I toured Bonaventure and am very pleased. The facility is gorgeous and spotless - restaurant-style dining, movie theater, salon, café, library, hobby rooms and lovely grounds. Apartments are modern and spacious with full kitchens, and the staff are warm, attentive, and go above and beyond. Meals and activities are excellent; overall it felt homey, well run, and worth a look.
Loved one of resident
Jul 2026
Pricing
Prices shown are estimates and subject to change. Contact your senior living advisor for current pricing.
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Amenities
Healthcare services
Activities of daily living assistance
Assistance with bathing
Assistance with dressing
Assistance with transfers
Coordination with health care providers
Hospice waiver
Medication management
Mental wellness program
Healthcare staffing
12-16 hour nursing
24-hour call system
24-hour supervision
Meals and dining
Diabetes diet
Meal preparation and service
Restaurant-style dining
Special dietary restrictions
Room
Air-conditioning
Cable
Fully furnished
Housekeeping and linen services
Kitchenettes
Private bathrooms
Telephone
Wifi
Memory care community services
Dementia waiver
Mild cognitive impairment
Specialized memory care programming
Transportation
Community operated transportation
Transportation arrangement
Transportation arrangement (medical)
Transportation arrangement (non-medical)
Transportation to doctors appointments
Common areas
Beauty salon
Computer center
Dining room
Fitness room
Gaming room
Garden
Outdoor 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
3.52·(94)
Overall rating
5
4
3
2
1
Care
3.0
Staff
3.4
Meals
3.0
Amenities
3.9
Value
2.2
Pros
Compassionate, resident-focused caregiving staff
Warm, personable front-desk and concierge interactions
Active social programming and varied daily activities
Wide range of amenities (movie theater, salon, game rooms, library)
Well-maintained common areas and attractive grounds
Restaurant-style dining room with dedicated kitchen staff
Special-diet accommodation and chef responsiveness
Large, modern apartments and upgraded finishes
Bright, home-like interior atmosphere
Strong sense of community and resident socialization
On-site wellness and exercise spaces
Supportive end-of-life and hospice coordination
Competitive pricing and perceived value for some units
Pet-friendly policy
Engaging volunteer and inter-resident support
Cons
Inconsistent staffing levels and high employee turnover
Gaps in management responsiveness and communication
Unreliable housekeeping and laundry service
Sanitation concerns in some resident rooms and shared areas
Inconsistent medication-administration and clinical-care processes
Variable dining quality and meal-service continuity
Weak onboarding and move-in assistance procedures
Memory-care leadership instability and variable program quality
Opaque pricing structures and undisclosed move-in fees
Infection-control and safety-practice concerns
Documentation and care-plan adherence gaps
Amenity availability and marketing inconsistencies
Security incident handling and resident-property protection gaps
Summary of reviews
The reviews for Bonaventure of Tigard present a strongly mixed picture. Many families and residents praise the community’s people and physical environment: staff are frequently described as warm, compassionate and resident-focused, common areas are attractive and well maintained, and the community offers a wide array of amenities (movie theater, salon, game rooms, library, exercise spaces) and active social programming. Several accounts highlight large, modern apartments, restaurant-style dining rooms, and staff willingness to accommodate special diets and end-of-life needs. For visitors and prospective residents, these elements contribute to an impression of a lively, home-like community with robust opportunities for social engagement.
Alongside positive descriptions, a consistent set of operational weaknesses appears across reviews. Staffing instability and high turnover are recurrent themes; reviewers describe insufficient staffing at key times (including nights and move-in), which has been linked to delayed assistance, missed checks, and families hiring private caregivers to meet needs. Housekeeping and laundry reliability are another frequent concern: issues include inconsistent room cleaning, damaged or missing laundry items, and broader sanitation concerns in some resident rooms and shared spaces. Relatedly, several reviews raise concerns about medication administration, clinical-care follow-through, and deviations from care plans, suggesting gaps in clinical oversight and documentation.
Dining and food service elicit polarized responses. Multiple reviewers commend a dedicated kitchen team, attentive chef responses to special diets, and attractive dining rooms; others describe inconsistent meal quality, cold or delayed service, and long dinner wait times. Activities and amenity programming are generally viewed as strengths when staffed and scheduled, with many residents enjoying crafts, exercise, live entertainment, and indoor hobby spaces. However, some families report that advertised amenities or events are not consistently available, indicating variability in program delivery.
Management and administrative practices are another area of divergence. Positive accounts note helpful, accommodating managers and staff who facilitate moves and respond to questions. Contrasting reviews describe slow or absent responses from leadership, unclear points of contact, recurring fee/price-disclosure problems (including non-refundable deposits and administrative fees), and dissatisfaction with how serious incidents were communicated to families. There are also several accounts raising infection-control and safety-practice concerns, including COVID-related complaints and at least one instance that led family members to question the facility’s practices; a small number of reviews include more serious allegations (for example, unsafe staff conduct or substance-use concerns), which warrant follow-up and, where appropriate, formal inquiry.
Overall, Bonaventure of Tigard appears to offer many of the physical and programmatic elements families seek—amenities, active programming, and moments of strong, compassionate caregiving—but the consistency of operational execution varies. Key patterns to evaluate during a visit include staffing levels and retention (especially for memory care and overnight shifts), housekeeping and laundry processes, medication-management and clinical documentation practices, infection-control policies, and a clear, written statement of fees and refundable/ non-refundable deposits. Asking for current staffing ratios, recent survey or inspection findings for memory care, examples of how care-plan changes are documented, and references from current families can help prospective residents and their families determine whether the facility’s strengths align with their expectations and care needs.
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Location
Bonaventure of Tigard is located at 15000 SW Hall Blvd, Tigard, OR, 97224.
About Bonaventure of Tigard
Bonaventure of Tigard sits in a quiet neighborhood less than five miles from the lively center of Tigard, Oregon, and offers a range of senior living choices, like independent living, assisted living, memory care, and even skilled nursing, all together in one community, so residents can stay as their needs change. The campus has suites and apartments in several layouts-studios, one-bedroom, and two-bedroom options in both assisted living and memory care, with every memory care suite being private and there are 23 memory care beds. The community is built to feel homelike and welcoming, with wide hallways, lots of natural light, and little touches like wall safes, individually controlled thermostats, microwaves in independent and assisted living units, washer and dryer hookups, and dishwashers and garbage disposals in all independent living units and cottages, and residents can enjoy patios, balconies, and outdoor walking paths for time outside if they wish or just stay inside and visit in the cozy sitting areas by the fireplace.
Residents find a lot of spaces to relax or be active, like beautifully designed common areas, a billiards room, a game room, computer work stations, a puzzle room, a library, a fitness center, a movie theater and TV room, a garden and hobby center, plus private meeting rooms and dining rooms for gatherings. The on-site café offers coffee, pastries, and frozen yogurt if someone just wants a snack, and the restaurant-style dining with anytime dining is convenient, with meals planned to be nutritious by chefs and meal planners. Activities and events are planned seven days a week for social, physical, and mental well-being, and there's a hospitality suite where folks can play shuffleboard or poker, and free WiFi throughout, which is handy for keeping in touch or reading the news.
The staff provide 24/7 support and can help with activities of daily living as needed in both assisted living and memory care, and monthly wellness clinics keep track of everyone's health. There are nurse call systems, enhanced front door security, and a wireless emergency call system for safety, and in memory care, the setting is designed to prevent wandering and help residents with Alzheimer's or dementia. Housekeeping, linen service, home maintenance, and all-inclusive utilities help make daily life easier. Transportation services are available for appointments or errands, so residents can get to where they need to go without worry.
Amenities like a full-service salon and beauty/barber shop, whirlpool room, accessible bathrooms, private mailboxes, cable and phone service with long-distance, plus pet-friendly policies and outdoor lounge areas make it practical and comfortable, and visitors are welcome in the lounges and patios. There are also complimentary laundry rooms, a courtyard, fitness and exercise centers, and even a fireplace and sitting area for relaxing at the end of the day. Bonaventure of Tigard sees to it that residents can have a maintenance-free lifestyle while staying connected and comfortable in a friendly, helpful, and joyful community, and the staff is recognized for being kind and supportive. The facility is reviewed biannually for its licensing, and memory care is provided in a residential care facility with specialized programs.
Founded in 1999 and headquartered in Salem, Oregon, Bonaventure Senior Living is a family-owned company operating 28 communities across Washington, Oregon, and Colorado. They offer independent living, assisted living, and memory care services with their "Retirement Perfected™" philosophy.
People often ask...
Bonaventure of Tigard offers competitive pricing, with rates starting at a cost of $6,000 per month.
Bonaventure of Tigard offers independent living, assisted living, and memory care.
There are 30 photos of Bonaventure of Tigard on Mirador.
Yes, Bonaventure of Tigard allows residents to age in place and adjust their level of care as needed.
The full address for this community is 15000 SW Hall Blvd, Tigard, OR 97224.
No, Bonaventure of Tigard 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.
Identified deficiencies across medication tracking, self-administration of meds, staffing based on acuity, staff training, and resident fire safety instruction.
Deficiency—Systems: Tracking Control Substances
Deficiency—Systems: Self-Administration of Meds
Deficiency—Staffing Requirements and Training: Staffing
Deficiency—Acuity Based Staffing Tool - ABST Time
Deficiency—Acuity Based Staffing Tool - Updates & Staffing Plan
Deficiency—Staffing Requirements and Training – Pre-service
Deficiency—Training Within 30 Days of Hire – Direct Care Staff
Deficiency—Fire and Life Safety: Training for Residents
16 Aug 2025Inspection
16 Aug 2025Inspection
Found staffing levels did not align with the Acuity-Based Staffing Tool and were insufficient to meet residents' needs.
Licensing—Failed to meet the scheduled and unscheduled needs of residents
16 Aug 2025Inspection
16 Aug 2025Inspection
Investigated the use of the Acuity-Based Staffing Tool, identified inconsistencies between the roster, care plans, and ABST data, and determined a violation of Oregon rules.
Licensing—Failed to use an ABST
14 Aug 2025Inspection
14 Aug 2025Inspection
Identified inconsistencies between the resident roster, care plans, and ABST data due to an outdated Acuity-Based Staffing Tool, violating applicable rules.
Licensing—Failed to use an ABST
08 Aug 2025Abuse: Neglect
08 Aug 2025Abuse: Neglect
Found neglect due to failure to plan for elopement risks and implement safety measures. The resident eloped from a secured area and staff were unaware.
Abuse—Failed to properly plan care
07 Aug 2025Inspection
07 Aug 2025Inspection
Identified deficiencies in updating the Acuity-Based Staffing Tool, with inconsistencies between the resident roster, care plans, and ABST data.
Licensing—Failed to use an ABST
26 Jul 2025Inspection
26 Jul 2025Inspection
Investigated the allegation and found that an acuity-based staffing tool was not developed, maintained, and implemented as required.
Licensing—Failed to provide service
10 Jun 2025Inspection
10 Jun 2025Inspection
Found failure to update the Acuity Based Staffing Tool at least quarterly. This failure violated Oregon Administrative Rules.
Licensing—Failed to use an ABST
30 May 2025Inspection
30 May 2025Inspection
Found that background checks were not submitted for all subject individuals to determine criminal fitness, constituting a licensing violation.
Licensing—Failed to hire according to administrative rules
30 May 2025Inspection
30 May 2025Inspection
Investigated an allegation of failing to properly plan care and found that quarterly evaluations on residents were not completed.
Licensing—Failed to properly plan care
30 May 2025Inspection
30 May 2025Inspection
Investigated and found inconsistencies between the resident roster, care plans, and ABST data, resulting in a violation of administrative rules.
Licensing—Failed to use an ABST
15 May 2025Abuse: Neglect
15 May 2025Abuse: Neglect
Found abuse by neglect resulting in harm to a resident when staff failed to intervene and to maintain a consistent daily routine to prevent an altercation.
Abuse—Failed to provide safe environment
11 May 2025Inspection
11 May 2025Inspection
Found a deficiency in updating the Acuity-Based Staffing Tool, resulting in inconsistencies between the resident roster, care plans, and ABST data.
Licensing—Failed to use an ABST
03 May 2025Inspection
03 May 2025Inspection
Determined that a deficiency occurred for not updating the Acuity Based Staffing Tool quarterly.
Licensing—Failed to use an ABST
01 May 2025Inspection
01 May 2025Inspection
Investigated a MAR-related allegation and found signatures on medication administration records for tasks completed by other staff, indicating MAR accuracy issues.
Licensing—Failed to provide a safe medication administration system
01 May 2025Inspection
01 May 2025Inspection
Identified failure to complete service plans after quarterly evaluations, violating Oregon Administrative Rules.
Licensing—Failed to properly plan care
15 Apr 2025Inspection
15 Apr 2025Inspection
Found insufficient awake qualified direct care staff to meet scheduled and unscheduled resident needs, including medication administration.
Licensing—Failed to provide appropriate staffing
10 Apr 2025Inspection
10 Apr 2025Inspection
Identified a deficiency for failing to update the Acuity Based Staffing Tool quarterly.
Licensing—Failed to use an ABST
06 Apr 2025Inspection
06 Apr 2025Inspection
Investigated the complaint and found a deficiency in safe medication administration and failure to test residents' blood sugar levels.
Licensing—Failed to provide a safe medication administration system
03 Apr 2025Abuse: Neglect
03 Apr 2025Abuse: Neglect
Investigated a failure to provide oxygen as required; findings substantiated that oxygen needs were not properly reflected in the care plan, risking serious harm.
Abuse—Failed to properly plan care
18 Mar 2025Complaint
18 Mar 2025Complaint
Investigated and found deficiencies in carrying out prescribed medication orders for one resident and in staffing to meet 24-hour needs.
Deficiency—Licensing Complaint Investigation
Deficiency—Systems: Treatment Orders
Deficiency—Staffing Requirements and Training: Staffing
Deficiency—Acuity Based Staffing Tool - Updates & Plan
23 Jan 2025Kitchen
23 Jan 2025Kitchen
Identified significant kitchen sanitation and storage deficiencies and dishwashing temperature problems; corrective actions initiated.
Identified sanitation and administration deficiencies after two visits, including significant kitchen sanitation issues and administration compliance concerns.
Investigated an altercation and found staff failed to monitor a resident per the service plan, resulting in injury; a fine was assessed for abuse by neglect.
Abuse—Failed to provide safe environment
29 Dec 2024Abuse: Neglect
29 Dec 2024Abuse: Neglect
Concluded that abuse by neglect occurred due to failure to properly plan safety for a known fall risk, leading to injuries.
Abuse—Failed to properly plan care
16 Dec 2024Inspection
16 Dec 2024Inspection
Found that a resident was not protected from physical abuse; a staff member threw a device at the resident, causing a head injury, and protections against abuse were not adequate.
Licensing—Failed to protect resident from physical abuse
09 Dec 2024Abuse: Neglect
09 Dec 2024Abuse: Neglect
Investigated allegations of neglect and abuse; found a failure to provide a safe environment, and a $375 fine was assessed.
Abuse—Failed to provide safe environment
04 Sept 2024Abuse: Neglect
04 Sept 2024Abuse: Neglect
Investigated an allegation that care staff did not follow the care plan for stand-by assist during ambulation, leading to an unwitnessed fall and a head wound; a fine was assessed.
Abuse—Failed to follow care plan
21 Aug 2024Inspection
21 Aug 2024Inspection
Investigated a failure to promptly notify the local Department office or local AAA of abuse or suspected abuse. Found a deficiency in timely notification.
Licensing—Failed to make facility or resident records accessible
09 Jun 2024Inspection
09 Jun 2024Inspection
Found inadequate qualified awake direct care staffing to meet 24-hour scheduled and unscheduled resident needs.
Licensing—Failed to meet the scheduled and unscheduled needs of residents
16 May 2024Abuse: Neglect
16 May 2024Abuse: Neglect
Investigated and found a failure to provide a safe environment, resulting in abuse and neglect, with a fine assessed.
Abuse—Failed to provide safe environment
16 May 2024Abuse: Neglect
16 May 2024Abuse: Neglect
Found a failure to provide a safe environment that constitutes abuse and neglect. A $375 fine was assessed.
Abuse—Failed to provide safe environment
09 Apr 2024Inspection
09 Apr 2024Inspection
Found insufficient qualified awake direct care staff to meet 24-hour scheduled and unscheduled needs of residents.
Licensing—Failed to meet the scheduled and unscheduled needs of residents
25 Oct 2023Licensure
25 Oct 2023Licensure
Identified deficiencies in kitchen sanitation practices and administration compliance, including improper food storage, labeling, and temperature controls.
Investigated the complaint about toileting assistance and call-light response; found neglect and abuse due to failing to follow the care plan, resulting in the resident's incontinence and humiliation, with a $250 fine assessed.
Abuse—Failed to follow care plan
23 Oct 2023Inspection
23 Oct 2023Inspection
Investigated an allegation of unsafe medication administration and found failure to visually observe residents taking medications.
Licensing—Failed to provide a safe medication administration system
02 Oct 2023Complaint
02 Oct 2023Complaint
Investigated a licensing complaint and identified deficiencies in service planning, medication administration, and treatment orders.
Deficiency—Licensing Complaint Investigation
Deficiency—Service Plan: General
Deficiency—Systems: Medication Administration
Deficiency—Systems: Treatment Orders
Deficiency—Staffing Requirements and Training: Staffing
02 Oct 2023Inspection
02 Oct 2023Inspection
Found that there were not enough qualified awake direct care staff to meet 24-hour needs, and residents were left without assistance when calling for help.
Licensing—Failed to provide appropriate staffing
02 Oct 2023Inspection
02 Oct 2023Inspection
Found that a service plan did not reflect the resident's needs identified in the evaluation. The related finding described leaving the resident wet and staff refusing to assist with bathroom needs.
Licensing—Failed to properly plan care
01 Sept 2023Inspection
01 Sept 2023Inspection
Found that the ABST was not updated to reflect resident care needs, with inconsistencies between the resident roster, care plans, and ABST data. This violated Oregon Administrative Rules.
Licensing—Failed to use an ABST
14 Aug 2023License Condition
14 Aug 2023License Condition
Investigated the complaint and found that records were falsified, and a written policy prohibiting falsification of records was not developed or implemented.
Regulatory Action—Failed to keep medication record current or accurate
14 Aug 2023License Condition
14 Aug 2023License Condition
Investigated and found that ABST was not fully implemented or updated as required.
Regulatory Action—Failed to use an ABST
14 Aug 2023License Condition
14 Aug 2023License Condition
Found insufficient awake direct care staff to meet residents' 24-hour needs.
Regulatory Action—Failed to meet the scheduled and unscheduled needs of residents
07 Aug 2023Inspection
07 Aug 2023Inspection
Identified missing physician orders for medications in resident records, indicating a record-keeping deficiency.
Licensing—Failed to obtain medication order
26 Jul 2023Abuse: Neglect
26 Jul 2023Abuse: Neglect
Investigated a complaint and found that a resident was not provided a safe environment, resulting in neglect and abuse.
Abuse—Failed to provide safe environment
18 Jun 2023Abuse: Neglect
18 Jun 2023Abuse: Neglect
Investigated a complaint and found a failure to provide a safe environment, resulting in abuse substantiation and a $500 fine.
Abuse—Failed to provide safe environment
02 Jun 2023Complaint
02 Jun 2023Complaint
Identified deficiencies in records and staffing processes, including acuity-based staffing considerations.
Deficiency—Licensing Complaint Investigation
Deficiency—Facility Administration: Records
Deficiency—Staffing Requirements and Training: Staffing
Deficiency—Acuity-Based Staffing Tool
02 Jun 2023Complaint
02 Jun 2023Complaint
Found deficiencies related to staffing requirements and training.
Deficiency—Licensing Complaint Investigation
Deficiency—Staffing Requirements and Training: Staffing
Deficiency—Staffing Requirements and Training – Pre-Serv
23 May 2023Abuse: Neglect
23 May 2023Abuse: Neglect
Investigated and found a failure to provide a safe medication administration system that led to a resident receiving another resident’s medications.
Abuse—Failed to provide a safe medication administration system
23 May 2023Inspection
23 May 2023Inspection
Found medication orders were not carried out as prescribed.
Licensing—Failed to administer medication as ordered
10 May 2023Inspection
10 May 2023Inspection
Determined that required services were not provided, with a resident not receiving showers for a week and staff not assisting with dressing a compression hose.
Licensing—Failed to provide service
09 May 2023Inspection
09 May 2023Inspection
Investigated an allegation that new staff were not oriented to the resident and their care needs; found that orientation was not provided before delivering personal care.
Licensing—Failed to provide service
09 May 2023Inspection
09 May 2023Inspection
Found that there were not enough qualified awake direct care staff to meet 24-hour scheduled and unscheduled needs, risking delayed responses to residents.
Licensing—Failed to provide appropriate staffing
28 Apr 2023Abuse: Neglect
28 Apr 2023Abuse: Neglect
Investigated and found that necessary services were not provided, constituting neglect and abuse; a $500 fine was assessed.
Abuse—Failed to provide service
13 Apr 2023Abuse: Neglect
13 Apr 2023Abuse: Neglect
Found a deficient safe medication administration system when the wrong medication was given, and training records were not provided; a $500 fine was assessed. Training gaps and risk to a resident were identified.
Abuse—Failed to provide a safe medication administration system
20 Feb 2023Abuse: Neglect
20 Feb 2023Abuse: Neglect
Found that staff failed to follow the care plan by missing the required two-hour safety checks, resulting in neglect and potential harm.
Abuse—Failed to follow care plan
06 Feb 2023Abuse: Neglect
06 Feb 2023Abuse: Neglect
Found an unsafe medication administration system that led to an incorrect insulin dose and hospital transport. A staff training gap contributed to the failure.
Abuse—Failed to provide a safe medication administration system
20 Dec 2022Abuse: Neglect
20 Dec 2022Abuse: Neglect
Found abuse and neglect due to failing to follow the care plan and insufficient staffing, which led to injuries.
Abuse—Failed to follow care plan
08 Dec 2022Abuse: Neglect
08 Dec 2022Abuse: Neglect
Investigated found violations of safe environment due to repeated falls with injuries, and a fine was assessed.
Abuse—Failed to provide safe environment
23 Oct 2022Abuse: Neglect
23 Oct 2022Abuse: Neglect
Investigated an abuse/neglect incident in which a resident punched another after approaching a room, resulting in a bloody lip and indicating a failure to provide a safe environment.
Abuse—Failed to provide safe environment
19 Oct 2022License Condition
19 Oct 2022License Condition
Cited a failure to update the ABST as required by Oregon Administrative Rules.
Regulatory Action—Failed to use an ABST
10 Oct 2022License Condition
10 Oct 2022License Condition
Investigated the allegation and identified a failure to meet residents' scheduled and unscheduled staffing needs due to not implementing an acuity-based staffing tool.
Regulatory Action—Failed to meet the scheduled and unscheduled needs of residents
20 Sept 2022Validation
20 Sept 2022Validation
Identified multiple deficiencies in resident records, health care services, infection control, and care planning during the re-licensure process, with follow-up efforts leading to substantial compliance.
Deficiency—Resident Move-In and Eval: Res Evaluation
Deficiency—Service Plan: General
Deficiency—Change of Condition and Monitoring
Deficiency—Resident Health Services
Deficiency—Rn Delegation and Teaching
Deficiency—Systems: Medications and Treatments
Deficiency—Systems: Tracking Control Substances
Deficiency—Systems: Medication Administration
Deficiency—Acuity-Based Staffing Tool
Deficiency—Training Within 30 Days: Direct Care Staff
Deficiency—Fire and Life Safety: Safety
Deficiency—Fire and Life Safety: Training For Residents
Deficiency—Inspections and Investigation: Insp Interval
Deficiency—General Building Exterior
Deficiency—Doors, Walls, Elevators, Odors
Deficiency—Administration Compliance
Deficiency—Staff Training Requirements
Deficiency—Compliance With Rules Health Care
Deficiency—Nutrition and Hydration
Deficiency—Activities
18 Sept 2022Abuse: Neglect
18 Sept 2022Abuse: Neglect
Found neglect due to failure to provide a safe environment and an adequate medication system, resulting in injury and missed medications.
Abuse—Failed to provide service
17 Sept 2022Abuse: Neglect
17 Sept 2022Abuse: Neglect
Found that staff failed to follow the care plan, resulting in neglect and abuse; a $500 fine was assessed.
Abuse—Failed to follow care plan
12 Sept 2022Validation
12 Sept 2022Validation
Identified multiple deficiencies in resident evaluations, change of condition monitoring, health service coordination, refusals, device safety, staffing, training, and fire safety instruction.
Deficiency—Comment
Deficiency—Resident Move-In and Eval: Res Evaluation
Deficiency—Change of Condition and Monitoring
Deficiency—Res Hlth Srvc: On- and Off-Site Health Srvc
Deficiency—Systems: Resident Right to Refuse
Deficiency—Restraints and Supportive Devices
Deficiency—Staffing Requirements and Training: Staffing
Deficiency—Acuity-Based Staffing Tool
Deficiency—Staffing Requirements and Training – Pre-Serv
Deficiency—Annual and Biennial Inservice For All Staff
Deficiency—Fire and Life Safety: Safety
Deficiency—Fire and Life Safety: Training For Residents
11 Sept 2022Abuse: Neglect
11 Sept 2022Abuse: Neglect
Concluded that a safe environment was not provided, constituting abuse and neglect.
Abuse—Failed to provide safe environment
11 Sept 2022Abuse: Neglect
11 Sept 2022Abuse: Neglect
Determined an unsafe environment led to harm; abuse/neglect confirmed with a $1,125 fine.
Abuse—Failed to provide safe environment
12 Jul 2022Abuse: Neglect
12 Jul 2022Abuse: Neglect
Identified inadequate supervision that allowed a resident to elope, constituting neglect and abuse; assessed a $375 fine.
Abuse—Failed to provide safe environment
11 Jun 2022Abuse: Neglect
11 Jun 2022Abuse: Neglect
Investigated the allegation and determined neglect and abuse occurred; a $500 fine was assessed.
Abuse—Failed to follow care plan
11 Dec 2021Abuse: Neglect
11 Dec 2021Abuse: Neglect
Determined that failure to follow the care plan allowed a resident to leave unsupervised and injure themselves; findings indicate abuse and neglect with a fine assessed.
Abuse—Failed to follow care plan
11 Nov 2021Abuse: Neglect
11 Nov 2021Abuse: Neglect
Found a failure to provide a safe environment that led to a resident’s fall and subsequent injury, and a $1,500 fine was assessed.
Abuse—Failed to provide safe environment
28 Oct 2021Abuse: Neglect
28 Oct 2021Abuse: Neglect
Investigated and found that a resident was not protected from inappropriate sexual contact, constituting abuse and neglect.
Abuse—Failed to protect resident from inappropriate sexual contact
18 Oct 2021Abuse: Neglect
18 Oct 2021Abuse: Neglect
Investigated an allegation of neglect and abuse and found failures to follow the care plan and to maintain a functioning door alarm, leading to elopement, severe head injury, hospitalization, and death.
Abuse—Failed to follow care plan
12 Oct 2021Abuse: Neglect
12 Oct 2021Abuse: Neglect
Investigated a complaint and found supervision was inadequate, allowing a resident to elope and be at risk; identified as neglect and abuse, with a fine assessed.
Abuse—Failed to provide safe environment
09 Aug 2021Abuse: Neglect
09 Aug 2021Abuse: Neglect
Found a failure to provide a safe environment for the resident, constituting abuse and neglect. A $375 fine was assessed.
Abuse—Failed to provide safe environment
16 Jul 2021Abuse: Neglect
16 Jul 2021Abuse: Neglect
Investigated a failure to provide hygiene and determined neglect resulting in skin breakdown. A $500 fine was assessed.
Abuse—Failed to provide or assist with hygiene
21 Jun 2021Abuse: Neglect
21 Jun 2021Abuse: Neglect
Investigated an elopement and found a failure to provide a safe environment for a resident. The finding indicates abuse/neglect with potential for harm.
Abuse—Failed to provide safe environment
28 May 2021Abuse: Neglect
28 May 2021Abuse: Neglect
Found a failure to administer an ordered insulin dose after an ER visit, resulting in an abuse/neglect finding.
Abuse—Failed to administer ordered medication
12 Apr 2021Inspection
12 Apr 2021Inspection
Investigated a complaint and found that bathing assistance to residents was not provided.
Licensing—Failed to provide or assist with hygiene
06 Jan 2021Inspection
06 Jan 2021Inspection
Investigated the allegation of insufficient staffing and found that awake, qualified direct care staff were not provided in sufficient numbers to meet scheduled and unscheduled resident needs.
Licensing—Failed to provide appropriate staffing
28 Dec 2020Inspection
28 Dec 2020Inspection
Investigated a sanitary food service allegation and found failures to prepare and serve food in sanitary conditions.
Licensing—Failed to provide sanitary food service conditions
25 Apr 2019Abuse: Neglect
25 Apr 2019Abuse: Neglect
Found neglect by failing to provide necessary services to maintain health and safety, risking serious harm; a $250 fine was assessed.
Abuse—Failed to provide service
25 Apr 2019Inspection
25 Apr 2019Inspection
Determined that there was a failure to report suspected abuse and assessed a $1,000 fine.
Licensing—Failed to report potential or suspected abuse
04 Apr 2019Abuse: Neglect
04 Apr 2019Abuse: Neglect
Investigated an allegation that a resident was not safe and found a failure to provide a safe environment.
Abuse—Failed to assure resident was safe
14 Nov 2018Abuse: Neglect
14 Nov 2018Abuse: Neglect
Found a deficiency for failing to provide a safe environment for residents, resulting in a $250 fine.
Abuse—Failed to assure resident was safe
14 Nov 2018Inspection
14 Nov 2018Inspection
Found that suspected abuse was not reported; a $750 fine was assessed.
Licensing—Failed to report potential or suspected abuse
18 Oct 2018Inspection
18 Oct 2018Inspection
Found violations involving failure to assist with transfer and neglect of care, resulting in injury or pain.
Licensing—Failed to assist with transfer
18 Sept 2018Abuse: Neglect
18 Sept 2018Abuse: Neglect
Found safety deficiencies related to protecting residents from inappropriate sexual contact. A fine was assessed.
Abuse—Failed to protect resident from inappropriate sexual contact
04 Sept 2018Abuse: Financial abuse
04 Sept 2018Abuse: Financial abuse
Investigated an allegation of financial exploitation and found a failure to protect a resident from financial exploitation and a failure to provide a safe environment, with theft of property involved.
Abuse—Failed to protect resident from financial exploitation
23 Dec 2017Abuse: Financial abuse
23 Dec 2017Abuse: Financial abuse
Found that a secure environment was not provided.
Abuse—Failed to provide safe environment
12 Dec 2017Inspection
12 Dec 2017Inspection
Concluded that a safe environment was not provided.
Licensing—Failed to provide safe environment
01 Dec 2017Inspection
01 Dec 2017Inspection
Found that a secured environment was not provided.
Licensing—Failed to provide safe environment
22 Jun 2017Abuse: Financial abuse
22 Jun 2017Abuse: Financial abuse
Investigated and found a failure to protect the RV from theft.
Abuse—Failed to provide safe environment
22 Sept 2016Inspection
22 Sept 2016Inspection
Investigated an allegation of failing to provide a safe environment. Found a deficiency and assessed a $200 civil penalty.
Licensing—Failed to provide safe environment
15 Sept 2016Abuse: Neglect
15 Sept 2016Abuse: Neglect
Found a failure to provide a safe environment, resulting in substantiated abuse/neglect.
Abuse—Failed to provide safe environment
10 Aug 2016Abuse: Neglect
10 Aug 2016Abuse: Neglect
Investigated an allegation of neglect and identified failures to properly plan care and to provide a safe environment.
Abuse—Failed to properly plan care
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