resident, everyone is welcomed into a vibrant and caring community.

    The community emphasizes an elevated living experience, balancing independence with support. Residents of Cedar Village Assisted Living enjoy private apartments that offer the comforts of home paired with the freedom of a maintenance-free lifestyle. Housekeeping and daily chores are managed by a dedicated staff, allowing residents to spend more time engaging in their passions, nurturing relationships, and appreciating the fullness of each day. There is a strong sense of camaraderie fostered by frequent social programs, enriching activities, and wellness classes, all designed to keep residents both engaged and fulfilled.

    Cedar Village is particularly known for its specialized Memory Care program, which provides compassionate and individualized care for those living with dementia or Alzheimer’s Disease. This attentive, round-the-clock support addresses residents’ physical, emotional, and spiritual needs, ensuring safety and dignity at every stage. Enriching activities and gourmet, chef-prepared meals help stimulate the senses and provide daily enjoyment. The staff at Cedar Village take pride in their resident-centered approach, prioritizing both well-being and personal fulfillment.

    One standout aspect of Cedar Village is the Spark™ program, a unique initiative crafted to help residents realize their full potential while enjoying a vibrant sense of purpose each day. Spark™ focuses on nurturing the natural spark within each individual—supporting their ideas, encouraging independence, and helping to bring personal projects and passions to life. By empowering residents to shape the community according to their interests, Cedar Village fosters a uniquely dynamic and supportive environment.

    Nestled in the scenic Willamette Valley, Cedar Village Assisted Living & Memory Care also offers easy access to Oregon’s rich cultural and natural attractions. The city of Salem features historic districts, fine dining, distinctive shopping, museums, and more, all just a short distance from the community. For those who enjoy exploring, Portland and the Oregon coast are comfortably accessible for day trips. Cedar Village stands as a premier choice for senior living, where safety, comfort, and an active, fulfilling lifestyle are always at the forefront.

    About Cogir Senior Living

    Cedar Village by Cogir is managed by Cogir Senior Living.

    Cogir Senior Living was founded in 1995 by Serge G. Duguay, a passionate real estate entrepreneur in Quebec, Canada. What began as a small family business has grown into one of North America's leading senior living operators. From humble beginnings with about a dozen U.S. communities in 2020, Cogir has experienced remarkable growth, approaching 100 communities across 11 states by 2025. The company's U.S. operations are headquartered in Sacramento, California, with additional offices in Scottsdale, Arizona, and Seattle, Washington, under the leadership of CEO David Eskenazy.

    People often ask...

    Cedar Village by Cogir offers competitive pricing, with rates starting at a cost of $6,604 per month.

    Cedar Village by Cogir offers independent living, assisted living, memory care, and board and care.

    There are 29 photos of Cedar Village by Cogir on Mirador.

    Yes, Cedar Village by Cogir allows residents to age in place and adjust their level of care as needed.

    The full address for this community is 4452 Lancaster Dr NE, Salem, OR 97305.

    No, Cedar Village by Cogir 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 number50R353
    StatusActive
    Facility typeResidential Care Facility
    Capacity24 residents
    Licensee4452 Lancaster Drive NE OpCo LLC
    EffectiveJanuary 15th, 2008
    Special certificationMemory Care
    View the official license record

    Inspection Reports

    133

    Reports

    0

    Type A Citations

    0

    Type B Citations

    5

    Complaints

    16

    Years

    18 Jun 2026Change of Owner
    Identified multiple deficiencies in resident service plans, medication orders, staffing evaluations, and fire drills, indicating noncompliance with several care and safety requirements.
    • DeficiencyService Plan: General
    • DeficiencySystems: Treatment Orders
    • DeficiencyAcuity Based Staffing Tool - Updates & Staffing Plan
    • DeficiencyFire and Life Safety: Safety
    28 May 2026Change of Owner
    Identified deficiencies in PRN psychotropic medication management and in staff training for memory care.
    • DeficiencySystems: Psychotropic Medication
    • DeficiencyStaff Training Requirements
    • DeficiencyCompliance with Rules Health Care
    29 Dec 2025Abuse: Neglect
    Determined that abuse by neglect occurred due to failure to properly plan care to keep the resident hydrated, which contributed to dehydration and a urinary tract infection.
    • AbuseFailed to properly plan care
    28 Dec 2025Abuse: Neglect
    Investigated a complaint of neglect related to skin care and found staff did not follow the care plan or apply prescribed skin creams, causing a rash to worsen into a yeast infection and discomfort.
    • AbuseFailed to follow care plan
    18 Sept 2025Abuse: Neglect
    Investigated a failure to properly plan care for a known fall risk, with deficiencies contributing to falls and serious injuries.
    • AbuseFailed to properly plan care
    18 Aug 2025Abuse: Neglect
    Found safety violations due to failure to provide a safe environment after noting prior injuries and an incident with a swollen finger, leading to a fine.
    • AbuseFailed to provide safe environment
    18 Aug 2025Abuse: Neglect
    Found neglect due to failure to provide a safe environment during transfers and ambulation, resulting in injuries to a known fall risk. A $375 fine was assessed.
    • AbuseFailed to provide safe environment
    07 Aug 2025Abuse: Neglect
    Identified violations for failing to provide a safe environment after an incident where a resident bit another, causing swelling and bleeding.
    • AbuseFailed to provide safe environment
    22 Jul 2025Abuse: Neglect
    Found a neglect of care violation for failing to plan care to prevent injuries of unknown origin, resulting in safety concerns for an Alleged Victim; a $500 fine was assessed.
    • AbuseFailed to properly plan care
    18 Jul 2025Abuse: Neglect
    Identified safety-care planning deficiencies that constituted neglect and abuse related to unknown injuries.
    • AbuseFailed to properly plan care
    16 Jun 2025Abuse: Neglect
    Found a failure to provide a safe environment that placed a resident at risk; a $375 fine was assessed.
    • AbuseFailed to provide safe environment
    07 Jun 2025Abuse: Neglect
    Investigated an alleged neglect and abuse incident where staff failed to follow the care plan, resulting in a resident being slapped by another resident; a $188 fine was assessed.
    • AbuseFailed to follow care plan
    06 Jun 2025Abuse: Neglect
    Investigated and found the resident was not kept safe from skin tears, resulting in neglect and abuse; a $250 fine was assessed.
    • AbuseFailed to provide safe environment
    05 Jun 2025Abuse: Neglect
    Investigated an allegation that a safe environment was not provided. Found a violation due to residents being in a common area unsupervised, resulting in neglect and abuse.
    • AbuseFailed to provide safe environment
    05 Jun 2025Abuse: Neglect
    Investigated an altercation between residents and found a failure to provide a safe environment that placed residents at risk of harm.
    • AbuseFailed to provide safe environment
    04 Jun 2025Licensure
    Multiple deficiencies across resident evaluations, service planning, health services, infection control, safety, staff training, and building maintenance were identified during two visits.
    • DeficiencyResident Move-in & Evaluation: Res Evaluation
    • DeficiencyService Plan: General
    • DeficiencyService Plan: Service Planning Team
    • DeficiencyChange of Condition and Monitoring
    • DeficiencyResident Health Services
    • DeficiencyInfection Prevention & Control
    • DeficiencySystems: Psychotropic Medication
    • DeficiencyRestraints and Supportive Devices
    • DeficiencyAnnual and Biennial Inservice for All Staff
    • DeficiencyFire and Life Safety: Safety
    • DeficiencyFire and Life Safety: Training for Residents
    • DeficiencyInspections and Investigation: Insp Interval
    • DeficiencyGeneral Building Exterior
    • DeficiencyGeneral Building: Doors-Walls, Cleanable
    • DeficiencyCall System
    • DeficiencyIndividual Rights Settings Right to Freedom
    30 May 2025License Condition
    Found deficiencies related to providing a safe environment. Evidence and interviews supported the finding.
    • Regulatory ActionFailed to provide safe environment
    23 May 2025Abuse: Neglect
    Found that insufficient care planning placed a resident at risk for harm and constitutes neglect and abuse; a $375 fine was assessed.
    • AbuseFailed to properly plan care
    23 May 2025Abuse: Neglect
    Investigated a complaint found that a resident did not receive a scheduled bath for about a week after returning from hospital, resulting in discomfort; a $250 fine was assessed.
    • AbuseFailed to provide or assist with hygiene
    15 May 2025Licensure
    Investigators found widespread deficiencies across abuse reporting, resident evaluations, service planning, change-of-condition monitoring, health services, safety, and resident rights.
    • DeficiencyReporting & Investigating Abuse-Other Action
    • DeficiencyResident Services: Activities
    • DeficiencyResident Move-in & Evaluation: Res Evaluation
    • DeficiencyService Plan: General
    • DeficiencyService Plan: Service Planning Team
    • DeficiencyChange of Condition and Monitoring
    • DeficiencyResident Health Services
    • DeficiencySystems: Tracking Control Substances
    • DeficiencySystems: Resident Right to Refuse
    • DeficiencySystems: Psychotropic Medication
    • DeficiencyRestraints and Supportive Devices
    • DeficiencyAcuity Based Staffing Tool - ABST Time
    • DeficiencyAcuity Based Staffing Tool - Updates & Staffing Plan
    • DeficiencyFire and Life Safety: Safety
    • DeficiencyFire and Life Safety: Training for Residents
    • DeficiencyDoors, Walls, Elevators, Odors
    • DeficiencyPlumbing Systems
    • DeficiencyCall Sys, Exit Dr Alarm, Phones, TV, or Cable
    • DeficiencyIndividual Privacy: Own Unit
    • DeficiencyIndividual Door Locks: Key Access
    • DeficiencyResident Move-in & Evaluation: Res Evaluation
    • DeficiencyAdministration Responsibilities
    • DeficiencyAdministration Compliance
    • DeficiencyCompliance with Rules Health Care
    • DeficiencyNutrition and Hydration
    • DeficiencyActivities
    07 Apr 2025Kitchen
    Found extensive deficiencies in kitchen sanitation, food storage, and serving temperatures, along with administration compliance gaps.
    • DeficiencyResident Services Meals, Food Sanitation Rule
    • DeficiencyAdministration Compliance
    07 Apr 2025Kitchen
    Found extensive sanitation and storage deficiencies in the kitchen and food areas that did not meet rules.
    • DeficiencyResident Services Meals, Food Sanitation Rule
    11 Nov 2024Abuse: Neglect
    Investigated found a failure to provide a safe environment that allowed a resident to exit on two occasions; a fine was assessed.
    • AbuseFailed to provide safe environment
    25 Oct 2024Abuse: Neglect
    Investigated a safety concern and found a failure to provide a safe environment, constituting abuse and neglect.
    • AbuseFailed to provide safe environment
    23 Oct 2024Abuse: Neglect
    Determined that failure to properly plan care placed residents at risk due to repeated altercations; a $188 fine assessed.
    • AbuseFailed to properly plan care
    15 Oct 2024Abuse: Neglect
    Determined that a safe environment was not provided, creating an elopement risk during a fire alarm and constituting abuse and neglect.
    • AbuseFailed to provide safe environment
    19 Aug 2024Inspection
    Found failure to report vaccination status for vaccinated individuals, residents, and staff for three months, violating monthly reporting requirements.
    • LicensingFailed to report vaccination status
    23 Jul 2024Abuse: Neglect
    Investigated a neglect allegation and found the resident's fall risk was not properly addressed through care planning. The resident sustained a leg fracture as a result.
    • AbuseFailed to properly plan care
    03 May 2024Abuse: Neglect
    Found failure to provide appropriate fall-prevention interventions, leading to a fall and hip fracture with related abuse/neglect findings and a $500 fine assessed.
    • AbuseFailed to provide safe environment
    25 Mar 2024Inspection
    Investigated and found a deficiency in implementing and updating an acuity-based staffing tool.
    • LicensingFailed to use an ABST
    25 Mar 2024Complaint
    Investigated a staffing issue and found the acuity-based staffing tool was not updated, and quarterly updates to some resident profiles were missing.
    • DeficiencyAcuity-Based Staffing Tool
    • DeficiencyTraining Within 30 Days: Direct Care Staff
    07 Mar 2024Inspection
    Determined that safe medication administration was not observed or evaluated unsupervised, and that caregivers were passing medication without proper training.
    • LicensingFailed to provide a safe medication administration system
    19 Feb 2024Abuse: Neglect
    Found inadequate care planning that allowed two bathroom falls resulting in injuries.
    • AbuseFailed to properly plan care
    03 Jan 2024Inspection
    Found that direct care staff were not oriented to residents, including awareness of residents' service plans. This deficiency left staff unaware of residents' service plans.
    • LicensingFailed to provide safe environment
    06 Nov 2023Licensure
    Investigated kitchen practices revealed violations related to food sanitation, temperature control, and administration during multiple visits.
    • DeficiencyComment
    • DeficiencyResident Services Meals, Food Sanitation Rule
    • DeficiencyInspections and Investigation: Insp Interval
    • DeficiencyAdministration Compliance
    06 Nov 2023Licensure
    Identified numerous kitchen sanitation and maintenance deficiencies, including dirty surfaces, damaged equipment, and infection control lapses. A follow-up visit reviewed the conditions.
    • DeficiencyComment
    • DeficiencyResident Services Meals, Food Sanitation Rule
    06 Oct 2023Complaint
    Found that an acuity-based staffing tool was not implemented or updated and did not reflect the correct care time for residents.
    • DeficiencyLicensing Complaint Investigation
    • DeficiencyAcuity-Based Staffing Tool
    06 Oct 2023Complaint
    Investigated and found ongoing bed bug infestations and a failure to prevent entry of rodents and other insects. Pest control actions had not prevented ongoing infestation.
    • DeficiencyLicensing Complaint Investigation
    • DeficiencyGeneral Building Exterior
    06 Oct 2023Inspection
    Investigated pest-control allegation and found failure to prevent entry of other insects.
    • LicensingFailed to control pests
    28 Sept 2023Inspection
    Investigated the allegation and found a pest-control deficiency. Failure to prevent entry of rodents and other insects violated Oregon Administrative Rules.
    • LicensingFailed to provide proper food/nutrition
    16 Sept 2023Abuse: Neglect
    Found inadequate supervision placed a resident at risk of harm. A $500 fine was assessed.
    • AbuseFailed to provide safe environment
    15 Sept 2023Abuse: Neglect
    Found a failure to provide a safe environment that resulted in abuse, and a $375 fine was assessed.
    • AbuseFailed to provide safe environment
    22 Aug 2023Abuse: Neglect
    Investigated a complaint alleging neglect and abuse due to an unsafe environment and inadequate interventions; found that a resident was pushed after wandering into another resident's room, indicating unsafe conditions.
    • AbuseFailed to provide safe environment
    01 Aug 2023Abuse: Neglect
    Identified a failure to provide a safe environment that placed a resident at risk of harm, constituting neglect and abuse.
    • AbuseFailed to provide safe environment
    01 Aug 2023Abuse: Neglect
    Found a failure to provide a safe environment, resulting in injuries after an altercation.
    • AbuseFailed to provide safe environment
    10 Jul 2023Complaint
    Investigated a complaint and found deficiencies in acuity-based staffing and pest prevention, including failure to implement/update ABST and ongoing bed bug infestation due to insufficient preventative measures.
    • DeficiencyLicensing Complaint Investigation
    • DeficiencyAcuity-Based Staffing Tool
    • DeficiencyGeneral Building Exterior
    16 Jun 2023Abuse: Neglect
    Found failure to properly plan care to prevent altercations, constituting neglect and abuse, with a $500 fine assessed.
    • AbuseFailed to properly plan care
    13 May 2023Abuse: Neglect
    Determined that neglect and abuse occurred due to failure to plan care and address a resident's unsafe behavior, risking safety; a $500 fine was assessed.
    • AbuseFailed to properly plan care
    25 Apr 2023Abuse: Neglect
    Fined for neglect due to failure to properly plan care, risking harm to a known fall risk resident; a $500 penalty was assessed.
    • AbuseFailed to properly plan care
    18 Apr 2023Abuse: Neglect
    Determined that an unsafe environment contributed to an incident between residents, with one resident hitting another, constituting abuse and neglect.
    • AbuseFailed to provide safe environment
    30 Jan 2023Abuse: Neglect
    Found neglect and abuse for failing to properly plan care, resulting in multiple falls and a fine.
    • AbuseFailed to properly plan care
    26 Jan 2023Inspection
    Found a pest control deficiency due to bed bug infestation and insufficient action to eliminate it.
    • LicensingFailed to control pests
    24 Dec 2022Abuse: Neglect
    Found neglect due to failure to properly plan care, resulting in bruising risk for a resident with thin skin. Observed lack of interventions after a prior fall and no guidance for staff to prevent further bruising.
    • AbuseFailed to properly plan care
    20 Dec 2022Abuse: Neglect
    Found neglect and abuse due to failure to properly plan care, which contributed to a fall with injury. A fine was assessed.
    • AbuseFailed to properly plan care
    14 Nov 2022Validation
    Identified deficiencies across administration, health services, meals, medications, and building operations, with follow-up showing substantial compliance thereafter.
    • DeficiencyComment
    • DeficiencyFacility Administration: Policy & Procedure
    • DeficiencyFacility Administration: Quality Improvement
    • DeficiencyResident Services Meals, Food Sanitation Rule
    • DeficiencyResident Move-In and Eval: Res Evaluation
    • DeficiencyService Plan: General
    • DeficiencyChange of Condition and Monitoring
    • DeficiencyResident Health Services
    • DeficiencyRn Delegation and Teaching
    • DeficiencySystems: Tracking Control Substances
    • DeficiencySystems: Treatment Orders
    • DeficiencySystems: Medication Administration
    • DeficiencyStaffing Requirements and Training – Pre-Serv
    • DeficiencyFire and Life Safety: Safety
    • DeficiencyInspections and Investigation: Insp Interval
    • DeficiencyGeneral Building Exterior
    • DeficiencyGeneral Building: Doors-Walls, Cleanable
    • DeficiencyResident Units
    • DeficiencyHouse Keeping and Sanitation
    14 Nov 2022Validation
    Identified widespread deficiencies across resident care, health services, sanitation, staff training, and safety with multiple repeat violations noted.
    • DeficiencyComment
    • DeficiencyResident Services Meals, Food Sanitation Rule
    • DeficiencyResident Move-In and Eval: Res Evaluation
    • DeficiencyService Plan: General
    • DeficiencyService Plan: Service Planning Team
    • DeficiencyChange of Condition and Monitoring
    • DeficiencyResident Health Services
    • DeficiencyRn Delegation and Teaching
    • DeficiencyInfection Prevention & Control
    • DeficiencySystems: Treatment Orders
    • DeficiencySystems: Medication Administration
    • DeficiencySystems: Psychotropic Medication
    • DeficiencyRestraints and Supportive Devices
    • DeficiencyFire and Life Safety: Safety
    • DeficiencyInspections and Investigation: Insp Interval
    • DeficiencyDoors, Walls, Elevators, Odors
    • DeficiencyHousekeeping and Laundry
    • DeficiencyAdministration Compliance
    • DeficiencyStaff Training Requirements
    • DeficiencyCompliance With Rules Health Care
    • DeficiencyResident Rooms
    11 Nov 2022Abuse: Neglect
    Investigated a fall-related complaint and found deficiencies in care planning that failed to reduce fall risk, resulting in a fracture.
    • AbuseFailed to properly plan care
    11 Oct 2022Complaint
    Investigated and identified deficiencies related to cleaning/repair of interior surfaces and floors, including a floor in need of replacement due to disrepair and staining.
    • DeficiencyLicensing Complaint Investigation
    • DeficiencyGeneral Building: Doors-Walls, Cleanable
    05 Oct 2022Inspection
    Investigated the allegation and identified a deficiency in keeping interior surfaces and equipment clean and in good repair.
    • LicensingFailed to provide safe environment
    13 Sept 2022Abuse: Neglect
    Identified neglect and abuse due to failing to respond to a resident's call light promptly, which led to a fall and related pain. The findings indicate the failure to answer the call light timely violated resident rights.
    • AbuseFailed to answer call light in a timely manner
    07 Jul 2022Abuse: Neglect
    Investigated a complaint and found a failure to provide a safe environment. An individual eloped through an open gate, creating risk of harm.
    • AbuseFailed to provide safe environment
    28 Jun 2022Abuse: Neglect
    Investigated and found that a resident was left unsupervised, resulting in injuries, and that a safe environment was not provided.
    • AbuseFailed to provide safe environment
    20 Jan 2022Abuse: Neglect
    Investigated a complaint and found abuse/neglect due to failure to provide a safe environment and prevent altercations; a $250 fine was assessed.
    • AbuseFailed to provide safe environment
    10 May 2021Abuse: Neglect
    Found neglect for failing to properly plan care, leading to a hip fracture of a known fall risk resident.
    • AbuseFailed to properly plan care
    19 Apr 2021Abuse: Neglect
    Found a violation of safe environment after a known elopement risk escaped through a patio gate, likely due to an outage and lack of gate security monitoring. A $188 fine was assessed.
    • AbuseFailed to provide safe environment
    16 Dec 2020Abuse: Neglect
    Found a neglect and abuse violation due to failing to administer pain medication on time, causing unnecessary pain and discomfort.
    • AbuseFailed to administer medication as ordered
    28 Sept 2020Abuse: Neglect
    Found deficiencies in care planning for a resident at risk of falls, and the fall led to an ankle fracture. The deficiencies were linked to neglect and abuse.
    • AbuseFailed to properly plan care
    14 Jun 2020Abuse: Neglect
    Determined that a safe environment was not provided, resulting in abuse and neglect. A $188 fine was assessed.
    • AbuseFailed to provide safe environment
    02 Jun 2020Inspection
    Investigated and found a deficient practice in maintaining a safe physical environment, which allowed a resident to elope when a gate was left unlocked.
    • LicensingFailed to maintain a safe physical environment
    24 Feb 2020Inspection
    Found a licensing violation due to insufficient staff to meet residents' needs. The allegation concerned failing to answer call lights promptly.
    • LicensingFailed to answer call light in a timely manner
    09 Feb 2020Inspection
    Identified a licensing violation for failing to answer call lights promptly, with repeated delays of 20 to 30 minutes.
    • LicensingFailed to answer call light in a timely manner
    25 Jan 2020Abuse: Neglect
    Found neglect and abuse due to failure to provide a safe environment after an altercation; a $250 fine was assessed.
    • AbuseFailed to provide safe environment
    21 Nov 2019Abuse: Neglect
    Investigated a resident fall caused by a walker with faulty brakes and found neglect and abuse due to failure to maintain equipment and provide fall-prevention interventions.
    • AbuseFailed to provide or maintain resident care equipment
    09 Aug 2019Abuse: Neglect
    Found neglect of basic care and supervision for an individual in care, creating significant risk of harm, and a $375 fine was assessed.
    • AbuseFailed to provide safe environment
    31 May 2019Inspection
    Identified a deficiency for failing to notify the resident's physician after the resident refused their medication.
    • LicensingFailure to provide a system that prevents theft or misuse of medication
    31 May 2019Inspection
    Investigated an allegation of inadequate hydration planning and found a deficiency in providing an individualized hydration plan throughout residents' waking hours.
    • LicensingFailed to assure proper hydration
    24 May 2019Abuse: Neglect
    Investigated a neglect allegation and found failure to supervise led to a resident's skin tear.
    • AbuseFailed to follow care plan
    07 Mar 2019Inspection
    Found that meals were not palatable and served cold, violating the applicable rule.
    • LicensingFailed to provide proper food/nutrition
    28 Jan 2019Inspection
    Found a deficiency for not providing a safe medication administration system following medications going missing when a resident moved.
    • LicensingFailed to provide a safe medication administration system
    31 Dec 2018Abuse: Neglect
    Found neglect in basic care related to falls, putting a resident at risk of serious harm and resulting in injury; a $500 fine was assessed.
    • AbuseFailed to adequately care plan related to falls
    31 Dec 2018Inspection
    Determined that suspected abuse was not reported and assessed a $1,000 fine.
    • LicensingFailed to report potential or suspected abuse
    04 Oct 2018Inspection
    Found a failure to provide a safe environment due to inadequate supervision, creating a risk of serious harm to an individual in care.
    • LicensingFailed to provide safe environment
    13 Aug 2018Condition
    Investigated the allegation of failure to provide a safe environment and found violations; a zero-dollar civil penalty was assessed.
    • Regulatory ActionFailed to provide safe environment
    26 Jul 2018Abuse: Sexual abuse
    Found a substantiated violation involving failure to protect a resident from inappropriate sexual contact by a staff member.
    • AbuseFailed to protect resident from inappropriate sexual contact
    17 Apr 2018Abuse: Neglect
    Identified a failure to assess and intervene on care needs that led to a fall and injuries.
    • AbuseFailed to properly plan care
    26 Mar 2018Inspection
    Found failure to report potential or suspected abuse; civil penalty assessed.
    • LicensingFailed to report potential or suspected abuse
    26 Mar 2018Abuse: Neglect
    Investigated a complaint about falls and found failures to assess and intervene that led to three falls and injuries.
    • AbuseFailed to adequately care plan related to falls
    06 Mar 2018Inspection
    Found a medication administration violation when the incorrect insulin was given, resulting in a resident being sent to the emergency room.
    • LicensingFailed to administer medication as ordered
    27 Feb 2018Abuse: Neglect
    Investigated a failure to follow the care plan that caused a resident to fall and cut their lip. A fine of $188 was assessed.
    • AbuseFailed to follow care plan
    03 Feb 2018Inspection
    Found an inadequate medication system that led to medications not being provided as ordered.
    • LicensingFailed to administer medication as ordered
    13 Oct 2017Abuse: Neglect
    Investigated abuse/neglect allegation and found inadequate screening or assessment that led to a resident-to-resident altercation.
    • AbuseFailed to perform adequate screening or assessment
    19 Jun 2017Abuse: Neglect
    Determined that there was an inadequate medication system, resulting in a resident receiving another resident's medications.
    • AbuseFailed to provide a safe medication administration system
    06 May 2017Abuse: Neglect
    Investigated and found deficiencies in the medication system that caused a resident to receive the wrong medications and end up in the emergency room.
    • AbuseFailed to provide a safe medication administration system
    18 Dec 2016Abuse: Physical Abuse
    Investigated abuse allegation and determined there was failure to protect a resident from rough treatment.
    • AbuseFailed to protect resident from rough treatment
    18 Dec 2016Abuse: Verbal/Mental abuse
    Investigated an allegation of verbal/mental abuse and concluded that a resident was not protected from humiliation, resulting in significant emotional harm.
    • AbuseFailed to protect resident from verbal abuse
    05 Oct 2016Inspection
    Investigated and found a licensing violation related to unsafe medication administration and pain medication management.
    • LicensingFailed to provide a safe medication administration system
    17 Jul 2016Inspection
    Investigated the allegation and found a deficiency in medication administration.
    • LicensingFailed to provide a safe medication administration system
    13 Nov 2015Inspection
    Determined that a licensing violation occurred due to failure to modify the service plan and document attempts to resolve the move-out reason.
    • LicensingFailed to adequately plan discharge
    07 Nov 2015Abuse: Sexual abuse
    Found a sexual abuse allegation involving inappropriate contact and inadequate supervision, creating a safety risk; a $300 fine was assessed.
    • AbuseFailed to protect resident from inappropriate sexual contact
    06 Nov 2015Abuse: Neglect
    Investigated a neglect allegation and found failure to properly assess and intervene on the resident's behalf, creating moderate harm or potential for serious harm.
    • AbuseFailed to assure timely medical treatment
    14 Jun 2015Abuse: Neglect
    Investigated a neglect allegation that staff failed to intervene when a resident's condition changed; found a failure to assess and intervene.
    • AbuseFailed to intervene when resident's condition changed
    15 Jan 2015Inspection
    Determined a safety deficiency where a safe environment wasn’t provided and one resident harmed another.
    • LicensingFailed to provide safe environment
    02 Oct 2014Inspection
    Found failure to provide appropriate care to a resident, indicating a breach of the care plan and related requirements.
    • LicensingFailed to follow care plan
    21 Sept 2014Abuse: Neglect
    Investigated the allegation of neglect and found failure to protect residents from physical aggression.
    • AbuseFailed to address resident's behavior
    12 Jan 2014Inspection
    Found failure to provide a safe environment for residents.
    • LicensingFailed to address resident's behavior
    30 Jun 2013Inspection
    Found a failure to provide a safe environment.
    • LicensingFailed to address resident's behavior
    16 Jun 2013Inspection
    Found inadequate falls-related care planning and unsafe conditions due to failure to provide a safe environment.
    • LicensingFailed to adequately care plan related to falls
    20 May 2013Abuse: Verbal/Mental abuse
    Investigated an allegation of verbal abuse and found a safety deficiency.
    • AbuseFailed to protect resident from verbal abuse
    16 May 2013Inspection
    Found a safety deficiency for failing to provide a safe environment.
    • LicensingFailed to address resident's behavior
    11 May 2013Abuse: Neglect
    Investigated a complaint and found a failure to provide a safe environment, resulting in a $300 fine.
    • AbuseFailed to properly plan care
    25 Apr 2013Inspection
    Investigated a complaint alleging failure to administer medication as ordered and found medication mismanagement placing a resident at risk.
    • LicensingFailed to administer medication as ordered
    07 Apr 2013Inspection
    Found a deficiency in medication management that could lead to harm. Cited a violation related to safe medication administration.
    • LicensingFailed to provide a safe medication administration system
    15 Mar 2013Abuse: Financial abuse
    Investigated a complaint of financial exploitation and found deficiencies related to protecting residents from financial exploitation and to providing a safe environment.
    • AbuseFailed to protect resident from financial exploitation
    15 Nov 2012Inspection
    Found that a safe environment was not provided. The case was classified as a minor harm or potential for moderate harm.
    • LicensingFailed to provide safe environment
    16 Apr 2012Abuse: Neglect
    Determined neglect occurred due to failure to seek medical attention after a resident's injury fall.
    • AbuseFailed to intervene when resident's condition changed
    25 Feb 2012Inspection
    Investigated the complaint and found a failure to provide a safe medication system.
    • LicensingFailed to administer ordered medication
    23 Dec 2011Abuse: Neglect
    Investigated allegations of neglect related to falls and found a failure to assess and intervene.
    • AbuseFailed to adequately care plan related to falls
    04 Nov 2011Abuse: Physical Abuse
    Investigated an allegation of physical abuse and found failure to protect a resident from rough treatment.
    • AbuseFailed to protect resident from rough treatment
    06 Oct 2011Abuse: Financial abuse
    Found a failure to provide a secure environment.
    • AbuseFailed to provide safe environment
    09 Sept 2011Inspection
    Investigated and found a deficiency in medication management. The allegation was supported.
    • LicensingFailed to provide a safe medication administration system
    19 Aug 2011Abuse: Neglect
    Investigated an abuse/neglect allegation about medication care and found deficiencies in safe administration; a $300 fine was assessed.
    • AbuseFailed to provide a safe medication administration system
    08 Aug 2011Abuse: Neglect
    Investigated a neglect allegation and identified a failure to provide a safe medication administration system, risking moderate harm; a fine was assessed.
    • AbuseFailed to provide a safe medication administration system
    07 Dec 2010Inspection
    Found failure to provide a safe and secure environment with minor harm potential.
    • LicensingFailed to provide safe environment
    19 Oct 2010Inspection
    Investigated the allegation and found that a safe environment was not provided.
    • LicensingFailed to provide safe environment
    11 Sept 2010Inspection
    Investigated the allegation and found a failure to provide a safe environment.
    • LicensingFailed to provide service
    25 Aug 2010Inspection
    Found a deficiency in providing a safe environment for RVs.
    • LicensingFailed to provide safe environment
    30 Jul 2010Abuse: Neglect
    Investigated an allegation of failing to perform adequate screening or assessment; found deficiencies and a $300 fine was assessed.
    • AbuseFailed to perform adequate screening or assessment
    07 Jul 2010Inspection
    Investigated and found failure to provide appropriate care to residents.
    • LicensingFailed to follow care plan
    01 Jul 2010Abuse: Verbal/Mental abuse
    Investigated and found that a staff member failed to protect a resident from humiliating treatment by another staff member.
    • AbuseFailed to protect resident from mental or emotional abuse
    19 May 2010Abuse: Neglect
    Found a substantiated allegation of failing to provide a safe environment; a fine was assessed.
    • AbuseFailed to provide safe environment
    14 Apr 2010Inspection
    Substantiated a failure to provide a safe environment. The finding identified a safety rule violation.
    • LicensingFailed to provide safe environment
    15 Mar 2010Abuse: Financial abuse
    Investigated a financial exploitation allegation and found a failure to protect residents from theft, resulting in a $300 fine assessed.
    • AbuseFailed to protect resident from financial exploitation
    25 Feb 2010Abuse: Neglect
    Determined that the neglect allegation regarding failure to intervene was supported. A $300 fine was assessed.
    • AbuseFailed to intervene when resident's condition changed

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