I'm very pleased with this community - the staff are caring, compassionate, and attentive, and it truly feels like family. The memory-care program is excellent with Montessori-based, engaging activities and outings, the facility is clean and bright, and communication gives me real peace of mind; I highly recommend it.
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
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
Mild cognitive impairment
Specialized memory care programming
Transportation
Community operated transportation
Transportation arrangement
Transportation arrangement (non-medical)
Common areas
Beauty salon
Computer center
Dining room
Fitness room
Gaming room
Garden
Outdoor space
Small library
Wellness center
Community services
Concierge services
Fitness programs
Move-in coordination
Activities
Community-sponsored activities
Planned day trips
Resident-run activities
Scheduled daily activities
Reviews
3.94·(50)
Overall rating
5
4
3
2
1
Care
4.1
Staff
4.2
Meals
3.1
Amenities
4.3
Value
2.8
Pros
Clean, bright, new facility
Well-maintained grounds and landscaping
Compassionate and attentive caregiving staff
Knowledgeable nursing and care coordination
Montessori-based dementia programming
Engaging, varied activities and outings
Small size allowing personalized attention
Secure entry and safety features
Regular housekeeping and laundry services
Prompt maintenance response
Family notifications and some effective communication
Peaceful, family-like atmosphere
Cons
Inconsistent meal quality and limited dietary accommodations
Staffing shortages and high employee turnover
Variable staff experience and training levels
Gaps between assessed/billed care level and delivered services
Inconsistent housekeeping and sanitation practices
Inconsistent family communication and telephone access
Perceived high cost relative to perceived value
Limited visitor parking and site-access constraints
Small resident room sizes
Inconsistent visitor-access monitoring and security procedures
Staff conduct and team-dynamics
Summary of reviews
Windsong at Eola Hills presents as a small, recently opened memory-care community with many attributes families value for dementia care. Multiple accounts describe a bright, clean, well-maintained building and attractive landscaping. The community emphasizes Montessori-based programming for residents with memory impairment; activity offerings are frequently described as varied and engaging, including music, games, outings and field trips, and one-on-one interactions that some families credit with improved appetite or engagement. Many reviewers highlighted a peaceful, family-like atmosphere and cited specific staff members and nurses who provide clear communication and timely updates.
Care quality is a prominent strength in several descriptions: caregiving staff are often characterized as compassionate, attentive and patient, and the nursing team is noted for effective care coordination in some cases. That said, recurring operational concerns temper those endorsements. The most consistent pattern relates to staffing: reviewers describe high turnover, periods of insufficient direct-care coverage, and variable staff experience. These staffing patterns are connected to reports of limited time for individualized care, uneven follow-through on tasks, and intermittent lapses in communication. A subset of comments also raises concerns about staff conduct and team dynamics; families considering placement should inquire about staffing ratios, turnover rates, and training processes.
Dining receives mixed evaluations. Some families praise appetizing, healthy meals and an engaged chef, while others describe inconsistent meal quality, cold service, limited alternatives for special diets (for example, celiac needs), and menu items that were not well accepted by residents. Nutritional and dietary-accommodation processes appear uneven; prospective residents should review sample menus, special-diet procedures, and meal service at different times of day.
The activities program and dementia-specific approach are among the facility's strongest features. Montessori-based activities, enthusiastic activity leadership, and frequent outings were repeatedly noted as contributing to resident engagement and social well-being. The small size of the community supports personalized programming and a high degree of participation for many residents.
Operational and logistical factors are mixed. The facility is new and generally well maintained; weekly housekeeping and laundry are standard. However, some families described variability in housekeeping quality. Practical issues include small resident rooms and limited visitor parking, which can affect daily routines and visits. Security features such as keypad entry are in place, but some accounts point to inconsistent front-door monitoring and visitor-access procedures. Cost is another theme: the community is positioned at a higher price point, and several families expressed concern about the balance between fees and perceived value—particularly where care level expectations or service consistency were questioned.
In summary, Windsong at Eola Hills is likely to appeal to families seeking a small, Montessori-focused memory-care setting with active programming and many staff who are described as caring and responsive. At the same time, the community shows recurring operational weaknesses that prospective residents and families should evaluate before committing: verify current staffing levels and turnover trends, observe meal service and special-diet accommodations, confirm how care levels are assessed and billed, and review access/parking logistics and communication protocols. A thorough in-person visit during different shifts and meal times, along with direct questions about staffing ratios and dietary policies, will help determine whether the facility’s strengths align with a family’s priorities and care needs.
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Location
Windsong at Eola Hills is located at 2030 Wallace Rd NW, Salem, OR, 97304.
About Windsong at Eola Hills
Windsong Memory Care at Eola Hills in Salem, Oregon, gives specialized care for people with Alzheimer's disease and other forms of dementia, and what they've done that's different is they use a Montessori Inspired Lifestyle® approach, and this means staff works to see what each person can still do and tries to give them activities and routines that let them stay engaged with life, so instead of feeling left out, residents get the chance to do things like gardening, crafting, cooking, baking, floral arranging, and telling stories-sometimes music too, and every day is planned with meals, social time, activities, and rest. The community has 64 beds, with rooms that can be private or semi-private, and the building is well-lit with safety call systems throughout, plus there's a state-of-the-art setup that helps make things feel comfortable and home-like. The staff, including trained caregivers and registered nurses, works around the clock and uses regular health checks to make sure each resident gets the right level of care, since care here can be adjusted across five levels depending on how much help a person needs-from daily living help to nurse monitoring, and the care assessment is personalized. Windsong at Eola Hills stands out as the first fully certified Montessori Senior Care Community in the world, and the people working here go through extra training in the Montessori Inspired Lifestyle®, under the guidance of Dr. Cameron Camp, and they try to create a setting that honors dignity, values individuality, and encourages positive social interaction. Meals are served restaurant-style, and they include utilities, activities, weekly housekeeping, laundry, medical and medication help in the room price, which averages about $4,700 a month with both semi-private and 1-bedroom options. The place has clean, well-maintained grounds, raised garden beds, community kitchens, and even a salon, so residents get to enjoy different spaces and activities designed for them. Reviewers have mentioned the positive, warm feeling at Windsong, the friendly staff, and the engaging atmosphere, and the community's memory care program focuses on helping people find meaningful moments every day. Windsong Memory Care at Eola Hills has won the Best of Senior Living 2025 recognition and holds a steady 4.0-star rating from 16 reviews. The facility is close to the local hospital, and with its 56 private apartments, it works hard to provide a calm, secure, and respectful home for people living with memory loss.
People often ask...
Windsong at Eola Hills offers competitive pricing, with rates starting at a cost of $4,995 per month.
Windsong at Eola Hills offers assisted living and memory care.
There are 22 photos of Windsong at Eola Hills on Mirador.
The full address for this community is 2030 Wallace Rd NW, Salem, OR 97304.
No, Windsong at Eola Hills 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 the allegation that records were not accessible; found a violation for failing to provide records.
Licensing—Failed to make facility or resident records accessible
06 Apr 2026Inspection
06 Apr 2026Inspection
Investigated a records-access allegation and found that records were not provided upon request, violating Oregon Administrative Rules.
Licensing—Failed to make facility or resident records accessible
06 Apr 2026Inspection
06 Apr 2026Inspection
Investigated an allegation that records were not accessible and found records were not provided to the Department upon request.
Licensing—Failed to make facility or resident records accessible
19 Feb 2026Change of Owner
19 Feb 2026Change of Owner
Identified multiple deficiencies related to fire drills, resident training, and exterior area management, including incomplete drill records and missing resident instruction.
Deficiency—Fire and Life Safety: Safety
Deficiency—Fire and Life Safety: Training for Residents
Deficiency—General Building Exterior
Deficiency—Administration Compliance
Deficiency—Staff Training Requirements
Deficiency—Outside Area
02 Dec 2025Inspection
02 Dec 2025Inspection
Determined that a medication administration violation occurred as alleged. The allegation involved failing to administer medication as ordered.
Licensing—Failed to administer medication as ordered
11 Nov 2025Inspection
11 Nov 2025Inspection
Investigated and found a failure to provide a safe medication administration system. Medications were not administered as ordered and were left unsecured, placing a resident at risk of harm.
Licensing—Failed to provide a safe medication administration system
08 Nov 2025Inspection
08 Nov 2025Inspection
Found that the Acuity-Based Staffing Tool was not updated to reflect residents' care needs, with inconsistencies among the roster, care plans, and ABST data.
Licensing—Failed to use an ABST
31 Oct 2025Abuse: Neglect
31 Oct 2025Abuse: Neglect
Identified inadequate supervision and an unsafe environment that amounted to abuse by neglect. A $375 fine was assessed.
Abuse—Failed to provide safe environment
31 Oct 2025Inspection
31 Oct 2025Inspection
Investigated and found that the Acuity-Based Staffing Tool was not updated to reflect resident population and care needs, with inconsistencies between the resident roster, care plans, and ABST data, violating Oregon Administrative Rules.
Licensing—Failed to use an ABST
24 Oct 2025Inspection
24 Oct 2025Inspection
Found that an Acuity-Based Staffing Tool did not accurately reflect resident needs and daily living requirements, and staffing did not meet the needs indicated by the tool.
Licensing—Failed to use an ABST
22 Oct 2025Inspection
22 Oct 2025Inspection
Investigated the allegation of failing to cooperate with an investigation and found noncompliance due to not providing requested documentation.
Licensing—Failed to cooperate with an investigation
20 Oct 2025Inspection
20 Oct 2025Inspection
Investigated and identified a documentation deficiency related to records requests. Found a violation of Oregon Administrative Rules.
Licensing—Failed to cooperate with an investigation
19 Oct 2025Inspection
19 Oct 2025Inspection
Investigated found deficiencies due to not using an ABST accurately, causing inconsistencies among the resident roster, care plans, and ABST data, and staffing not aligned with needs.
Licensing—Failed to use an ABST
17 Oct 2025Inspection
17 Oct 2025Inspection
Investigated deficiencies in ABST use and staffing levels not aligned with resident needs.
Licensing—Failed to use an ABST
13 Oct 2025Abuse: Neglect
13 Oct 2025Abuse: Neglect
Investigated a report of abuse and found failures to follow care plan interventions, contributing to a resident-to-resident altercation and harm.
Abuse—Failed to follow care plan
11 Oct 2025Abuse: Neglect
11 Oct 2025Abuse: Neglect
Found abuse by neglect due to failure to implement interventions for a known fall risk, resulting in a fall and injuries requiring hospitalization. The resident was hospitalized from October 11 to 13, 2025.
Abuse—Failed to properly plan care
11 Oct 2025Abuse: Neglect
11 Oct 2025Abuse: Neglect
Investigated and found failure to follow the resident's care plan to prevent falls, resulting in a fall and hospitalization; a $1500 fine was assessed.
Abuse—Failed to follow care plan
26 Sept 2025Inspection
26 Sept 2025Inspection
Investigated the allegation of non-cooperation and found that documentation was not provided when requested.
Licensing—Failed to cooperate with an investigation
17 Sept 2025Abuse: Neglect
17 Sept 2025Abuse: Neglect
Investigated an allegation of neglect and found failures to provide a safe environment and to follow the service plan.
Abuse—Failed to provide safe environment
09 Sept 2025Abuse: Neglect
09 Sept 2025Abuse: Neglect
Investigated a safety concern and found a deficiency in ensuring a safe environment due to inadequate elopement training, and a $188 fine was assessed.
Abuse—Failed to provide safe environment
08 Sept 2025Inspection
08 Sept 2025Inspection
Investigated the allegation and found a violation for failing to provide documentation upon request.
Licensing—Failed to cooperate with an investigation
21 Aug 2025Inspection
21 Aug 2025Inspection
Investigated and found that documentation was not provided upon request.
Licensing—Failed to cooperate with an investigation
20 Aug 2025Kitchen
20 Aug 2025Kitchen
Identified sanitation, food handling, and texture-modification deficiencies in the kitchen and dining operations, along with gaps in menu communication and administration compliance.
Deficiency—Inspections and Investigation: Insp Interval
Deficiency—Administration Compliance
30 Jul 2025Inspection
30 Jul 2025Inspection
Found failure to provide documentation upon request.
Licensing—Failed to cooperate with an investigation
12 Jun 2025Abuse: Neglect
12 Jun 2025Abuse: Neglect
Investigated found failure to answer call lights in a timely manner, indicating neglect and abuse, with a fine assessed.
Abuse—Failed to answer call light in a timely manner
10 Jun 2025Abuse: Neglect
10 Jun 2025Abuse: Neglect
Identified violations of safety and resident rights due to neglect and abuse; a $375 fine was assessed.
Abuse—Failed to provide safe environment
04 Jun 2025Abuse: Neglect
04 Jun 2025Abuse: Neglect
Found that staff did not reorder anxiety medication per policy, resulting in a missed dose and increased distress.
Abuse—Failed to follow care plan
30 May 2025Inspection
30 May 2025Inspection
Investigated an allegation of non-cooperation and determined a violation for failing to provide documentation upon request.
Licensing—Failed to cooperate with an investigation
24 May 2025Abuse: Neglect
24 May 2025Abuse: Neglect
Found inadequate supervision and failure to follow the ISP, resulting in a resident’s fall and hip fracture.
Abuse—Failed to provide safe environment
23 May 2025Abuse: Neglect
23 May 2025Abuse: Neglect
Determined a safe medication administration system was not provided, constituting abuse and neglect; a $375 fine was assessed.
Abuse—Failed to administer medication as ordered
21 Apr 2025Abuse: Neglect
21 Apr 2025Abuse: Neglect
Investigated a narcotics management issue and found an unsafe medication administration system that allowed narcotics to be unaccounted for and potentially diverted.
Abuse—Failed to provide a safe medication administration system
18 Apr 2025Abuse: Neglect
18 Apr 2025Abuse: Neglect
Found that care planning and safety measures were not followed, leading to an incident where a resident was slapped by another resident and experienced discomfort.
Abuse—Failed to provide safe environment
07 Mar 2025Abuse: Neglect
07 Mar 2025Abuse: Neglect
Investigated and found violations for neglect and abuse related to not following a care plan and serving mushrooms despite dietary restrictions.
Abuse—Failed to provide proper food/nutrition
03 Mar 2025Inspection
03 Mar 2025Inspection
Investigated the allegation of unsafe dietary practices and neglect; found failures to provide correct texture diets and to follow the care plan, risking choking.
Licensing—Failed to provide safe environment
03 Mar 2025Abuse: Neglect
03 Mar 2025Abuse: Neglect
Found neglect related to dietary mismanagement, including failure to follow care plans and provide prescribed textures and thickened liquids.
Abuse—Failed to follow care plan
07 Feb 2025Inspection
07 Feb 2025Inspection
Found a violation for failing to protect a resident from verbal/emotional abuse. The incident involved a staff member yelling and cursing during a transfer, causing distress.
Licensing—Failed to protect resident from verbal abuse
05 Jan 2025Abuse: Neglect
05 Jan 2025Abuse: Neglect
Investigated and found a failure to provide a safe environment, constituting neglect and abuse. The incident involved a shove that caused a skin tear.
Abuse—Failed to provide safe environment
04 Jan 2025Abuse: Neglect
04 Jan 2025Abuse: Neglect
Investigated a safety incident and concluded that the care plan wasn't followed and a resident wasn't kept safe, constituting abuse and neglect.
Abuse—Failed to provide safe environment
21 Dec 2024Abuse: Neglect
21 Dec 2024Abuse: Neglect
Investigated and found a failure to provide a safe environment, constituting neglect and abuse.
Abuse—Failed to provide safe environment
11 Dec 2024Abuse: Neglect
11 Dec 2024Abuse: Neglect
Investigated a complaint and found a failure to provide a safe environment, resulting in neglect and abuse.
Abuse—Failed to provide safe environment
14 Nov 2024Abuse: Neglect
14 Nov 2024Abuse: Neglect
Investigated found that a staff member grabbed the resident's head and pulled them backward during dinner, placing the resident at risk, and care to keep the resident safe was not provided.
Abuse—Failed to provide safe environment
19 Oct 2024Inspection
19 Oct 2024Inspection
Found a violation where a staff member pinched a resident during care, causing pain, and failed to keep the resident safe from physical abuse.
Licensing—Failed to protect resident from physical abuse
10 Oct 2024Inspection
10 Oct 2024Inspection
Found that a staff member did not follow the fall-prevention care plan for a resident, resulting in a fall with head and other injuries.
Licensing—Failed to follow care plan
09 Sept 2024Inspection
09 Sept 2024Inspection
Found violations involving verbal abuse of a resident and failure to protect the resident from verbal/emotional abuse. The actions also amounted to neglect of care.
Licensing—Failed to protect resident from verbal abuse
01 Sept 2024Abuse: Neglect
01 Sept 2024Abuse: Neglect
Found that a safe environment was not provided for a resident, resulting in distress and fear after an altercation with another resident.
Abuse—Failed to provide safe environment
18 Aug 2024Inspection
18 Aug 2024Inspection
Investigated an allegation of unsafe medication administration and found that a prescribed dose was not delivered as ordered, leading to a missed dose and subsequent restlessness and drowsiness for a resident.
Licensing—Failed to provide a safe medication administration system
17 Aug 2024Inspection
17 Aug 2024Inspection
Investigated and found that a safe medication administration system was not provided, resulting in incorrect doses and increased anxiety.
Licensing—Failed to provide a safe medication administration system
13 Aug 2024Abuse: Neglect
13 Aug 2024Abuse: Neglect
Investigated a complaint about safety and care; found that a resident was slapped by another resident and that interventions and care planning to address behavior were not adequately implemented.
Abuse—Failed to provide safe environment
12 Aug 2024Abuse: Neglect
12 Aug 2024Abuse: Neglect
Investigated and found a failure to provide a safe medication administration system, resulting in a double-dose administration and a hospital visit; a fine was assessed.
Abuse—Failed to provide a safe medication administration system
07 Aug 2024Abuse: Neglect
07 Aug 2024Abuse: Neglect
Investigated the allegation of neglect and abuse related to failing to provide a safe environment and found that interventions for a resident's behavior were not implemented, resulting in injuries.
Abuse—Failed to provide safe environment
18 Jul 2024Licensure
18 Jul 2024Licensure
Identified sanitation and administration deficiencies in the kitchen and related operations, with subsequent visits addressing multiple items and ultimately reaching substantial compliance.
Deficiency—Inspections and Investigation: Insp Interval
Deficiency—Administration Compliance
17 Jul 2024Abuse: Neglect
17 Jul 2024Abuse: Neglect
Identified neglect and abuse due to failure to implement interventions for a resident's known aggressive behavior, leading to multiple resident-to-resident altercations.
Abuse—Failed to properly plan care
12 Jul 2024Abuse: Neglect
12 Jul 2024Abuse: Neglect
Found violations for failing to intervene after a resident with a history of conflicts, leading to two altercations including an assault. A $375 fine was assessed.
Abuse—Failed to provide safe environment
30 Jun 2024Abuse: Neglect
30 Jun 2024Abuse: Neglect
Investigated fall-history care and found inadequate planning. The resident fell outside another resident’s room without a mobility device, resulting in injury.
Abuse—Failed to properly plan care
20 Jun 2024Abuse: Neglect
20 Jun 2024Abuse: Neglect
Identified a failure to provide a safe environment that allowed an elopement from a secured area without staff awareness; a fine was assessed.
Abuse—Failed to provide safe environment
29 Mar 2024Abuse: Neglect
29 Mar 2024Abuse: Neglect
Investigated a known fall-risk resident and found the care plan was not followed, leaving the resident in a wheelchair overnight and causing a fractured hip requiring surgery. A $2,500 fine was assessed.
Abuse—Failed to follow care plan
12 Mar 2024Abuse: Neglect
12 Mar 2024Abuse: Neglect
Determined that a safe medication administration system was not provided, resulting in the wrong dose of behavioral medication and increased risk.
Abuse—Failed to provide a safe medication administration system
29 Feb 2024Abuse: Neglect
29 Feb 2024Abuse: Neglect
Investigated and found violations for failure to plan appropriate care, leading to a resident fall and injury; a fine was assessed.
Abuse—Failed to properly plan care
28 Jan 2024Abuse: Neglect
28 Jan 2024Abuse: Neglect
Investigated and found a failure in the safe medication administration system that led to a wrong dose of behavioral medication and potential harm.
Abuse—Failed to provide a safe medication administration system
28 Jan 2024Abuse: Neglect
28 Jan 2024Abuse: Neglect
Identified a deficiency in providing medications, resulting in neglect and abuse; assessed a $338 fine.
Abuse—Failed to have medication available
28 Jan 2024Abuse: Neglect
28 Jan 2024Abuse: Neglect
Found neglect for failing to provide medical treatment as ordered; a $1,125 fine was assessed.
Abuse—Failed to provide medical treatment as ordered
08 Jan 2024Abuse: Neglect
08 Jan 2024Abuse: Neglect
Found neglect and abuse due to failure to properly plan fall interventions, which led to repeated falls and pain; a fine was assessed.
Abuse—Failed to properly plan care
08 Nov 2023Abuse: Neglect
08 Nov 2023Abuse: Neglect
Found failure to properly plan care, resulting in multiple skin injuries to a resident. A $188 fine was assessed.
Abuse—Failed to properly plan care
05 Nov 2023Abuse: Neglect
05 Nov 2023Abuse: Neglect
Investigated and found that failure to follow the care plan led to a resident pinching another resident, causing pain.
Abuse—Failed to follow care plan
30 Oct 2023Validation
30 Oct 2023Validation
Identified multiple deficiencies in abuse reporting, move-in evaluations, service plans, acuity-based staffing, exit alarms, and staff training. Overall, substantial compliance was determined.
Deficiency—Resident Move-In and Eval: Res Evaluation
Deficiency—Service Plan: General
Deficiency—Acuity-Based Staffing Tool
Deficiency—Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable
Deficiency—Administration Compliance
Deficiency—Staff Training Requirements
Deficiency—Compliance With Rules Health Care
12 Apr 2023Inspection
12 Apr 2023Inspection
Found that a staff member failed to follow the resident's service plan during signs of agitation, resulting in a physical altercation and unsafe conditions.
Licensing—Failed to protect resident from physical abuse
04 Jan 2023Licensure
04 Jan 2023Licensure
Found repeated deficiencies in kitchen cleanliness and dishwashing temperatures across multiple visits.
Deficiency—Inspections and Investigation: Insp Interval
Deficiency—Administration Compliance
18 Sept 2022Abuse: Neglect
18 Sept 2022Abuse: Neglect
Found violations of resident rights constituting neglect and abuse after a resident suffered a broken ankle due to failure to implement interventions following a fall.
Abuse—Failed to properly plan care
11 Sept 2022Inspection
11 Sept 2022Inspection
Investigated a hypoglycemia-related medication safety incident and found that a staff member administered diabetic medication contrary to protocol, risking serious harm to a resident.
Licensing—Failed to provide a safe medication administration system
22 Aug 2022Abuse: Neglect
22 Aug 2022Abuse: Neglect
Found that a resident ran out of inhaler medication for three doses, risking harm because protocol to prevent running out was not followed.
Abuse—Failed to administer medication as ordered
18 Aug 2022Inspection
18 Aug 2022Inspection
Found a violation for failing to administer prescribed medication.
Licensing—Failed to administer ordered medication
18 Jul 2022Abuse: Neglect
18 Jul 2022Abuse: Neglect
Found violations of resident rights due to failure to follow the care plan, resulting in neglect and abuse; assessed a $500 fine.
Abuse—Failed to follow care plan
03 Jul 2022Abuse: Neglect
03 Jul 2022Abuse: Neglect
Concluded there was a failure to provide a safe environment, constituting abuse and neglect. A $375 fine was assessed.
Abuse—Failed to provide safe environment
02 Jul 2022Abuse: Neglect
02 Jul 2022Abuse: Neglect
Found a failure to provide a safe environment that led to about 14 falls and related pain. The findings indicate neglect of care and abuse of resident rights.
Abuse—Failed to provide safe environment
06 Apr 2022Inspection
06 Apr 2022Inspection
Investigated a complaint about a known fall risk resident. Found that staff failed to follow the care plan, resulting in a fall and injury and violations of resident rights.
Licensing—Failed to follow care plan
06 Mar 2022Abuse: Neglect
06 Mar 2022Abuse: Neglect
Investigated neglect allegations found that staff failed to follow the care plan, causing skin sores and undue pain.
Abuse—Failed to follow care plan
24 Feb 2022Abuse: Neglect
24 Feb 2022Abuse: Neglect
Found a violation of the care plan and neglect after staff failed to transport a resident in a wheelchair, resulting in a fall and injury; a $1,500 fine was assessed.
Abuse—Failed to follow care plan
11 Feb 2022Abuse: Neglect
11 Feb 2022Abuse: Neglect
Investigated and found that staff did not follow a resident's care plan, placing a resident at risk and constituting abuse and neglect. A $500 fine was assessed.
Abuse—Failed to follow care plan
18 Jan 2022Abuse: Neglect
18 Jan 2022Abuse: Neglect
Determined that the resident's fall history was not properly addressed in care planning, resulting in neglect and abuse. A $500 fine was assessed.
Abuse—Failed to properly plan care
05 Jan 2022Abuse: Neglect
05 Jan 2022Abuse: Neglect
Identified deficiencies in training and a safe medication administration system that left PM doses unadministered, creating risk. A $188 fine was assessed.
Abuse—Failed to provide a safe medication administration system
28 Dec 2021Abuse: Neglect
28 Dec 2021Abuse: Neglect
Found neglect due to inadequate care planning and failure to implement fall interventions after multiple falls, leading to ongoing risk and injury.
Abuse—Failed to properly plan care
28 Dec 2021License Condition
28 Dec 2021License Condition
Found a failure to provide a safe environment.
Regulatory Action—Failed to provide safe environment
13 Dec 2021Validation
13 Dec 2021Validation
Found multiple deficiencies across abuse reporting, move-in evaluations, service planning, change of condition monitoring, health services, staff training, fire safety, resident rights, activities, behavior, and room identification.
Deficiency—Resident Move-In and Eval: Res Evaluation
Deficiency—Service Plan: General
Deficiency—Change of Condition and Monitoring
Deficiency—Resident Health Services
Deficiency—Systems: Resident Right to Refuse
Deficiency—Training Within 30 Days: Direct Care Staff
Deficiency—Fire and Life Safety: Safety
Deficiency—Fire and Life Safety: Training For Residents
Deficiency—Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable
Deficiency—Administration Compliance
Deficiency—Staff Training Requirements
Deficiency—Compliance With Rules Health Care
Deficiency—Activities
Deficiency—Behavior
Deficiency—Resident Rooms
13 Dec 2021Abuse: Neglect
13 Dec 2021Abuse: Neglect
Investigated and found that staff failed to follow the care plan for a resident at risk of falling, resulting in injuries; a fine was assessed.
Abuse—Failed to follow care plan
10 Dec 2021Inspection
10 Dec 2021Inspection
Found a violation for failing to administer medication as ordered.
Licensing—Failed to administer medication as ordered
02 Dec 2021Abuse: Neglect
02 Dec 2021Abuse: Neglect
Found that inadequate care planning for residents with known aggressive behaviors led to multiple resident-to-resident altercations and inappropriate touching, indicating neglect and abuse.
Abuse—Failed to properly plan care
18 Nov 2021Abuse: Neglect
18 Nov 2021Abuse: Neglect
Found neglect and abuse due to failure to supervise known aggressive behaviors, resulting in injuries; a $500 fine was assessed.
Abuse—Failed to provide safe environment
26 Oct 2021Abuse: Neglect
26 Oct 2021Abuse: Neglect
Investigated a complaint and found inadequate care planning for a resident's known aggressive behaviors, which led to a physical altercation and harm; a fine was assessed.
Abuse—Failed to properly plan care
20 Oct 2021Abuse: Neglect
20 Oct 2021Abuse: Neglect
Investigated a dining-room fall and found neglect for failing to follow the care plan, resulting in the resident being unsupervised and injured.
Abuse—Failed to follow care plan
27 Sept 2021Abuse: Neglect
27 Sept 2021Abuse: Neglect
Found abuse and neglect due to a staff member touching a resident's private parts and inadequate safety planning.
Abuse—Failed to properly plan care
19 Aug 2021Abuse: Neglect
19 Aug 2021Abuse: Neglect
Investigated and found that a safe environment was not provided, resulting in minor harm to a resident during an altercation; a $250 fine was assessed.
Abuse—Failed to provide safe environment
14 Aug 2021Abuse: Neglect
14 Aug 2021Abuse: Neglect
Investigated and found that the care plan was not followed, resulting in a fall and injury; a $500 fine was assessed.
Abuse—Failed to follow care plan
27 Jul 2021Abuse: Neglect
27 Jul 2021Abuse: Neglect
Investigated and found that the care plan to keep residents separated was not followed, leaving two residents alone and resulting in abuse/neglect.
Abuse—Failed to follow care plan
29 May 2021Abuse: Neglect
29 May 2021Abuse: Neglect
Found inadequate care planning for falls risk, resulting in a fall and hip fracture; a fine was assessed.
Abuse—Failed to properly plan care
16 Apr 2021Inspection
16 Apr 2021Inspection
Investigated the allegation of failing to provide infection control and verified failure to exercise reasonable precautions against conditions that may threaten residents' health and safety.
Licensing—Failed to provide infection control
12 Apr 2021Inspection
12 Apr 2021Inspection
Found insufficient qualified awake direct care staff to meet 24-hour needs of residents.
Licensing—Failed to provide appropriate staffing
05 Sept 2020Abuse: Neglect
05 Sept 2020Abuse: Neglect
Identified hygiene and oral care violations that constituted neglect and abuse; a $500 fine was assessed.
Abuse—Failed to provide or assist with hygiene
12 Aug 2020Abuse: Neglect
12 Aug 2020Abuse: Neglect
Found neglect and abuse due to insufficient supervision and staff support. A $338 fine was assessed.
Abuse—Failed to provide safe environment
02 May 2020Abuse: Neglect
02 May 2020Abuse: Neglect
Identified a failure to properly plan care for a resident's fall risk, leading to multiple unmitigated falls and severe injuries culminating in death.
Abuse—Failed to properly plan care
27 Apr 2020Abuse: Neglect
27 Apr 2020Abuse: Neglect
Investigated a complaint and found neglect and abuse for not following a resident's care plan during safety checks, resulting in a fall and head injury.
Abuse—Failed to follow care plan
26 Mar 2020Abuse: Neglect
26 Mar 2020Abuse: Neglect
Identified supervision failures that allowed an altercation causing injury; a violation of resident rights and neglect/abuse occurred, with a $375 fine assessed.
Abuse—Failed to provide safe environment
25 Mar 2020Abuse: Neglect
25 Mar 2020Abuse: Neglect
Found that the care plan requiring non-slip footwear was not followed, resulting in a fall with injuries.
Abuse—Failed to follow care plan
02 Mar 2020Inspection
02 Mar 2020Inspection
Found that a staff member spoke inappropriately to a resident on multiple occasions and the provider failed to protect the resident from verbal and emotional abuse.
Licensing—Failed to protect resident from verbal abuse
06 Dec 2019Inspection
06 Dec 2019Inspection
Found that the door alarm or call system was not kept in good repair.
Licensing—Failed to maintain functional door alarm or call system
11 Sept 2019Abuse: Neglect
11 Sept 2019Abuse: Neglect
Found neglect for failing to provide a safe environment, resulting in a resident being injured when another person punched them.
Abuse—Failed to provide safe environment
06 Jul 2019Abuse: Neglect
06 Jul 2019Abuse: Neglect
Identified neglect that left a resident unsafe, resulting in a fall and hip fracture.
Abuse—Failed to adequately care plan related to falls
01 Jul 2019Inspection
01 Jul 2019Inspection
Determined that there was a failure to report suspected abuse.
Licensing—Failed to report potential or suspected abuse
23 May 2019Abuse: Neglect
23 May 2019Abuse: Neglect
Found substantiated neglect for failing to provide basic hygiene care, resulting in a resident with dried feces in the peri area and a significant rash.
Abuse—Failed to provide or assist with hygiene
05 Apr 2019Abuse: Neglect
05 Apr 2019Abuse: Neglect
Found neglect that resulted in infected decubitus ulcers and hospitalization; assessed a $500 fine.
Abuse—Failed to provide appropriate skin care
05 Apr 2019Inspection
05 Apr 2019Inspection
Determined that reporting requirements were not met for suspected abuse. A $1,000 fine was assessed.
Licensing—Failed to report potential or suspected abuse
31 Mar 2019Abuse: Neglect
31 Mar 2019Abuse: Neglect
Determined that neglect occurred, resulting in harm, and a fine was assessed.
Abuse—Failed to provide safe environment
08 Mar 2019Abuse: Neglect
08 Mar 2019Abuse: Neglect
Found neglect that left a resident without basic care and supervision, resulting in an injury. A $188 fine was assessed.
Abuse—Failed to provide safe environment
04 Mar 2019Abuse: Neglect
04 Mar 2019Abuse: Neglect
Found that basic care was not provided, resulting in a resident falling and experiencing pain. A fine was assessed.
Abuse—Failed to care plan in accordance with assessment
13 Feb 2019Inspection
13 Feb 2019Inspection
Investigated a hygiene complaint and found failure to provide or assist with hygiene.
Licensing—Failed to provide or assist with hygiene
11 Feb 2019Abuse: Neglect
11 Feb 2019Abuse: Neglect
Found neglect by failing to maintain safety, resulting in a resident being pushed to the floor.
Abuse—Failed to care plan in accordance with assessment
02 Feb 2019Abuse: Neglect
02 Feb 2019Abuse: Neglect
Investigated a neglect allegation and found safety failures that led to a person being pushed to the floor; a fine was assessed.
Abuse—Failed to care plan in accordance with assessment
29 Dec 2018Abuse: Neglect
29 Dec 2018Abuse: Neglect
Identified neglect of a resident resulting in physical harm; a fine was assessed.
Abuse—Failed to adequately care plan related to falls
18 Sept 2018Abuse: Neglect
18 Sept 2018Abuse: Neglect
Found neglect of basic care that could harm a resident and assessed a fine.
Abuse—Failed to protect resident from rough treatment
28 Aug 2018Inspection
28 Aug 2018Inspection
Investigated an allegation of failing to report suspected abuse; assessed a $750 fine.
Licensing—Failed to report potential or suspected abuse
28 Aug 2018Abuse: Neglect
28 Aug 2018Abuse: Neglect
Identified neglect for failing to provide basic care and appropriate medical treatment when a resident's condition changed, resulting in harm; a $250 fine was assessed.
Abuse—Failed to intervene when resident's condition changed
27 Jul 2018Abuse: Neglect
27 Jul 2018Abuse: Neglect
Found neglect due to failing to provide basic care to maintain health and safety, resulting in physical harm.
Abuse—Failed to provide safe environment
12 Jul 2018Abuse: Neglect
12 Jul 2018Abuse: Neglect
Identified neglect of a resident's basic care and safety by failing to provide essential care and protecting the person from harm.
Abuse—Failed to provide safe environment
10 Jun 2018Inspection
10 Jun 2018Inspection
Found that a safe environment was not maintained, resulting in a physical altercation between residents.
Licensing—Failed to provide safe environment
29 Mar 2018Abuse: Neglect
29 Mar 2018Abuse: Neglect
Investigated and found the neglect allegation supported, noting failure to assess and intervene when one resident grabbed another resident's walker and struck them in the head.
Abuse—Failed to properly plan care
28 Feb 2018Abuse: Neglect
28 Feb 2018Abuse: Neglect
Investigated a neglect allegation and found violations of the care plan that led to a resident fall; a $375 fine was assessed.
Abuse—Failed to follow care plan
04 Feb 2018Inspection
04 Feb 2018Inspection
Found a licensing violation for failing to provide a safe environment, resulting in a resident-to-resident altercation.
Licensing—Failed to provide safe environment
24 Dec 2017Abuse: Neglect
24 Dec 2017Abuse: Neglect
Determined that neglect occurred, resulting in a fall that caused a broken left clavicle.
Abuse—Failed to follow care plan
11 Dec 2017Inspection
11 Dec 2017Inspection
Found failure to follow the care plan that led to a resident to resident altercation; a $300 fine was assessed.
Licensing—Failed to follow care plan
24 Nov 2017Abuse: Neglect
24 Nov 2017Abuse: Neglect
Investigated an allegation of neglect; found an unsafe environment that led to a resident injury. A fine was assessed.
Abuse—Failed to follow care plan
24 Oct 2017Inspection
24 Oct 2017Inspection
Investigated a complaint and found a failure to provide a safe environment, which resulted in a resident-to-resident altercation.
Licensing—Failed to provide safe environment
29 Sept 2017Abuse: Neglect
29 Sept 2017Abuse: Neglect
Investigated a records-related complaint and found a failure to provide basic safety, which led to a large bruise on a resident after a fall.
Abuse—Failed to follow care plan
24 Sept 2017Inspection
24 Sept 2017Inspection
Investigated and found a failure to protect residents from a resident-to-resident physical altercation.
Licensing—Failed to provide safe environment
18 Sept 2017Inspection
18 Sept 2017Inspection
Investigated a complaint and found a failure to protect residents from a physical altercation.
Licensing—Failed to provide safe environment
14 Sept 2017Inspection
14 Sept 2017Inspection
Investigated a safety allegation and found residents were not kept safe from a physical altercation.
Licensing—Failed to provide safe environment
17 Jul 2017Inspection
17 Jul 2017Inspection
Investigated and found a failure to assess and intervene that allowed one resident to strike another in the face.
Licensing—Failed to provide safe environment
25 Apr 2017Abuse: Neglect
25 Apr 2017Abuse: Neglect
Investigated and found the care plan was not followed, resulting in a fall with a laceration that required staples.
Abuse—Failed to follow care plan
25 Feb 2017Inspection
25 Feb 2017Inspection
Determined that AVs were not protected from resident-to-resident altercations. A safety deficiency was identified.
Licensing—Failed to provide safe environment
12 Oct 2016Abuse: Neglect
12 Oct 2016Abuse: Neglect
Investigated the allegation and found a deficiency where a resident was not protected from a physical altercation, resulting in bruising and a skin tear to the arm.
Abuse—Failed to address resident's behavior
30 Aug 2016Inspection
30 Aug 2016Inspection
Found that a secure environment was not provided, creating potential for harm.
Licensing—Failed to provide safe environment
13 Aug 2016Inspection
13 Aug 2016Inspection
Investigated and found that medications were not administered as ordered.
Licensing—Failed to administer medication as ordered
13 Aug 2016Abuse: Financial abuse
13 Aug 2016Abuse: Financial abuse
Investigated an allegation of financial abuse and failure to provide a safe environment; findings showed a resident was not protected from theft of medications.
Abuse—Failed to provide safe environment
03 Dec 2015Inspection
03 Dec 2015Inspection
Concluded that there was a failure to administer medication as ordered due to an inadequate medication system.
Licensing—Failed to administer medication as ordered
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