Pricing ranges from
    $3,500 – 8,931/month

    Fieldstone Village at Keizer Ridge Assisted Living & Memory Care

    1165 McGee Ct, Salem, OR 97303
    • Assisted Living
    • Memory Care

    Warm caring community with peace

    I moved my mother here and I'm very pleased overall. The staff are warm, attentive and genuinely caring, the community is clean, bright and well-kept with lovely grounds, and there are plenty of activities, outings and helpful services that keep residents engaged. Security, medical support and responsive management give me peace of mind-I'd recommend touring if you're looking for a welcoming, home-like place.

    Loved one of resident
    Sep 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

    • 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

    Common areas

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

    Community services

    • Concierge services
    • Fitness programs
    • Move-in coordination

    Activities

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

    Reviews

    4.03·(72)

    Overall rating

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

      4.0
    • Staff

      4.1
    • Meals

      3.8
    • Amenities

      3.9
    • Value

      2.8

    Pros

    • Warm, friendly, and respectful staff interactions
    • Individualized, compassionate memory-care support
    • Staff familiarity with residents’ preferences and personalities
    • Clean, bright, and well-maintained interior spaces
    • Attractive, spacious apartments and hotel- or lodge-style setting
    • Varied activities, entertainment, outings, and family events
    • Restaurant-style dining with menu choices and generally positive food feedback
    • Transportation for appointments and community outings
    • Responsive communication from some administrators and care teams
    • Well-kept grounds and garden areas

    Cons

    • Staffing levels that may not match residents’ higher-acuity support needs
    • Delays responding to requests for assistance
    • Inconsistent follow-through on care plans, grooming, and medication support
    • Management continuity and staff-morale concerns
    • Variable meal satisfaction and room-service temperature
    • Inconsistent move-in orientation and individualized care coordination
    • Inconsistent front-desk communication and resident assistance
    • Concerns about staff-resident financial boundaries and complaint accountability

    Summary of reviews

    Experiences at The Village at Keizer Ridge vary considerably across residents, care needs, and reported management periods. Many families describe warm, attentive care, with particular praise for memory care staff who learn residents’ routines and preferences and support their social and emotional needs. Other families raise concerns about whether care plans are consistently followed, including personal-care, grooming, and medication support. The strongest recurring operational concern is staffing: families describe delayed responses to requests for help and difficulty meeting the needs of residents requiring more hands-on assistance. Some families feel the community is better suited to residents who are relatively independent, while positive memory-care experiences are also prominent.

    Staff interactions are often described as kind, respectful, and welcoming, and residents are frequently recognized by name. Families also value responsive administrators and care teams, though experiences with communication and assistance are not uniform. Reports of management changes, staff turnover, and low morale accompany concerns about staffing and care consistency. A small number of accounts also describe an unhelpful or discourteous reception experience. One family made a serious allegation involving an employee’s financial dealings with a resident and expressed concern about the organization’s response; this is an individual account and does not establish a broader pattern, but it raises a concern about oversight and accountability.

    Dining feedback is mixed. Families and residents often appreciate the restaurant-style service, menu choices, and food quality, while others describe dissatisfaction with meals or delays and temperature issues with food delivered to rooms. Activities are a notable strength, with accounts of exercise, games, crafts, entertainment, outings, seasonal events, and family gatherings. Participation can depend on residents’ interests, mobility, and the activity schedule; one resident also described difficulty obtaining dedicated space and supplies for resident-led crafts.

    The building and grounds receive consistently favorable comments for their attractive, bright, clean, and well-kept appearance. Families praise the spacious apartments, comfortable common areas, garden, transportation, and overall welcoming atmosphere. Some prospective families, however, find the community large or hotel-like and prefer a smaller, more intimate setting. Overall, the reviews point to appealing surroundings and substantial activity offerings, alongside a need to verify current staffing, response times, care-plan follow-through, medication processes, and communication practices—particularly when a resident requires frequent or two-person assistance.

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    Location

    Map showing location of Fieldstone Village at Keizer Ridge Assisted Living & Memory Care

    Fieldstone Village at Keizer Ridge Assisted Living & Memory Care is located at 1165 McGee Ct, Salem, OR, 97303.

    About Fieldstone Village at Keizer Ridge Assisted Living & Memory Care

    Village At Keizer Ridge Memory Care is a residential care facility with 23 beds, all dedicated to supporting older adults with memory concerns like Alzheimer's and other types of dementia, and folks here will notice the place was built for memory care needs, with secured areas and indoor walking paths to help reduce confusion and prevent wandering. The community offers both assisted living and memory care services, including help with things like bathing, dressing, and managing medicine, so someone who needs more support later on can often transition to a higher level of care without leaving the campus, which can be a comfort for both residents and their families. There are several floor plans available, including one-bedroom and studio apartments, and shared rooms, all with kitchenettes, refrigerators, Wi-Fi, cable TV, and ADA-compliant bathrooms for safety and convenience.

    Everyone who lives here gets access to a lot of amenities such as a gym, a wellness center, housekeeping and laundry service, and there's a salon and spa right on-site for haircuts or just to relax, plus a coffee shop and a restaurant that serves homemade, fresh meals all day and night. Meals are made by chefs and are healthy and varied, and families say the dining experience is pretty special. Residents can spend time outdoors in the secure courtyard, walk the landscaped paths, or look after the raised garden beds, and when they want to stay inside, there's plenty to keep them busy, from movies in the theater to books in the library, games in the game room, and a multimedia room for things like movie nights. The activity calendar is full, with art classes, music, fitness sessions, community trips, and resident-led activities, all meant to keep everyone active and socially connected, and the staff, who are on-site day and night, work to make sure people always have a safe and stable environment.

    Transportation is provided to local places, and healthcare professionals like dermatologists and pharmacists are nearby, which can make medical appointments easier. There's also a private dining room, a family meeting room, a spacious patio, and social spaces where people can gather for conversation or relax on their own, and the living spaces stay clean thanks to regular housekeeping and linens service. The whole place is pet-friendly, and the well-loved poodle in the community brings a bit of extra joy for residents and visitors. Cascadia Senior Living operates the facility, with a good reputation for care and community spirit, and the commitment is clear from the way staff pay attention to residents' unique habits, interests, and comfort. People here get tailored dementia support, a daily routine, and specialized tech to help with memory, while still having choices and independence where possible. Respite care is available for short stays. Overall, Village At Keizer Ridge Memory Care offers a warm, stable setting with activities, safety, and specialized care, aimed at helping older adults with memory needs live meaningful, comfortable days, supported by a caring and consistent team.

    About Frontier Senior Living

    Fieldstone Village at Keizer Ridge Assisted Living & Memory Care is managed by Frontier Senior Living.

    Frontier Management is a leading senior living provider in the United States, operating over 120 communities across 19 states. Headquartered in Durham, Oregon, Frontier offers a range of senior living options, including independent living, assisted living, and memory care. Founded in 2000, Frontier has grown significantly and has been recognized for its excellence in senior care, earning multiple prestigious industry awards.

    One of Frontier's hallmark programs is the Spark program, rooted in Montessori-style practices, which promotes purpose and engagement among residents. Initially designed for memory care, this program has been expanded to other types of care within Frontier's communities. The Spark program empowers residents to have an active role in their community, enhancing their daily lives through meaningful activities.

    Frontier is also known for its dedication to resident health and well-being. Their communities offer comprehensive services tailored to individual needs, including customized healthcare plans through the Frontier Advantage Network, which aims to extend residents' stay by keeping them healthier for longer periods.

    The company has undergone significant changes and growth in recent years, including a rebranding effort to refresh its image and enhance its services. Frontier's communities are spread across various states including Arizona, California, Florida, Georgia, Idaho, Illinois, Indiana, Iowa, Louisiana, Massachusetts, Mississippi, Missouri, Montana, Nebraska, Nevada, Oregon, Tennessee, Texas, Utah, Washington, and Wisconsin.

    Frontier Management's commitment to quality care, innovative programs, and extensive service options makes it a prominent name in senior living, continually striving to meet the evolving needs of its residents.

    People often ask...

    Fieldstone Village at Keizer Ridge Assisted Living & Memory Care offers competitive pricing, with rates starting at a cost of $3,500 per month.

    Fieldstone Village at Keizer Ridge Assisted Living & Memory Care offers assisted living and memory care.

    There are 37 photos of Fieldstone Village at Keizer Ridge Assisted Living & Memory Care on Mirador.

    The full address for this community is 1165 McGee Ct, Salem, OR 97303.

    No, Fieldstone Village at Keizer Ridge Assisted Living & 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 number50M427
    StatusActive
    Facility typeResidential Care Facility
    Capacity23 residents
    LicenseeCSL Keizer Ridge OR Tenant, LLC
    EffectiveFebruary 18th, 2016
    Special certificationMemory Care
    View the official license record

    Inspection Reports

    131

    Reports

    0

    Type A Citations

    0

    Type B Citations

    4

    Complaints

    10

    Years

    02 Jun 2026Inspection
    Investigated the records request and found failure to provide records to the Department upon request.
    • Licensing—Failed to make facility or resident records accessible
    02 Jun 2026Inspection
    Found that records were not provided to the Department upon request.
    • Licensing—Failed to make facility or resident records accessible
    02 Jun 2026Inspection
    Found that records were not provided when requested.
    • Licensing—Failed to cooperate with an investigation
    24 Apr 2026Inspection
    Found that medication orders were not carried out as prescribed.
    • Licensing—Failed to administer medication as ordered
    17 Feb 2026Kitchen
    Found extensive kitchen sanitation and storage deficiencies with non-operational equipment, improper temperatures, and improperly labeled/open foods.
    • Deficiency—Resident Services Meals, Food Sanitation Rule
    17 Feb 2026Kitchen
    Identified multiple sanitation and administration deficiencies related to meals and kitchen operations. The problems included dirty kitchen areas and improper temperature and storage monitoring.
    • Deficiency—Resident Services Meals, Food Sanitation Rule
    • Deficiency—Administration Compliance
    07 Dec 2025Abuse: Neglect
    Investigated the allegation of neglect and abuse and identified a failure to provide a safe environment, with a $250 fine assessed.
    • Abuse—Failed to provide safe environment
    17 Nov 2025Inspection
    Investigated the allegation and identified a deficiency related to quarterly Acuity-Based Staffing Tool evaluations.
    • Licensing—Failed to use an ABST
    13 Nov 2025Inspection
    Identified a deficiency in using ABST results to develop and routinely update the posted staffing plan and to complete or update ABST evaluations for each resident quarterly.
    • Licensing—Failed to use an ABST
    11 Nov 2025Abuse: Neglect
    Found neglect and abuse due to failure to provide necessary services and care planning, resulting in a resident fall with injuries; a $500 fine was assessed.
    • Abuse—Failed to provide service
    11 Nov 2025Abuse: Neglect
    Investigated and found neglect for failing to provide required care and interventions. A $500 fine was assessed.
    • Abuse—Failed to provide service
    25 Oct 2025Abuse: Neglect
    Investigated a neglect allegation and found that scheduled narcotic medication was not provided for two days due to untimely re-ordering, resulting in pain and discomfort.
    • Abuse—Failed to administer medication as ordered
    25 Oct 2025Inspection
    Found that ABST results were not used to develop and routinely update the posted staffing plan and ABST evaluations for each resident quarterly.
    • Licensing—Failed to use an ABST
    23 Oct 2025Inspection
    Investigated determined that ABST evaluations were not completed or updated quarterly for each resident.
    • Licensing—Failed to use an ABST
    04 Oct 2025Inspection
    Found that the licensee failed to use ABST results to develop and routinely update the posted staffing plan and to complete or update and review ABST evaluations for each resident quarterly.
    • Licensing—Failed to use an ABST
    26 Sept 2025Inspection
    Investigated the allegation of an unsafe environment and found a deficiency for not developing, maintaining, and implementing an acuity-based staffing tool as required.
    • Licensing—Failed to provide safe environment
    10 Sept 2025Inspection
    Found failure to develop, maintain, and implement an acuity-based staffing tool as required by the rule. This deficiency could leave staff with insufficient coverage during med passes when assistance requirements are high.
    • Licensing—Failed to provide safe environment
    08 Sept 2025Inspection
    Found failure to develop, maintain, and implement an acuity-based staffing tool.
    • Licensing—Failed to update staffing plan based on ABST
    02 Sept 2025Inspection
    Identified a deficiency in staffing planning due to failure to develop, maintain, and implement an Acuity Based Staffing Tool.
    • Licensing—Failed to update staffing plan based on ABST
    27 Jun 2025Inspection
    Investigated the staffing allegation and found a failure to develop, maintain, and implement an Acuity Based Staffing Tool.
    • Licensing—Failed to update staffing plan based on ABST
    05 Feb 2025Abuse: Neglect
    Found deficiencies in care planning to address a resident's inappropriate touching behavior, creating risk to other residents.
    • Abuse—Failed to follow care plan
    05 Feb 2025Inspection
    Found that ABST evaluations were not completed or updated for each resident quarterly.
    • Licensing—Failed to use an ABST
    28 Jan 2025Inspection
    Identified failure to complete or update and review quarterly Acuity-Based Staffing Tool evaluations for each resident, violating Oregon Administrative Rules.
    • Licensing—Failed to use an ABST
    01 Jan 2025Abuse: Neglect
    Investigated and found neglect for failing to follow the care plan by not assisting with bathing. The resident was at risk due to unsupervised bathing.
    • Abuse—Failed to follow care plan
    21 Dec 2024Abuse: Neglect
    Investigated a medication administration incident and found that a staff member gave the wrong medication and did not verify the recipient's medication card, leading to drowsiness and impairment.
    • Abuse—Failed to provide a safe medication administration system
    11 Oct 2024License Condition
    Found deficiencies in providing a safe environment.
    • Regulatory Action—Failed to provide safe environment
    27 Sept 2024Change of Owner
    Found multiple deficiencies in move-in evaluations, service planning, health services, medication management, staffing, and building accessibility. The deficiencies affected numerous residents and involved missing elements, poor documentation, and gaps in coordination with outside providers.
    • Deficiency—Resident Move-in and Eval: Res Evaluation
    • Deficiency—Service Plan: General
    • Deficiency—Service Plan: Service Planning Team
    • Deficiency—Change of Condition and Monitoring
    • Deficiency—Resident Health Services
    • Deficiency—RN Delegation and Teaching
    • Deficiency—Res Hlth Srvc: On- and Off-Site Health Srvc
    • Deficiency—Systems: Medications and Treatments
    • Deficiency—Systems: Tracking Control Substances
    • Deficiency—Systems: Treatment Orders
    • Deficiency—Systems: Resident Right to Refuse
    • Deficiency—Systems: Medication Administration
    • Deficiency—Systems: Self-Administration of Meds
    • Deficiency—Systems: Psychotropic Medication
    • Deficiency—Acuity Based Staffing Tool - Elements
    • Deficiency—Staffing Requirements and Training ? Pre-service
    • Deficiency—Training Within 30 Days of Hire ? Direct Care Staff
    • Deficiency—Annual and Biennial Inservice for All Staff
    • Deficiency—General Building Exterior
    • Deficiency—General Building Interior
    • Deficiency—Physical Setting: Individual Accessible
    25 Sept 2024Change of Owner
    Identified multiple deficiencies across care areas, including monitoring changes of condition, health services, medication administration, staff training, privacy, and licensing compliance.
    • Deficiency—Change of Condition and Monitoring
    • Deficiency—Resident Health Services
    • Deficiency—Systems: Tracking Control Substances
    • Deficiency—Systems: Medication Administration
    • Deficiency—Systems: Psychotropic Medication
    • Deficiency—Training within 30 days: Direct Care Staff
    • Deficiency—Individual Privacy: Own Unit
    • Deficiency—Administration Compliance
    • Deficiency—Staff Training Requirements
    • Deficiency—Compliance with Rules Health Care
    03 Sept 2024Inspection
    Found neglect and abuse for failing to provide a brief change after a resident requested toileting assistance.
    • Licensing—Failed to assist with toileting
    27 Aug 2024Inspection
    Investigated and found deficiencies for failing to protect a resident from financial exploitation.
    • Licensing—Failed to protect resident from financial exploitation
    26 Aug 2024Inspection
    Investigated and concluded that a resident was subjected to financial exploitation, and a rule violation occurred.
    • Licensing—Failed to protect resident from financial exploitation
    08 Aug 2024Complaint
    Found staffing and equipment deficiencies that risked resident safety, including insufficient awake direct care staff and a malfunctioning call light system with delayed responses.
    • Deficiency—Staffing Requirements and Training: Staffing
    • Deficiency—General Building: Doors-Walls, Cleanable
    23 Jun 2024Inspection
    Investigated and found that the medication was not reordered, resulting in three days without the daily blood pressure dose.
    • Licensing—Failed to have medication available
    14 Jun 2024Inspection
    Investigated the allegation of financial exploitation and found a resident's money taken by an unknown person, with a failure to protect the resident from financial abuse.
    • Licensing—Failed to protect resident from financial exploitation
    12 Jun 2024Inspection
    Found that an acuity-based staffing tool was not fully implemented or updated.
    • Licensing—Failed to use an ABST
    07 Jun 2024Inspection
    Found insufficient numbers of qualified awake direct care staff to meet residents' 24-hour scheduled and unscheduled needs.
    • Licensing—Failed to meet the scheduled and unscheduled needs of residents
    07 Jun 2024Inspection
    Investigated allegation found that equipment for resident care was not kept clean and in good repair.
    • Licensing—Failed to provide or maintain resident care equipment
    05 Jun 2024Complaint
    Found deficiencies in medication administration and staffing after investigation, with multiple prescribed medications not administered and delayed call-light responses due to staffing shortages.
    • Deficiency—Systems: Treatment Orders
    • Deficiency—Staffing Requirements and Training: Staffing
    02 Apr 2024Abuse: Neglect
    Investigated and found neglect due to delaying medical treatment, resulting in pain and discomfort for a resident.
    • Abuse—Failed to assure timely medical treatment
    01 Apr 2024Inspection
    Determined that a licensing violation occurred due to failure to fully implement and update an Acuity Based Staffing Tool.
    • Licensing—Failed to provide safe environment
    01 Apr 2024Inspection
    Investigated the allegation of a failure to provide a safe environment and found insufficient awake direct care staff to meet residents' 24-hour needs.
    • Licensing—Failed to provide safe environment
    26 Mar 2024Inspection
    Investigated an allegation of failing to administer medication as ordered and found medications were not carried out as prescribed, with several residents' medications discontinued without orders.
    • Licensing—Failed to administer medication as ordered
    24 Mar 2024Abuse: Neglect
    Found violations of resident rights resulting in neglect and abuse due to failure to properly plan care to prevent falls, and assessed a $2,000 fine.
    • Abuse—Failed to properly plan care
    24 Mar 2024Abuse: Neglect
    Found peri care after incontinence was not completed, leading to skin breakdown and moisture-related damage. Identified as neglect and abuse.
    • Abuse—Failed to provide peri care
    08 Mar 2024Abuse: Neglect
    Determined that a known fall-risk resident's care plan was not updated with effective fall interventions after recovery from a spinal fracture, leading to another fall with injuries.
    • Abuse—Failed to properly plan care
    19 Feb 2024Inspection
    Found that a staff member took the resident's phone charger, constituting financial abuse and neglect, and that the resident was not protected from financial abuse.
    • Licensing—Failed to protect resident from financial exploitation
    29 Jan 2024Abuse: Neglect
    Determined neglect and abuse occurred due to failure to properly plan interventions for the resident's fall history, leading to several non-injury falls.
    • Abuse—Failed to properly plan care
    29 Dec 2023Abuse: Neglect
    Investigated and found that improper care planning led to multiple falls and a vertebral fracture, indicating neglect and abuse of a resident.
    • Abuse—Failed to properly plan care
    14 Dec 2023Abuse: Neglect
    Found neglect and abuse due to failure to plan and implement care, resulting in multiple falls and resident discomfort.
    • Abuse—Failed to properly plan care
    13 Dec 2023Abuse: Neglect
    Found neglect due to failure to properly plan care, leading to repeated falls and a serious injury.
    • Abuse—Failed to properly plan care
    17 Nov 2023License Condition
    Found that ABST was not adopted to determine appropriate staffing levels.
    • Regulatory Action—Failed to staff as indicated by ABST
    14 Nov 2023Licensure
    Found significant deficiencies in kitchen sanitation and equipment, with a follow-up showing substantial compliance.
    • Deficiency—Comment
    • Deficiency—Resident Services Meals, Food Sanitation Rule
    14 Nov 2023Licensure
    Identified multiple deficiencies in the kitchen and memory care kitchenette related to sanitation, equipment integrity, and infection control. A follow-up visit found substantial compliance.
    • Deficiency—Comment
    • Deficiency—Resident Services Meals, Food Sanitation Rule
    • Deficiency—Administration Compliance
    19 Oct 2023Abuse: Neglect
    Investigated a failure to provide a safe medication administration system that left a patient without leukemia medication for several days and at risk for harm.
    • Abuse—Failed to provide a safe medication administration system
    19 Oct 2023Abuse: Neglect
    Investigated an abuse/neglect allegation and found a failure to provide a safe medication administration system, resulting in a resident going without leukemia medication for several days in October 2023.
    • Abuse—Failed to provide a safe medication administration system
    15 Oct 2023Abuse: Neglect
    Found violations for failing to provide a safe medication administration system by not dispensing a resident's medications for about five days, risking serious harm.
    • Abuse—Failed to provide a safe medication administration system
    15 Oct 2023Abuse: Neglect
    Investigated a medication administration failure that left a resident without prescribed medications for about five days, risking serious harm. Found this failure constitutes neglect of care and abuse.
    • Abuse—Failed to provide a safe medication administration system
    25 Sept 2023Complaint
    Investigated deficiencies identified: service plans not implemented as evaluated, medications not observed during administration, treatment orders not followed, and failure to adopt an acuity-based staffing tool.
    • Deficiency—Licensing Complaint Investigation
    • Deficiency—Service Plan: General
    • Deficiency—Systems: Medication Administration
    • Deficiency—Systems: Treatment Orders
    • Deficiency—Acuity-Based Staffing Tool
    25 Sept 2023Inspection
    Found a deficiency in safe medication administration because staff did not visually observe residents taking medications unless permitted by the prescriber.
    • Licensing—Failed to provide a safe medication administration system
    22 Sept 2023Inspection
    Investigated the complaint and found a deficiency in medication administration safety when a resident received another resident's levothyroxine.
    • Licensing—Failed to provide a safe medication administration system
    31 Aug 2023Inspection
    Determined that a resident was financially exploited and protections against exploitation were not maintained.
    • Licensing—Failed to protect resident from financial exploitation
    27 Aug 2023Inspection
    Determined that medication and treatment orders were not carried out as prescribed, violating Oregon Administrative Rules.
    • Licensing—Failed to provide a safe medication administration system
    23 Aug 2023Inspection
    Found a violation where the service plan did not reflect the resident's needs identified in the evaluation.
    • Licensing—Failed to properly plan care
    04 Aug 2023License Condition
    Identified failure to use ABST results to develop and routinely update staffing plan.
    • Regulatory Action—Failed to staff as indicated by ABST
    28 Jul 2023Abuse: Neglect
    Found a failure to provide a safe medication administration system that placed a resident at risk for harm, with a $375 fine assessed.
    • Abuse—Failed to provide a safe medication administration system
    23 Jun 2023Abuse: Neglect
    Found deficiencies in care planning for a known fall risk, leading to a hip fracture after a fall.
    • Abuse—Failed to properly plan care
    28 May 2023Abuse: Neglect
    Investigated an allegation of neglect and abuse resulting from a failure to provide a safe medication administration system, placing a resident at risk for harm due to missed seizure medication on two days.
    • Abuse—Failed to provide a safe medication administration system
    28 May 2023Inspection
    Found that a transfer was not performed per the care plan, causing a fall and fracture and constituting neglect, abuse, and violation of resident rights.
    • Licensing—Failed to follow care plan
    01 May 2023Validation
    Identified deficiencies in move-in evaluations, acuity-based staffing, fire safety documentation, and administration of licensing rules during a re-licensure process.
    • Deficiency—Comment
    • Deficiency—Resident Move-In and Eval: Res Evaluation
    • Deficiency—Acuity-Based Staffing Tool
    • Deficiency—Fire and Life Safety: Safety
    • Deficiency—Inspections and Investigation: Insp Interval
    • Deficiency—Administration Compliance
    • Deficiency—Compliance With Rules Health Care
    24 Apr 2023Validation
    Found deficiencies in reporting abuse, monitoring changes of condition, tracking controlled substances, fire safety, and equipment maintenance; concluded substantial compliance after follow-up.
    • Deficiency—Comment
    • Deficiency—Reporting & Investigating Abuse-Other Action
    • Deficiency—Change of Condition and Monitoring
    • Deficiency—Systems: Tracking Control Substances
    • Deficiency—Fire and Life Safety: Safety
    • Deficiency—Inspections and Investigation: Insp Interval
    • Deficiency—General Building: Doors-Walls, Cleanable
    19 Mar 2023Abuse: Neglect
    Investigated and found a failure to properly plan for a resident's safety, resulting in a fall with injury and a finding of abuse and neglect.
    • Abuse—Failed to properly plan care
    17 Mar 2023Abuse: Neglect
    Found failure to follow the care plan, resulting in abuse and neglect.
    • Abuse—Failed to follow care plan
    15 Feb 2023Inspection
    Found violations for failure to provide a safe medication administration system, with mood-altering medication not administered for 30 days or more.
    • Licensing—Failed to provide a safe medication administration system
    06 Feb 2023Abuse: Neglect
    Investigated a medication safety issue and found a failure to provide a safe medication administration system, resulting in a resident running out of pain medication and experiencing withdrawal; a $375 fine was assessed.
    • Abuse—Failed to provide a safe medication administration system
    27 Jan 2023Abuse: Neglect
    Found violations of care plan adherence and supervision of medications, constituting abuse and neglect.
    • Abuse—Failed to follow care plan
    27 Jan 2023Abuse: Neglect
    Found failure to provide prescribed medication when stockouts occurred, leaving the resident in pain.
    • Abuse—Failed to have medication available
    18 Jan 2023Inspection
    Investigated a complaint about an unsafe medication administration system and determined a safety failure occurred.
    • Licensing—Failed to provide a safe medication administration system
    09 Dec 2022Abuse: Neglect
    Investigated and found neglect due to improper care planning for a known fall risk, leading to a fall and fracture.
    • Abuse—Failed to properly plan care
    29 Nov 2022Licensure
    Determined substantial compliance with meal service and sanitation requirements.
    • Deficiency—Comment
    29 Nov 2022Licensure
    Determined substantial compliance with meal service and food sanitation requirements.
    • Deficiency—Comment
    15 Nov 2022Abuse: Neglect
    Found neglect and abuse due to failure to implement interventions after repeated falls, resulting in a head injury and hospital transport, with a $250 fine assessed.
    • Abuse—Failed to properly plan care
    07 Nov 2022Inspection
    Investigated allegations of financial exploitation and found a staff member accepted $300 from a resident and withdrew it via ATM, and protections against financial abuse were not maintained.
    • Licensing—Failed to protect resident from financial exploitation
    24 Oct 2022Abuse: Neglect
    Investigated a report of neglect and abuse; found that inadequate staff resulted in a resident wandering off and at risk, with a fine assessed.
    • Abuse—Failed to follow care plan
    20 Oct 2022Inspection
    Investigated allegations found missing pain medication and that an unknown person took it, violating resident rights and constituting neglect and financial abuse. The provider failed to protect residents from financial abuse under state rules.
    • Licensing—Failed to provide a safe medication administration system
    03 Oct 2022Inspection
    Investigated a failure to provide a safe medication administration system, resulting in neglect and abuse.
    • Licensing—Failed to provide a safe medication administration system
    01 Oct 2022Inspection
    Investigated a medication handling issue and found deficiencies in proper storage and MAR clarity for insulin administration. A loose insulin pen was found and MAR did not clearly reflect insulin given to two residents.
    • Licensing—Failed to properly secure or store medication
    30 Sept 2022Inspection
    Found improper medication storage and MAR discrepancies for insulin administration, including a loose insulin pen and only one injection in the sharps container while MAR indicated both residents received insulin.
    • Licensing—Failed to properly secure or store medication
    28 Sept 2022Complaint
    Identified failures to administer medications as prescribed, including a missed dose and medications left in a cart.
    • Deficiency—Licensing Complaint Investigation
    • Deficiency—Systems: Treatment Orders
    28 Sept 2022Abuse: Neglect
    Investigated a medication error that led to a seizure. Concluded a safe medication administration system was not provided, constituting abuse and neglect.
    • Abuse—Failed to provide a safe medication administration system
    16 Sept 2022Inspection
    Investigated the allegation that medication and treatment orders were not carried out; found orders not followed.
    • Licensing—Failed to administer medication as ordered
    16 Sept 2022Abuse: Neglect
    Investigated found a failure to provide a safe medication administration system, placing a resident at risk for harm. The resident went without needed medication for three passes.
    • Abuse—Failed to provide a safe medication administration system
    16 Sept 2022Inspection
    Found a medication administration violation where orders were not followed.
    • Licensing—Failed to administer medication as ordered
    26 Jul 2022Abuse: Neglect
    Found that a daily injectable medication was not administered as ordered, placing the resident at risk for serious harm; a fine was assessed.
    • Abuse—Failed to administer medication as ordered
    28 Jun 2022Abuse: Neglect
    Determined a failure to provide a safe environment that led to a resident pushing another; the conduct was found to be abuse and neglect.
    • Abuse—Failed to provide safe environment
    25 Jun 2022Abuse: Neglect
    Investigated found that a staff member gave a resident another resident's medication and was not delegated or trained to dispense medications.
    • Abuse—Failed to provide a safe medication administration system
    20 Jun 2022Abuse: Neglect
    Found a failure to provide a safe medication administration system that left a resident without morning insulin, causing severe hyperglycemia and hospital observation. A $1,500 fine was assessed.
    • Abuse—Failed to provide a safe medication administration system
    01 Jun 2022Inspection
    Determined that a safe medication administration system was not provided after finding four medications left in a resident's room and not administered.
    • Licensing—Failed to provide a safe medication administration system
    06 May 2022Abuse: Neglect
    Found violations for neglect of care due to failing to administer prescribed medication, leaving the resident without medication for about a week and increasing confusion.
    • Abuse—Failed to administer medication as ordered
    18 Mar 2022Abuse: Neglect
    Found a failure to provide a safe medication administration system, resulting in a resident not receiving prescribed pain medication for at least five doses and unable to sleep.
    • Abuse—Failed to provide a safe medication administration system
    22 Feb 2022Abuse: Neglect
    Found failures to monitor changes in condition and notify a nurse, placing a resident at risk of serious harm; a fine was assessed.
    • Abuse—Failed to provide oversight and monitoring of change of condition
    08 Aug 2021Inspection
    Found insufficient staff to meet residents' needs, with call lights taking up to 30 minutes to respond.
    • Licensing—Failed to answer call light in a timely manner
    09 Jul 2021Abuse: Neglect
    Found that a known fall-risk resident with dementia did not receive meaningful interventions to prevent falls, resulting in a broken arm and a neglect/abuse finding.
    • Abuse—Failed to properly plan care
    04 Jul 2021Abuse: Neglect
    Investigated the allegations and found failures to properly plan care to protect a resident from falls, resulting in neglect and abuse findings and a $250 fine.
    • Abuse—Failed to properly plan care
    10 Jun 2021Inspection
    Investigated and found that a resident's fall-prevention plan was not updated after multiple falls, resulting in a further fall and injury.
    • Licensing—Failed to provide safe environment
    27 Apr 2021Abuse: Neglect
    Found neglect and abuse due to failure to intervene when the resident's condition changed. A $500 fine was assessed.
    • Abuse—Failed to intervene when resident's condition changed
    28 Jan 2021Abuse: Neglect
    Found neglect due to failure to provide proper hygienic care, resulting in skin breakdown and discomfort.
    • Abuse—Failed to provide or assist with hygiene
    25 Dec 2020Abuse: Neglect
    Found that the care plan for toenail care was not followed, causing discomfort and constituting neglect and abuse; a $250 fine was assessed.
    • Abuse—Failed to follow care plan
    30 Nov 2020Abuse: Neglect
    Investigated and found that care providers failed to ensure physician services for a resident, resulting in neglect and abuse.
    • Abuse—Failed to assure physician services
    08 Jun 2020Abuse: Neglect
    Found neglect and abuse due to failure to develop an appropriate care plan for a resident at fall risk. The lack of a care plan left the resident exposed to repeated falls and potential harm.
    • Abuse—Failed to properly plan care
    06 Mar 2020Abuse: Neglect
    Determined that supervision and staff support to mitigate known fall risks were inadequate, resulting in an injury fall and unsafe environment.
    • Abuse—Failed to provide safe environment
    12 Feb 2020Abuse: Neglect
    Found that supervision and resident safety were not adequately provided, placing a resident at risk. A substantiated abuse/neglect finding was issued with a $188 fine.
    • Abuse—Failed to provide safe environment
    22 Dec 2019Abuse: Neglect
    Found that a staff member did not follow the care plan to redirect when near a resident, resulting in a hit to the back of the neck and risk of harm.
    • Abuse—Failed to provide safe environment
    12 Dec 2019Inspection
    Identified a safety deficiency due to a resident fall and a 43-minute delay in staff responding to a call light, which led to injury.
    • Licensing—Failed to assure resident was safe
    20 Jun 2019Abuse: Neglect
    Investigated and found neglect due to failure to ensure timely medical treatment, creating a serious risk of harm from delayed care for an open wound.
    • Abuse—Failed to assure timely medical treatment
    11 Jun 2019Abuse: Neglect
    Found neglect by failing to provide the individual with basic care, services, and supervision to keep them safe; a $188 fine was assessed.
    • Abuse—Failed to follow care plan
    26 Jul 2018Inspection
    Found that suspected abuse was not reported. A violation was substantiated and a $750 fine was assessed.
    • Licensing—Failed to report potential or suspected abuse
    26 Jul 2018Abuse: Neglect
    Investigated a complaint and found neglectful care that could put a resident at serious risk of harm and caused unreasonable discomfort; a $500 fine was assessed.
    • Abuse—Failed to provide service
    07 May 2018Inspection
    Investigated the allegation that medication management was unsafe, resulting in the wrong medication being administered.
    • Licensing—Failed to provide a safe medication administration system
    07 Feb 2018Inspection
    Investigated an allegation that a service was not provided and found it substantiated.
    • Licensing—Failed to provide service
    07 Feb 2018Inspection
    Found a food-safety deficiency.
    • Licensing—Failed to assure food safety
    13 Jul 2017Inspection
    Investigated an allegation of improper medication administration and found a deficient medication system that allowed self-administration of insulin and missed alerts.
    • Licensing—Failed to administer medication as ordered
    02 May 2017Inspection
    Concluded that medications were not administered as ordered, resulting in the resident receiving too much medication.
    • Licensing—Failed to administer medication as ordered
    02 May 2017Inspection
    Investigated and found that ordered medication was not administered properly, risking harm to a resident.
    • Licensing—Failed to administer ordered medication
    13 Mar 2017Inspection
    Identified a deficient medication system that resulted in a resident being given another resident's medication.
    • Licensing—Failed to provide a safe medication administration system
    25 Jan 2017Abuse: Neglect
    Found a failure to maintain an adequate medication system, leading to medication shortages and receiving another resident's medications in error.
    • Abuse—Failed to provide a safe medication administration system
    03 Dec 2016Inspection
    Found improper management of resident medications, leading to hospitalization.
    • Licensing—Failed to provide a safe medication administration system
    20 May 2016Inspection
    Investigated a staffing and training deficiency and substantiated a violation related to employee preservice orientation and caregiver training.
    • Licensing—Failed to provide safe environment
    20 May 2016Inspection
    Investigated an allegation of unsafe environment and found that unannounced fire drills were not conducted and recorded every other month at different times.
    • Licensing—Failed to provide safe environment
    20 May 2016Inspection
    Investigated an allegation of unsanitary food service conditions and identified a violation of food sanitation rules related to kitchen and food storage.
    • Licensing—Failed to provide sanitary food service conditions
    03 May 2016Inspection
    Identified deficiencies in the medication system that did not follow doctors' orders for residents' medications.
    • Licensing—Failed to provide a safe medication administration system
    08 Apr 2016Abuse: Neglect
    Found a deficiency in the medication administration system and assessed a $300 fine.
    • Abuse—Failed to provide a safe medication administration system

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