I'm very pleased with the compassionate, engaged staff who knew residents by name and provided personalized, safety-focused care and regular check-ins. The small, homey community is clean and well-decorated with private rooms, chef-prepared meals, cozy communal areas and seasonal activities, and hospice coordination and management were responsive and accommodating to our family. Overall a comfortable, caring place where my loved one was well taken care of.
Loved one of resident
Jul 2026
Pricing
Prices shown are estimates and subject to change. Contact your senior living advisor for current pricing.
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Amenities
Healthcare services
Activities of daily living assistance
Assistance with bathing
Assistance with dressing
Assistance with transfers
Medication management
Mental wellness program
Healthcare staffing
24-hour call system
24-hour supervision
Meals and dining
Diabetes diet
Meal preparation and service
Restaurant-style dining
Special dietary restrictions
Room
Cable
Fully furnished
Housekeeping and linen services
Kitchenettes
Telephone
Wifi
Memory care community services
Mild cognitive impairment
Specialized memory care programming
Common areas
Beauty salon
Dining room
Garden
Outdoor space
Small library
Community services
Move-in coordination
Activities
Community-sponsored activities
Resident-run activities
Scheduled daily activities
Reviews
4.64·(14)
Overall rating
5
4
3
2
1
Care
5.0
Staff
5.0
Meals
4.0
Amenities
4.3
Value
5.0
Pros
Compassionate, engaged caregiving staff
Staff who know residents by name
Individualized, safety-focused care
Effective hospice and end-of-life coordination
Regular check-ins and responsive management
Chef-prepared meals and dining assistance
Seasonal activities and event programming
Cozy, home-like communal spaces
Private rooms with appropriate furnishings
Support for large family gatherings and visitors
Clean, well-decorated interior
Small community with one-on-one attention
Good value and owner responsiveness
COVID-era supportive practices
Cons
Intermittent staff turnover affecting continuity of care
Smaller-than-average private room sizes
Occasional cleanliness inconsistencies in some bathrooms
Variable family satisfaction with overall experience
Summary of reviews
Overall impression: Reviews describe Sweet Bye N Bye - Evergreen West as a small, home-like senior living community with a clearly expressed focus on personalized care and resident comfort. Positive themes emphasize compassionate, engaged staff; private, well-furnished rooms; chef-prepared meals; and communal spaces that are cozy and seasonally decorated. Families frequently highlight staff responsiveness, organized hospice coordination, and an accommodating approach to visitors and family events.
Care and staff: Care quality is portrayed as individualized and safety-conscious. Staff are often described as knowing residents by name, providing regular check-ins, assisting at mealtimes, and offering emotional as well as physical support. Teamwork and effective communication with hospice providers are noted strengths. At the same time, reviewers indicate intermittent staff turnover, which can affect continuity of assignments and family confidence. Prospective families should ask about current staffing ratios, turnover trends, and orientation/continuity plans to understand how the facility manages transitions.
Dining and activities: The facility offers chef-prepared meals served in a communal dining area, with assistance available during mealtimes for residents who need it. Activity programming is described as engaging and seasonally themed, with events and decorations that contribute to a home-like atmosphere. The small scale of the community supports one-on-one attention during activities and meals, and the staff are described as accommodating when families bring guests for larger gatherings.
Facilities and cleanliness: Physical spaces are generally described as clean, well-decorated, and comfortable, with appropriately furnished private rooms (bed, chest of drawers, side table, recliner). The community's smaller size is presented as an asset for intimacy and individualized attention, though it translates into smaller private room footprints. A minority of comments reference cleanliness issues localized to bathroom areas; families may wish to inquire about cleaning schedules, sanitation protocols, and inspection practices during a tour.
Management and notable patterns: Management and ownership receive positive remarks for helpfulness and communication, and the facility was described as supportive during the COVID period. The dominant pattern is positive—compassionate staff, coordinated clinical support, and a home-like environment—but there is some variability in family satisfaction, and at least one strongly negative overall experience is noted. That variability appears linked to staffing continuity and localized cleanliness concerns rather than the core program elements.
Practical advice for families: Visit in person to assess room size and layout, observe mealtime service, and meet front-line staff. Ask for details about staffing stability, shift coverage, and staff orientation. Request documentation of housekeeping and infection-control protocols, and inquire how the facility coordinates with hospice and family members during care transitions. These targeted questions will help clarify whether the facility's strengths align with a prospective resident's needs and expectations.
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Location
Sweet Bye N Bye - Evergreen West is located at 2855 Evergreen Ave NE, Salem, Oregon, 97301.
About Sweet Bye N Bye - Evergreen West
Sweet Bye N Bye - Evergreen West sits in a quiet neighborhood in Salem, Oregon, less than five miles from downtown and near the Willamette River, and the place has 28 licensed beds, all set aside for people who need memory care and help with daily life, so families can find some peace of mind knowing their loved ones are in a safe, home-like setting. The facility is licensed as a Residential Care Facility and mostly focuses on seniors who have Alzheimer's disease or other forms of dementia, and the goal is to help residents feel comfortable, keep confusion low, and prevent wandering. There's a full-time activity director on staff who creates activities that keep people engaged, and the team keeps an eye on residents at all hours, day and night, to make sure they're safe and getting the help they need. The building has handicap accessibility and high-speed internet, and the location aims to give every resident a high quality of life in a group home type of setting, with regular safety checks and care plans made for each person. The staff gets special education about dementia and memory loss, so they know how to care for seniors with those challenges. Even though no unique programs or fancy extras are mentioned, the community offers sincere, steady support and is part of SeniorAdvisor.com's listings, with good ratings from people who've used their services. There are three Sweet Bye N Bye Memory Care community locations, and this particular place offers virtual tours for anyone who'd like to learn more about what daily life is like there.
People often ask...
Sweet Bye N Bye - Evergreen West offers competitive pricing, with rates starting at a cost of $6,336 per month.
Sweet Bye N Bye - Evergreen West offers assisted living and memory care.
There are 11 photos of Sweet Bye N Bye - Evergreen West on Mirador.
The full address for this community is 2855 Evergreen Ave NE, Salem, Oregon 97301.
No, Sweet Bye N Bye - Evergreen West 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.
Investigated a neglect allegation and found that staff failed to provide a safe environment by not monitoring residents, creating risk of harm in common areas.
Abuse—Failed to provide safe environment
08 Jun 2025Abuse: Neglect
08 Jun 2025Abuse: Neglect
Found neglect and abuse due to failure to provide a safe environment. Staff were not monitoring individuals in common areas, allowing harm to occur.
Abuse—Failed to provide safe environment
01 May 2025Abuse: Neglect
01 May 2025Abuse: Neglect
Investigated abuse and neglect allegations and determined a failure to provide a safe environment for a resident.
Abuse—Failed to provide safe environment
09 Apr 2025Kitchen
09 Apr 2025Kitchen
Investigated deficiencies in meals, sanitation, and administration compliance, with multiple observed kitchen and service concerns including temperature control, cleanliness, and texture diets.
Found deficiencies in meal service and food sanitation, including dirty kitchen surfaces and improper dishwashing. Administration compliance concerns were also identified.
Identified extensive deficiencies across resident rights, service planning, infection control, medication administration, staffing, and safety, indicating lapses in dignity, privacy, and resident safety.
Deficiency—Resident Rights and Protection - General
Deficiency—Acuity Based Staffing Tool - Updates & Staffing Plan
Deficiency—Annual and Biennial Inservice for All Staff
Deficiency—Fire and Life Safety: Safety
Deficiency—General Building Exterior
Deficiency—Doors, Walls, Elevators, Odors
Deficiency—Housekeeping and Laundry
Deficiency—Plumbing Systems
Deficiency—Call Sys, Exit Dr Alarm, Phones, TV, or Cable
Deficiency—Individual Rights Settings: Privacy, Dignity
Deficiency—Individual Door Locks: Key Access
Deficiency—Administration Compliance
Deficiency—Compliance with Rules Health Care
08 Feb 2024Licensure
08 Feb 2024Licensure
Found multiple deficiencies in kitchen sanitation, temperature control, and administration during the initial visit, with follow-up indicating substantial compliance for meals and food sanitation on the second visit.
Investigated a licensure complaint and identified deficiencies related to staffing requirements and the acuity-based staffing tool.
Deficiency—Licensing Complaint Investigation
Deficiency—Staffing Requirements and Training: Staffing
Deficiency—Acuity-Based Staffing Tool
22 Jan 2024Complaint
22 Jan 2024Complaint
Investigated a licensure complaint and found that an acuity-based staffing tool was not fully implemented or updated for two sampled residents.
Deficiency—Licensing Complaint Investigation
Deficiency—Acuity-Based Staffing Tool
04 Dec 2023Abuse: Neglect
04 Dec 2023Abuse: Neglect
Found neglect for failing to assist with eating and drinking and to follow laxative orders, which led to dehydration. A fine was assessed.
Abuse—Failed to assist with eating
21 Jul 2023Inspection
21 Jul 2023Inspection
Found a staffing deficiency due to insufficient awake direct care staff to meet residents' 24-hour needs, with only one caregiver on night shift for those requiring two-person assists.
Licensing—Failed to provide appropriate staffing
14 May 2023Inspection
14 May 2023Inspection
Found a safety violation due to failure to provide a safe environment when a resident at high risk for elopement left the locked memory care area without assistance.
Licensing—Failed to provide safe environment
12 May 2023Inspection
12 May 2023Inspection
Investigated the allegation and found a deficiency in updating the Acuity-Based Staffing Tool to reflect resident needs. Inconsistencies were identified between the resident roster, care plans, posted staffing plan, and the data entered into the ABST.
Licensing—Failed to use an ABST
03 May 2023Licensure
03 May 2023Licensure
Found deficiencies related to kitchen sanitation and administration during the initial review, followed by substantial compliance on a follow-up visit.
Identified neglect of care and abuse due to failure to regularly change incontinence briefs, leaving the resident in urine and feces and causing redness and a sore.
Abuse—Failed to assist with toileting
31 Jan 2023Licensure
31 Jan 2023Licensure
Identified deficiencies in food sanitation and non-food-contact surfaces, including uncovered tray deliveries and worn surfaces, with a follow-up determining substantial compliance with the applicable rules.
Investigated a staffing tool issue and found inconsistencies between the resident roster, care plans, posted staffing plan, and ABST data.
Licensing—Failed to use an ABST
16 Dec 2022Abuse: Neglect
16 Dec 2022Abuse: Neglect
Determined there was a failure to provide a safe environment, which led to a physical altercation and discomfort for a resident. A $250 fine was assessed.
Abuse—Failed to provide safe environment
01 Sept 2022Inspection
01 Sept 2022Inspection
Investigated and found a failure to submit timely weekly reporting of vaccinated individuals, residents, and staff for August 2022.
Licensing—Failed to submit timely or adequate staffing documentation
16 Aug 2022Abuse: Neglect
16 Aug 2022Abuse: Neglect
Investigated found failure to provide a safe environment by not implementing interventions or monitoring according to known behavior, resulting in a physical altercation and undue discomfort to the involved resident.
Abuse—Failed to provide safe environment
14 Jul 2022Abuse: Neglect
14 Jul 2022Abuse: Neglect
Investigated an allegation of abuse and neglect involving medication administration; found the provider failed to provide a safe medication administration system, resulting in harm to a resident, with one staff member held responsible and another not found to have wrongdoing, and a $500 fine assessed.
Abuse—Failed to provide a safe medication administration system
01 Jun 2022Inspection
01 Jun 2022Inspection
Found that the respondent failed to submit timely or adequate staffing documentation and failed to comply with weekly vaccination reporting requirements to the proper authority for 30 days.
Licensing—Failed to submit timely or adequate staffing documentation
03 May 2022Abuse: Neglect
03 May 2022Abuse: Neglect
Determined neglect and abuse due to failing to provide a safe environment, which led to a physical altercation and undue discomfort for a resident.
Abuse—Failed to provide safe environment
07 Feb 2022Inspection
07 Feb 2022Inspection
Investigated the allegation and found a deficiency for failing to provide a safe environment.
Licensing—Failed to provide safe environment
17 Aug 2021Validation
17 Aug 2021Validation
Identified multiple deficiencies across resident care, medications, abuse reporting, sanitation, and safety during the re-licensure process.
Deficiency—Resident Move-In and Eval: Res Evaluation
Deficiency—Service Plan: General
Deficiency—Change of Condition and Monitoring
Deficiency—Systems: Treatment Orders
Deficiency—Systems: Medication Administration
Deficiency—Systems: Psychotropic Medication
Deficiency—Inspections and Investigation: Insp Interval
Deficiency—General Building Exterior
Deficiency—Doors, Walls, Elevators, Odors
Deficiency—Housekeeping and Laundry
Deficiency—Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable
Deficiency—General Comments
Deficiency—Administration Compliance
Deficiency—Staff Training Requirements
Deficiency—Compliance With Rules Health Care
Deficiency—Activities
Deficiency—Secure Outdoor Recreation Area
17 Aug 2021Validation
17 Aug 2021Validation
Found multiple deficiencies in monitoring residents' conditions, following physician orders, handling refusals, laundry disinfection, door alarms, administration compliance, health care services, nutrition and hydration plans, and activities.
Deficiency—Comment
Deficiency—Change of Condition and Monitoring
Deficiency—Systems: Treatment Orders
Deficiency—Systems: Resident Right to Refuse
Deficiency—Housekeeping and Laundry
Deficiency—Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable
Deficiency—Administration Compliance
Deficiency—Compliance With Rules Health Care
Deficiency—Nutrition and Hydration
Deficiency—Activities
09 Apr 2021Abuse: Neglect
09 Apr 2021Abuse: Neglect
Investigated found a safe environment not provided due to wrongful restraint during showering without medical orders, creating risk to a resident.
Abuse—Failed to provide safe environment
23 Mar 2021Inspection
23 Mar 2021Inspection
Investigated allegations of caregiver abuse toward a resident and found a physical abuse incident and a failure to provide a safe environment.
Licensing—Failed to provide safe environment
20 Jul 2020Abuse: Neglect
20 Jul 2020Abuse: Neglect
Found a failure to provide a safe environment, resulting in abuse and neglect; a $188 fine was assessed.
Abuse—Failed to provide safe environment
14 Jul 2020Inspection
14 Jul 2020Inspection
Investigated and found a failure to provide a safe medication administration system and to administer medications, creating risk of harm.
Licensing—Failed to provide a safe medication administration system
29 Apr 2020Abuse: Neglect
29 Apr 2020Abuse: Neglect
Found that the care plan wasn't followed, resulting in multiple falls and an abrasion, constituting neglect and abuse.
Abuse—Failed to follow care plan
22 Apr 2020Abuse: Neglect
22 Apr 2020Abuse: Neglect
Found neglect and abuse for not following the care plan in the common area, causing a resident fall and hospital transport; a $188 fine was assessed.
Abuse—Failed to follow care plan
01 Apr 2020Abuse: Neglect
01 Apr 2020Abuse: Neglect
Found a failure to provide a safe environment that could lead to harm after an unwitnessed altercation. A $188 fine was assessed.
Abuse—Failed to provide safe environment
24 Mar 2020Abuse: Neglect
24 Mar 2020Abuse: Neglect
Investigated a complaint and found a failure to provide a safe environment for a resident. A monetary penalty was assessed.
Abuse—Failed to provide safe environment
23 Mar 2020Abuse: Neglect
23 Mar 2020Abuse: Neglect
Found inadequate care planning for falls risk, with bruising observed on the resident.
Abuse—Failed to properly plan care
25 Feb 2020Abuse: Neglect
25 Feb 2020Abuse: Neglect
Found a failure to provide a safe environment, with multiple bruises observed on a resident over time and no new interventions put in place to reduce bruising.
Abuse—Failed to provide safe environment
23 Feb 2020Abuse: Neglect
23 Feb 2020Abuse: Neglect
Identified neglect due to failure to follow the care plan, resulting in a resident leaving the room unsupervised and sustaining facial injuries.
Abuse—Failed to follow care plan
27 Jan 2020Abuse: Neglect
27 Jan 2020Abuse: Neglect
Identified neglect and abuse for failing to address known fall risks, resulting in a resident's forehead laceration after repeated falls.
Abuse—Failed to properly plan care
22 Jan 2020Abuse: Neglect
22 Jan 2020Abuse: Neglect
Investigated and found neglect and abuse due to failing to plan care for known fall risks, leading to multiple falls and bruising.
Abuse—Failed to properly plan care
22 Jan 2020Abuse: Neglect
22 Jan 2020Abuse: Neglect
Found that falls-risk care was not properly planned, resulting in multiple falls and findings of neglect and abuse.
Abuse—Failed to properly plan care
07 Jan 2020Abuse: Neglect
07 Jan 2020Abuse: Neglect
Investigated a complaint and found a failure to properly plan care to address fall risk, leading to multiple falls and an injury, with a fine assessed.
Abuse—Failed to properly plan care
12 Dec 2019Abuse: Neglect
12 Dec 2019Abuse: Neglect
Found failures to follow residents' care plans that led to an altercation and were abusive and neglectful; a fine was assessed.
Abuse—Failed to follow care plan
02 Oct 2019Abuse: Neglect
02 Oct 2019Abuse: Neglect
Identified neglect and abuse due to failing to implement fall-risk interventions and staff support, resulting in multiple falls.
Abuse—Failed to properly plan care
25 Sept 2019Abuse: Neglect
25 Sept 2019Abuse: Neglect
Investigated a complaint and found failures to implement fall-risk interventions and staff support, resulting in neglect and abuse.
Abuse—Failed to properly plan care
10 Aug 2019Abuse: Verbal/Mental abuse
10 Aug 2019Abuse: Verbal/Mental abuse
Investigated found that a verbal abuse incident occurred and supervision to prevent it was inadequate, resulting in emotional harm to a resident.
Abuse—Failed to protect resident from verbal abuse
12 Jun 2019Abuse: Neglect
12 Jun 2019Abuse: Neglect
Investigated the complaint and found neglect that led to a resident fall and injury. Assessed a $375 fine.
Abuse—Failed to adequately care plan related to falls
03 May 2019Abuse: Neglect
03 May 2019Abuse: Neglect
Investigated the allegation of neglect and found that basic care and services were not provided, resulting in a resident’s ICU admission with a UTI, very low blood pressure, and bruising from a fall.
Abuse—Failed to adequately care plan related to falls
02 May 2019Inspection
02 May 2019Inspection
Investigated an allegation of failing to assist with toileting and identified a deficiency in toileting assistance.
Licensing—Failed to assist with toileting
27 Apr 2019Abuse: Neglect
27 Apr 2019Abuse: Neglect
Investigated and found neglect due to failure to supervise staff, which led to delayed medical care for a resident.
Abuse—Failed to assure timely medical treatment
23 Feb 2019Abuse: Neglect
23 Feb 2019Abuse: Neglect
Concluded neglect resulting in a resident having an infected wound on the leg due to failure to provide basic care.
Abuse—Failed to intervene when resident's condition changed
19 Jan 2019Abuse: Neglect
19 Jan 2019Abuse: Neglect
Found neglect related to falls resulting in an individual in care falling, hitting their head, and sustaining a scratch on the thigh. A $375 fine was assessed.
Abuse—Failed to adequately care plan related to falls
13 Jan 2019Abuse: Neglect
13 Jan 2019Abuse: Neglect
Found neglect resulting in a fall with injury due to lack of supervision and mobility assistance.
Abuse—Failed to provide safe environment
28 Nov 2018Abuse: Neglect
28 Nov 2018Abuse: Neglect
Determined neglect by failing to provide basic care to keep the individual safe from risk of serious harm.
Abuse—Failed to provide safe environment
26 Nov 2018Abuse: Neglect
26 Nov 2018Abuse: Neglect
Found neglect due to failure to administer ordered medication, resulting in physical harm; a fine was assessed.
Abuse—Failed to administer ordered medication
22 Nov 2018Abuse: Neglect
22 Nov 2018Abuse: Neglect
Investigated a neglect allegation and found failure to provide basic care to maintain safety resulting in physical harm.
Abuse—Failed to follow care plan
15 Nov 2018Abuse: Neglect
15 Nov 2018Abuse: Neglect
Found neglect related to falls care; basic care to keep the resident safe was not provided, and a fine was assessed.
Abuse—Failed to adequately care plan related to falls
24 Jun 2018Inspection
24 Jun 2018Inspection
Investigated a failure to report suspected abuse and imposed a $750 fine.
Licensing—Failed to report potential or suspected abuse
24 Jun 2018Abuse: Neglect
24 Jun 2018Abuse: Neglect
Found a neglect violation related to unsafe medication administration and failure to provide basic care, causing four days of unreasonable discomfort; a $500 fine was assessed.
Abuse—Failed to provide a safe medication administration system
06 May 2018Abuse: Neglect
06 May 2018Abuse: Neglect
Found neglect due to failure to follow the care plan, resulting in an unsafe environment and risk of serious harm.
Abuse—Failed to follow care plan
06 May 2018Inspection
06 May 2018Inspection
Found failure to report suspected abuse and assessed a $750 fine.
Licensing—Failed to report potential or suspected abuse
16 Apr 2018Abuse: Neglect
16 Apr 2018Abuse: Neglect
Investigated an allegation of abuse/neglect related to medication security and found a failure to prevent theft or misuse of medication.
Abuse—Failure to provide a system that prevents theft or misuse of medication
13 Apr 2018Inspection
13 Apr 2018Inspection
Found failures to assess and intervene on care needs, resulting in elopement.
Licensing—Failed to properly plan care
21 Mar 2018Abuse: Neglect
21 Mar 2018Abuse: Neglect
Found a failure to provide a safe medication system, resulting in theft of medications. Violations cited.
Abuse—Failure to provide a system that prevents theft or misuse of medication
07 Dec 2017Inspection
07 Dec 2017Inspection
Investigated and found a deficiency in protecting a resident from a noninjury physical assault.
Licensing—Failed to provide safe environment
29 Nov 2017Abuse: Neglect
29 Nov 2017Abuse: Neglect
Found deficiencies for failure to assess and intervene, resulting in a resident fall and hand fracture. A $300 fine was assessed.
Abuse—Failed to properly plan care
28 Nov 2017Abuse: Neglect
28 Nov 2017Abuse: Neglect
Determined that an inadequate medication ordering and administration system led to a resident missing a dose of pain medication and experiencing pain.
Abuse—Failed to provide a safe medication administration system
06 Nov 2017Inspection
06 Nov 2017Inspection
Found nail care was not provided, resulting in a resident's toenail cutting into the resident's toe.
Licensing—Failed to provide service
22 Sept 2017Inspection
22 Sept 2017Inspection
Investigated allegations found that care needs were not assessed or intervened, resulting in a physical altercation between residents.
Licensing—Failed to provide safe environment
15 Jul 2017Inspection
15 Jul 2017Inspection
Investigated the allegation of inadequate care and identified inadequate care.
Licensing—Failed to provide service
10 Jul 2017Inspection
10 Jul 2017Inspection
Investigated the allegation that medication was not administered as ordered and identified a deficiency in carrying out the prescription as prescribed.
Licensing—Failed to administer medication as ordered
09 Jul 2017Inspection
09 Jul 2017Inspection
Concluded that the medication management was unsafe, resulting in residents running out of certain medications.
Licensing—Failed to provide a safe medication administration system
14 Jun 2017Inspection
14 Jun 2017Inspection
Identified an inadequate medication administration system, resulting in a PRN shortage and another resident receiving a different resident's medication as a stopgap.
Licensing—Failed to provide a safe medication administration system
19 May 2017Abuse: Financial abuse
19 May 2017Abuse: Financial abuse
Investigated an allegation of financial abuse and found a failure to prevent theft of jewelry worth $900.
Abuse—Failed to provide safe environment
28 Apr 2017Abuse: Neglect
28 Apr 2017Abuse: Neglect
Investigated a neglect allegation that staff failed to provide a safe medication administration system. Found the medication system deficient, resulting in a resident missing pain doses and experiencing pain.
Abuse—Failed to provide a safe medication administration system
15 Apr 2017Inspection
15 Apr 2017Inspection
Determined that the medication administration system was not adequately maintained, resulting in a resident not receiving medications as ordered for two days.
Licensing—Failed to provide a safe medication administration system
13 Apr 2017Abuse: Neglect
13 Apr 2017Abuse: Neglect
Investigated a complaint and found neglect-related violations. The finding showed failure to assess and intervene, resulting in a resident altercation.
Abuse—Failed to address resident's behavior
22 Mar 2017Abuse: Neglect
22 Mar 2017Abuse: Neglect
Investigated a neglect allegation and found care plan was not followed, causing a resident to fall and suffer an injury. A $400 fine was assessed.
Abuse—Failed to follow care plan
16 Mar 2017Inspection
16 Mar 2017Inspection
Found a deficiency where a resident was not protected from physical attack by another resident.
Licensing—Failed to provide safe environment
16 Mar 2017Abuse: Neglect
16 Mar 2017Abuse: Neglect
Found a failure to provide a safe environment that led to one resident grabbing another.
Abuse—Failed to provide safe environment
09 Mar 2017Inspection
09 Mar 2017Inspection
Found a deficiency in providing a safe environment, which led to a noninjury physical altercation between residents.
Licensing—Failed to provide safe environment
07 Mar 2017Inspection
07 Mar 2017Inspection
Concluded that a failure to provide a safe environment occurred, resulting in a noninjury physical altercation.
Licensing—Failed to provide safe environment
14 Feb 2017Abuse: Neglect
14 Feb 2017Abuse: Neglect
Investigated a neglect allegation related to falls and found failures to assess and intervene, resulting in a resident fall requiring emergency care.
Abuse—Failed to adequately care plan related to falls
11 Feb 2017Abuse: Financial abuse
11 Feb 2017Abuse: Financial abuse
Investigated the allegation of financial exploitation and found a failure to protect a resident from theft resulting in missing property.
Abuse—Failed to protect resident from financial exploitation
09 Feb 2017Abuse: Physical Abuse
09 Feb 2017Abuse: Physical Abuse
Found failure to provide a safe environment, resulting in multiple skin tears and bruising.
Abuse—Failed to provide safe environment
12 Jan 2017Abuse: Neglect
12 Jan 2017Abuse: Neglect
Found that the care plan was not followed, resulting in an injury fall.
Abuse—Failed to follow care plan
09 Jan 2017Inspection
09 Jan 2017Inspection
Found that care plan was not followed, resulting in a resident fall from h/h bed.
Licensing—Failed to follow care plan
03 Jan 2017Abuse: Neglect
03 Jan 2017Abuse: Neglect
Investigated a complaint and found a failure to intervene when the resident's condition changed, leading to hospitalization.
Abuse—Failed to intervene when resident's condition changed
25 Dec 2016Abuse: Financial abuse
25 Dec 2016Abuse: Financial abuse
Found that residents were not protected from theft of cash and personal items.
Abuse—Failed to protect resident from financial exploitation
09 Nov 2016Inspection
09 Nov 2016Inspection
Investigated and found that care providers failed to assess and intervene, causing an exacerbation of a medical condition.
Licensing—Failed to provide service
25 Oct 2016Abuse: Neglect
25 Oct 2016Abuse: Neglect
Investigated a failure to intervene when a resident's condition changed, with civil penalties assessed. Found violations of two rules.
Abuse—Failed to intervene when resident's condition changed
16 Oct 2016Abuse: Financial abuse
16 Oct 2016Abuse: Financial abuse
Found a resident's funds were not protected, resulting in $900 missing from a filing cabinet.
Abuse—Failed to protect resident from financial exploitation
15 Oct 2016Abuse: Neglect
15 Oct 2016Abuse: Neglect
Determined that staff failed to assess and intervene when a resident's condition changed, leading to multiple injury-related falls.
Abuse—Failed to intervene when resident's condition changed
06 Jul 2016Abuse: Financial abuse
06 Jul 2016Abuse: Financial abuse
Investigated a financial exploitation allegation and found a failure to protect a resident from theft.
Abuse—Failed to protect resident from financial exploitation
23 Jun 2016Abuse: Neglect
23 Jun 2016Abuse: Neglect
Investigated and found noncompliance with the care plan.
Abuse—Failed to follow care plan
06 Jun 2016Abuse: Neglect
06 Jun 2016Abuse: Neglect
Found failure to protect narcotic medications from theft; the issue was substantiated and a $400 fine was assessed.
Abuse—Failure to provide a system that prevents theft or misuse of medication
01 Jun 2016Abuse: Neglect
01 Jun 2016Abuse: Neglect
Investigated and found a failure to assess and intervene, resulting in a resident crying out in pain when touched.
Abuse—Failed to provide safe environment
18 Apr 2016Abuse: Financial abuse
18 Apr 2016Abuse: Financial abuse
Investigated the allegation and found that there was a failure to maintain an accurate medication system.
Abuse—Failed to provide a safe medication administration system
09 Apr 2016Abuse: Neglect
09 Apr 2016Abuse: Neglect
Found a deficiency for failing to protect residents' medications from theft.
Abuse—Failure to provide a system that prevents theft or misuse of medication
03 Apr 2016Inspection
03 Apr 2016Inspection
Investigated a licensing violation involving failure to assess and intervene to provide a safe environment. The finding was substantiated.
Licensing—Failed to provide safe environment
01 Sept 2015Inspection
01 Sept 2015Inspection
Found deficiencies in documenting residents' behaviors in care plans and progress notes, and in aligning the service plan with identified needs and preferences.
Licensing—Failed to communicate necessary information
01 Sept 2015Inspection
01 Sept 2015Inspection
Investigated a failure to document resident preference in the care plan for administering medications with applesauce.
Licensing—Failed to properly plan care
08 Dec 2014Abuse: Neglect
08 Dec 2014Abuse: Neglect
Investigated and found a failure to provide a safe environment due to inadequate falls care planning.
Abuse—Failed to adequately care plan related to falls
23 Apr 2014Inspection
23 Apr 2014Inspection
Investigated an allegation and substantiated deficiencies in medication administration and RV medication management.
Licensing—Failed to provide a safe medication administration system
17 Apr 2014Abuse: Neglect
17 Apr 2014Abuse: Neglect
Determined that abuse/neglect occurred and identified deficiencies in administrative oversight tied to tagging noncompliance.
Abuse—Failed to provide safe environment
13 Feb 2014Abuse: Neglect
13 Feb 2014Abuse: Neglect
Investigated an allegation of neglect and determined that timely medical treatment was not provided.
Abuse—Failed to assure timely medical treatment
13 Feb 2014Abuse: Neglect
13 Feb 2014Abuse: Neglect
Investigated the allegation of failing to administer medications as ordered and identified a medication administration violation.
Abuse—Failed to administer medication as ordered
19 Jun 2012Abuse: Neglect
19 Jun 2012Abuse: Neglect
Investigated a failure to provide a safe environment.
Abuse—Failed to provide safe environment
11 May 2011Inspection
11 May 2011Inspection
Investigated and determined that a safe environment was not provided.
Licensing—Failed to provide safe environment
15 Jul 2010Abuse: Neglect
15 Jul 2010Abuse: Neglect
Investigated the allegation and found a failure to provide a safe medication administration system, resulting in an imminent danger order with a license condition.
Abuse—Failed to provide a safe medication administration system
25 Jun 2010Abuse: Neglect
25 Jun 2010Abuse: Neglect
Investigated the complaint and found failures to answer call lights promptly and to prevent a fall, with delays in providing assistance.
Abuse—Failed to answer call light in a timely manner
09 Jun 2010Inspection
09 Jun 2010Inspection
Found failure to maintain an adequate medication system and safe administration practices.
Licensing—Failed to provide a safe medication administration system
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