I moved both my parents in and I'm very pleased. The building and grounds are beautiful and well kept, apartments are roomy and move-in was easy, and chef-prepared meals (included) are consistently enjoyed. Management and staff are warm, attentive and genuinely caring, with weekly housekeeping, laundry service, activities and a welcoming, family-like atmosphere - I recommend it as a top local option.
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
Respite program
Healthcare staffing
12-16 hour nursing
24-hour call system
24-hour supervision
Meals and dining
Diabetes diet
Meal preparation and service
Restaurant-style dining
Special dietary restrictions
Room
Air-conditioning
Cable
Fully furnished
Housekeeping and linen services
Kitchenettes
Private bathrooms
Telephone
Wifi
Memory care community services
Dementia waiver
Mild cognitive impairment
Specialized memory care programming
Transportation
Community operated transportation
Located close to restaurants
Located close to shopping centers
Transportation arrangement
Transportation arrangement (medical)
Transportation arrangement (non-medical)
Transportation to doctors appointments
Common areas
Beauty salon
Computer center
Dining room
Fitness room
Gaming room
Garden
Outdoor patio
Outdoor space
Pet friendly
Religious/meditation center
Small library
Wellness center
Community services
Concierge services
Fitness programs
Move-in coordination
Activities
Community-sponsored activities
Planned day trips
Resident-run activities
Scheduled daily activities
Reviews
3.72·(64)
Overall rating
5
4
3
2
1
Care
3.6
Staff
3.7
Meals
3.9
Amenities
3.6
Value
2.6
Pros
Compassionate, attentive direct-care staff
Family-like, welcoming community atmosphere
Wide range of social activities and clubs
Regular scheduled excursions and transportation
On-site memory-care neighborhood
Chef-prepared and varied meal offerings (when consistent)
Weekly apartment cleaning service
On-site laundry service
Pet-friendly environment with staff support for pet care
Bright, cheery common spaces and restaurant-style dining area
Attractive rooms with scenic views
Accessible courtyards and backyard-style outdoor spaces
Variety of floor plans and apartment sizes
Helpful, informative and low-pressure admissions tours
On-site amenities (hairdresser, facility bus)
Ongoing renovations and generally well-maintained public areas
Ample parking and a convenient location close to family
Hospice and end-of-life support availability
Cons
Inconsistent meal quality and limited therapeutic-diet accommodation
Inadequate staffing levels and high frontline turnover
Gaps in medication-administration practices and after-hours clinical response
Weak management responsiveness and frequent leadership turnover
Cleanliness and maintenance follow-through issues
Billing and service-delivery reconciliation problems
Limited or uneven memory-care environment and programming
Safety-practice gaps for mobility assistance and bathing oversight
Infrastructure and amenity reliability concerns (elevator, Wi‑Fi)
Wayfinding and entrance accessibility inconsistencies
Care-plan communication and coordination shortfalls
Summary of reviews
Overview
Orchard Heights presents a mixed but instructive picture for prospective residents and families. Many reviews emphasize strong, compassionate frontline caregivers, a warm, family-like atmosphere, active social programming, attractive living spaces, and helpful admissions tours. At the same time, a recurring set of operational problems — staffing instability, management turnover, inconsistent dining, gaps in clinical responsiveness, and maintenance or billing follow-through — appears across multiple accounts and warrants careful inquiry during a visit.
Care and Staff
Direct-care staff are frequently described as caring, attentive, and familiar with residents’ preferences; multiple accounts praise individual caregivers for building relationships and providing reliable day-to-day assistance. However, reviewers also describe inconsistent clinical oversight: staffing shortages, high turnover (including supervisory roles), and limited on-site nurse coverage at times. These operational patterns correlate with concerns about medication-administration practices (notably insulin handling and after-hours delays), delayed responses to clinical issues, and occasional incontinence-care or toileting response gaps. Prospective families should ask about staffing ratios, nurse coverage hours, medication protocols, and recent staff retention efforts.
Dining and Nutrition
Dining is a polarizing area. Many residents and families compliment chef-prepared meals, three-course dining, and an appealing restaurant-style dining room. Conversely, other accounts describe inconsistent food quality, reliance on pre-prepared/canned items at times, and limited accommodation for therapeutic diets (for example, sodium-restricted needs). Reviewers noted improvements when kitchen staffing was stabilized. Visitors should sample current menus, ask about therapeutic-diet processes and accommodation policies, and confirm whether kitchen staffing has changed recently.
Activities and Memory Care
The facility offers broad social programming: daily activities, clubs, live music, regular outings, and use of a facility bus. This programming supports a sense of belonging for many residents, and the campus is described as active and social. Memory-care services are present on-site, but accounts vary: some families find the memory neighborhood supportive, while others describe it as less inviting or having fewer activities and an isolated location. Clarify the memory-care program specifics, staffing, and daily activity schedule during a tour.
Facilities and Amenities
Physical amenities are a clear strength for many reviewers: bright common areas, scenic views, accessible courtyards, pet-friendly policies, a restaurant-style dining area, and a range of apartment sizes. Ongoing renovations and generally well-kept public spaces are noted positively. At the same time, maintenance follow‑through is an area of concern in some reports (delayed repairs, entrance/wayfinding issues, and occasional exterior maintenance shortcomings). A few reviewers cited infrastructure reliability problems such as elevator downtime and inconsistent in-room Wi‑Fi. Confirm the current condition of priority areas (bathrooms, elevators, exterior access) and the typical maintenance response time.
Management, Billing, and Communication
Admissions staff and some managers are praised for compassionate, non-pressured tours and timely follow-up. Nonetheless, a substantial pattern in reviews points to weak management responsiveness, frequent leadership changes, and communication shortfalls with families. Several accounts describe billing or service-delivery discrepancies and dissatisfaction with management follow-through. These patterns can affect trust and the ease of resolving issues. Prospective families should ask for written service and billing policies, the escalation path for clinical and non-clinical concerns, and the facility’s recent leadership/turnover history.
Notable Patterns and Suggested Questions for Visitors
Pattern: strong direct-care relationships but operational instability at supervisory and clinical oversight levels. Pattern: appealing physical environment paired with maintenance and cleanliness follow-through variability. Pattern: robust activity calendar and transportation, but memory-care programming and resources appear uneven.
Suggested questions for tours: What are current staffing ratios for day/evening/night shifts and nurse coverage hours? How are medications documented and audited, and what is the after-hours clinical response protocol? How are therapeutic diets accommodated and who oversees menu planning? What is the process for maintenance requests and typical response time? What is the facility’s billing dispute process and what services are included versus optional fees? Does the facility accept Medicaid and how is Wi‑Fi provided to residents?
Conclusion
Orchard Heights has many attributes families value: engaged caregivers, lively social programming, attractive grounds and dining spaces, and a community feel. However, there are consistent operational concerns — notably staffing stability, medication and after‑hours clinical response, meal consistency and therapeutic-diet accommodation, maintenance follow-through, and management responsiveness — that significantly affect the lived experience for some residents. A focused in-person visit that probes the specific areas above will help determine whether the facility’s current operational state aligns with a prospective resident’s clinical and lifestyle needs.
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Location
Prestige Senior Living Orchard Heights is located at 695 Orchard Heights Rd NW, Salem, OR, 97304.
About Prestige Senior Living Orchard Heights
Prestige Senior Living Orchard Heights offers a vibrant and supportive environment in Salem, Oregon, dedicated to enriching the lives of its residents through a blend of comfort, community, and exceptional care. The community is designed for individuals seeking an active and fulfilling senior lifestyle without the burdens of home maintenance, allowing them to enjoy all the amenities of home while focusing on what truly matters most to them. Residents are welcomed into a friendly, family-like atmosphere where camaraderie flourishes, and each day presents new opportunities for engagement, wellness, and relaxation.
The cornerstone of life at Prestige Senior Living Orchard Heights is its industry-leading approach to wellness, epitomized by the innovative Celebrations program. This wellness initiative is rooted in six distinct categories that nurture the mind, body, and spirit, granting residents the freedom and choices to celebrate life every day. Through a diverse range of exhilarating activities and a full calendar of enriching events, residents are encouraged to explore new horizons, maintain a healthy lifestyle, and achieve personal fulfillment. The programming is thoughtfully designed to support an optimum level of health and wellness, acknowledging that every individual’s journey in aging is unique.
Prestige Senior Living Orchard Heights is also renowned for its award-winning Expressions Memory Care program. This unique approach to dementia and Alzheimer’s care incorporates innovative techniques and life enrichment programming specifically tailored for those living with cognitive impairments. Expressions transforms everyday activities into meaningful experiences, providing an outlet for creativity through arts, learning, and spirituality, and embraces the philosophy that “Life is an Activity.” Memory care residents are supported in an environment where dignity, respect, and engagement are paramount, ensuring they remain productive, active, and connected with their sense of self.
The amenities at Prestige Senior Living Orchard Heights are designed to deliver a first-class experience. Residents have access to thoughtfully designed private and communal spaces, including a library, private dining room, sitting areas, a theater, and a beautifully maintained courtyard. There are always fresh and exciting events curated by the dedicated team, ensuring that there is never a dull moment for anyone in the community. Residents can choose from a variety of comfortable floorplans, allowing them to select the home that best suits their needs and preferences.
Overall, Prestige Senior Living Orchard Heights stands out as a place where residents can truly thrive, supported by unparalleled care, a warm and active community, and a host of opportunities to live life to its fullest. With a passionate team always striving to enrich residents' lives and a comprehensive wellness philosophy, it is a community where seniors can enjoy their years with joy, dignity, and meaning.
About Prestige Care
Prestige Senior Living Orchard Heights is managed by Prestige Care.
Founded in 1985 but tracing its roots to 1946, Prestige Care began with Sarah Delamarter, a nursing pioneer who started caring for seniors in her Troutdale, Oregon home. What began as a compassionate effort to support her family evolved into a multi-generational legacy when her grandsons Harold and Dr. Rick Delamarter, along with business partner Greg Vislocky, expanded the business throughout the western United States. Today, this family-owned company remains headquartered in Vancouver, Washington, maintaining Sarah's original spirit of personalized, compassionate care. Prestige Care operates over 75 communities across seven western states including Oregon, Washington, California, Arizona, Nevada, Idaho, and Montana.
People often ask...
Prestige Senior Living Orchard Heights offers competitive pricing, with rates starting at a cost of $6,836 per month.
Prestige Senior Living Orchard Heights offers assisted living and memory care.
There are 25 photos of Prestige Senior Living Orchard Heights on Mirador.
The full address for this community is 695 Orchard Heights Rd NW, Salem, OR 97304.
No, Prestige Senior Living Orchard Heights 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.
Concluded that a record-keeping deficiency existed due to failure to determine and document required actions when a resident experiences a short-term change of condition.
Licensing—Failed to keep resident record current or accurate
11 Feb 2026Abuse: Neglect
11 Feb 2026Abuse: Neglect
Found neglect for failing to follow a care plan, which led to a resident injury from a fall; a fine was assessed.
Abuse—Failed to follow care plan
11 Feb 2026Inspection
11 Feb 2026Inspection
Found failure to update and review ABST evaluations for each resident quarterly.
Licensing—Failed to use an ABST
03 Sept 2025Abuse: Neglect
03 Sept 2025Abuse: Neglect
Investigated and found that a staff member verbally abused a resident and failed to protect the resident from verbal abuse, constituting neglect and abuse.
Abuse—Failed to protect resident from verbal abuse
03 Sept 2025Inspection
03 Sept 2025Inspection
Investigated an allegation of rough handling of a resident; found the actions violated resident rights and constituted abuse and neglect.
Licensing—Failed to protect resident from physical abuse
03 Sept 2025Abuse: Neglect
03 Sept 2025Abuse: Neglect
Cited neglect and abuse due to rough handling of a resident, and assessed a $375 fine.
Abuse—Failed to protect resident from physical abuse
29 Aug 2025Abuse: Neglect
29 Aug 2025Abuse: Neglect
Found that care planned for mobility support wasn't followed, resulting in a resident fall and pain.
Abuse—Failed to follow care plan
29 Aug 2025Abuse: Neglect
29 Aug 2025Abuse: Neglect
Investigated found neglect for failing to ensure timely medical treatment after falls, leading to a left knee fracture.
Abuse—Failed to assure timely medical treatment
22 Aug 2025Abuse: Neglect
22 Aug 2025Abuse: Neglect
Found neglect and physical abuse related to rough care, with a fine assessed.
Abuse—Failed to protect resident from physical abuse
19 Aug 2025Abuse: Neglect
19 Aug 2025Abuse: Neglect
Investigated and found neglect due to failure to properly plan care to mitigate fall risk, which led to multiple injuries.
Abuse—Failed to properly plan care
24 Jun 2025Licensure
24 Jun 2025Licensure
Identified multiple deficiencies across abuse reporting, resident activities, changes of condition monitoring, infection control, fire safety, resident privacy, door locks, call systems, administration, and staff training.
Deficiency—Training Within 30 Days of Hire – Direct Care Staff
Deficiency—Fire and Life Safety: Safety
Deficiency—Fire and Life Safety: Training for Residents
Deficiency—Doors, Walls, Elevators, Odors
Deficiency—Call Sys, Exit Dr Alarm, Phones, TV, or Cable
Deficiency—Individual Privacy: Own Unit
Deficiency—Individual Door Locks: Key Access
Deficiency—Administration Compliance
Deficiency—Staff Training Requirements
Deficiency—Compliance with Rules Health Care
02 May 2025Kitchen
02 May 2025Kitchen
Identified sanitation and safety deficiencies in the kitchen, including cleanliness issues, improper equipment setup, lack of sanitization materials, and staff knowledge gaps.
Found deficiencies in food sanitation and administration compliance, including extensive kitchen sanitation issues and failure to follow licensing rules.
Determined that care planning failed to address personal care needs, resulting in neglect when showers were refused and the resident was not kept clean.
Abuse—Failed to properly plan care
12 Jan 2025Inspection
12 Jan 2025Inspection
Investigated and determined that a staff member engaged in sexual abuse with a resident and the resident was not protected from abuse.
Licensing—Failed to protect resident from inappropriate sexual contact
15 Feb 2024Licensure
15 Feb 2024Licensure
Identified extensive deficiencies in kitchen sanitation and administration during the initial assessment; a follow-up found substantial compliance with applicable rules.
Identified sanitation and equipment deficiencies in the kitchen during the initial visit; follow-up found substantial compliance with meals and food sanitation rules.
Found that care plans were not followed, resulting in a skin tear and indicating neglect and abuse.
Licensing—Failed to follow care plan
22 Sept 2023Abuse: Neglect
22 Sept 2023Abuse: Neglect
Investigated an allegation of medication mismanagement and financial exploitation; found failures to prevent theft and protect the resident from exploitation. The issues included inadequate narcotic color verification, insufficient two-person narcotic audits, and unsafe medication practices that allowed exploitation.
Abuse—Failure to provide a system that prevents theft or misuse of medication
06 Sept 2023License Condition
06 Sept 2023License Condition
Identified a deficiency for not using an acuity-based staffing tool to accurately reflect the time needed to care for residents.
Regulatory Action—Failed to use an ABST
31 Jul 2023Validation
31 Jul 2023Validation
Identified numerous deficiencies in resident move-in evaluations, care planning, condition monitoring, health services, staffing and training, and safety practices.
Deficiency—Comment
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—Systems: Treatment Orders
Deficiency—Acuity-Based Staffing Tool
Deficiency—Staffing Requirements and Training – Pre-Serv
Deficiency—Training Within 30 Days: Direct Care Staff
Deficiency—Annual and Biennial Inservice For All Staff
Deficiency—Fire and Life Safety: Safety
Deficiency—Fire and Life Safety: Training For Residents
Deficiency—Inspections and Investigation: Insp Interval
Deficiency—General Building Interior
25 May 2023Abuse: Neglect
25 May 2023Abuse: Neglect
Investigated a neglect allegation and found multiple falls with inadequate interventions, culminating in a hip fracture after a later fall.
Abuse—Failed to properly plan care
14 Apr 2023Abuse: Neglect
14 Apr 2023Abuse: Neglect
Investigated and found a failure to provide a safe medication administration system, contributing to hospitalization after an approximately eighteen-day discontinuation of mental health medication. A $500 fine was assessed.
Abuse—Failed to administer medication as ordered
17 Mar 2023Abuse: Neglect
17 Mar 2023Abuse: Neglect
Found neglect and abuse due to failure to properly plan care for falls, resulting in approximately eleven falls and related injuries.
Abuse—Failed to properly plan care
14 Feb 2023License Condition
14 Feb 2023License Condition
Investigated the allegation that staffing did not align with ABST and found failure to implement and update ABST in accordance with OAR 411-054-0037.
Regulatory Action—Failed to staff as indicated by ABST
14 Feb 2023License Condition
14 Feb 2023License Condition
Found insufficient direct care staff to meet residents' scheduled and unscheduled needs, with a delayed response to a call button.
Regulatory Action—Failed to meet the scheduled and unscheduled needs of residents
24 Jan 2023Abuse: Neglect
24 Jan 2023Abuse: Neglect
Investigated an allegation of neglect and found that care planning and interventions were insufficient, contributing to multiple falls and injuries for a known high-risk resident.
Abuse—Failed to provide service
13 Dec 2022Complaint
13 Dec 2022Complaint
Investigated and found deficiencies in infection prevention and control, staffing adequacy, Acuity-Based Staffing Tool implementation, and pest control.
Deficiency—Licensing Complaint Investigation
Deficiency—Infection Prevention & Control
Deficiency—Staffing Requirements and Training: Staffing
Deficiency—Acuity-Based Staffing Tool
Deficiency—General Building Exterior
07 Dec 2022Licensure
07 Dec 2022Licensure
Identified deficiencies in kitchen sanitation and improper holding temperatures for foods.
Identified widespread sanitation deficiencies in the kitchen during the initial visit; follow-up found substantial compliance with required food sanitation standards.
Found neglect of care due to failure to provide appropriate services, resulting in multiple falls and an injury; a fine was assessed.
Abuse—Failed to provide service
09 Nov 2022Inspection
09 Nov 2022Inspection
Investigated a complaint and found a failure to follow masking requirements. Identified a violation of Oregon Administrative Rules.
Licensing—Failed to provide infection control
09 Nov 2022Inspection
09 Nov 2022Inspection
Investigated the pest-control allegation and identified failure to prevent rodent entry.
Licensing—Failed to control pests
04 Nov 2022Abuse: Neglect
04 Nov 2022Abuse: Neglect
Investigated neglect and abuse due to failure to provide needed services, resulting in a fractured hip after additional falls; a fine was assessed.
Abuse—Failed to provide service
04 Nov 2022Abuse: Neglect
04 Nov 2022Abuse: Neglect
Found neglect and abuse due to failure to provide appropriate services, resulting in multiple falls and harm, with a fine assessed.
Abuse—Failed to provide service
07 Oct 2022License Condition
07 Oct 2022License Condition
Investigated and found failure to use ABST as required by Oregon Administrative Rules.
Regulatory Action—Failed to use an ABST
28 Jul 2022Abuse: Neglect
28 Jul 2022Abuse: Neglect
Found that failure to provide appropriate services led to multiple falls and discomfort, constituting neglect and abuse; a fine was assessed.
Abuse—Failed to provide service
27 Jun 2022Validation
27 Jun 2022Validation
Investigated a relicensure case and identified multiple deficiencies in activities, service planning, health services, medication management, staffing, nutrition, and safety. Concluded with substantial compliance.
Deficiency—Comment
Deficiency—Resident Services: Activities
Deficiency—Resident Move-In and Eval: Res Evaluation
Deficiency—Service Plan: General
Deficiency—Change of Condition and Monitoring
Deficiency—Resident Health Services
Deficiency—Systems: Medication Administration
Deficiency—Systems: Psychotropic Medication
Deficiency—Acuity-Based Staffing Tool
Deficiency—Fire and Life Safety: Safety
Deficiency—Inspections and Investigation: Insp Interval
Deficiency—Administration Compliance
Deficiency—Staff Training Requirements
Deficiency—Compliance With Rules Health Care
Deficiency—Nutrition and Hydration
Deficiency—Activities
Deficiency—Behavior
24 Jun 2022Abuse: Neglect
24 Jun 2022Abuse: Neglect
Found that services were not provided to meet the resident's needs related to falls, resulting in multiple falls and injuries. A $450 fine was assessed.
Abuse—Failed to provide service
16 Jun 2022Inspection
16 Jun 2022Inspection
Investigated the staffing allegation and found direct care staff were insufficient to meet scheduled and unscheduled resident needs, with none on duty and only two med aides performing personal care tasks.
Licensing—Failed to provide appropriate staffing
14 May 2022Abuse: Neglect
14 May 2022Abuse: Neglect
Investigated and found the care plan was not followed, leading to a physical altercation and resident discomfort. A $500 fine was assessed.
Abuse—Failed to follow care plan
14 Apr 2022Abuse: Neglect
14 Apr 2022Abuse: Neglect
Investigated a complaint about resident-to-resident aggression; failure to intervene led to a skin tear after one resident entered another's room and swung a comb.
Abuse—Failed to follow care plan
11 Apr 2022Abuse: Neglect
11 Apr 2022Abuse: Neglect
Found violations of the care plan and resident rights that caused harm, constituting neglect and abuse.
Abuse—Failed to follow care plan
09 Feb 2022Abuse: Neglect
09 Feb 2022Abuse: Neglect
Found failure to follow the care plan during meals, resulting in breathing trouble and aspiration pneumonia. A fine was assessed.
Abuse—Failed to follow care plan
07 Feb 2022Inspection
07 Feb 2022Inspection
Concluded that inadequate professional oversight of the medication administration system led to frequent medication shortages and residents going without medications.
Licensing—Failed to have medication available
25 Jan 2022Abuse: Neglect
25 Jan 2022Abuse: Neglect
Determined that staff failed to plan for residents' known behaviors, leading to a resident-to-resident altercation and a substantiated finding of abuse and neglect.
Abuse—Failed to properly plan care
25 Jan 2022Abuse: Neglect
25 Jan 2022Abuse: Neglect
Investigated a resident-to-resident incident and found failure to properly plan care for known behaviors, indicating abuse and neglect.
Abuse—Failed to properly plan care
18 Jan 2022Inspection
18 Jan 2022Inspection
Investigated and found interior odors did not meet odor-control requirements.
Licensing—Failed to provide appropriate housekeeping services
05 Jan 2022Abuse: Neglect
05 Jan 2022Abuse: Neglect
Investigated a resident safety incident involving inappropriate sexual contact and found that protections were lacking, resulting in a $450 fine.
Abuse—Failed to protect resident from inappropriate sexual contact
25 Dec 2021Abuse: Neglect
25 Dec 2021Abuse: Neglect
Found a failure to administer medication as ordered, resulting in neglect and abuse; a $225 fine was assessed.
Abuse—Failed to administer medication as ordered
13 Dec 2021Abuse: Neglect
13 Dec 2021Abuse: Neglect
Found neglect and abuse due to failure to properly care plan for a resident relying on care from the facility, which led to a resident-to-resident incident and head injury; a fine was assessed.
Abuse—Failed to properly plan care
16 Oct 2021Abuse: Neglect
16 Oct 2021Abuse: Neglect
Investigated a complaint and found failure to provide appropriate services to meet mobility needs, resulting in multiple falls and discomfort. Found neglect of care that constitutes abuse.
Abuse—Failed to provide service
13 Sept 2021Abuse: Neglect
13 Sept 2021Abuse: Neglect
Investigated a complaint alleging neglect due to delayed medical treatment. Found failures to provide timely care and proper documentation, with a $250 fine assessed.
Abuse—Failed to assure timely medical treatment
31 Jul 2021Abuse: Neglect
31 Jul 2021Abuse: Neglect
Investigated and found neglect and abuse related to medication management, with failures to monitor blood pressure and administer prescribed meds, resulting in a $1,500 fine.
Abuse—Failed to provide service
11 Mar 2021Abuse: Neglect
11 Mar 2021Abuse: Neglect
Determined violations involving neglect and abuse due to failure to plan and intervene for a resident's falls, leading to multiple falls and a hospital visit with surgical intervention.
Abuse—Failed to properly plan care
29 Dec 2020Inspection
29 Dec 2020Inspection
Found that medication and treatment orders were not carried out.
Licensing—Failed to administer medication as ordered
03 Dec 2020Abuse: Neglect
03 Dec 2020Abuse: Neglect
Found a failure to provide a safe medication administration system, resulting in missed medications that put a resident at risk.
Abuse—Failed to provide a safe medication administration system
04 Oct 2020Abuse: Neglect
04 Oct 2020Abuse: Neglect
Investigated and found that a prescribed medication was not administered as ordered, resulting in neglect and abuse. A $1,500 fine was assessed.
Abuse—Failed to administer medication as ordered
28 Aug 2020Inspection
28 Aug 2020Inspection
Identified a violation where medication orders were not carried out as prescribed.
Licensing—Failed to obtain medication order
06 Aug 2020Inspection
06 Aug 2020Inspection
Found a deficiency in the safe medication and treatment system.
Licensing—Failed to provide a safe medication administration system
20 Jul 2020Abuse: Neglect
20 Jul 2020Abuse: Neglect
Investigated an allegation of unsafe medication administration; identified a deficient safe medication system and assessed a $500 fine.
Abuse—Failed to provide a safe medication administration system
16 Jul 2020Abuse: Neglect
16 Jul 2020Abuse: Neglect
Found a failure to provide a safe medication administration system, leading to multiple prescription shortages and related resident discomfort.
Abuse—Failed to provide a safe medication administration system
04 Jul 2020Abuse: Neglect
04 Jul 2020Abuse: Neglect
Investigated an allegation of neglect found staff failed to attach a required tab alarm, leading to a fall with head injury; a prior alarm malfunction contributed, and a fine was assessed.
Abuse—Failed to follow care plan
04 Jul 2020Abuse: Neglect
04 Jul 2020Abuse: Neglect
Investigated a resident fall history with insufficient care planning and monitoring, resulting in death and a civil penalty.
Abuse—Failed to properly plan care
27 Jun 2020Inspection
27 Jun 2020Inspection
Investigated involuntary seclusion and found that a resident was confined to bed using a wheelchair and furniture, constituting abuse and creating an unsafe environment.
Licensing—Failed to provide safe environment
25 Jun 2020Inspection
25 Jun 2020Inspection
Found a safety lapse when someone left the premises unassisted through an unlocked gate. This created a potential safety risk due to an unsafe environment.
Licensing—Failed to provide safe environment
25 Jun 2020Abuse: Neglect
25 Jun 2020Abuse: Neglect
Investigated the allegation of improper care planning related to falls and found that interventions to mitigate fall risk were not adequately implemented, leading to injuries.
Abuse—Failed to properly plan care
03 Feb 2020Inspection
03 Feb 2020Inspection
Found that residents were not treated with dignity and respect.
Licensing—Failed to provide social services
09 Jan 2020Inspection
09 Jan 2020Inspection
Investigated and found a deficiency for failing to provide transportation for medical or social purposes. The finding cited residential services requirements.
Licensing—Failed to provide transportation for medical or social purposes
26 Sept 2019Abuse: Verbal/Mental abuse
26 Sept 2019Abuse: Verbal/Mental abuse
Investigated and found verbal abuse occurred due to supervision failure, causing emotional harm.
Abuse—Failed to protect resident from verbal abuse
01 Jul 2019Abuse: Neglect
01 Jul 2019Abuse: Neglect
Determined that abuse/neglect occurred when two gait belts were linked to restrain a high fall risk resident, causing discomfort, with care provided by an unqualified staff member; a $188 fine was assessed.
Abuse—Failed to use restraint properly
07 Jun 2019Inspection
07 Jun 2019Inspection
Found failure to report suspected abuse. A $750 fine was assessed.
Licensing—Failed to report potential or suspected abuse
06 May 2019Inspection
06 May 2019Inspection
Found that equipment for residents' health, safety and comfort was not kept in good working order, including a stove in the kitchen not working.
Licensing—Failed to assure food safety
01 May 2019Inspection
01 May 2019Inspection
Found that prescribed medications were not administered as ordered, with doses missed or given late.
Licensing—Failed to administer medication as ordered
01 May 2019Inspection
01 May 2019Inspection
Investigated the allegation and found a failure to coordinate outside services necessary to support the resident's health, including canceling a necessary medical appointment without informing the resident.
Licensing—Failed to provide transportation for medical or social purposes
12 Mar 2019Abuse: Neglect
12 Mar 2019Abuse: Neglect
Investigated found a failure to provide a safe medication administration system that led to unadministered pain medication and resident discomfort, with inconsistent audits and missing training documents.
Abuse—Failed to provide a safe medication administration system
05 Mar 2019Abuse: Neglect
05 Mar 2019Abuse: Neglect
Investigated a neglect allegation and found that basic care and supervision were not provided, resulting in harm. A $500 fine was assessed.
Abuse—Failed to provide safe environment
05 Mar 2019Inspection
05 Mar 2019Inspection
Found failure to report suspected abuse, resulting in a licensing violation and a $1,000 fine.
Licensing—Failed to report potential or suspected abuse
02 Mar 2019Abuse: Neglect
02 Mar 2019Abuse: Neglect
Investigated a neglect allegation and found serious deficiencies in care and supervision that caused a resident to fall, sustain serious injuries, and require hospital care, with a $2,500 fine assessed.
Abuse—Failed to adequately care plan related to falls
30 Jan 2019Abuse: Neglect
30 Jan 2019Abuse: Neglect
Found neglect for failing to supervise safety, allowing an individual to leave; a fine was assessed.
Abuse—Failed to properly plan care
28 Jan 2019Inspection
28 Jan 2019Inspection
Concluded that a failure to provide service occurred.
Licensing—Failed to provide service
12 Jan 2019Abuse: Neglect
12 Jan 2019Abuse: Neglect
Investigated neglect by failing to maintain health and safety, resulting in a resident being struck.
Abuse—Failed to provide safe environment
10 Jan 2019Abuse: Neglect
10 Jan 2019Abuse: Neglect
Investigated and found a failure to implement interventions for a known fall risk, leading to an unassisted exit and fall with injury; a $1,125 fine was assessed.
Abuse—Failed to properly plan care
10 Jan 2019Abuse: Neglect
10 Jan 2019Abuse: Neglect
Determined neglect due to failure to supervise care, resulting in inappropriate touching and serious loss of dignity; a $375 fine assessed.
Abuse—Failed to properly plan care
07 Jan 2019Inspection
07 Jan 2019Inspection
Investigated the allegation of failing to provide or maintain resident care equipment and found deficiencies in building requirements; the allegation was substantiated.
Licensing—Failed to provide or maintain resident care equipment
26 Oct 2018Abuse: Neglect
26 Oct 2018Abuse: Neglect
Investigated a complaint and found neglect resulting in harm due to failure to provide basic care to maintain safety. A $375 fine was assessed.
Abuse—Failed to properly plan care
23 Oct 2018Inspection
23 Oct 2018Inspection
Found a substantiated licensing violation alleging failure to assist with toileting.
Licensing—Failed to assist with toileting
23 Oct 2018Abuse: Neglect
23 Oct 2018Abuse: Neglect
Investigated and found neglect of basic care that led to an infection after a shower was not provided for 35 weeks.
Abuse—Failed to provide service
23 Oct 2018Inspection
23 Oct 2018Inspection
Investigated and found a failure to report suspected abuse, with a fine assessed.
Licensing—Failed to report potential or suspected abuse
17 Aug 2018Abuse: Neglect
17 Aug 2018Abuse: Neglect
Investigated a neglect allegation and found failure to provide basic care, creating serious risk; a $2,500 fine was assessed.
Abuse—Failed to provide service
17 Aug 2018Inspection
17 Aug 2018Inspection
Found failure to report suspected abuse; a $1,000 fine was assessed.
Licensing—Failed to report potential or suspected abuse
17 Jul 2018Abuse: Neglect
17 Jul 2018Abuse: Neglect
Found neglect due to failure to provide a safe medication administration system, resulting in loss of medication. A fine of $375 was assessed.
Abuse—Failed to provide a safe medication administration system
14 Jul 2018Abuse: Physical Abuse
14 Jul 2018Abuse: Physical Abuse
Investigated a physical abuse allegation and found failure to protect a resident from rough treatment, resulting in a $2,500 fine.
Abuse—Failed to protect resident from rough treatment
28 Jun 2018Abuse: Neglect
28 Jun 2018Abuse: Neglect
Found a neglect deficiency for failing to administer anticoagulants as ordered, affecting resident safety. Imposed a $500 fine.
Abuse—Failed to administer medication as ordered
28 Jun 2018Inspection
28 Jun 2018Inspection
Found failure to report suspected abuse. A $750 fine was assessed.
Licensing—Failed to report potential or suspected abuse
15 Jun 2018Abuse: Neglect
15 Jun 2018Abuse: Neglect
Investigated an abuse/neglect allegation and found failure to assess and intervene for falls, resulting in a fracture and pain; a fine was assessed.
Abuse—Failed to adequately care plan related to falls
15 Jun 2018Inspection
15 Jun 2018Inspection
Found a violation for failing to report potential or suspected abuse and assessed a $750 fine.
Licensing—Failed to report potential or suspected abuse
07 Jun 2018Abuse: Neglect
07 Jun 2018Abuse: Neglect
Concluded that a neglect allegation involved failure to provide service, leading to multiple falls with injuries, and a $450 fine was assessed.
Abuse—Failed to provide service
13 Feb 2018Abuse: Neglect
13 Feb 2018Abuse: Neglect
Investigated and found a failure to provide a safe environment, resulting in multiple altercations and bruising.
Abuse—Failed to provide safe environment
15 Nov 2017Inspection
15 Nov 2017Inspection
Determined that the allegation of failing to properly plan care occurred and identified safety deficiencies where residents were not kept safe from physical altercations.
Licensing—Failed to properly plan care
26 Oct 2017Inspection
26 Oct 2017Inspection
Found deficiencies in the medication administration system.
Licensing—Failed to provide a safe medication administration system
23 Oct 2017Abuse: Neglect
23 Oct 2017Abuse: Neglect
Found an inadequate medication system that led to a resident receiving another resident's morning medications; a $350 fine was assessed.
Abuse—Failed to provide a safe medication administration system
25 Aug 2017Inspection
25 Aug 2017Inspection
Investigated a complaint and found a violation for failing to provide a safe environment by not preventing a resident-to-resident physical altercation. Assessed a $300 fine.
Licensing—Failed to provide safe environment
16 Jun 2017Inspection
16 Jun 2017Inspection
Determined that medication management records were not maintained accurately, resulting in a resident missing three scheduled doses.
Licensing—Failed to administer medication as ordered
25 Apr 2017Abuse: Neglect
25 Apr 2017Abuse: Neglect
Identified failure to assess and intervene, which resulted in a resident-to-resident altercation.
Abuse—Failed to provide safe environment
23 Apr 2017Abuse: Neglect
23 Apr 2017Abuse: Neglect
Investigated and found a failure to assess and intervene, leading to a resident-to-resident altercation.
Abuse—Failed to provide safe environment
17 Feb 2017Abuse: Neglect
17 Feb 2017Abuse: Neglect
Investigated the allegation of neglect; found the resident was not protected from injuries and the behavior issue was not addressed.
Abuse—Failed to address resident's behavior
17 Feb 2017Abuse: Neglect
17 Feb 2017Abuse: Neglect
Investigated and concluded that a safe environment was not provided, resulting in a resident-to-resident altercation.
Abuse—Failed to provide safe environment
23 Jan 2017Abuse: Neglect
23 Jan 2017Abuse: Neglect
Investigated a medication safety issue and found a violation that led to wrong medications being administered and hospitalization. A $300 fine was assessed.
Abuse—Failed to provide a safe medication administration system
16 Jan 2017Abuse: Financial abuse
16 Jan 2017Abuse: Financial abuse
Investigated a financial exploitation allegation and found that a resident was not protected from theft of medications.
Abuse—Failed to protect resident from financial exploitation
12 Jun 2016Abuse: Financial abuse
12 Jun 2016Abuse: Financial abuse
Investigated and identified a deficiency in protecting residents from medication theft.
Abuse—Failure to provide a system that prevents theft or misuse of medication
13 Sept 2015Abuse: Neglect
13 Sept 2015Abuse: Neglect
Investigated neglect allegation found there was not a safe environment due to resident-to-resident altercations.
Abuse—Failed to address resident's behavior
29 May 2015Abuse: Financial abuse
29 May 2015Abuse: Financial abuse
Determined that financial exploitation occurred due to failure to protect residents' resources. Findings showed misappropriation of residents' resources.
Abuse—Failed to protect resident from financial exploitation
29 May 2015Abuse: Neglect
29 May 2015Abuse: Neglect
Investigated and found a substantiated failure to protect a resident from theft and financial exploitation.
Abuse—Failed to protect resident from financial exploitation
25 Mar 2015Abuse: Neglect
25 Mar 2015Abuse: Neglect
Determined that the resident's care plan was not followed.
Abuse—Failed to follow care plan
22 Aug 2014Inspection
22 Aug 2014Inspection
Found a failure to provide a safe medication administration system.
Licensing—Failed to provide a safe medication administration system
29 May 2014Inspection
29 May 2014Inspection
Investigated a complaint and found a violation of resident rights due to inappropriate treatment.
Licensing—Failed to assure resident rights
14 May 2014Inspection
14 May 2014Inspection
Investigated the allegation and found that proper care was not provided for the RV.
Licensing—Failed to provide service
14 May 2014Inspection
14 May 2014Inspection
Found an inadequate medication system that allowed multiple pain patches to be found, creating potential harm.
Licensing—Failed to provide a safe medication administration system
05 May 2014Abuse: Neglect
05 May 2014Abuse: Neglect
Concluded that medications were not administered as ordered, resulting in a narcotic overdose to a resident.
Abuse—Failed to administer medication as ordered
24 Apr 2014Abuse: Neglect
24 Apr 2014Abuse: Neglect
Investigated the neglect allegation and found a failure to provide a safe medication administration system; a $300 fine was assessed.
Abuse—Failed to provide a safe medication administration system
21 Nov 2013Inspection
21 Nov 2013Inspection
Investigated an allegation of not providing a safe environment; found a deficient safe environment.
Licensing—Failed to provide safe environment
23 Mar 2012Abuse: Financial abuse
23 Mar 2012Abuse: Financial abuse
Investigated a financial abuse allegation and found that a resident's money was not protected from being taken.
Abuse—Failed to provide safe environment
28 Feb 2012Abuse: Financial abuse
28 Feb 2012Abuse: Financial abuse
Concluded that a safe and secure environment was not provided and substantiated a financial abuse allegation.
Abuse—Failed to provide safe environment
01 Feb 2012Abuse: Neglect
01 Feb 2012Abuse: Neglect
Investigated the neglect allegation and found that appropriate care was not provided to a resident.
Abuse—Failed to provide service
20 Jan 2012Abuse: Verbal/Mental abuse
20 Jan 2012Abuse: Verbal/Mental abuse
Investigated and found a violation involving demeaning verbal comments toward a resident and failure to protect from verbal abuse.
Abuse—Failed to protect resident from verbal abuse
12 Jan 2012Abuse: Financial abuse
12 Jan 2012Abuse: Financial abuse
Found a failure to provide a safe and secure environment for a resident.
Abuse—Failed to provide safe environment
20 Oct 2011Abuse: Financial abuse
20 Oct 2011Abuse: Financial abuse
Investigated the allegation and found that a safe and secure environment was not provided.
Abuse—Failed to provide safe environment
29 Sept 2011Inspection
29 Sept 2011Inspection
Investigated a complaint alleging failure to provide a safe environment; found violations relating to protecting a resident from inappropriate sexual contact.
Licensing—Failed to provide safe environment
20 Sept 2011Inspection
20 Sept 2011Inspection
Found a failure to provide a safe and secure environment.
Licensing—Failed to provide safe environment
18 Jul 2011Abuse: Financial abuse
18 Jul 2011Abuse: Financial abuse
Investigated the allegation and found a resident was not provided with a secure environment.
Abuse—Failed to provide safe environment
22 May 2011Abuse: Neglect
22 May 2011Abuse: Neglect
Found failure to provide a safe environment for a resident. A $300 fine was assessed.
Abuse—Failed to provide safe environment
28 Apr 2011Abuse: Neglect
28 Apr 2011Abuse: Neglect
Found deficiencies related to failing to administer ordered medication and providing appropriate care to a resident.
Abuse—Failed to administer ordered medication
08 Nov 2010Abuse: Financial abuse
08 Nov 2010Abuse: Financial abuse
Investigated and found a failure to provide a safe and secure environment.
Abuse—Failed to provide safe environment
11 May 2010Abuse: Financial abuse
11 May 2010Abuse: Financial abuse
Investigated the allegation of financial abuse and determined there was a failure to provide a safe and secure medication administration system.
Abuse—Failed to provide a safe medication administration system
20 Apr 2010Abuse: Neglect
20 Apr 2010Abuse: Neglect
Concluded that the neglect allegation involving oversight and monitoring of change of condition was supported.
Abuse—Failed to provide oversight and monitoring of change of condition
14 Feb 2010Inspection
14 Feb 2010Inspection
Determined that medications were not managed properly, creating a safety risk for residents.
Licensing—Failed to provide safe environment
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