South Beach Manor Memory Care

    411 SE 35th St, South Beach, OR 97366
    • Assisted Living
    • Memory Care

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    Date of Tour
    Time Window
    Tour Type

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    Amenities

    Healthcare services

    • Activities of daily living assistance
    • Assistance with bathing
    • Assistance with dressing
    • Assistance with transfers
    • Coordination with health care providers
    • Medication management
    • Mental wellness program
    • Respite program

    Healthcare staffing

    • 24-hour call system
    • 24-hour supervision

    Meals and dining

    • Diabetes diet
    • Meal preparation and service
    • Special dietary restrictions

    Room

    • Cable
    • Fully furnished
    • Housekeeping and linen services
    • Kitchenettes
    • Private bathrooms
    • Telephone
    • Wifi

    Memory care community services

    • Dementia waiver
    • Mild cognitive impairment
    • Specialized memory care programming

    Transportation

    • Community operated transportation
    • Transportation arrangement (medical)
    • Transportation to doctors appointments

    Common areas

    • Beauty salon
    • Dining room
    • Garden
    • Outdoor patio
    • Outdoor space

    Community services

    • Move-in coordination

    Activities

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

    Reviews

    4.93·(30)

    Overall rating

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

      5.0
    • Staff

      4.9
    • Meals

      4.9
    • Amenities

      5.0
    • Value

      4.9

    Pros

    • Compassionate, attentive staff
    • Personalized staff–resident relationships
    • Clean, well-maintained facility
    • Active, varied activity program
    • Frequent music and live entertainment
    • Regular group exercise and engagement routines
    • Responsive management and timely maintenance
    • Strong family communication and condition updates
    • Hospice and end-of-life support available
    • Small, home-like environment

    Cons

    • Visitor-access procedures that require staff assistance
    • Occasional mismatch between tour impressions and day-to-day conditions
    • Smaller facility scale that may limit amenities compared with larger communities

    Summary of reviews

    Across the summaries, families and guests consistently emphasize high-quality, person-centered care. Care is described as compassionate and attentive, with staff taking time to know residents by name and provide assistance with personal needs. Reviewers highlight strong clinical attentiveness — including updates on changes in condition and coordinated hospice support when needed — which contributes to family confidence and peace of mind.

    Staff and management receive repeated praise for professionalism, warmth, and responsiveness. Specific staff members are named as advocates and positive points of contact, and management is credited with prompt maintenance and addressing issues quickly. The facility is characterized as small and home-like; reviewers say this scale supports personalized attention and a nurturing atmosphere but may also imply fewer large-scale amenities than bigger communities.

    Programming and social engagement are clear strengths. The community offers a varied activity schedule, frequent musical and live-entertainment visits, and regular group exercise routines that reviewers associate with resident engagement and enjoyment. Families note a welcoming reception on arrival and an overall positive visiting experience.

    Housekeeping and facility upkeep are repeatedly described as strong: the building is bright, clean, and well-maintained. One operational friction noted across comments is the visitor-entry process; door-code or access procedures can require staff assistance and create minor inconvenience for visitors. A small number of comments also suggest an occasional mismatch between initial tour impressions and the ongoing, day-to-day experience, which points to the value of extended visits or follow-up questions during the decision process.

    There is limited specific feedback about dining quality or menu variety in these summaries, so prospective families should ask the community directly about meal service, accommodations for dietary needs, and sample menus during a tour. Overall, the prevailing patterns are strong on staff quality, resident engagement, cleanliness, and responsiveness from management, with visitor-access logistics and small-scale amenity limits being the main operational caveats to consider when evaluating fit.

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    Location

    South Beach Manor Memory Care is located at 411 SE 35th St, South Beach, OR, 97366.

    About South Beach Manor Memory Care

    South Beach Manor Memory Care sits in South Beach, Oregon, and serves folks throughout Lincoln County, including Waldport and Newport, so families in the area have a local place focused on helping those with memory loss. The facility is set up for 41 residents, all living in apartments that have their own bathrooms and can be set up with cable and phone service, and each apartment has emergency call devices for safety and peace of mind. Staff and licensed nurses are on hand all day and night, with 24-hour assistance, and they've got special care for people living with Alzheimer's, dementia, and similar conditions, including incontinence care, diabetic care, and support for those who can't get around on their own.

    The community surrounds a big, safe courtyard where raised flower beds, walking paths, and a gazebo with covered seating spots invite residents outdoors, and these wide hallways through the building make movement and exercise easier for everyone even on rainy days. Around the inside, you'll see spacious shared areas too-places with fireplaces and TVs, a big open dining room with lots of daylight, an Activity Room, and spots for watching TV or reading. Other rooms let folks take part in daily events like exercise classes, musical performances, and socials, and there's a salon run by a licensed beautician for haircuts and more.

    South Beach Manor Memory Care pays special attention to meaningful activities with its Life Skills Stations, which offer self-directed, dementia-friendly options that help residents feel engaged and independent, plus there's a solid Activities and Life Enrichment Program to keep days from getting dull. The base rent includes an apartment, three dietitian-approved meals a day with alternate options at every meal, snacks available any time, and weekly housekeeping and laundry, so residents stay comfortable with less to worry about. Transportation and escorts are arranged for trips and outings, while community involvement and family connections stay a focus. Apartments and common spaces have fire safety features like smoke detectors and sprinklers, plus electronic security for added protection.

    The place is known for kind staff who offer help and treat everyone with dignity and warmth, and it's even picked up awards for its meals, activities, and friendly atmosphere, which speaks well for the way residents and their families feel there. Residents can take scenic drives, join waterfront outings, enjoy flexible group and solo activities, and relax in cozy corners or engaged discussion areas, whichever suits them best that day. South Beach Manor Memory Care offers respite care when families need short-term help, keeps care plans updated for each person, and stays active with outside organizations like the Oregon Health Care Association. Everything here aims to help residents keep a sense of belonging, independence, and well-being, and to meet the day-to-day needs that come up in memory care living.

    People often ask...

    South Beach Manor Memory Care offers assisted living and memory care.

    There are 43 photos of South Beach Manor Memory Care on Mirador.

    The full address for this community is 411 SE 35th St, South Beach, OR 97366.

    No, South Beach Manor Memory Care does not offer respite care. Respite care in assisted living communities provides temporary, short-term relief for primary caregivers by offering professional care for their loved ones. It allows individuals to stay in an assisted living community for a limited time, giving caregivers a break while ensuring residents receive necessary support and assistance with daily activities.

    Safety & Compliance

    In Oregon, the Department of Human Services' Aging & People with Disabilities program licenses assisted living and residential care facilities, conducting inspections, complaint investigations, and renewals.

    License number50R476
    StatusActive
    Facility typeResidential Care Facility
    Capacity41 residents
    LicenseeSouth Beach Manor OPCO, LLC
    EffectiveJuly 22nd, 2019
    Special certificationMemory Care
    View the official license record

    Inspection Reports

    171

    Reports

    0

    Type A Citations

    0

    Type B Citations

    4

    Complaints

    12

    Years

    17 Aug 2026Inspection
    Investigated the records request allegation and substantiated a failure to provide documentation upon request.
    • Licensing—Failed to cooperate with an investigation
    17 Aug 2026Inspection
    Investigated the allegation of failing to cooperate; found a violation for not providing requested documentation.
    • Licensing—Failed to cooperate with an investigation
    17 Aug 2026Inspection
    Found that required records weren't provided to the Department upon request, violating Oregon administrative rules.
    • Licensing—Failed to submit timely or adequate staffing documentation
    17 Aug 2026Inspection
    Found that staffing records were not provided to the Department upon request, violating Oregon administrative rules.
    • Licensing—Failed to submit timely or adequate staffing documentation
    17 Aug 2026Inspection
    Found that required staffing records were not provided upon request.
    • Licensing—Failed to submit timely or adequate staffing documentation
    17 Aug 2026Inspection
    Investigated licensing issue and found a failure to provide records upon request.
    • Licensing—Failed to submit timely or adequate staffing documentation
    17 Aug 2026Inspection
    Investigated an allegation of failing to submit timely or adequate staffing documentation and found that required records were not provided to the Department upon request.
    • Licensing—Failed to submit timely or adequate staffing documentation
    02 Jun 2026Inspection
    Investigated the allegation that records were not accessible; found failure to provide records to the Department upon request.
    • Licensing—Failed to make facility or resident records accessible
    30 May 2026Inspection
    Identified a staffing deficiency due to failure to implement and maintain an Acuity-Based Staffing Tool.
    • Licensing—Failed to staff as indicated by ABST
    14 Feb 2026Abuse: Neglect
    Investigated a complaint found that a resident did not receive required 1:1 supervision and sustained a skin injury due to insufficient staffing and failure to follow the service plan.
    • Abuse—Failed to provide service
    15 Jan 2026Inspection
    Determined a staffing records deficiency occurred after failing to provide records upon request.
    • Licensing—Failed to submit timely or adequate staffing documentation
    15 Jan 2026Inspection
    Found that records were not provided upon request. This constitutes a violation of Oregon Administrative Rules.
    • Licensing—Failed to make facility or resident records accessible
    15 Jan 2026Inspection
    Investigated an allegation of failing to submit timely or adequate staffing documentation; found a records-keeping violation.
    • Licensing—Failed to submit timely or adequate staffing documentation
    15 Jan 2026Inspection
    Found that records were not provided to the Department upon request.
    • Licensing—Failed to make facility or resident records accessible
    10 Dec 2025Inspection
    Investigated the staffing allegation and found that an Acuity Based Staffing Tool was not developed, maintained, or implemented.
    • Licensing—Failed to update staffing plan based on ABST
    14 Nov 2025Abuse: Neglect
    Found failures to provide care and manage incontinence, causing urine-soaked clothing and loss of dignity.
    • Abuse—Failed to provide service
    08 Nov 2025Abuse: Neglect
    Investigated and found neglect of care and abuse, with a $500 fine assessed.
    • Abuse—Failed to provide service
    18 Oct 2025Inspection
    Investigated an allegation of staffing plan failure and found lack of an acuity-based staffing tool.
    • Licensing—Failed to update staffing plan based on ABST
    18 Oct 2025Abuse: Neglect
    Investigated found neglect and abuse due to failures in care planning and addressing aggressive behavior, resulting in resident injury. A $500 fine was assessed.
    • Abuse—Failed to provide service
    05 Oct 2025Inspection
    Investigated the staffing allegation and concluded there was a failure to develop, maintain, and implement an Acuity Based Staffing Tool.
    • Licensing—Failed to update staffing plan based on ABST
    24 Sept 2025License Condition
    Concluded that a safe environment was not provided, putting residents at risk of immediate jeopardy.
    • Regulatory Action—Failed to provide safe environment
    20 Sept 2025Inspection
    Found a deficiency in updating the staffing plan based on ABST and in developing, maintaining, and implementing an acuity-based staffing tool.
    • Licensing—Failed to update staffing plan based on ABST
    05 Sept 2025Abuse: Neglect
    Investigated found neglect and abuse resulting in emotional and physical harm due to failure to follow the care plan and manage a known resident's behavior. A fine was assessed.
    • Abuse—Failed to provide service
    05 Sept 2025Abuse: Neglect
    Investigated found neglect and abuse due to failure to provide required care and safety monitoring, leading to injury. A $375 fine was assessed.
    • Abuse—Failed to provide service
    05 Sept 2025Inspection
    Identified inconsistencies between the resident roster, care plans, and ABST data due to an outdated Acuity-Based Staffing Tool.
    • Licensing—Failed to use an ABST
    05 Sept 2025Inspection
    Found deficiencies in staffing planning, including failure to update the ABST-based staffing plan and to develop, maintain, and implement an acuity-based staffing tool.
    • Licensing—Failed to update staffing plan based on ABST
    13 Jul 2025Abuse: Neglect
    Investigated found that staff failed to provide services and to maintain a safe environment, resulting in an assault on a resident.
    • Abuse—Failed to provide service
    22 Jun 2025Abuse: Neglect
    Investigated a failure to properly plan care that contributed to an unwitnessed fall with head injury; violations were found and a fine assessed.
    • Abuse—Failed to properly plan care
    22 Jun 2025Inspection
    Investigated an allegation of failing to update the staffing plan based on ABST and found that an Acuity-Based Staffing Tool was not developed, maintained, or implemented.
    • Licensing—Failed to update staffing plan based on ABST
    11 May 2025Inspection
    Investigated and found a deficiency in developing, maintaining, and implementing an Acuity-Based Staffing Tool.
    • Licensing—Failed to use an ABST
    08 May 2025Inspection
    Found that the required Acuity-Based Staffing Tool was not developed, maintained, or implemented.
    • Licensing—Failed to meet the scheduled and unscheduled needs of residents
    06 May 2025Inspection
    Investigated a staffing allegation and found a deficiency for not developing an acuity-based staffing tool.
    • Licensing—Failed to staff as indicated by ABST
    15 Apr 2025Abuse: Neglect
    Investigated and found neglect of care and abuse occurred; a $375 fine was assessed.
    • Abuse—Failed to provide service
    06 Apr 2025Abuse: Neglect
    Investigated and found neglect of care and abuse due to failure to provide services and a safe environment for a resident.
    • Abuse—Failed to provide service
    06 Apr 2025Inspection
    Identified a deficiency for failing to develop, maintain, and implement an acuity-based staffing tool, resulting in unmet resident needs.
    • Licensing—Failed to meet the scheduled and unscheduled needs of residents
    06 Apr 2025Abuse: Neglect
    Found neglect of care and abuse due to failure to address aggressive behaviors and provide a safe environment, resulting in injuries to an alleged victim.
    • Abuse—Failed to provide safe environment
    19 Mar 2025Inspection
    Found failure to develop, maintain, and implement an Acuity-Based Staffing Tool. This constitutes a violation of Oregon Administrative Rules.
    • Licensing—Failed to staff as indicated by ABST
    06 Dec 2024Inspection
    Investigated staffing levels did not align with the Acuity-Based Staffing Tool, with inconsistencies between the staffing schedule and ABST data and staffing not meeting residents' scheduled and unscheduled needs.
    • Licensing—Failed to staff as indicated by ABST
    15 Nov 2024Abuse: Neglect
    Investigated and found that failure to properly plan care contributed to falls and harm, constituting neglect and abuse. A fine was assessed.
    • Abuse—Failed to properly plan care
    10 Oct 2024Inspection
    Identified an outdated ABST that did not reflect resident needs and found inconsistencies between the roster, care plans, and ABST data, violating Oregon Administrative Rules.
    • Licensing—Failed to use an ABST
    09 Oct 2024Complaint
    Investigated and found failures to update an acuity-based staffing tool and to account for two-person transfers, causing staffing plan discrepancies.
    • Deficiency—Acuity Based Staffing Tool - Abst Time
    • Deficiency—Acuity Based Staffing Tool - Updates & Plan
    09 Oct 2024Inspection
    Investigated ABST accuracy and found deficiencies in reflecting resident population and care needs, with inconsistencies between roster, care plans, and ABST data.
    • Licensing—Failed to use an ABST
    09 Oct 2024Inspection
    Found an outdated ABST that did not reflect resident needs, with inconsistencies between the roster, care plans, and ABST data.
    • Licensing—Failed to use an ABST
    09 Oct 2024Inspection
    Identified inconsistencies between the resident roster, care plans, and ABST data, indicating the Acuity-Based Staffing Tool was not up to date.
    • Licensing—Failed to use an ABST
    03 Oct 2024Inspection
    Identified that resident records were not prepared, complete, accurate, or preserved. This reflects a deficiency in records management.
    • Licensing—Failed to keep resident record current or accurate
    21 Sept 2024Abuse: Neglect
    Found deficiencies in care planning and interventions to mitigate fall risk, leading to a fall and related injury. The findings indicate neglect and abuse.
    • Abuse—Failed to properly plan care
    20 Sept 2024Inspection
    Investigated the allegation and found a deficiency in not fully implementing and updating an acuity-based staffing tool.
    • Licensing—Failed to use an ABST
    19 Sept 2024Inspection
    Found a deficiency in maintaining an updated Acuity-Based Staffing Tool that accurately reflects residents' care needs, with inconsistencies between the roster, care plans, and ABST data.
    • Licensing—Failed to use an ABST
    18 Sept 2024Inspection
    Found that the acuity-based staffing tool was not fully implemented or updated. An investigation determined this violated Oregon Administrative Rules.
    • Licensing—Failed to use an ABST
    31 Aug 2024Inspection
    Identified inconsistencies between the resident roster, care plans, and data in the Acuity-Based Staffing Tool indicating it was not up to date.
    • Licensing—Failed to use an ABST
    26 Aug 2024Inspection
    Found inconsistencies between the resident roster, care plans, and ABST data due to an outdated ABST, violating Oregon Administrative Rules.
    • Licensing—Failed to use an ABST
    23 Jul 2024Abuse: Neglect
    Investigated and substantiated neglect and abuse involving failure to provide adequate care and safety monitoring for a resident, including failed safety checks and a fall. The finding ties to insufficient care planning and monitoring of changes in condition.
    • Abuse—Failed to provide service
    16 Jul 2024Abuse: Neglect
    Investigated and found neglect and abuse due to failure to plan care and mitigate fall risk, resulting in injury.
    • Abuse—Failed to properly plan care
    15 Jul 2024Abuse: Neglect
    Investigated found neglect and abuse due to failure to properly plan care, resulting in fall risk and skin injury. A fine was assessed.
    • Abuse—Failed to properly plan care
    09 Jul 2024Licensure
    Determined substantial compliance with meal service and food sanitation requirements.
    • Deficiency—Comment
    23 Jun 2024Abuse: Neglect
    Found deficiencies in care planning and safety for a resident with known behavioral history. This led to neglect and abuse.
    • Abuse—Failed to properly plan care
    19 Jun 2024Abuse: Neglect
    Found fall risk management and care planning failures that led to a fall injury and ongoing discomfort for a resident.
    • Abuse—Failed to properly plan care
    12 Jun 2024Complaint
    Identified deficiencies in updating the acuity-based staffing tool and in fire safety measures.
    • Deficiency—Facility Administration: Operation
    • Deficiency—Staffing Requirements and Training: Staffing
    • Deficiency—Acuity-Based Staffing Tool
    • Deficiency—Fire and Life Safety: Egress, First Aid
    10 Jun 2024Abuse: Neglect
    Found neglect and abuse for failing to provide oral hygiene care, resulting in unreasonable discomfort and loss of personal dignity for the resident.
    • Abuse—Failed to provide service
    29 May 2024Abuse: Neglect
    Investigated a care complaint and found neglect of care due to failure to provide oral hygiene services, resulting in a $500 fine.
    • Abuse—Failed to provide service
    25 May 2024Abuse: Neglect
    Investigated and substantiated neglect and abuse due to failure to monitor and plan care after a treatment likely to cause itching, resulting in scratches on a resident.
    • Abuse—Failed to properly plan care
    24 May 2024Inspection
    Found deficiencies in maintaining an up-to-date ABST that reflects resident care needs, with inconsistencies between the roster, care plans, and ABST data.
    • Licensing—Failed to use an ABST
    20 May 2024Abuse: Neglect
    Found that the care plan to prevent falls was not followed, leading to a resident sliding from a wheelchair and sustaining injuries; a $500 fine was assessed.
    • Abuse—Failed to follow care plan
    19 May 2024Inspection
    Found deficiencies in supervision, training, and overall staff conduct.
    • Licensing—Failed to provide safe environment
    19 May 2024Inspection
    Identified obstruction of stairways, halls, doorways, passageways, and exits, risking safety.
    • Licensing—Failed to provide safe environment
    19 May 2024Inspection
    Investigated and found insufficient staff to provide a safe environment.
    • Licensing—Failed to provide safe environment
    01 May 2024Abuse: Neglect
    Determined that neglect occurred due to failure to properly plan care and implement effective fall-prevention interventions, leading to an unwitnessed fall with knee injuries.
    • Abuse—Failed to properly plan care
    24 Apr 2024Abuse: Neglect
    Investigated found a failure to provide a safe environment, with multiple falls and injuries among a resident, culminating in a $500 fine.
    • Abuse—Failed to provide safe environment
    23 Apr 2024Abuse: Neglect
    Investigated found that care planning failed to address increasing fall risk and safety, with a $500 fine assessed.
    • Abuse—Failed to properly plan care
    22 Apr 2024Inspection
    Identified deficiencies in the acuity-based staffing tool, with inconsistencies between the roster, care plans, and ABST data.
    • Licensing—Failed to use an ABST
    20 Apr 2024Abuse: Neglect
    Investigated a fall-risk case and found that interventions were not added to the resident's care plan, increasing risk of harm. A $1,500 fine was assessed.
    • Abuse—Failed to properly plan care
    17 Apr 2024Abuse: Neglect
    Investigated a failure to provide a safe environment, which led to multiple falls and injuries for an at-risk resident; a $1500 fine was assessed.
    • Abuse—Failed to provide safe environment
    10 Apr 2024Inspection
    Found a deficiency due to an out-of-date Acuity-Based Staffing Tool that did not reflect resident needs, with inconsistencies between the roster, care plans, and ABST data.
    • Licensing—Failed to use an ABST
    10 Apr 2024Complaint
    Found confidentiality breaches due to an unlocked computer and accessible records, and found failures to implement and document a resident's behavioral interventions.
    • Deficiency—Resident Rights and Protection - General
    • Deficiency—Service Plan: General
    10 Apr 2024Inspection
    Found that medical and other records were not kept confidential; the investigation determined no licensing violation or abuse occurred.
    • Licensing—Failed to assure resident rights
    01 Apr 2024Abuse: Neglect
    Investigated found that new diet orders were not added to the resident's care plan and interventions were delayed, amid significant weight loss and hospice placement.
    • Abuse—Failed to properly plan care
    20 Mar 2024Abuse: Neglect
    Investigated a complaint and found fall prevention interventions were inadequate and staffing insufficient, and care planning failed to protect a known fall-risk resident from falls.
    • Abuse—Failed to properly plan care
    20 Mar 2024Abuse: Neglect
    Investigated a fall-related allegation and found failures to properly plan care and provide adequate staff to intervene, resulting in a resident fall and injury.
    • Abuse—Failed to properly plan care
    14 Mar 2024Inspection
    Identified a failure to immediately notify the Department office or local authorities about abuse or suspected abuse.
    • Licensing—Failed to report potential or suspected abuse
    14 Mar 2024Inspection
    Determined that a medication administration deficiency occurred.
    • Licensing—Failed to keep medication record current or accurate
    09 Mar 2024Abuse: Neglect
    Found neglect and abuse due to failure to properly plan care and mitigate rising fall risk. This resulted in a witnessed fall with injuries and an unsafe environment for the resident.
    • Abuse—Failed to properly plan care
    09 Mar 2024Abuse: Neglect
    Found inadequate staffing allowed an altercation and placed a resident at risk for harm; a fine was assessed.
    • Abuse—Failed to provide appropriate staffing
    09 Mar 2024Abuse: Neglect
    Determined that failure to properly plan care for a fall-risk resident amounted to neglect and abuse, with a $500 fine assessed.
    • Abuse—Failed to properly plan care
    07 Mar 2024Abuse: Neglect
    Investigated a neglect allegation and found failures to properly plan care for a resident at risk of falls, leading to ongoing fall-related harm risk.
    • Abuse—Failed to properly plan care
    07 Mar 2024Abuse: Neglect
    Investigated and found improper care planning led to neglect and abuse, with the resident found on the floor with feces on hands, arms, legs, and face.
    • Abuse—Failed to properly plan care
    01 Mar 2024Abuse: Neglect
    Found neglect and abuse due to failure to properly plan and implement interventions to address ongoing falls after an unwitnessed fall, leading to injuries and hospital transport.
    • Abuse—Failed to properly plan care
    16 Feb 2024Inspection
    Found a deficiency for not having an identified intervention to address a resident's behavior.
    • Licensing—Failed to address resident's behavior
    10 Feb 2024Abuse: Neglect
    Investigated and determined that care-plan interventions were not followed, resulting in neglect and abuse; a $500 fine assessed.
    • Abuse—Failed to follow care plan
    28 Jan 2024Abuse: Neglect
    Investigated and found neglect and abuse due to failure to properly plan care, resulting in a resident being found on the floor with feces and a loss of personal dignity.
    • Abuse—Failed to properly plan care
    28 Jan 2024Abuse: Neglect
    Found neglect and abuse for failing to properly plan care and address ongoing falls. A fine was assessed.
    • Abuse—Failed to properly plan care
    24 Jan 2024Abuse: Neglect
    Investigated a complaint about care planning and falls; found failures to implement interventions to reduce falls, resulting in neglect and abuse.
    • Abuse—Failed to properly plan care
    16 Jan 2024Abuse: Neglect
    Investigated allegations of an unsafe environment and found neglect and abuse due to inadequate interventions for aggressive residents and wandering that caused injuries.
    • Abuse—Failed to provide safe environment
    07 Jan 2024Abuse: Neglect
    Investigated the allegation found neglect and abuse due to failure to plan care for ongoing falls, with a fine assessed.
    • Abuse—Failed to properly plan care
    30 Dec 2023Abuse: Neglect
    Found failure to provide a safe environment, resulting in neglect and abuse. A $375 fine was assessed.
    • Abuse—Failed to provide safe environment
    18 Dec 2023Abuse: Neglect
    Investigated a complaint and found neglect and abuse due to failing to plan care and implement fall prevention for a known fall risk, resulting in an unwitnessed fall and discomfort.
    • Abuse—Failed to properly plan care
    08 Dec 2023Abuse: Neglect
    Investigated and found that inadequate staffing and supervision during the night allowed a resident at risk of falls to wander unsupervised, resulting in injury. This constitutes neglect of care.
    • Abuse—Failed to provide appropriate staffing
    08 Dec 2023Abuse: Neglect
    Investigated the complaint and found that care planning and safety interventions were not properly implemented, resulting in a resident's fall and head injury.
    • Abuse—Failed to properly plan care
    01 Dec 2023Abuse: Neglect
    Identified a failure to implement meaningful interventions or a care plan for a resident's fall risk, resulting in an unwitnessed fall with injuries; a fine was assessed.
    • Abuse—Failed to properly plan care
    26 Nov 2023Abuse: Neglect
    Investigated an allegation of neglect and abuse; found failure to properly care plan and implement interventions to address ongoing falls, violating resident rights.
    • Abuse—Failed to properly plan care
    24 Nov 2023Abuse: Neglect
    Investigated a fall-risk resident safety issue and found a failure to provide a safe environment, with repeated falls and ongoing risk.
    • Abuse—Failed to provide safe environment
    15 Nov 2023Abuse: Neglect
    Found neglect and abuse; assessed a $1,125 fine.
    • Abuse—Failed to provide service
    15 Nov 2023Abuse: Neglect
    Investigated the complaint and found care plan interventions were not followed, contributing to an unwitnessed fall and injury due to wet conditions after cleaning.
    • Abuse—Failed to follow care plan
    11 Nov 2023Abuse: Neglect
    Found violations for neglect and abuse due to failure to plan care, placing residents at risk.
    • Abuse—Failed to properly plan care
    11 Nov 2023Abuse: Neglect
    Found a failure to provide a safe environment, with abuse/neglect identified and a $375 fine assessed.
    • Abuse—Failed to provide safe environment
    01 Nov 2023Abuse: Neglect
    Found neglect and abuse due to failure to implement interventions to reduce altercations, placing a resident at risk for harm; a fine was assessed.
    • Abuse—Failed to properly plan care
    21 Oct 2023Abuse: Neglect
    Determined that inadequate care planning and failure to implement fall-risk interventions for a resident led to multiple falls and injuries, constituting neglect and abuse.
    • Abuse—Failed to properly plan care
    21 Oct 2023Abuse: Neglect
    Found violations of resident rights due to neglect that contributed to multiple falls and injuries.
    • Abuse—Failed to provide service
    08 Oct 2023Abuse: Neglect
    Found violations for failing to properly plan care for a known fall risk, resulting in neglect and abuse. A $375 fine was assessed.
    • Abuse—Failed to properly plan care
    30 Sept 2023Abuse: Neglect
    Investigated a complaint and found a failure to provide a safe environment, constituting neglect and abuse.
    • Abuse—Failed to provide safe environment
    24 Sept 2023Abuse: Neglect
    Investigated an abuse/neglect allegation and found failures to plan care contributed to a resident head injury. The incident required hospital treatment.
    • Abuse—Failed to properly plan care
    15 Sept 2023Abuse: Neglect
    Investigated abuse and neglect found that interventions and a safe environment were not provided, resulting in harm to a resident with a fine assessed.
    • Abuse—Failed to provide safe environment
    27 Aug 2023Abuse: Neglect
    Determined a failure to provide a safe environment, leading to an altercation and injury; a fine was assessed.
    • Abuse—Failed to provide safe environment
    26 Aug 2023Abuse: Neglect
    Investigated the allegation of neglect and found the care plan was not followed, resulting in a fall and injury to a known fall risk resident.
    • Abuse—Failed to follow care plan
    26 Aug 2023Abuse: Neglect
    Investigated an incident of aggressive behavior that harmed a resident and found safety measures were not adequately addressed.
    • Abuse—Failed to provide safe environment
    18 Aug 2023Abuse: Neglect
    Investigated the allegation of abuse and neglect and found the care plan did not clearly address how to handle the resident's habit of holding onto the wheelchair, and staff directions were unclear, resulting in a skin tear during repositioning.
    • Abuse—Failed to properly plan care
    11 Aug 2023Abuse: Neglect
    Found a resident was not protected from inappropriate sexual contact, causing emotional distress; identified as abuse and neglect.
    • Abuse—Failed to protect resident from inappropriate sexual contact
    05 Aug 2023Abuse: Neglect
    Found inadequate interventions and care planning for two residents with a history of aggression, resulting in an unsafe environment and abuse.
    • Abuse—Failed to provide safe environment
    30 Jul 2023Abuse: Neglect
    Found violations for failure to properly plan care to prevent falls, risking serious harm, and assessed a $500 fine.
    • Abuse—Failed to properly plan care
    28 Jul 2023Abuse: Neglect
    Investigated and found neglect and abuse due to failure to plan care for a known fall risk, resulting in multiple falls and injuries; a fine was assessed.
    • Abuse—Failed to properly plan care
    10 Jul 2023Validation
    Identified multiple deficiencies across care, safety, and administrative areas during the relicensure process, including failure to investigate abuse, inadequate resident assessments, and poor facility conditions.
    • Deficiency—Comment
    • Deficiency—Reporting & Investigating Abuse-Other Action
    • Deficiency—Resident Services Meals, Food Sanitation Rule
    • Deficiency—Resident Move-In and Eval: Res Evaluation
    • Deficiency—Change of Condition and Monitoring
    • Deficiency—Systems: Treatment Orders
    • Deficiency—Systems: Treatment Administration
    • Deficiency—Acuity-Based Staffing Tool
    • Deficiency—Training Within 30 Days: Direct Care Staff
    • Deficiency—Fire and Life Safety: Safety
    • Deficiency—Inspections and Investigation: Insp Interval
    • Deficiency—Doors, Walls, Elevators, Odors
    • Deficiency—Administration Compliance
    • Deficiency—Compliance With Rules Health Care
    • Deficiency—Activities
    09 Jul 2023Abuse: Neglect
    Determined that a safe environment was not provided.
    • Abuse—Failed to provide safe environment
    09 Jul 2023Abuse: Neglect
    Investigated and substantiated neglect and abuse for failing to provide a safe environment and appropriate care.
    • Abuse—Failed to provide safe environment
    09 Jun 2023License Condition
    Found failure to use an ABST as required.
    • Regulatory Action—Failed to use an ABST
    04 Jun 2023Abuse: Neglect
    Investigated fall-risk care planning and found deficiencies in interventions that allowed repeated falls and led to a sacrum fracture. Violations were cited.
    • Abuse—Failed to properly plan care
    25 May 2023Abuse: Neglect
    Found that the care was not properly planned for a known fall risk, leading to multiple falls and injuries. A $3,000 fine was assessed.
    • Abuse—Failed to properly plan care
    25 May 2023Abuse: Neglect
    Determined that there were deficiencies showing neglect and abuse due to failure to implement effective, person-centered interventions after repeated falls, resulting in injuries.
    • Abuse—Failed to properly plan care
    15 May 2023Abuse: Neglect
    Concluded that neglect and abuse occurred due to failure to implement effective, person-centered interventions after repeated falls, resulting in injuries.
    • Abuse—Failed to properly plan care
    09 May 2023Abuse: Neglect
    Investigated an allegation of neglect and found a failure to provide a safe environment that harmed a resident.
    • Abuse—Failed to provide safe environment
    11 Apr 2023Complaint
    Identified deficiencies related to failing to fully implement and update an acuity-based staffing tool and to document all ADLs with staffing time.
    • Deficiency—Licensing Complaint Investigation
    • Deficiency—Acuity-Based Staffing Tool
    01 Dec 2022Inspection
    Found failure to submit timely or adequate staffing documentation for weekly reporting of vaccinated individuals, residents, and staff; substantiated.
    • Licensing—Failed to submit timely or adequate staffing documentation
    23 Aug 2022Abuse: Neglect
    Found a failure to provide a safe environment that led to a resident-to-resident altercation and minor harm; a fine was assessed.
    • Abuse—Failed to provide safe environment
    03 Aug 2022Abuse: Neglect
    Found failures to implement interventions or appropriate care plans for known behaviors, resulting in a physical altercation with injuries on August 3, 2022.
    • Abuse—Failed to properly plan care
    03 Aug 2022Abuse: Neglect
    Investigated the complaint and found a failure to plan care for known behaviors, leading to a physical altercation with injuries. This involved neglect of resident rights and abuse.
    • Abuse—Failed to properly plan care
    31 Jul 2022Abuse: Neglect
    Found neglect and abuse due to failure to protect a resident from inappropriate sexual contact and to implement appropriate care plans, placing a resident at risk.
    • Abuse—Failed to protect resident from inappropriate sexual contact
    22 Jul 2022Abuse: Neglect
    Determined neglect and abuse due to failure to plan care, leading to a resident harming another and creating an unsafe environment.
    • Abuse—Failed to properly plan care
    29 Jun 2022Abuse: Neglect
    Investigated a failure to provide a safe environment that led to an altercation and injury. Found abuse and neglect.
    • Abuse—Failed to provide safe environment
    02 Jun 2022Abuse: Neglect
    Found that interventions and an appropriate care plan for the Alleged Victim’s known behaviors were not implemented, resulting in an altercation with injuries on or about June 2, 2022.
    • Abuse—Failed to properly plan care
    03 Apr 2022Abuse: Neglect
    Investigated found neglect in fall-risk care planning and interventions after a resident fall, with a fine assessed.
    • Abuse—Failed to properly plan care
    20 Mar 2022Abuse: Neglect
    Identified failure to plan and implement care for known fall risk, which led to a head injury and a $500 fine assessed.
    • Abuse—Failed to properly plan care
    03 Mar 2022Abuse: Neglect
    Investigated found failure to plan and implement interventions for a known fall risk, resulting in a painful fall and a $500 fine.
    • Abuse—Failed to properly plan care
    09 Feb 2022Abuse: Neglect
    Identified failures to plan and implement fall-risk interventions, leading to a resident fall with an abrasion; repeated prior interventions instead of updating the care plan.
    • Abuse—Failed to properly plan care
    28 Jan 2022Abuse: Neglect
    Found failures to implement meaningful fall-risk interventions and appropriate care planning for a resident at risk of falls; a 500 fine was assessed.
    • Abuse—Failed to properly plan care
    19 Jan 2022Abuse: Neglect
    Found deficiencies in fall-risk care planning and interventions, indicating neglect and abuse. Assessed a $500 fine.
    • Abuse—Failed to properly plan care
    03 Jan 2022Abuse: Neglect
    Identified failures to plan and implement care for a known fall risk, resulting in a fall and a $500 fine assessed.
    • Abuse—Failed to properly plan care
    14 Nov 2021Abuse: Neglect
    Found that fall risk care planning was inadequate, contributing to repeated resident falls and injuries.
    • Abuse—Failed to properly plan care
    06 Nov 2021Abuse: Neglect
    Investigated and found that care planning for falls risk was not done properly, resulting in injuries and an abuse/neglect finding; a fine was assessed.
    • Abuse—Failed to properly plan care
    31 Oct 2021Abuse: Neglect
    Investigated a resident fall-risk case and found failure to plan care, resulting in neglect and abuse; a $2,500 fine was assessed.
    • Abuse—Failed to properly plan care
    15 Sept 2021Abuse: Neglect
    Investigated a fall-related care planning issue and found the facility failed to plan appropriately to mitigate fall risk, resulting in abuse/neglect findings and a $1,000 fine.
    • Abuse—Failed to properly plan care
    15 Sept 2021Abuse: Neglect
    Investigated and found failures to properly plan care and implement interventions to reduce fall risk, resulting in violations and a $1,000 fine.
    • Abuse—Failed to properly plan care
    09 Sept 2021Abuse: Neglect
    Investigated, found neglect and abuse due to failure to properly plan and implement care, leading to a skin injury requiring medical attention.
    • Abuse—Failed to properly plan care
    26 Aug 2021Abuse: Neglect
    Concluded that there was a failure to provide a safe environment, resulting in an unwitnessed altercation and injury.
    • Abuse—Failed to provide safe environment
    03 Jul 2021Abuse: Neglect
    Found that the facility failed to properly plan care to mitigate fall risk, resulting in neglect and abuse.
    • Abuse—Failed to properly plan care
    08 Jun 2021Abuse: Neglect
    Investigated allegations of abuse and neglect and found a failure to provide a safe environment that caused scratches and bruising.
    • Abuse—Failed to provide safe environment
    06 Jun 2021Abuse: Neglect
    Found violations for failing to provide a safe environment, resulting in a skin injury; a $375 fine assessed.
    • Abuse—Failed to provide safe environment
    16 May 2021Abuse: Neglect
    Investigated an allegation of neglect and abuse due to failure to plan care for falls; findings supported the allegation and a $500 fine was assessed.
    • Abuse—Failed to properly plan care
    28 Apr 2021Abuse: Neglect
    Found abuse and neglect due to failing to provide required care, including proper compression stockings. Delays and missing equipment contributed to inadequate care.
    • Abuse—Failed to provide service
    16 Apr 2021Abuse: Neglect
    Investigated and found safety gaps and inadequate care planning that led to a resident altercation and pain.
    • Abuse—Failed to provide safe environment
    23 Mar 2021Abuse: Neglect
    Found deficiencies for failing to properly plan care around a resident’s self-transfer, which led to a fall and injury. A $375 fine was assessed.
    • Abuse—Failed to properly plan care
    22 Mar 2021Abuse: Neglect
    Investigated and found neglect and abuse due to failing to provide a safe environment and properly escort a resident with known aggression. This failure led to a physical altercation and unreasonable discomfort.
    • Abuse—Failed to provide safe environment
    19 Jan 2021Abuse: Neglect
    Investigated an allegation of abuse and neglect involving failure to properly plan care related to a resident's intimate interactions, which led to a restraining order and removal from the facility and a fine was assessed.
    • Abuse—Failed to properly plan care
    16 Jan 2021Abuse: Neglect
    Found a neglect/abuse violation for failing to provide a safe environment; an incident occurred with an alleged victim found in another resident’s room engaging in sexual behaviors.
    • Abuse—Failed to provide safe environment
    14 Jan 2021Abuse: Neglect
    Found the facility failed to care plan per assessment, resulting in neglect and abuse; a $500 fine was assessed.
    • Abuse—Failed to care plan in accordance with assessment
    28 Dec 2020Abuse: Neglect
    Investigated and found failure to administer ordered medication on several dates, resulting in neglect and abuse; a fine was assessed.
    • Abuse—Failed to administer ordered medication
    23 Dec 2020Abuse: Neglect
    Found neglect and abuse due to failure to care plan for a resident with significant cognitive deficits, and assessed a $1,500 fine.
    • Abuse—Failed to properly plan care
    19 Oct 2020Abuse: Neglect
    Found deficiencies related to failure to plan care for a resident's known exit-seeking behaviors, which contributed to elopement.
    • Abuse—Failed to properly plan care
    08 Sept 2020Abuse: Neglect
    Investigated an allegation of neglect and abuse related to exit-seeking behavior; found a resident left the premises without an adequate care plan, putting them at risk of serious harm. A $500 fine was assessed.
    • Abuse—Failed to properly plan care
    07 Sept 2020Abuse: Neglect
    Determined that the resident's care plan did not adequately address fall risk or implement interventions, resulting in multiple falls and injury risk.
    • Abuse—Failed to properly plan care
    01 Feb 2020Abuse: Neglect
    Found violations of resident care standards due to failure to address a changing condition and to intervene, resulting in weight loss over seven months.
    • Abuse—Failed to intervene when resident's condition changed
    21 Feb 2014Abuse: Neglect
    Investigated and found a failure to provide transfer assistance that caused a fall with injuries. Violations were cited.
    • Abuse—Failed to follow care plan
    21 Feb 2014Abuse: Neglect
    Investigated an allegation of neglect and found a failure to follow the service plan during a two-person transfer, resulting in injuries.
    • Abuse—Failed to follow care plan
    06 Feb 2014Abuse: Neglect
    Investigated an allegation that care was not properly planned; resulted in a civil penalty.
    • Abuse—Failed to properly plan care

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