I moved my mom here and I'm very pleased. The staff are friendly, attentive and knowledgeable, the community is clean and well-maintained with lovely, park-like grounds, and there are plenty of engaging activities and on-site memory care. Meals, housekeeping and communication have been good, and the convenient location gives us peace of mind - I would 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
Coordination with health care providers
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
Special dietary restrictions
Room
Air-conditioning
Cable
Fully furnished
Housekeeping and linen services
Internet
Kitchenettes
Private bathrooms
Telephone
Wifi
Memory care community services
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
Pet friendly
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
3.81·(128)
Overall rating
5
4
3
2
1
Care
3.5
Staff
3.8
Meals
3.1
Amenities
3.6
Value
2.7
Pros
Compassionate, attentive caregiving team
Active, varied activities program (arts, outings, fitness)
Robust memory-care programming with high staff-to-resident ratio
Clean, bright common areas with a resort-like ambiance
Well-maintained landscaped grounds and wildlife views
Proximity to Meridian Park Hospital and convenient I-5 access
Housekeeping and laundry services included
Dining with multiple entree choices and room-delivery option
On-site amenities (salon, patios, gardens, pet therapy)
Flexible month-to-month housing and structured service plan
Transportation shuttle service for nearby destinations
Small, home-like community atmosphere
Cons
Inconsistent staffing levels and frequent employee turnover
Variable responsiveness and gaps in family communication
Inconsistent meal quality and limited menu variety
Interior maintenance deficits and dated apartment finishes
Sanitation and housekeeping inconsistencies in resident rooms
Medication-management and documentation concerns
Opaque billing and unclear extra-fee policies
Limited transportation radius for medical appointments
Small memory-care capacity and occasional restrictive programming
Uneven admissions orientation and follow-through processes
Summary of reviews
Brookdale River Valley Tualatin elicits a broad range of family impressions: many families praise the facility's caregiving staff, activity offerings, grounds and proximity to medical services, while others raise operational concerns that affect day-to-day experience. The community presents as a small, home-like campus with bright common areas, patios and well-maintained landscaped grounds that many reviewers found calming and attractive. The location near Meridian Park Hospital and easy access to I‑5 are frequently noted as advantages.
Care quality and staffing: Staff are commonly described as compassionate, attentive and able to form close relationships with residents; memory-care staff in particular are repeatedly commended for engagement and a higher staff-to-resident ratio. At the same time, reviewers describe uneven staffing levels, periods of turnover, and occasional slow response times to calls for assistance. These patterns translate into variable experiences with timeliness of care, medication handling, and consistency of assigned caregivers. A small number of reviews include serious allegations about medication administration and staff conduct; these should prompt direct inquiry during tours and contract review.
Dining: The community offers an open-dining format with multiple entree choices, meal-delivery options, and generally generous portions. Several families appreciated the dining environment and friendly dining staff. However, dining quality is inconsistent: menu variety and preparation standards are described as cafeteria-style or mass-produced in some accounts, with occasional complaints about cold meals or unappealing dishes. Prospective residents should sample meals and ask about dietary accommodations and menu rotation.
Activities and social life: Activities are a strong point for many households. The program includes arts and crafts, gardening and raised beds, live music, group games, outings, fitness classes and animal therapy visits. Families describe an engaged activities coordinator and many opportunities for socialization; a few reviewers requested more personalized engagement for residents with advanced dementia.
Facilities and maintenance: Common areas are frequently described as clean, bright and resort-like, and renovations or upgrades to shared spaces are underway in places. Units vary: some apartments are well-appointed with balconies and good natural light, while others show dated finishes, maintenance needs (loose closet doors, worn cabinetry), and inconsistent housekeeping attention. Sanitation and room-cleaning frequency are cited as strengths by some families and as concerns by others, indicating variability in execution.
Management, admissions and billing: Experiences with administration and admissions are mixed. Several families report responsive managers and helpful admissions staff; others describe unclear follow-through after move-in, inconsistent communication, billing errors, and lack of clarity about included services and extra fees (community fee, point-based service plans, medication-management fees, etc.). There are also comments about marketing and sales pressure. Prospective families should request a clear, itemized fee schedule and ask how staffing ratios and turnover are managed.
Notable patterns and guidance for families: Reviewers’ experiences cluster at two ends — many highly positive accounts of caring staff, strong activities and pleasant grounds, and a set of critical accounts focused on staffing consistency, dining quality, maintenance, communication, and medication/documentation practices. Prospective residents should tour the memory-care area (and ask about capacity and program restrictions), sample meals, review the contract for extra charges and the service-plan point system, inquire about current staffing levels and turnover, and ask for examples of how the community addresses complaints and medication errors. A focused walk-through of an occupied apartment and direct conversations with current families can help assess how consistently the facility delivers on the strengths many families describe.
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Location
Brookdale River Valley Tualatin is located at 19200 SW 65th Ave, Tualatin, OR, 97062.
About Brookdale River Valley Tualatin
Brookdale River Valley Tualatin sits in Tualatin, Oregon, close to Legacy Meridian Park Hospital and near highways I-5 and I-205, so getting to and from the community tends to be easy, and the grounds have attractive landscaping, a covered driveway, and patios with seating that let folks enjoy the outdoors and watch the seasonal leaves change, plus there's always space outside for some company or a breath of fresh air. The building offers a range of living options, including studios, one-bedroom, and suite layouts, with private rooms that get natural light through their windows or glass doors and often come with wood-style flooring, beds already made up with comforters, and storage with a dresser and nightstand. Inside, residents can find a library, a movie room, a fireplace, a billiards room with card tables, and computers to use, along with common areas for relaxing or socializing and spacious dining rooms with nice views out the windows when people gather for meals made with quality ingredients. The community has 120 beds, 26 for memory care, and supports different needs by offering independent living for those who want less chores and more social time, assisted living for help with things like dressing, eating, or bathing, and memory care for someone dealing with Alzheimer's or dementia, with care plans developed alongside the resident so everyone knows what's needed each day. They've also got skilled nursing on site for those requiring medical help and continuing care retirement programs for changing needs, while daily life includes things like housekeeping, laundry, transportation, and pet-friendly features, plus amenities like a beauty and barber shop and internet access for folks who want to keep in touch with family or read the news. Brookdale River Valley Tualatin participates in the Best of Senior Living awards, and the staff here is known for being friendly and helpful, so the community feels warm and people stick around to chat in the courtyard or join in events and signature programs that keep everyone moving or learning. The facility follows standards set by the Oregon Health Care Association and includes medication management and help with daily activities as part of its regular services. People often mention how meals are nutritious and shared with friends in the dining rooms, and the outdoor spaces get used for both group activities and quiet moments. They've got a dedicated website page for information and keep a blog going to let residents and families know what's new. This assisted living community from the Brookdale Senior Living network covers everything from independent living to skilled care, giving seniors and their families one spot for both today's needs and whatever might come tomorrow.
About Brookdale
Brookdale River Valley Tualatin is managed by Brookdale.
Brookdale Senior Living Inc. (NYSE: BKD) is the largest senior living operator in the United States, managing over 640 communities with capacity for approximately 59,000 residents across 41 states and employing around 36,000 associates. Founded in 1978 and publicly traded since 2005, Brookdale solidified its market leadership through major acquisitions including American Retirement Corporation (2006) and Emeritus Senior Living (2014), making it the only national full-spectrum senior living company. Headquartered in Nashville, Tennessee, Brookdale has topped the American Seniors Housing Association's ASHA 50 list and Argentum's largest providers list for multiple consecutive years.
The company's comprehensive care continuum includes independent living, assisted living, memory care, skilled nursing, and continuing care retirement communities (CCRCs). Brookdale's signature Clare Bridge program, developed over 30 years ago by dementia-care experts, provides specialized Alzheimer's and dementia care through two distinct levels: Clare Bridge communities for comprehensive memory support and the Clare Bridge Solace program for advanced-stage dementia residents. The program is recognized by the Alzheimer's Association® for incorporating evidence-based Dementia Care Practice Recommendations and features secure environments, enclosed courtyards, Daily Path programming with six structured activities daily, and the InTouch technology platform offering personalized brain-stimulating games and therapeutic content.
Brookdale's holistic Optimum Life® wellness approach balances six dimensions—Purposeful, Physical, Emotional, Social, Spiritual, and Intellectual—implemented through signature programs including B-Fit (eight exercise class options), Brain Fit (mental fitness workouts), My Life Story (resident storytelling), EngagementPlus (interest-based connections), Growing Together (collaborative learning), and The Ageless Spirit (kindness and gratitude practices). The Embrace Family Partnership provides caregiver education and support for families of memory care residents.
The company's Brookdale HealthPlus® care coordination model, winner of the 2024 Argentum Best of the Best Award placing it among the top 1% of operators, is a technology-enabled healthcare service featuring dedicated RN Care Managers who proactively manage residents' health, coordinate care transitions, and help prevent avoidable hospitalizations. Communities using HealthPlus report 78% fewer urgent care visits, 36% fewer hospitalizations, and 63% more completed annual wellness visits. The Personal Solutions program delivers hygiene products, medications, and daily necessities directly to residents' doors with discreet packaging and monthly billing convenience.
Following a strategic divestiture of its home health and hospice operations to HCA Healthcare (completed December 2023), Brookdale now focuses exclusively on senior living operations while maintaining its position as the industry's largest operator, committed to its mission of enriching lives with compassion, respect, excellence, and integrity.
People often ask...
Brookdale River Valley Tualatin offers competitive pricing, with rates starting at a cost of $5,634 per month.
Brookdale River Valley Tualatin offers independent living, assisted living, and memory care.
There are 27 photos of Brookdale River Valley Tualatin on Mirador.
Yes, Brookdale River Valley Tualatin allows residents to age in place and adjust their level of care as needed.
The full address for this community is 19200 SW 65th Ave, Tualatin, OR 97062.
No, Brookdale River Valley Tualatin 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 in resident evaluations, service planning, and medication management, including incomplete move-in assessments, unclear service plans, inaccurate medication records, and inadequate handling of refusals and PRN psychotropic medications.
Deficiency—Resident Move-in & Evaluation: Res Evaluation
Deficiency—Service Plan: General
Deficiency—Systems: Resident Right to Refuse
Deficiency—Systems: Medication Administration
Deficiency—Systems: Self-Administration of Meds
Deficiency—Systems: Psychotropic Medication
Deficiency—Compliance with Rules Health Care
28 Dec 2025Inspection
28 Dec 2025Inspection
Found service plans did not reflect residents' needs and preferences identified in evaluations. This violated Oregon Administrative Rule.
Licensing—Failed to provide service
28 Dec 2025Inspection
28 Dec 2025Inspection
Found a violation of Change of Conditions and Monitoring requirements; the allegation of failing to obtain appropriate consultation accompanied the finding.
Licensing—Failed to obtain appropriate consultation
03 Jul 2025Complaint
03 Jul 2025Complaint
Identified deficiencies in acuity-based staffing oversight and shift staffing plans, including mismatches between the staffing tool and the posted plan and resident-specific ADL data.
Deficiency—Acuity Based Staffing Tool - Updates & Plan
03 Jul 2025Inspection
03 Jul 2025Inspection
Investigated an allegation of an unsafe environment and found the provider failed to evaluate and monitor the resident, refer to the nurse, document changes, and update the service plan in line with state requirements.
Licensing—Failed to provide safe environment
03 Jul 2025Inspection
03 Jul 2025Inspection
Found a deficiency in implementing a service plan that reflects residents' needs, violating regulatory requirements.
Licensing—Failed to follow care plan
09 Apr 2025Kitchen
09 Apr 2025Kitchen
Identified deficiencies in kitchen sanitation practices and administration compliance, including observed cleaning needs and failure to follow licensing rules.
Investigated the allegation of financial exploitation and determined that no licensing violation or abuse occurred.
Licensing—Failed to protect resident from financial exploitation
24 Jul 2024Inspection
24 Jul 2024Inspection
Investigated the allegation of failing to provide a safe environment and found a deficiency in fully implementing and updating an acuity-based staffing tool.
Licensing—Failed to provide safe environment
01 May 2024Abuse: Neglect
01 May 2024Abuse: Neglect
Found a failure to provide a safe environment when the backyard gate was left unlocked, allowing a resident to leave unaccompanied into a busy roadway, risking harm.
Abuse—Failed to provide safe environment
13 Feb 2024Abuse: Neglect
13 Feb 2024Abuse: Neglect
Investigated found the 1:1 care requirement wasn't followed, and an incident involved striking another person, causing pain; a $169 fine was assessed.
Abuse—Failed to follow care plan
12 Feb 2024Abuse: Neglect
12 Feb 2024Abuse: Neglect
Investigated and found neglect and abuse due to failing to transfer a resident to bed, leaving them in a wheelchair overnight and causing discomfort. A $500 fine was assessed.
Abuse—Failed to properly plan care
12 Feb 2024Abuse: Neglect
12 Feb 2024Abuse: Neglect
Identified failures to provide the ordered diet and to assist with meals, risking dehydration and aspiration. Also found repeated serving of the wrong diet texture and lack of eating assistance.
Abuse—Failed to provide medical treatment as ordered
07 Dec 2023Licensure
07 Dec 2023Licensure
Found deficiencies in kitchen sanitation and food handling during the December 2023 finding; a March 2024 revisit confirmed compliance with applicable rules.
Found a deficiency in acuity-based staffing tool implementation and updates. It did not meet the required staffing tool standards.
Licensing—Failed to provide safe environment
23 Nov 2023Abuse: Neglect
23 Nov 2023Abuse: Neglect
Found a failure to provide a safe environment that led to a resident fall; a $188 fine was assessed.
Abuse—Failed to provide safe environment
18 Oct 2023Complaint
18 Oct 2023Complaint
Found staffing shortages and language barriers that affected resident care and delayed call-light responses.
Deficiency—Licensing Complaint Investigation
Deficiency—Staffing Requirements and Training: Staffing
Deficiency—Acuity-Based Staffing Tool
Deficiency—Training Within 30 Days: Direct Care Staff
18 Oct 2023Inspection
18 Oct 2023Inspection
Determined that qualified awake direct care staff were not provided in sufficient numbers to meet 24-hour needs.
Licensing—Failed to provide service
17 Oct 2023Inspection
17 Oct 2023Inspection
Found deficiencies in staff communication and language skills that hindered their ability to communicate with residents, staff, family members, and health care professionals.
Licensing—Failed to provide service
17 Oct 2023Inspection
17 Oct 2023Inspection
Found insufficient qualified direct care staff to meet residents' scheduled and unscheduled needs.
Licensing—Failed to provide service
15 Aug 2023Inspection
15 Aug 2023Inspection
Found that showers and safe transferring assistance were not provided. The finding was classified as a violation.
Licensing—Failed to provide service
24 May 2023Inspection
24 May 2023Inspection
Found that staff lacked sufficient communication and language skills required by the rule.
Licensing—Failed to provide service
24 May 2023Inspection
24 May 2023Inspection
Found insufficient qualified awake direct care staff to meet 24-hour needs.
Licensing—Failed to provide service
22 May 2023Inspection
22 May 2023Inspection
Found insufficient qualified awake direct care staff to meet residents' scheduled and unscheduled needs.
Licensing—Failed to provide service
21 Apr 2023License Condition
21 Apr 2023License Condition
Found insufficient staffing to meet residents' scheduled and unscheduled needs, including 2-person transfers and unanswered call lights.
Regulatory Action—Failed to meet the scheduled and unscheduled needs of residents
21 Apr 2023License Condition
21 Apr 2023License Condition
Found failure to implement an Acuity-Based Staffing Tool as required.
Regulatory Action—Failed to use an ABST
05 Feb 2023Abuse: Neglect
05 Feb 2023Abuse: Neglect
Found that care planning and interventions for fall history were not properly implemented, leading to pain and discomfort.
Abuse—Failed to properly plan care
24 Dec 2022Abuse: Neglect
24 Dec 2022Abuse: Neglect
Investigated an allegation of neglect and found failures in care planning for fall history, leading to an unwitnessed fall and head injury and resulting pain.
Abuse—Failed to properly plan care
30 Nov 2022Inspection
30 Nov 2022Inspection
Investigated found that a staff member pushed a resident back into a chair, causing discomfort, and that the facility failed to protect the resident from physical abuse.
Licensing—Failed to protect resident from physical abuse
17 Nov 2022Inspection
17 Nov 2022Inspection
Investigated the allegation of financial exploitation and concluded that a resident's property was not protected from theft, leading to substantiation.
Licensing—Failed to protect resident from financial exploitation
15 Nov 2022Validation
15 Nov 2022Validation
Found multiple deficiencies across governance, resident rights, care planning, monitoring of condition changes, health services, infection control, medication management, safety, and staff training during a relicensure process.
Deficiency—Comment
Deficiency—Facility Administration: Operation
Deficiency—Resident Rights and Protection - General
Deficiency—Resident Move-In and Eval: Res Evaluation
Deficiency—Service Plan: General
Deficiency—Service Plan: Service Planning Team
Deficiency—Change of Condition and Monitoring
Deficiency—Resident Health Services
Deficiency—Infection Prevention & Control
Deficiency—Systems: Tracking Control Substances
Deficiency—Systems: Self-Administration of Meds
Deficiency—Restraints and Supportive Devices
Deficiency—Staffing Requirements and Training – Pre-Serv
Deficiency—Training Within 30 Days: Direct Care Staff
Deficiency—Annual and Biennial Inservice For All Staff
Deficiency—Fire and Life Safety: Safety
Deficiency—Fire and Life Safety: Training For Residents
Deficiency—Inspections and Investigation: Insp Interval
Deficiency—Administration Compliance
Deficiency—Staff Training Requirements
Deficiency—Compliance With Rules Health Care
Deficiency—Behavior
Deficiency—Outside Area
12 Nov 2022Abuse: Neglect
12 Nov 2022Abuse: Neglect
Investigated a complaint and found a failure to implement interventions and care planning for a resident’s fall history, resulting in an unwitnessed fall with head injury and discomfort. A $1500 fine was assessed.
Abuse—Failed to properly plan care
27 Oct 2022Inspection
27 Oct 2022Inspection
Found insufficient direct care staff to meet scheduled and unscheduled resident needs.
Licensing—Failed to provide service
27 Oct 2022Inspection
27 Oct 2022Inspection
Found that the Acuity Based Staffing Tool was not fully implemented and updated as required.
Licensing—Failed to provide service
18 Oct 2022Inspection
18 Oct 2022Inspection
Investigated a complaint and found medication administration did not follow orders as prescribed.
Licensing—Failed to administer medication as ordered
18 Oct 2022Inspection
18 Oct 2022Inspection
Investigated and confirmed a deficiency that the medication administration record was not kept current with post-operation medications.
Licensing—Failed to keep medication record current or accurate
04 Oct 2022Complaint
04 Oct 2022Complaint
Identified multiple deficiencies affecting resident health and safety, including inadequate ADL assistance, improper medication/treatment administration, staffing gaps, and communication barriers.
Deficiency—Reasonable Precautions
Deficiency—Resident Services: Adls
Deficiency—Service Plan: General
Deficiency—Systems: Treatment Orders
Deficiency—Systems: Medication Administration
Deficiency—Staffing Requirements and Training: Staffing
Deficiency—Acuity-Based Staffing Tool
Deficiency—Training Within 30 Days: Direct Care Staff
12 Sept 2022Inspection
12 Sept 2022Inspection
Found a deficiency for unsafe medication administration that resulted in administering another resident's medication.
Licensing—Failed to provide a safe medication administration system
07 Aug 2022Abuse: Neglect
07 Aug 2022Abuse: Neglect
Investigated and found a failure to follow the care plan related to fall history, leading to a fall and injury. A $250 fine was assessed.
Abuse—Failed to follow care plan
11 Jul 2022Abuse: Neglect
11 Jul 2022Abuse: Neglect
Found neglect for failing to provide a safe environment, risking resident safety; a $250 fine assessed.
Abuse—Failed to provide safe environment
05 Jun 2022Abuse: Neglect
05 Jun 2022Abuse: Neglect
Investigated a failure to properly plan care related to a resident's fall history, resulting in injury and discomfort.
Abuse—Failed to properly plan care
19 May 2022Abuse: Neglect
19 May 2022Abuse: Neglect
Found a failure to provide a safe medication administration system, resulting in injections given without meals and an ER visit.
Abuse—Failed to provide a safe medication administration system
17 May 2022Abuse: Neglect
17 May 2022Abuse: Neglect
Investigated violations found failure to plan and implement care for a resident's fall history, leading to injury and discomfort; a fine was assessed.
Abuse—Failed to properly plan care
01 Mar 2022Inspection
01 Mar 2022Inspection
Found a deficiency for failing to submit timely or adequate staffing documentation. Occurred for 27 days in February 2022.
Licensing—Failed to submit timely or adequate staffing documentation
01 Mar 2022Inspection
01 Mar 2022Inspection
Found insufficient staffing to meet residents' scheduled and unscheduled needs. The deficiency included inadequate staffing to assist with bathing and laundry.
Licensing—Failed to provide appropriate staffing
23 Feb 2022Inspection
23 Feb 2022Inspection
Found a failure to protect a resident from financial exploitation. An individual entrusted to assist did not return with the debit card or funds.
Licensing—Failed to protect resident from financial exploitation
01 Feb 2022Inspection
01 Feb 2022Inspection
Found a violation for failing to provide a safe environment when feces-covered bedding was left in residents' showers.
Licensing—Failed to provide safe environment
01 Feb 2022Inspection
01 Feb 2022Inspection
Investigated and substantiated failure to provide services per the service plan, including not cutting up residents' food as required.
Licensing—Failed to provide service
01 Feb 2022Abuse: Neglect
01 Feb 2022Abuse: Neglect
Found failure to provide appropriate services according to the resident's needs, resulting in the resident being soiled and losing dignity, constituting neglect and abuse.
Abuse—Failed to provide service
01 Feb 2022Inspection
01 Feb 2022Inspection
Found failure to provide household services as required, with meals left in residents' rooms for more than five days.
Licensing—Failed to provide service
20 Jan 2022Inspection
20 Jan 2022Inspection
Found that staff lacked sufficient communication and language skills to interact with residents, family members, other staff, and health care professionals.
Licensing—Failed to provide appropriate staffing
11 Oct 2021Inspection
11 Oct 2021Inspection
Investigated and found failure to follow medication orders and to discontinue use after physician orders were discontinued.
Licensing—Failed to administer medication as ordered
11 Sept 2021Inspection
11 Sept 2021Inspection
Investigated an allegation of sexual abuse and found the resident was not protected from sexual abuse.
Licensing—Failed to protect resident from inappropriate sexual contact
09 Sept 2021Abuse: Neglect
09 Sept 2021Abuse: Neglect
Investigated a complaint and found that cash belonging to a resident was missing due to financial exploitation, and protection from exploitation was not provided. A $250 fine was assessed.
Abuse—Failed to protect resident from financial exploitation
26 Jul 2021Inspection
26 Jul 2021Inspection
Found that resident service plans did not reflect residents' needs.
Licensing—Failed to properly plan care
26 Jul 2021Inspection
26 Jul 2021Inspection
Verified lack of incident response policies and procedures.
Licensing—Failed to investigate injury of unknown origin to rule out abuse
26 Jul 2021Inspection
26 Jul 2021Inspection
Investigated the allegation and verified obstruction of stairways, halls, doorways, passageways, and exits.
Licensing—Failed to provide safe environment
26 Jul 2021Inspection
26 Jul 2021Inspection
Found that exit doors were not equipped with an alarm or acceptable system to alert staff when residents exited.
Licensing—Failed to maintain functional door alarm or call system
01 Jun 2021Abuse: Neglect
01 Jun 2021Abuse: Neglect
Investigation found a failure to protect a resident from inappropriate sexual contact and neglect due to inadequate interventions and care planning. A $1,013 fine was assessed.
Abuse—Failed to protect resident from inappropriate sexual contact
10 May 2021Inspection
10 May 2021Inspection
Found that services to assist with activities of daily living, including oral and nail care, were not provided as required.
Licensing—Failed to provide service
05 May 2021Abuse: Neglect
05 May 2021Abuse: Neglect
Investigated and found a failure to provide a safe environment resulting in abuse and neglect; a $375 fine was assessed.
Abuse—Failed to provide safe environment
25 Mar 2021Abuse: Neglect
25 Mar 2021Abuse: Neglect
Found a failure to provide a safe medication administration system, leaving a resident at risk due to medication found unused. A $500 fine was assessed.
Abuse—Failed to administer ordered medication
25 Mar 2021Inspection
25 Mar 2021Inspection
Investigated and found a violation for not visually observing residents take their medications.
Licensing—Failed to administer medication as ordered
19 Mar 2021Abuse: Neglect
19 Mar 2021Abuse: Neglect
Investigated an allegation of improper care planning for a resident; findings showed failure to properly care plan, risking serious harm and constituting abuse and neglect. A $500 fine was assessed.
Abuse—Failed to properly plan care
19 Feb 2021Abuse: Neglect
19 Feb 2021Abuse: Neglect
Identified violations for neglect and abuse due to failure to properly plan care related to a resident's fall history, resulting in injury and discomfort.
Abuse—Failed to properly plan care
20 Jan 2021Abuse: Neglect
20 Jan 2021Abuse: Neglect
Found neglect for not following the care plan, resulting in an unwitnessed fall with injury.
Abuse—Failed to follow care plan
03 Nov 2020Abuse: Neglect
03 Nov 2020Abuse: Neglect
Investigated a neglect and abuse allegation found that a staff member did not follow the resident's care plan during repositioning, causing pain; a fine was assessed.
Abuse—Failed to follow care plan
30 Sept 2020Abuse: Neglect
30 Sept 2020Abuse: Neglect
Found inadequate supervision that allowed a resident to elope, creating risk of harm.
Abuse—Failed to provide safe environment
30 Sept 2020Abuse: Neglect
30 Sept 2020Abuse: Neglect
Found neglect and abuse due to failure to provide a non-slip mat during bathing and to address post-fall pain, resulting in an injury and a $450 fine.
Abuse—Failed to provide service
29 Sept 2020Abuse: Neglect
29 Sept 2020Abuse: Neglect
Found failure to implement interventions and care planning for a resident's fall history, which led to another fall with injury.
Abuse—Failed to properly plan care
29 Sept 2020Abuse: Neglect
29 Sept 2020Abuse: Neglect
Identified deficiencies in resident services and skin care that led to wounds and hospital transport, and assessed a $2,500 fine.
Abuse—Failed to provide service
04 Sept 2020Abuse: Neglect
04 Sept 2020Abuse: Neglect
Found neglect and abuse due to failure to provide appropriate services, resulting in a resident wearing urine-soaked clothes on two occasions in late August 2020 and early September 2020. A fine of $1,350 was assessed.
Abuse—Failed to provide service
24 Aug 2020Inspection
24 Aug 2020Inspection
Found a violation involving failure to visually observe medication administration unless the prescriber allowed otherwise.
Licensing—Failed to provide a safe medication administration system
24 Aug 2020Inspection
24 Aug 2020Inspection
Found service plans did not reflect residents' needs and preferences.
Licensing—Failed to properly plan care
18 Aug 2020Abuse: Neglect
18 Aug 2020Abuse: Neglect
Found neglect and abuse due to failure to provide adequate services and respond to a resident’s change in condition, resulting in hospitalization for open wounds and poor hygiene.
Abuse—Failed to provide service
13 Aug 2020Abuse: Neglect
13 Aug 2020Abuse: Neglect
Found that a resident's belongings and funds were not protected, resulting in loss and financial exploitation; a $450 fine was assessed.
Abuse—Failed to protect resident from financial exploitation
08 Jul 2020Abuse: Neglect
08 Jul 2020Abuse: Neglect
Determined neglect and abuse from failing to plan care for a resident's fall history, resulting in an unwitnessed fall and hospital transfer with injury.
Abuse—Failed to properly plan care
02 Jul 2020Inspection
02 Jul 2020Inspection
Determined that a safe medication administration system was not provided.
Licensing—Failed to provide a safe medication administration system
09 Jun 2020Inspection
09 Jun 2020Inspection
Investigated a medication administration issue and found orders were not carried out as prescribed.
Licensing—Failed to administer medication as ordered
26 May 2020Inspection
26 May 2020Inspection
Investigated an allegation that immediate written notice was not provided to a resident when service rates increased; the issue was verified.
Licensing—Failed to communicate necessary information
14 May 2020Inspection
14 May 2020Inspection
Investigated an allegation of failing to communicate necessary information; found that relevant information and documentation were not provided to an outside provider or emergency personnel.
Licensing—Failed to communicate necessary information
11 May 2020Abuse: Neglect
11 May 2020Abuse: Neglect
Investigated and found neglect due to failure to implement appropriate interventions and monitoring for a resident with known fall history, resulting in head bruising; a fine was assessed.
Abuse—Failed to assure resident was safe
04 May 2020Abuse: Neglect
04 May 2020Abuse: Neglect
Found neglect and abuse due to failure to meet the resident's needs and follow a hydration plan, which led to possible dehydration. A fine was assessed.
Abuse—Failed to provide service
01 May 2020Inspection
01 May 2020Inspection
Found that residents' water intake was not monitored, indicating a hydration deficiency.
Licensing—Failed to assure proper hydration
01 May 2020Inspection
01 May 2020Inspection
Investigated a diabetic diet deficiency and found that the resident did not receive a diabetic diet.
Licensing—Failed to provide a therapeutic diet
24 Apr 2020Inspection
24 Apr 2020Inspection
Investigated the complaint and found medication orders were not followed, and the wrong medicine was given.
Licensing—Failed to keep resident record current or accurate
24 Apr 2020Inspection
24 Apr 2020Inspection
Investigated an allegation that necessary information wasn't communicated; findings confirmed the issue.
Licensing—Failed to communicate necessary information
24 Apr 2020Inspection
24 Apr 2020Inspection
Investigated the allegation and found a policy failure prohibiting falsification of records.
Licensing—Failed to provide a safe medication administration system
17 Apr 2020Abuse: Neglect
17 Apr 2020Abuse: Neglect
Investigated a failure to follow the resident's care plan and provide supervision, which led to the resident leaving unsupervised and being transported to the hospital, exposing them to risk of serious harm. A fine was assessed.
Abuse—Failed to follow care plan
28 Mar 2020Abuse: Neglect
28 Mar 2020Abuse: Neglect
Investigated and found neglect and abuse due to failure to seek timely medical treatment and to ensure a call pendant was worn, resulting in an unwitnessed fall and hospital transfer.
Abuse—Failed to assure timely medical treatment
17 Mar 2020Inspection
17 Mar 2020Inspection
Found failure to provide modified special diets appropriate for residents' needs.
Licensing—Failed to provide a therapeutic diet
06 Feb 2020Abuse: Neglect
06 Feb 2020Abuse: Neglect
Found neglect and abuse due to failure to provide a safe environment and adequately monitor residents, leading to a physical altercation and injury to the alleged victim.
Abuse—Failed to provide safe environment
29 Jan 2020Inspection
29 Jan 2020Inspection
Found that a resident was financially exploited and protection against exploitation failed.
Licensing—Failed to protect resident from financial exploitation
21 Sept 2019Abuse: Neglect
21 Sept 2019Abuse: Neglect
Found neglect and abuse due to improper care planning for a resident's skin injuries, which led to another injury. A fine was assessed.
Abuse—Failed to properly plan care
20 Aug 2019Abuse: Neglect
20 Aug 2019Abuse: Neglect
Investigated the complaint and found neglect due to inadequate supervision that led to an elopement and risk of serious harm; a $375 fine was assessed.
Abuse—Failed to follow care plan
03 Aug 2019Abuse: Neglect
03 Aug 2019Abuse: Neglect
Investigated an allegation of neglect involving protection from inappropriate sexual contact; found that an informed care plan was not developed, creating risk of serious harm, and a fine was assessed.
Abuse—Failed to protect resident from inappropriate sexual contact
23 Jun 2019Abuse: Neglect
23 Jun 2019Abuse: Neglect
Found failure to follow the fall-risk care plan, resulting in an unwitnessed fall and discomfort; a fine was assessed.
Abuse—Failed to follow care plan
27 May 2019Abuse: Neglect
27 May 2019Abuse: Neglect
Investigated a complaint about falls-related care planning. Findings substantiated neglect due to inadequate interventions that resulted in physical harm, with a $375 fine assessed.
Abuse—Failed to adequately care plan related to falls
30 Apr 2019Inspection
30 Apr 2019Inspection
Identified a deficiency for failing to report suspected abuse; a $1000 fine was assessed.
Licensing—Failed to report potential or suspected abuse
22 Mar 2019Abuse: Neglect
22 Mar 2019Abuse: Neglect
Concluded that neglect occurred due to inadequate supervision, resulting in significant emotional harm to a resident, and assessed a $375 fine.
Abuse—Failed to protect resident from inappropriate sexual contact
17 Mar 2019Abuse: Neglect
17 Mar 2019Abuse: Neglect
Investigated a neglect allegation and substantiated failure to provide basic care or services necessary to maintain health and safety, creating a risk of serious harm.
Abuse—Failed to properly plan care
16 Mar 2019Abuse: Neglect
16 Mar 2019Abuse: Neglect
Found neglect involving failure to provide basic care that created risk of serious harm. A $375 fine was assessed.
Abuse—Failed to follow care plan
22 Feb 2019Abuse: Neglect
22 Feb 2019Abuse: Neglect
Found neglect by failing to maintain a secure setting, which created risk of serious harm, and assessed a fine.
Abuse—Failed to provide safe environment
08 Feb 2019Condition
08 Feb 2019Condition
Identified violations for failing to provide a safe environment.
Regulatory Action—Failed to provide safe environment
07 Feb 2019Abuse: Neglect
07 Feb 2019Abuse: Neglect
Investigated an allegation of neglect and found that basic care to prevent elopement was not provided, creating a risk of serious harm to a resident. A $250 fine was assessed.
Abuse—Failed to properly plan care
02 Jan 2019Inspection
02 Jan 2019Inspection
Investigated the allegation and found a deficiency in abuse investigations that did not meet requirements.
Licensing—Failed to investigate injury of unknown origin to rule out abuse
15 Aug 2018Abuse: Neglect
15 Aug 2018Abuse: Neglect
Investigated found a failure to intervene when a resident's condition changed, resulting in harm; a $250 fine was assessed.
Abuse—Failed to intervene when resident's condition changed
03 Aug 2018Inspection
03 Aug 2018Inspection
Found a failure to develop and implement written policies and procedures on medical emergency response for all shifts. A resident went to the emergency room by ambulance and staff refused to supply medical documents to emergency responders.
Licensing—Failed to provide service
30 Apr 2018Abuse: Neglect
30 Apr 2018Abuse: Neglect
Investigated a complaint and found a neglect deficiency for failing to respond to a call light in a timely manner, creating a risk of harm. A $250 fine was assessed.
Abuse—Failed to answer call light in a timely manner
15 Apr 2018Inspection
15 Apr 2018Inspection
Found failure to report suspected abuse and assessed a $1,000 fine.
Licensing—Failed to report potential or suspected abuse
28 Feb 2018Inspection
28 Feb 2018Inspection
Determined that failing to assess the individual appropriately created a risk of suicide.
Licensing—Failed to perform adequate screening or assessment
12 Feb 2018Abuse: Physical Abuse
12 Feb 2018Abuse: Physical Abuse
Investigated and found a deficiency in protecting a resident from physical harm.
Abuse—Failed to protect resident from rough treatment
09 Aug 2017Inspection
09 Aug 2017Inspection
Investigated and found failure to assist residents with activities of daily living.
Licensing—Failed to provide service
09 Aug 2017Inspection
09 Aug 2017Inspection
Identified a licensing violation for failing to maintain an odor-free environment, with a strong urine smell in resident rooms.
Licensing—Failed to provide appropriate housekeeping services
02 May 2017Abuse: Neglect
02 May 2017Abuse: Neglect
Determined that a safe environment was not provided, resulting in a resident-to-resident altercation.
Abuse—Failed to provide safe environment
21 Apr 2017Inspection
21 Apr 2017Inspection
Investigated a food safety allegation and found a deficiency in preparing and serving food.
Licensing—Failed to assure food safety
09 Feb 2017Inspection
09 Feb 2017Inspection
Investigated the allegation of an unsafe physical environment and identified a safety deficiency.
Licensing—Failed to maintain a safe physical environment
03 Feb 2017Inspection
03 Feb 2017Inspection
Found that a safe medication administration system was not provided and a resident received incorrect medications.
Licensing—Failed to provide a safe medication administration system
03 Jan 2017Inspection
03 Jan 2017Inspection
Found that caregivers did not demonstrate satisfactory performance for any duties within the first 30 days of hire.
Licensing—Failed to provide service
29 Dec 2016Inspection
29 Dec 2016Inspection
Investigated a complaint and found a failure to provide a safe environment that resulted in a resident-to-resident altercation.
Licensing—Failed to provide safe environment
27 Dec 2016Abuse: Neglect
27 Dec 2016Abuse: Neglect
Investigated and found care planning deficiencies leading to significant weight loss, and a $400 fine was assessed.
Abuse—Failed to properly plan care
16 Oct 2016Abuse: Financial abuse
16 Oct 2016Abuse: Financial abuse
Investigated an allegation of financial abuse and a safety failure; found a failure to protect personal property from loss.
Abuse—Failed to provide safe environment
21 May 2016Abuse: Neglect
21 May 2016Abuse: Neglect
Investigated a complaint and found a failure to provide a safe environment. A $300 fine was assessed.
Abuse—Failed to provide safe environment
13 May 2016Abuse: Neglect
13 May 2016Abuse: Neglect
Found that a resident-to-resident altercation occurred due to failure to provide a safe environment, resulting in injury.
Abuse—Failed to provide safe environment
09 May 2016Inspection
09 May 2016Inspection
Investigated allegation found insufficient direct care staffing to meet residents' 24-hour needs.
Licensing—Failed to provide appropriate staffing
28 Apr 2016Inspection
28 Apr 2016Inspection
Found insufficient direct care staffing to meet the 24-hour needs of residents.
Licensing—Failed to provide appropriate staffing
12 Apr 2016Abuse: Verbal/Mental abuse
12 Apr 2016Abuse: Verbal/Mental abuse
Determined that a resident was not protected from threats of humiliation or harassment.
Abuse—Failed to protect resident from mental or emotional abuse
07 Apr 2016Inspection
07 Apr 2016Inspection
Concluded the failure to report suspected abuse immediately, with the allegation found substantiated.
Licensing—Failed to provide safe environment
28 Mar 2016Inspection
28 Mar 2016Inspection
Investigated an allegation that resident rights were not assured and found a deficiency related to protecting residents' health, safety, or welfare.
Licensing—Failed to assure resident rights
28 Mar 2016Inspection
28 Mar 2016Inspection
Found a failure to report abuse or suspected abuse to the proper authorities, resulting in a licensing violation.
Licensing—Failed to report potential or suspected abuse
24 Mar 2016Abuse: Neglect
24 Mar 2016Abuse: Neglect
Investigated and found a failure to provide a safe environment, resulting in a violation and a $200 fine assessed.
Abuse—Failed to provide safe environment
22 Feb 2016Inspection
22 Feb 2016Inspection
Investigated a complaint and found a deficiency where a resident was not protected from inappropriate contact.
Licensing—Failed to provide safe environment
18 Feb 2016Inspection
18 Feb 2016Inspection
Found a deficiency for failing to assist with bathing and washing hair.
Licensing—Failed to provide or assist with hygiene
18 Feb 2016Inspection
18 Feb 2016Inspection
Found failure to administer medication as ordered, constituting a licensing violation.
Licensing—Failed to administer medication as ordered
11 Feb 2016Abuse: Neglect
11 Feb 2016Abuse: Neglect
Found a failure to assess and intervene to keep a resident safe from injury.
Abuse—Failed to provide safe environment
28 Dec 2015Abuse: Neglect
28 Dec 2015Abuse: Neglect
Found abuse/neglect due to failure to protect a resident from inappropriate contact; a $450 fine assessed.
Abuse—Failed to protect resident from inappropriate sexual contact
20 Oct 2015Inspection
20 Oct 2015Inspection
Found a failure to provide a safe environment. The issue was substantiated.
Licensing—Failed to provide safe environment
13 May 2015Abuse: Neglect
13 May 2015Abuse: Neglect
Found a neglect-related safety violation for failing to protect a resident from elopement.
Abuse—Failed to provide safe environment
05 Dec 2013Abuse: Neglect
05 Dec 2013Abuse: Neglect
Investigated an allegation of neglect and found the care plan was not followed, resulting in skin tears.
Abuse—Failed to follow care plan
24 Oct 2013Abuse: Financial abuse
24 Oct 2013Abuse: Financial abuse
Investigated a financial abuse allegation and found a failure to provide a safe and secure environment.
Abuse—Failed to provide safe environment
30 Jul 2012Inspection
30 Jul 2012Inspection
Found that medication was not administered as ordered and there was no safe medication administration system.
Licensing—Failed to administer medication as ordered
20 Jun 2012Abuse: Financial abuse
20 Jun 2012Abuse: Financial abuse
Found failure to provide a safe environment, resulting in the theft of narcotics from a resident's apartment.
Abuse—Failed to provide safe environment
30 Mar 2012Inspection
30 Mar 2012Inspection
Concluded that staff failed to administer medication as ordered, resulting in inadequate care.
Licensing—Failed to administer medication as ordered
15 Mar 2012Abuse: Neglect
15 Mar 2012Abuse: Neglect
Investigated a claim of neglect and found inadequate staffing that led to a delayed response after a resident fall.
Abuse—Failed to answer call light in a timely manner
03 Feb 2012Inspection
03 Feb 2012Inspection
Investigated and found failure to provide timely medical intervention for a resident.
Licensing—Failed to provide medical treatment as ordered
21 Jan 2012Inspection
21 Jan 2012Inspection
Found a failure to maintain a safe environment that led to a resident fracture.
Licensing—Failed to follow care plan
21 Jan 2012Abuse: Neglect
21 Jan 2012Abuse: Neglect
Found that timely medical attention was not provided for a resident.
Abuse—Failed to assure timely medical treatment
04 Jan 2012Abuse: Financial abuse
04 Jan 2012Abuse: Financial abuse
Found failure to maintain a secure environment, resulting in narcotics theft from a resident's apartment.
Abuse—Failed to provide safe environment
04 Jan 2012Inspection
04 Jan 2012Inspection
Investigated a medication administration violation in which a resident was allowed to self-administer medications despite physician orders that staff should administer them.
Licensing—Failed to administer ordered medication
18 Oct 2011Inspection
18 Oct 2011Inspection
Found that resident rights were not protected, with threats of punishment, deprivation or humiliation observed.
Licensing—Failed to assure resident rights
24 Aug 2011Abuse: Neglect
24 Aug 2011Abuse: Neglect
Investigated a care deficiency that led to a resident fracture; a $300 fine was assessed.
Abuse—Failed to follow care plan
21 Feb 2011Abuse: Neglect
21 Feb 2011Abuse: Neglect
Concluded that staff failed to monitor a resident, leading to a fall and the resident remaining on the floor for a long period because the door alarm or call system was not functioning.
Abuse—Failed to maintain functional door alarm or call system
30 Nov 2010Inspection
30 Nov 2010Inspection
Investigated the allegation that medication was not administered as ordered and found a deficiency in care.
Licensing—Failed to administer medication as ordered
20 Sept 2010Inspection
20 Sept 2010Inspection
Found a failure to protect the RV from theft, creating risk of harm to residents' property.
Licensing—Failed to provide safe environment
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