Santiam Gardens

1625 Center St NE, Salem, OR 97301

Assisted Living

Warm, caring, clean family community

I live here and am very pleased with the warm, beautiful community and clean, comfortable building. The staff are exceptional-attentive, genuinely caring, and consistently go above and beyond; meals are delicious, activities are diverse, and the dining room view is lovely. I highly recommend this family-like, value-driven community for compassionate, attentive care.

Current/former resident

Jul 2026

Reviews

4.27·(11)

Overall rating

Care
5.0
Staff
5.0
Meals
5.0
Amenities
4.3
Value
4.3

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Location

Santiam Gardens is located at 1625 Center St NE, Salem, OR, 97301.

About Santiam Gardens

Santiam Gardens Residential Care sits right in the heart of Salem, Oregon, at 1625 Center St NE, close to places like the State Capitol, Wilson Park, Salem Center, Riverfront City Park, and Salem Hospital, and the facility is surrounded by tree-lined walking paths, gardens, and a back patio where residents can sit outside along Mill Creek for fresh air or a nice lunch. The community has 55 beds and offers a variety of living options, like studio, single, and two-bedroom assisted living apartments each month, plus semi-private and private rooms in the nursing section, all fitted with emergency response systems, high ceilings, air conditioning and heating, wall-to-wall carpet, and smoke-free spaces, with all utilities included and apartment maintenance handled by staff. Assisted living, memory care, and nursing home services are available for long-term or short-term stays, and the space is set up for those who need help with daily activities, mobility needs, medication management, and more personal care like bathing, dressing, grooming, walking, wheelchair help, or bathing and toileting support. Residents will find amenities like a dining room with restaurant-style meals prepared by an on-site chef, a fitness center, a beauty salon and barbershop, washers and dryers, kitchens or kitchenettes, a library, cable TV and high-speed internet, WiFi, maintenance and safety features, housekeeping five days a week, and laundry service twice a week, plus pet-friendly outdoor areas, an outside patio, guest parking, resident parking, and a café or bistro. There are health services offered by on-site nurses, with ongoing checks and assessments, along with medical care that can include podiatry, wound care, medication help, support for diabetes, Coumadin therapy, tracheotomy and feeding tube care, and incontinence management, and the team can coordinate with outside providers for physical, speech, or occupational therapy, home health, and hospice as needed, always with care plans overseen by registered nurses. The facility takes special diets and meal preferences into account, offers vegetarian options, and allows for guest meals and anytime dining, along with special programs and entertainment options. Residents can join in on a wide range of activities organized by a full-time activities department, like social events, crafts, educational classes, group or one-on-one activities, games, and health and wellness programs, all in various common spaces that are cleaned daily; some rooms have roll-in showers, ground floor units, and lock boxes for security. Transportation and care assistants are available, and the maintenance staff keeps the building in good shape with daily cleaning of shared areas and apartments. Santiam Gardens focuses on letting residents access local resources and community services as needed, with support in place for mobility, specialized care equipment like Hoyer lifts, and end-of-life care tailored to personal wishes. The facility is linked to the Oregon Health Care Association and aims for a homelike setting with safety and comfort in mind throughout the building.

People often ask...

Santiam Gardens offers assisted living.

There are 2 photos of Santiam Gardens on Mirador.

The full address for this community is 1625 Center St NE, Salem, OR 97301.

No, Santiam Gardens 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 number	50R125
Status	Active
Facility type	Residential Care Facility
Capacity	55 residents
Licensee	Ohana Salem Operations, LLC
Effective	July 1st, 1986

View the official license record

Inspection Reports

156

Reports

Type A Citations

Type B Citations

Complaints

Years

09 Dec 2025Inspection		09 Dec 2025Inspection Observed staff member verbally abused a resident by yelling and derogatory remarks, causing emotional distress and indicating a failure to protect the resident from staff verbal abuse. Licensing—Failed to provide safe environment
03 Dec 2025Inspection		03 Dec 2025Inspection Found that requested records were not provided by the due date, violating state administrative rules. Licensing—Failed to provide safe environment
25 Aug 2025Inspection		25 Aug 2025Inspection Identified deficiencies in the Acuity-Based Staffing Tool and related data, with inconsistencies between the resident roster and care plans that violated state rules. Licensing—Failed to use an ABST
22 Aug 2025Abuse: Neglect		22 Aug 2025Abuse: Neglect Investigated an allegation of abuse and neglect; found that AV's behavioral history and need for two-person supervision were not documented, increasing risk of harm, and a fine was assessed. Abuse—Failed to provide safe environment
28 Jul 2025Inspection		28 Jul 2025Inspection Found that ABST did not accurately reflect residents' needs, with inconsistencies between roster, care plans, and ABST, and staffing not aligned to ABST levels. Licensing—Failed to use an ABST
28 Jul 2025Abuse: Neglect		28 Jul 2025Abuse: Neglect Determined that a safe medication administration system was not provided, resulting in a resident receiving a double dose of antipsychotic and being transported to the emergency department; a fine was assessed. Abuse—Failed to provide a safe medication administration system
16 Jul 2025Inspection		16 Jul 2025Inspection Found deficiencies in the Acuity-Based Staffing Tool and related records, with inconsistencies between roster, care plans, and ABST data that affected staffing levels. Licensing—Failed to use an ABST
26 Jun 2025Abuse: Neglect		26 Jun 2025Abuse: Neglect Found a breakdown in the medication management system that led to inappropriate narcotic administration and signs of overdose, constituting neglect and abuse; a $1,500 fine was assessed. Abuse—Failed to provide a safe medication administration system
26 Jun 2025Inspection		26 Jun 2025Inspection Identified deficiencies in ABST use, including mismatches between resident needs, care plans, and ABST data, resulting in staffing not aligned with resident needs. Licensing—Failed to use an ABST
17 Jun 2025Inspection		17 Jun 2025Inspection Found deficiencies in ABST accuracy and staffing levels that did not reflect resident needs, with inconsistencies between the roster, care plans, and ABST data. Licensing—Failed to use an ABST
18 May 2025Inspection		18 May 2025Inspection Identified deficiencies in ABST usage and staffing with inconsistencies between rosters, care plans, and ABST data. Licensing—Failed to use an ABST
17 Apr 2025Inspection		17 Apr 2025Inspection Found deficiencies in the Acuity-Based Staffing Tool accuracy and related staffing levels, with inconsistencies between the resident roster, care plans, and ABST data. Licensing—Failed to use an ABST
16 Apr 2025Inspection		16 Apr 2025Inspection Identified deficiencies in the Acuity-Based Staffing Tool that did not accurately reflect resident needs and ADLs, with inconsistencies between the roster, care plans, and ABST data. Licensing—Failed to use an ABST
12 Mar 2025Inspection		12 Mar 2025Inspection Found deficiencies in the acuity-based staffing tool and staffing levels, with inconsistencies between the resident roster, care plans, and ABST data. Staffing did not meet the levels indicated by the ABST to address scheduled and unscheduled resident needs, in violation of Oregon Administrative Rules. Licensing—Failed to use an ABST
07 Mar 2025Inspection		07 Mar 2025Inspection Investigated and found a failure to provide a safe medication administration system, resulting in the wrong insulin being given and hypoglycemia. Licensing—Failed to provide a safe medication administration system
01 Oct 2024Abuse: Neglect		01 Oct 2024Abuse: Neglect Investigated found a failure to provide a safe medication administration system, resulting in missed doses and adverse effects due to delayed medication delivery. Abuse—Failed to provide a safe medication administration system
15 Sept 2024Abuse: Neglect		15 Sept 2024Abuse: Neglect Found violations for failure to properly plan care for a resident's behaviors, constituting abuse and neglect. The incident placed a resident at risk for harm. Abuse—Failed to properly plan care
28 Aug 2024Complaint		28 Aug 2024Complaint Investigated a complaint and found multiple deficiencies related to policy, safety, and care, including failure to implement a smoking policy, unsafe environment due to drug use and homeless visitors, medication management lapses, persistent odors, and absence of manual emergency call systems. Deficiency—Facility Administration: Policy & Procedure Deficiency—Resident Rights and Protection - General Deficiency—Systems: Treatment Orders Deficiency—Doors, Walls, Elevators, Odors Deficiency—Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable
28 Aug 2024Complaint		28 Aug 2024Complaint Identified deficiencies in policy and procedure, resident activities, and acuity-based staffing, linked to a licensure complaint, with potential for moderate harm. Deficiency—Facility Administration: Policy & Procedure Deficiency—Resident Services: Activities Deficiency—Acuity-Based Staffing Tool
28 Aug 2024Inspection		28 Aug 2024Inspection Investigated the allegation of inadequate housekeeping and found interior odors indicating a rule violation. Licensing—Failed to provide appropriate housekeeping services
08 Aug 2024Inspection		08 Aug 2024Inspection Identified a safety deficiency after reports of a resident using drugs and soliciting others to use drugs, indicating failure to provide a safe environment. Licensing—Failed to provide safe environment
08 Aug 2024Inspection		08 Aug 2024Inspection Found no daily program of social and recreational activities and no activity calendar, violating Oregon Administrative Rules. Licensing—Failed to provide appropriate activities
08 Aug 2024Inspection		08 Aug 2024Inspection Found that written policies and procedures for responding to and resolving resident complaints were not developed or implemented. A resident voiced issues, but management did not respond or follow up. Licensing—Failed to provide service
05 Jul 2024Inspection		05 Jul 2024Inspection Investigated allegations found failure to carry out medication and treatment orders as prescribed. A licensing violation was identified. Licensing—Failed to have medication available
05 Jul 2024Inspection		05 Jul 2024Inspection Found deficiencies in the medication administration system, including failure to order medications in time and to maintain a sufficient stock, which could affect treatment. Licensing—Failed to provide a safe medication administration system
03 Jun 2024Inspection		03 Jun 2024Inspection Identified a staff medication administration failure that left a resident without prescribed medications, causing neuropathic foot pain and discomfort and revealed an unsafe medication system. Licensing—Failed to provide a safe medication administration system
24 May 2024Inspection		24 May 2024Inspection Found that a manually operated emergency call system was not provided in each toilet and bathing facility used by residents and visitors. Licensing—Failed to maintain functional door alarm or call system
24 May 2024Inspection		24 May 2024Inspection Determined that resident rights were not assured due to ineffective methods for responding to and resolving resident complaints. Licensing—Failed to assure resident rights
23 May 2024Inspection		23 May 2024Inspection Investigated the allegation and found a violation for failing to administer medication as ordered. Licensing—Failed to administer medication as ordered
13 May 2024Inspection		13 May 2024Inspection Investigated the allegation and found that an updated ABST did not accurately reflect resident needs. Inconsistencies were identified between the resident roster, care plans, and ABST data. Licensing—Failed to use an ABST
11 May 2024Abuse: Neglect		11 May 2024Abuse: Neglect Investigated a complaint and found that a safe medication administration system was not provided, resulting in a missed seizure medication dose and risk of serious harm. Abuse—Failed to provide a safe medication administration system
05 May 2024Inspection		05 May 2024Inspection Found a violation for failing to provide a safe and homelike environment. Licensing—Failed to provide safe environment
15 Apr 2024Validation		15 Apr 2024Validation Identified deficiencies in complaint handling, service plans, coordination with outside providers, medication administration, acuity-based staffing, waste management, and laundry practices; subsequent follow-up noted substantial compliance. Deficiency—Comment Deficiency—Facility Administration: Policy & Procedure Deficiency—Service Plan: General Deficiency—Res Hlth Srvc: On- and Off-Site Health Srvc Deficiency—Systems: Medication Administration Deficiency—Acuity-Based Staffing Tool Deficiency—General Building Exterior Deficiency—Housekeeping and Laundry Deficiency—Individual Door Locks: Key Access Deficiency—Individual Visitors: Any Time Deficiency—Limitations: Threats to Health and Safety
27 Mar 2024Inspection		27 Mar 2024Inspection Investigated a complaint and found a smoking policy was not developed or implemented. This was determined to violate Oregon Administrative Rules. Licensing—Failed to provide safe environment
19 Mar 2024Complaint		19 Mar 2024Complaint Investigated a complaint and identified that training for direct care staff was not completed within 30 days. Deficiency—Training Within 30 Days: Direct Care Staff
19 Mar 2024Inspection		19 Mar 2024Inspection Investigated and found a deficiency for failing to verify direct care staff performance in any duty assigned. Licensing—Failed to provide inservice
08 Feb 2024Inspection		08 Feb 2024Inspection Investigated and found deficiencies in training to determine direct care staff competency and in maintaining documentation of demonstrated competency. Staff did not know how to properly transfer residents. Licensing—Failed to provide appropriate staffing
06 Feb 2024Complaint		06 Feb 2024Complaint Identified deficiencies related to resident rights, medication administration, staffing, and call/communication systems. Deficiency—Resident Rights and Protection - General Deficiency—Systems: Medication Administration Deficiency—Staffing Requirements and Training: Staffing Deficiency—Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable
20 Dec 2023Abuse: Neglect		20 Dec 2023Abuse: Neglect Investigated found that the resident did not receive adequate care planning and timely responses, resulting in ongoing pain and constituting neglect/abuse. Abuse—Failed to properly plan care
16 Dec 2023Abuse: Neglect		16 Dec 2023Abuse: Neglect Investigated and found that the care plan was not followed, leaving a resident in soaked briefs with unnecessary discomfort and skin breakdown due to lack of scheduled toileting and needed care. Abuse—Failed to follow care plan
16 Dec 2023Inspection		16 Dec 2023Inspection Investigated a complaint and determined that a staff member failed to follow the resident's care plan, causing unreasonable discomfort that constitutes neglect; another staff member was not found to have abused. A $450 fine was assessed. Licensing—Failed to provide safe environment
16 Dec 2023Abuse: Neglect		16 Dec 2023Abuse: Neglect Found that inadequate care planning for a resident's fall history resulted in multiple falls and ongoing discomfort. Abuse—Failed to properly plan care
07 Dec 2023Licensure		07 Dec 2023Licensure Determined substantial compliance with meal service and food sanitation requirements after a kitchen review. Deficiency—Comment
30 Nov 2022Licensure		30 Nov 2022Licensure Determined that the facility was in substantial compliance with applicable meal service and food sanitation rules. Deficiency—Comment
08 Jul 2022Inspection		08 Jul 2022Inspection Investigated a complaint and found that residents lived in an unlicensed setting, violating Oregon Administrative Rules. Licensing—Failed to obtain a facility license
01 Jul 2022Inspection		01 Jul 2022Inspection Investigated the staffing documentation allegation and found a failure to submit weekly vaccination reporting to the proper authority for 30 days. Licensing—Failed to submit timely or adequate staffing documentation
01 Dec 2020Abuse: Neglect		01 Dec 2020Abuse: Neglect Found that the facility failed to follow the resident's catheter care plan, risking harm, and a fine was assessed. Abuse—Failed to follow care plan
05 Nov 2020Abuse: Neglect		05 Nov 2020Abuse: Neglect Investigated a complaint of neglect and abuse and found a resident did not receive timely medical care after reporting discomfort, resulting in a wound that needed treatment; a fine was assessed. Abuse—Failed to provide service
07 Aug 2020Inspection		07 Aug 2020Inspection Determined that a staff member verbally abused an individual and that the environment failed to provide a safe setting. Licensing—Failed to provide safe environment
07 Aug 2020Inspection		07 Aug 2020Inspection Determined a violation for failing to provide a safe environment and for verbal abuse that caused distress to a resident. Licensing—Failed to provide safe environment
30 Jul 2020Abuse: Neglect		30 Jul 2020Abuse: Neglect Found a failure to provide a safe medication administration system that led to the resident paying out of pocket for catheter supplies. This was identified as neglect and abuse with a fine assessed. Abuse—Failed to provide a safe medication administration system
07 Jul 2020Inspection		07 Jul 2020Inspection Determined that there was inadequate professional oversight of the medication and treatment administration system. Licensing—Failed to provide a safe medication administration system
07 Jul 2020Inspection		07 Jul 2020Inspection Investigated a complaint about medication administration records and determined that an accurate MAR for all medications was not kept. Licensing—Failed to provide a safe medication administration system
07 Jul 2020Inspection		07 Jul 2020Inspection Investigated the medication administration allegation and found that medication orders were not carried out as prescribed. Licensing—Failed to provide a safe medication administration system
20 Jun 2020Abuse: Neglect		20 Jun 2020Abuse: Neglect Investigated an allegation of abuse/neglect and found failure to properly plan care for a known risk of self-transfer, leading to several falls. Abuse—Failed to properly plan care
17 Jun 2020Inspection		17 Jun 2020Inspection Investigated an allegation that bathing assistance was not provided; findings were verified. Licensing—Failed to provide service
17 Jun 2020Inspection		17 Jun 2020Inspection Investigated the allegation and found cleanliness deficiencies related to interior materials and surfaces. Licensing—Failed to assure food safety
08 Jun 2020Abuse: Neglect		08 Jun 2020Abuse: Neglect Found failure to properly care plan for the resident's fall risk and to implement updated fall interventions after multiple falls, leading to hospitalization. Abuse—Failed to properly plan care
05 Jun 2020Inspection		05 Jun 2020Inspection Investigated a pest-control allegation and found that measures to prevent entry of rodents and other insects were inadequate. Licensing—Failed to control pests
05 Jun 2020Inspection		05 Jun 2020Inspection Confirmed the allegation that a safe environment was not provided for residents. Licensing—Failed to provide safe environment
05 Jun 2020Inspection		05 Jun 2020Inspection Found the allegation that service plans did not reflect residents' needs. Licensing—Failed to properly plan care
05 Jun 2020Inspection		05 Jun 2020Inspection Investigated an allegation that residents were not assisted with activities of daily living, including bathing and grooming, and verified the deficiency. Licensing—Failed to provide service
02 Jun 2020Inspection		02 Jun 2020Inspection Investigated and determined that staff did not follow the resident's care plan for mobility/transfer, causing pain and a skin tear, and the environment was not safe. Licensing—Failed to provide safe environment
28 May 2020Abuse: Neglect		28 May 2020Abuse: Neglect Found failure to properly plan care for a high fall-risk resident, resulting in a fall with facial injury; identified as abuse and neglect. Abuse—Failed to properly plan care
05 May 2020Inspection		05 May 2020Inspection Found a smoking policy violation due to staff and residents smoking near the door. Licensing—Failed to assure resident was safe
05 May 2020Inspection		05 May 2020Inspection Investigated a safety allegation and found exits were obstructed, posing a safety hazard in an emergency. Licensing—Failed to assure resident was safe
28 Mar 2020Abuse: Neglect		28 Mar 2020Abuse: Neglect Found that the care plan for addressing suicidal ideation was not followed, resulting in neglect and abuse. Abuse—Failed to follow care plan
24 Mar 2020Abuse: Neglect		24 Mar 2020Abuse: Neglect Investigated and determined that care planning for falls was inadequate, resulting in neglect and abuse findings. Abuse—Failed to properly plan care
06 Mar 2020Inspection		06 Mar 2020Inspection Investigated an allegation of a failure to provide a safe environment and found that a resident's money was stolen due to failure to protect property. This constitutes a level 2 licensing violation. Licensing—Failed to provide safe environment
03 Mar 2020Abuse: Neglect		03 Mar 2020Abuse: Neglect Investigated and found deficiencies in fall-risk assessment and care planning after a resident fall, leading to a second fall and hospital transport. Abuse—Failed to properly plan care
28 Feb 2020Inspection		28 Feb 2020Inspection Found that a resident's money went missing due to failure to protect property, resulting in financial exploitation by an unknown individual. Licensing—Failed to provide safe environment
28 Feb 2020Abuse: Neglect		28 Feb 2020Abuse: Neglect Found that fall risk planning was inadequate, resulting in six falls and ongoing risk. Abuse—Failed to properly plan care
27 Feb 2020Inspection		27 Feb 2020Inspection Investigated and found insufficient staff to meet residents' scheduled and unscheduled needs, leading to delayed responses to call lights. Licensing—Failed to answer call light in a timely manner
25 Feb 2020Inspection		25 Feb 2020Inspection Investigated an allegation of a nonfunctional door alarm or call system and identified deficiencies in keeping equipment in good repair. Licensing—Failed to maintain functional door alarm or call system
24 Feb 2020Inspection		24 Feb 2020Inspection Found a deficiency for failing to protect a resident's property from theft. Licensing—Failed to provide safe environment
24 Feb 2020Inspection		24 Feb 2020Inspection Found a violation for failing to provide a safe environment, resulting in theft and financial exploitation of a resident. Licensing—Failed to provide safe environment
21 Feb 2020Inspection		21 Feb 2020Inspection Found that hygiene assistance with showers was not provided as required. Licensing—Failed to provide or assist with hygiene
12 Feb 2020Abuse: Neglect		12 Feb 2020Abuse: Neglect Found failures to properly plan for fall risk and implement preventive interventions, resulting in neglect and abuse. Assessed a $1,500 fine. Abuse—Failed to properly plan care
03 Feb 2020Inspection		03 Feb 2020Inspection Investigated the allegation of theft and found that resident property was not adequately protected, constituting financial exploitation and abuse. Money went missing from a resident's room and was attributed to another resident. Licensing—Failed to provide safe environment
30 Jan 2020Inspection		30 Jan 2020Inspection Investigated and found a failure to protect a resident's property from theft, with one individual determined to have stolen the resident's cigarettes and another cleared of wrongdoing. Licensing—Failed to provide safe environment
28 Jan 2020Inspection		28 Jan 2020Inspection Investigated an allegation of theft and unsafe environment; money disappeared from a resident's room and property was not protected, constituting abuse. Licensing—Failed to provide safe environment
24 Jan 2020Inspection		24 Jan 2020Inspection Investigated an allegation of an unsafe environment and concluded that a resident's money was stolen by another person, with property protection failures identified. Licensing—Failed to provide safe environment
21 Jan 2020Inspection		21 Jan 2020Inspection Investigated and found a licensing violation involving failure to follow a resident's care plan, causing pain during dressing and indicating a safety lapse. Licensing—Failed to follow care plan
14 Jan 2020Inspection		14 Jan 2020Inspection Found a violation for failing to protect a resident's property from theft, tied to an unsafe-environment allegation. Money disappeared from a room due to theft by an unknown person. Licensing—Failed to provide safe environment
05 Jan 2020Abuse: Neglect		05 Jan 2020Abuse: Neglect Determined that the resident did not receive daily baths for over two months, leading to a skin rash due to failure to follow the care plan. Abuse—Failed to follow care plan
19 Dec 2019Inspection		19 Dec 2019Inspection Found insufficient staff to meet scheduled and unscheduled resident needs, resulting in a resident waiting about 2 hours for assistance. Licensing—Failed to answer call light in a timely manner
19 Dec 2019Inspection		19 Dec 2019Inspection Found that a daily program of social and recreational activities was not provided. Licensing—Failed to provide service
18 Dec 2019Inspection		18 Dec 2019Inspection Investigated an allegation of failing to provide service and found a licensing violation. Licensing—Failed to provide service
02 Dec 2019Abuse: Neglect		02 Dec 2019Abuse: Neglect Found neglect due to failure to follow the care plan, including not assisting with showers, dressing, or applying cream to sores. A $500 fine was assessed. Abuse—Failed to follow care plan
02 Dec 2019Inspection		02 Dec 2019Inspection Investigated a report of suspected abuse and identified a license violation for failing to report it; a $1,000 fine was assessed. Licensing—Failed to report potential or suspected abuse
24 Oct 2019Abuse: Neglect		24 Oct 2019Abuse: Neglect Found neglect in basic care that led to wounds worsening due to failure to provide required care and services. Abuse—Failed to follow care plan
24 Oct 2019Inspection		24 Oct 2019Inspection Found failure to report suspected abuse; a $1,000 fine was assessed. Licensing—Failed to report potential or suspected abuse
07 Oct 2019Inspection		07 Oct 2019Inspection Investigated and found a failure to report suspected abuse; assessed a $1,000 fine. Licensing—Failed to report potential or suspected abuse
07 Oct 2019Abuse: Neglect		07 Oct 2019Abuse: Neglect Found neglect due to failing to provide basic care, resulting in an individual left on the toilet for an extended period and hospitalized after a fall. A $1500 fine was assessed. Abuse—Failed to assist with toileting
26 Jul 2019Abuse: Neglect		26 Jul 2019Abuse: Neglect Found neglect resulting in injury to a resident during a transfer; a $500 fine was assessed. Abuse—Failed to follow care plan
28 Jun 2019Inspection		28 Jun 2019Inspection Found failure to report suspected abuse and assessed a $1000 fine. Licensing—Failed to report potential or suspected abuse
28 Jun 2019Abuse: Neglect		28 Jun 2019Abuse: Neglect Investigated a neglect allegation involving failure to provide basic care that led to minor harm. Violations of care standards were cited and a fine was assessed. Abuse—Failed to provide safe environment
28 Jun 2019Abuse: Neglect		28 Jun 2019Abuse: Neglect Found a failure to provide a safe environment and basic care, resulting in a bruise of unknown origin on a resident's forearm. A $250 fine was assessed. Abuse—Failed to provide safe environment
28 Jun 2019Inspection		28 Jun 2019Inspection Found that the provider failed to report potential or suspected abuse. Licensing—Failed to report potential or suspected abuse
06 Jun 2019Abuse: Neglect		06 Jun 2019Abuse: Neglect Found neglect by failing to adequately supervise or train staff, resulting in risk of serious harm. A $250 fine was assessed. Abuse—Failed to follow care plan
06 Jun 2019Inspection		06 Jun 2019Inspection Found a failure to report suspected abuse and assessed a $1,000 fine. Licensing—Failed to report potential or suspected abuse
27 May 2019Abuse: Neglect		27 May 2019Abuse: Neglect Investigated a neglect allegation about medication administration and found deficiencies that allowed the theft of 60 narcotic tablets. Abuse—Failed to provide a safe medication administration system
27 May 2019Abuse: Neglect		27 May 2019Abuse: Neglect Found neglect in providing a safe medication administration system, resulting in the theft of 60 tablets of a narcotic medication; a $188 fine was assessed. Abuse—Failed to provide a safe medication administration system
27 May 2019Abuse: Neglect		27 May 2019Abuse: Neglect Found neglect in medication management that allowed theft of narcotic tablets and assessed a $188 fine. Abuse—Failed to provide a safe medication administration system
03 May 2019Inspection		03 May 2019Inspection Investigated the allegation and found deficiencies in staffing or staff training practices, including failing to respond to call lights promptly. Licensing—Failed to answer call light in a timely manner
01 Apr 2019Abuse: Neglect		01 Apr 2019Abuse: Neglect Investigated a neglect allegation and found a violation related to unsafe medication management, which allowed the theft of narcotics; a fine was assessed. Abuse—Failed to provide a safe medication administration system
01 Apr 2019Abuse: Neglect		01 Apr 2019Abuse: Neglect Found neglect-related deficiencies in the medication management system that allowed theft of narcotic tablets and resulted in a $188 fine. Abuse—Failed to provide a safe medication administration system
22 Feb 2019Inspection		22 Feb 2019Inspection Investigated a complaint that call lights were not answered promptly, resulting in nighttime delays for residents. Licensing—Failed to answer call light in a timely manner
15 Feb 2019Abuse: Neglect		15 Feb 2019Abuse: Neglect Investigated the complaint and found neglect due to failing to regularly reposition a resident and change a soiled brief, resulting in discomfort and loss of personal dignity. Abuse—Failed to answer call light in a timely manner
12 Feb 2019Inspection		12 Feb 2019Inspection Substantiated the allegation of failure to report potential or suspected abuse and assessed a $1000 fine. Licensing—Failed to report potential or suspected abuse
08 Feb 2019Inspection		08 Feb 2019Inspection Investigated a staffing allegation and concluded there was a staffing deficiency. Licensing—Failed to provide appropriate staffing
29 Jan 2019Inspection		29 Jan 2019Inspection Found that money disappeared from a resident's room due to theft by an unknown person. This showed a failure to protect resident property and provide a safe environment. Licensing—Failed to provide safe environment
26 Nov 2018Inspection		26 Nov 2018Inspection Found failure to report suspected abuse. A $750 fine was assessed. Licensing—Failed to report potential or suspected abuse
14 Oct 2018Abuse: Neglect		14 Oct 2018Abuse: Neglect Found neglect due to failing to answer a call light promptly, resulting in serious loss of personal dignity; a $500 fine assessed. Abuse—Failed to answer call light in a timely manner
02 Jul 2018Inspection		02 Jul 2018Inspection Investigated a complaint and determined a licensing violation occurred due to neglecting personal care, which led to UTIs. Licensing—Failed to provide service
18 Jan 2018Abuse: Financial abuse		18 Jan 2018Abuse: Financial abuse Found that a safe environment for residents' belongings was not maintained, resulting in the theft of jewelry. Abuse—Failed to provide safe environment
15 Aug 2017Abuse: Neglect		15 Aug 2017Abuse: Neglect Investigated a complaint alleging neglect; determined neglect occurred, resulting in a resident being dropped and injured. Abuse—Failed to protect resident from rough treatment
15 Aug 2017Abuse: Neglect		15 Aug 2017Abuse: Neglect Found that medications were not ordered, resulting in residents going without prescribed pain medication. A $400 fine was assessed. Abuse—Failed to administer medication as ordered
08 Aug 2017Abuse: Neglect		08 Aug 2017Abuse: Neglect Investigated an allegation of neglect related to medication administration and found the medication/treatment system was not adequately maintained, resulting in missed morphine doses and pain. Abuse—Failed to administer medication as ordered
08 Aug 2017Inspection		08 Aug 2017Inspection Found that staff failed to communicate appropriately with onsite providers, deferring a hospice nurse to a medication aide after the nurse requested to speak with the RN. Licensing—Failed to provide service
08 Aug 2017Inspection		08 Aug 2017Inspection Found that resident services were not provided as required due to low staffing on Mondays. Licensing—Failed to provide appropriate staffing
08 Aug 2017Inspection		08 Aug 2017Inspection Investigated an allegation that medication and wound care were not provided as ordered. Found failure to carry out medication and prescribed treatment orders. Licensing—Failed to provide medical treatment as ordered
07 Aug 2017Inspection		07 Aug 2017Inspection Investigated an allegation of inadequate screening or assessment and found that an RN failed to assess residents as required. Licensing—Failed to perform adequate screening or assessment
07 Aug 2017Inspection		07 Aug 2017Inspection Investigated the allegation of failing to provide a safe, homelike environment and found a water meter left uncovered on the grass. Licensing—Failed to provide safe environment
07 Aug 2017Inspection		07 Aug 2017Inspection Found that a resident's call button went unanswered, resulting in a fall and risk to health and safety. Licensing—Failed to provide service
31 Jul 2017Inspection		31 Jul 2017Inspection Investigated a complaint alleging failure to administer medication as ordered and determined the allegation to be substantiated. Licensing—Failed to administer medication as ordered
31 Jul 2017Inspection		31 Jul 2017Inspection Concluded that retaliation against resident/complainant occurred. Licensing—Retaliated against resident/complainant
31 Jul 2017Inspection		31 Jul 2017Inspection Investigated the allegation of failing to provide or assist with hygiene and found it substantiated. Licensing—Failed to provide or assist with hygiene
20 Jul 2017Inspection		20 Jul 2017Inspection Found bathing assistance not provided as required. Licensing—Failed to provide or assist with hygiene
20 Jul 2017Inspection		20 Jul 2017Inspection Found insufficient staffing to meet 24-hour resident needs and delays in answering call lights. Licensing—Failed to provide appropriate staffing
20 Jul 2017Inspection		20 Jul 2017Inspection Found caregivers were not trained as required, and staff did not know how to transfer residents. Licensing—Failed to provide service
16 Jul 2017Inspection		16 Jul 2017Inspection Found that medications were not administered as ordered, resulting in missed doses of a scheduled medication. Licensing—Failed to administer medication as ordered
11 Jul 2017Inspection		11 Jul 2017Inspection Found that medications were not administered as ordered, resulting in several missed doses of a scheduled medication. Licensing—Failed to administer medication as ordered
21 Jun 2017Abuse: Sexual abuse		21 Jun 2017Abuse: Sexual abuse Investigated a complaint alleging sexual abuse and failure to protect a resident from inappropriate sexual contact. Found a deficiency in protecting residents from inappropriate sexual conduct. Abuse—Failed to protect resident from inappropriate sexual contact
30 Mar 2017Inspection		30 Mar 2017Inspection Found deficiencies in medication management that led to medications not being given. Licensing—Failed to provide a safe medication administration system
13 Jan 2017Inspection		13 Jan 2017Inspection Identified a failure to provide a safe environment that resulted in a resident receiving cannabis via an edible and experiencing abnormal behavioral concerns. Licensing—Failed to provide safe environment
14 Jul 2016Inspection		14 Jul 2016Inspection Found insufficient awake staffing to meet residents' 24-hour needs. Licensing—Failed to provide appropriate staffing
30 Jun 2016Abuse: Financial abuse		30 Jun 2016Abuse: Financial abuse Investigated an allegation of financial abuse and found a failure to provide a safe environment by not protecting the RVs from theft. Abuse—Failed to provide safe environment
10 Dec 2015Abuse: Neglect		10 Dec 2015Abuse: Neglect Investigated the allegation of neglect involving failure to properly plan care. Abuse—Failed to properly plan care
23 Nov 2015Abuse: Financial abuse		23 Nov 2015Abuse: Financial abuse Investigated the allegation of financial abuse and found a failure to protect residents from theft of property. Abuse—Failed to provide safe environment
28 Oct 2015Abuse: Financial abuse		28 Oct 2015Abuse: Financial abuse Investigated and substantiated a financial abuse involving theft of money due to failure to prevent it. Abuse—Failed to provide safe environment
24 Jul 2015Abuse: Financial abuse		24 Jul 2015Abuse: Financial abuse Investigated the allegation of financial abuse and identified a deficiency for failing to provide a safe environment. Abuse—Failed to provide safe environment
15 Mar 2015Abuse: Neglect		15 Mar 2015Abuse: Neglect Investigated the allegation and found care did not intervene when a resident's condition changed. Abuse—Failed to intervene when resident's condition changed
01 Feb 2015Abuse: Neglect		01 Feb 2015Abuse: Neglect Investigated allegation of unsafe medication administration; found the medication system inadequate. Abuse—Failed to provide a safe medication administration system
10 Dec 2014Inspection		10 Dec 2014Inspection Found that care did not follow the care plan, creating minor harm or potential for moderate harm. Licensing—Failed to follow care plan
05 Sept 2014Abuse: Neglect		05 Sept 2014Abuse: Neglect Concluded there was inadequate oversight and monitoring of a change in condition, and improper treatment was provided to a resident. Abuse—Failed to provide oversight and monitoring of change of condition
20 Aug 2014Abuse: Neglect		20 Aug 2014Abuse: Neglect Investigated an allegation of failure to provide oversight and monitoring of change of condition; findings supported a violation and a fine was assessed. Abuse—Failed to provide oversight and monitoring of change of condition
27 May 2014Abuse: Neglect		27 May 2014Abuse: Neglect Investigated a neglect allegation and found that proper care was not provided. Abuse—Failed to provide service
02 May 2014Abuse: Neglect		02 May 2014Abuse: Neglect Identified a failure to assess and intervene related to falls, resulting in a significant occurrence. Abuse—Failed to adequately care plan related to falls
02 Dec 2013Inspection		02 Dec 2013Inspection Found a safety deficiency indicating residents were not kept safe. Licensing—Failed to assure resident was safe
28 Aug 2013Inspection		28 Aug 2013Inspection Found failure to provide a safe environment. Licensing—Failed to provide safe environment
27 Jul 2012Abuse: Neglect		27 Jul 2012Abuse: Neglect Determined that oversight and monitoring of changes in condition were inadequate. Abuse—Failed to provide oversight and monitoring of change of condition
01 Jun 2011Inspection		01 Jun 2011Inspection Found that a safe medication administration system was not adequately maintained. Licensing—Failed to provide a safe medication administration system
18 May 2011Abuse: Neglect		18 May 2011Abuse: Neglect Investigated the allegation and found a deficiency in medication management due to failure to administer ordered medication. Abuse—Failed to administer ordered medication
21 Apr 2011Abuse: Neglect		21 Apr 2011Abuse: Neglect Found that peri care was not provided adequately, resulting in substantiated neglect. Abuse—Failed to provide peri care
22 Feb 2011Abuse: Neglect		22 Feb 2011Abuse: Neglect Investigated a neglect allegation and found ongoing noncompliance with multiple rules, with no monetary penalty assessed. Abuse—Failed to provide service

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