Rose Linn Care Center & Rose Linn Vintage Place

    2330 Debok Rd, West Linn, OR 97068
    • Independent Living
    • Assisted Living
    • Memory Care
    • Skilled Nursing

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    Date of Tour
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    Tour Type

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    Amenities

    Healthcare services

    • Activities of daily living assistance
    • Assistance with bathing
    • Assistance with dressing
    • Assistance with transfers
    • Medication management
    • Mental wellness program

    Healthcare staffing

    • 12-16 hour nursing
    • 24-hour call system
    • 24-hour supervision

    Meals and dining

    • Diabetes diet
    • Meal preparation and service
    • Restaurant-style dining
    • Special dietary restrictions

    Room

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

    Memory care community services

    • Mild cognitive impairment
    • Specialized memory care programming

    Transportation

    • Community operated transportation
    • Transportation arrangement
    • Transportation arrangement (non-medical)

    Common areas

    • Beauty salon
    • Computer center
    • Dining room
    • Fitness room
    • Gaming room
    • Garden
    • Outdoor space
    • Small library
    • Wellness center

    Community services

    • Concierge services
    • Fitness programs
    • Move-in coordination

    Activities

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

    Reviews

    3.69·(52)

    Overall rating

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

      3.9
    • Staff

      3.8
    • Meals

      1.9
    • Amenities

      4.1
    • Value

      3.3

    Pros

    • Compassionate and attentive direct-care staff
    • Knowledgeable and experienced clinical and nursing staff
    • Effective dementia-care practices
    • Personalized, detail-oriented care
    • Family-like staff–resident relationships
    • Engaging activities and scheduled outings
    • Live music and entertainment programming
    • Variety of apartment and suite accommodations
    • Clean, well-maintained facility interior
    • Welcoming reception and front-desk staff
    • Hospice and end-of-life support services
    • Competitive pricing for the local market

    Cons

    • Unstable staffing levels and high turnover
    • Inconsistent leadership and HR practices
    • Staff conduct and workplace culture
    • Inconsistent food quality and mealtime management
    • Gaps in clinical oversight and medication-observation practices
    • Security and environmental-safety gaps
    • Opaque or restrictive admissions and insurance policies
    • Inconsistent family communication and management responsiveness
    • Perceived poor value relative to cost

    Summary of reviews

    Overall impression: Reviewers present a mixed picture. Many families and visitors highlight strong day-to-day caregiving, individualized attention, and an active small-community atmosphere. At the same time, recurring operational and leadership issues are described that appear to affect staff morale, service consistency, and some aspects of resident safety and dining.

    Care and staff: A substantial number of comments praise direct-care staff as compassionate, attentive, and detail-oriented; reviewers mention successful clinical outcomes in individual cases and effective dementia care. Several reviewers described staff forming family-like bonds with residents, being knowledgeable, and providing thoughtful gestures that support resident well-being. However, other comments point to unstable staffing levels, high turnover, and inconsistent HR practices that strain continuity of care. These operational pressures are associated with concerns about staff conduct, workplace culture, and uneven discipline; families should verify current staffing stability and staff-to-resident ratios during a tour.

    Clinical oversight and safety: There are positive notes about hospice support and competent clinical interventions in individual cases, but reviewers also raised concerns about medication-observation practices, limited onsite physician/psychiatrist availability, and the facility’s response during infectious outbreaks. A few accounts describe lapses in secured-environment measures and alarm reliability. Prospective families may want to ask for details on clinical coverage schedules, medication-administration protocols, infection-control history, and security systems during an in-person visit.

    Dining and household operations: Opinions on dining are notably polarized. Multiple reviewers express dissatisfaction with food quality, presentation, and mealtime management, including instances where food-handling or serving practices felt inappropriate to families. Others describe acceptable meals and a pleasant dining environment. Given the inconsistency, arrange to sample a meal and ask about menu planning, dietary accommodations, and food-safety procedures.

    Activities and facilities: The facility’s smaller scale is associated with lower noise levels, a cozy community feel, and a good range of activities — bingo, parties, meetings, live music, and outings are singled out positively. Rooms and apartments receive favorable comments for size and cleanliness, and reviewers appreciate the variety of accommodations available. Parking and visitor logistics were noted in a few comments as an operational annoyance but not a dominant theme.

    Management and admissions: Management receives mixed reviews. Some families describe responsive, organized leadership, while others raise concerns about unprofessional behavior, inconsistent discipline, nepotism/favoritism, and abrupt staff terminations. Admissions and eligibility criteria are described as restrictive by some prospective residents, with requests for clear explanations about insurance and billing requirements recommended prior to application. Communication consistency between leadership and families appears to be an area of ongoing variability.

    Notable patterns and guidance: The dominant positive pattern is consistent, compassionate caregiving and a warm, activity-rich community; the dominant negative pattern is operational instability driven by leadership and staffing challenges, plus inconsistent dining and some clinical oversight concerns. Prospective residents and families would be well served to conduct an in-person tour, meet direct-care staff, sample a meal, review staffing schedules and clinical coverage, ask about security and alarm systems, and request clarification of admissions and insurance policies. Verifying recent inspection or state-report history and asking for references from current families can help clarify whether the cited operational concerns have been addressed.

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    Medicare Ratings

    4·/ 5
    • Overall

    • Health Inspection

    • Staffing

    • Quality Measures

    Ratings from the U.S. Centers for Medicare & Medicaid Services (Care Compare). View on Medicare.gov

    Location

    Rose Linn Care Center & Rose Linn Vintage Place is located at 2330 Debok Rd, West Linn, OR, 97068.

    About Rose Linn Care Center & Rose Linn Vintage Place

    Rose Linn is a welcoming senior care community nestled in West Linn, Oregon, dedicated to providing a continuum of care to meet the changing needs of its residents. The campus encompasses both Rose Linn Vintage Place and Rose Linn Care Center, each thoughtfully designed to create a sense of home and comfort for the individuals who live there. Rose Linn Vintage Place specializes in memory care and residential care, offering supportive environments tailored for those who need assistance with daily living, as well as those experiencing the challenges of memory loss. Rose Linn Care Center extends its care through skilled, 24-hour nursing services, addressing more complex medical needs with compassion and expertise.

    At the heart of Rose Linn is a deeply held belief that caring for residents is about more than simply managing symptoms—it is about understanding people and fostering meaningful connections. The staff goes the extra mile to nurture a loving and supportive atmosphere, always seeking to make life as fulfilling as possible for each resident. The community's activity department actively curates engaging programs and opportunities for enrichment, ensuring residents have outlets for connection, creativity, and enjoyment. This dedication to resident well-being is woven throughout every aspect of daily life, from specialized activities to moments of shared laughter and celebration.

    Culinary care is another cornerstone of life at Rose Linn. The campus boasts an industrial-sized kitchen and a dedicated resident chef, preparing nutritious and appealing meals that cater to the diverse needs of individuals at various stages of their aging and healing journeys. Meals are more than just nourishment; they are an opportunity for residents to come together, socialize, and enjoy the comforts of home-cooked food in a warm setting.

    Recent enhancements to the campus, such as the unveiling of a newly renovated outdoor courtyard, reflect Rose Linn’s ongoing commitment to providing spaces where residents can relax, connect, and thrive. The outdoor area is designed to foster both quiet reflection and joyful gatherings, making summers especially vibrant for all who live and work at the community.

    Rose Linn frequently celebrates its staff and promotes a sense of togetherness among residents, team members, and visiting families. Spirit weeks, complete with themed dress-up days and special treats like visits from local food vendors, are just one example of the ways Rose Linn brings joy and camaraderie to daily life. Through every season and every activity, the community is bound by a collective goal: to positively influence the lives of residents and ensure everyone feels valued and cared for as part of the Rose Linn family.

    People often ask...

    Rose Linn Care Center & Rose Linn Vintage Place offers independent living, assisted living, memory care, and skilled nursing.

    There are 25 photos of Rose Linn Care Center & Rose Linn Vintage Place on Mirador.

    Yes, Rose Linn Care Center & Rose Linn Vintage Place allows residents to age in place and adjust their level of care as needed.

    The full address for this community is 2330 Debok Rd, West Linn, OR 97068.

    No, Rose Linn Care Center & Rose Linn Vintage Place 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 number50R270
    StatusActive
    Facility typeResidential Care Facility
    Capacity70 residents
    LicenseeWest Linn Care Center Operating Company, LLC
    EffectiveMarch 19th, 2001
    Special certificationMemory Care
    View the official license record

    Inspection Reports

    90

    Reports

    0

    Type A Citations

    0

    Type B Citations

    3

    Complaints

    16

    Years

    21 Nov 2025Inspection
    Investigated an allegation and found a violation for failing to provide records upon request.
    • Licensing—Failed to make facility or resident records accessible
    21 Feb 2025Abuse: Neglect
    Investigated and found that safety protections were not followed, resulting in injuries when an aggressive resident was not redirected according to the care plan.
    • Abuse—Failed to provide safe environment
    26 Aug 2024Complaint
    Identified deficiencies in updating service plans and acuity-based staffing tools, and in 24-hour resident monitoring, RN delegation, and staff teaching. These gaps affected care planning and oversight.
    • Deficiency—Service Plan: General
    • Deficiency—Change of Condition and Monitoring
    • Deficiency—Rn Delegation and Teaching
    • Deficiency—Acuity-Based Staffing Tool
    26 Aug 2024Inspection
    Concluded that no licensing violation occurred after investigating the nursing delegation allegation.
    • Licensing—Failed to comply with nursing delegation requirement
    26 Aug 2024Inspection
    Investigated and found deficiencies in ABST accuracy and data alignment, with inconsistencies between the resident roster, care plans, and ABST data.
    • Licensing—Failed to use an ABST
    15 Aug 2024Abuse: Neglect
    Found that an unwitnessed fall occurred and the provider failed to address decline and increased weakness, constituting abuse and neglect; a fine was assessed.
    • Abuse—Failed to provide safe environment
    20 May 2024Validation
    Investigated deficiencies across weight management, RN oversight, nutrition and hydration, behavior interventions, staff training, and security measures; a follow-up visit found substantial compliance.
    • Deficiency—Comment
    • Deficiency—Change of Condition and Monitoring
    • Deficiency—Resident Health Services
    • Deficiency—Resident Units
    • Deficiency—Administration Compliance
    • Deficiency—Staff Training Requirements
    • Deficiency—Compliance With Rules Health Care
    • Deficiency—Nutrition and Hydration
    • Deficiency—Behavior
    30 Apr 2024Inspection
    Investigated an allegation of failing to investigate an unknown-origin injury to rule out abuse and found a deficiency in 24-hour resident monitoring and injury documentation.
    • Licensing—Failed to investigate injury of unknown origin to rule out abuse
    30 Apr 2024Abuse: Neglect
    Found neglect of care and abuse due to failure to follow the care plan, resulting in a hip fracture.
    • Abuse—Failed to follow care plan
    12 Apr 2024Abuse: Neglect
    Found a failure to provide a safe environment, resulting in neglect and abuse; a fine was assessed.
    • Abuse—Failed to provide safe environment
    10 Jan 2024Inspection
    Found a licensing violation related to care planning; service plans were not available to staff and did not reflect residents' needs.
    • Licensing—Failed to care plan in accordance with assessment
    03 Dec 2023Abuse: Neglect
    Found neglect and abuse due to failure to follow the care plan, which left a resident without their mobility device and caused a fall with injuries.
    • Abuse—Failed to follow care plan
    08 Jun 2023Inspection
    Found a failure to meet residents' scheduled and unscheduled needs because an Acuity Based Staffing Tool was not fully implemented or updated.
    • Licensing—Failed to meet the scheduled and unscheduled needs of residents
    01 May 2023Inspection
    Found a licensing violation for failing to submit timely weekly reporting of vaccinated individuals, residents, and staff over a 30-day period.
    • Licensing—Failed to submit timely or adequate staffing documentation
    12 Apr 2023Complaint
    Investigated a complaint and identified deficiencies in background checks, service planning, tracking of controlled substances, treatment orders, staffing, and training.
    • Deficiency—Licensing Complaint Investigation
    • Deficiency—Facility Administration: Operation
    • Deficiency—Service Plan: General
    • Deficiency—Systems: Tracking Control Substances
    • Deficiency—Systems: Treatment Orders
    • Deficiency—Staffing Requirements and Training: Staffing
    • Deficiency—Staffing Rqmt and Training: Training Rqmts
    • Deficiency—Training Within 30 Days: Direct Care Staff
    01 Apr 2023Inspection
    Found failures to submit timely weekly reporting of vaccinated individuals, residents, and staff for 30 days.
    • Licensing—Failed to submit timely or adequate staffing documentation
    14 Feb 2023Licensure
    Identified deficiencies in kitchen cleanliness and food storage during the initial visit, with a follow-up finding substantial compliance on the revisit.
    • Deficiency—Comment
    • Deficiency—Resident Services Meals, Food Sanitation Rule
    • Deficiency—Administration Compliance
    09 Dec 2022Inspection
    Found a deficiency in tracking and disposing of controlled substances, affecting safe medication administration. The allegation that a safe medication administration system was not provided was supported.
    • Licensing—Failed to provide a safe medication administration system
    09 Dec 2022Abuse: Neglect
    Determined that a resident's narcotics were not destroyed and 30 pills went missing, with an unknown perpetrator taking the medication, indicating financial abuse and neglect. A $188 fine was assessed.
    • Abuse—Failed to protect resident from financial exploitation
    09 Dec 2022Inspection
    Investigated the allegation and concluded a licensing violation occurred due to failure to obtain background checks.
    • Licensing—Failed to provide safe environment
    06 Dec 2022License Condition
    Investigated an allegation that an organization failed to use an Acuity Based Staffing Tool as required. Found that ABST was not used.
    • Regulatory Action—Failed to use an ABST
    01 Dec 2022Inspection
    Determined noncompliance with weekly vaccination reporting for residents, staff, and vaccinated individuals for 30 days.
    • Licensing—Failed to submit timely or adequate staffing documentation
    23 Nov 2022Inspection
    Investigated an allegation of unsafe medication administration and concluded a licensing violation occurred.
    • Licensing—Failed to provide a safe medication administration system
    23 Nov 2022Inspection
    Concluded that a licensing violation occurred due to lack of a training program to determine direct care staff competency through evaluation, observation, or testing.
    • Licensing—Failed to provide appropriate staffing
    23 Nov 2022Inspection
    Investigated and found a failure to have an approved system for tracking controlled substances and disposing of unused medications, resulting in a licensing violation.
    • Licensing—Failed to provide a safe medication administration system
    23 Nov 2022Inspection
    Concluded that a staffing violation occurred due to failing to fully implement and update an acuity-based staffing tool.
    • Licensing—Failed to provide appropriate staffing
    23 Nov 2022Inspection
    Investigated an allegation of insufficient staffing and concluded that there was a licensing violation due to not having enough awake qualified direct care staff to meet the scheduled and unscheduled needs of residents.
    • Licensing—Failed to provide appropriate staffing
    17 Oct 2022Inspection
    Investigated the nursing delegation allegation and concluded a deficiency existed related to documenting the ability to supervise medication and treatment administration unsupervised.
    • Licensing—Failed to comply with nursing delegation requirement
    01 Oct 2022Inspection
    Found a licensing violation for failure to submit timely weekly reports on vaccinated individuals, residents, and staff; a $7,500 fine was assessed.
    • Licensing—Failed to submit timely or adequate staffing documentation
    28 Sept 2022Abuse: Neglect
    Found neglect and abuse due to failure to assess, intervene, and plan care after repeated falls, resulting in a hip fracture.
    • Abuse—Failed to care plan in accordance with assessment
    20 Sept 2022Complaint
    Identified deficiencies in Acuity-Based Staffing Tool implementation, including missing ADLs and training gaps affecting staffing planning.
    • Deficiency—Licensing Complaint Investigation
    • Deficiency—Acuity-Based Staffing Tool
    25 Jul 2022Abuse: Neglect
    Identified failures to follow the care plan for safety checks and ensure access to the resident's room, leading to a fall and injury requiring hospital care.
    • Abuse—Failed to follow care plan
    12 Jul 2022Inspection
    Investigated a medication administration incident and found a failure to provide a safe medication administration system, with another resident's medication given to a different resident and risk of serious harm.
    • Licensing—Failed to provide a safe medication administration system
    23 Mar 2022Abuse: Neglect
    Identified a failure to provide a safe environment that allowed elopement and resulted in safety concerns; a fine was assessed.
    • Abuse—Failed to provide safe environment
    21 Dec 2021Abuse: Neglect
    Found a violation for failing to provide a safe environment, which led to a resident being hit by another resident; the finding indicated neglect and abuse.
    • Abuse—Failed to provide safe environment
    21 Dec 2021Abuse: Neglect
    Found failure to provide a safe environment resulting in a resident-to-resident altercation and neglect/abuse; a fine was assessed.
    • Abuse—Failed to provide safe environment
    09 Dec 2021Abuse: Neglect
    Investigated an allegation of neglect related to unsafe medication administration and found a safe medication administration system was not provided, with a fine assessed.
    • Abuse—Failed to provide a safe medication administration system
    02 Dec 2021Abuse: Neglect
    Found that a safe environment was not provided, placing a resident at risk when a resident became agitated and pushed them.
    • Abuse—Failed to provide safe environment
    14 Oct 2021Inspection
    Found violations related to a safe medication administration system, resulting in a resident receiving wrong medications and experiencing drowsiness and discomfort.
    • Licensing—Failed to provide a safe medication administration system
    13 Oct 2021Inspection
    Found that medication was not administered as ordered, causing increased agitation and distress for the resident.
    • Licensing—Failed to administer medication as ordered
    08 Sept 2021Inspection
    Concluded that a licensing violation occurred due to failure to provide a safe medication administration system.
    • Licensing—Failed to provide a safe medication administration system
    30 Aug 2021Validation
    Identified multiple deficiencies across care and safety domains during licensure activities, including abuse investigations, health services, medication management, fire safety, exterior safety, nutrition, activities, behavior, and care planning. The findings showed failures to investigate suspected abuse, monitor weight loss, document insulin delegation, maintain MAR accuracy, conduct proper fire drills, and develop individualized plans.
    • Deficiency—Comment
    • Deficiency—Reporting & Investigating Abuse-Other Action
    • Deficiency—Resident Health Services
    • Deficiency—Rn Delegation and Teaching
    • Deficiency—Systems: Medication Administration
    • 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—Administration Compliance
    • Deficiency—Compliance With Rules Health Care
    • Deficiency—Nutrition and Hydration
    • Deficiency—Activities
    • Deficiency—Behavior
    13 Aug 2021Inspection
    Concluded that the care plan was not followed, resulting in an injury and lack of peri care after toileting; found neglect and abuse.
    • Licensing—Failed to follow care plan
    02 Apr 2021Inspection
    Investigated the allegation and found the residency agreement did not include move-out criteria.
    • Licensing—Failed to communicate necessary information
    03 Nov 2020Inspection
    Investigated an allegation of a deficient medication administration system and found that an accurate Medication Administration Record was not maintained.
    • Licensing—Failed to provide a safe medication administration system
    03 Nov 2020Inspection
    Determined that medication and treatment orders were not carried out as prescribed.
    • Licensing—Failed to administer medication as ordered
    03 Nov 2020Inspection
    Investigated the allegation of failing to report abuse or neglect incidents to local SPD and verified a failure to report.
    • Licensing—Failed to report potential or suspected abuse
    30 Sept 2020Inspection
    Investigated the allegation and found a failure to maintain a safe physical environment; the finding was substantiated.
    • Licensing—Failed to maintain a safe physical environment
    27 Aug 2020Inspection
    Investigated and found a violation of resident rights and protections.
    • Licensing—Failed to assure resident rights
    27 Aug 2020Inspection
    Investigated and identified a failure to report potential or suspected abuse to the local SPD.
    • Licensing—Failed to report potential or suspected abuse
    18 Aug 2020Inspection
    Found that a staff member verbally abused and ridiculed a resident during activities of daily living, creating an unsafe environment.
    • Licensing—Failed to provide safe environment
    11 Aug 2020Abuse: Neglect
    Investigated and found that a resident's known history of falls was not addressed in care planning, risking harm and constituting abuse.
    • Abuse—Failed to properly plan care
    10 Aug 2020Abuse: Neglect
    Found a failure to provide a safe environment that resulted in a resident leg injury, indicating abuse and neglect.
    • Abuse—Failed to provide safe environment
    22 Jul 2020Inspection
    Found that the residency agreement did not include criteria for move-out notification or intra-facility move.
    • Licensing—Failed to properly admit or re-admit
    18 Feb 2020Inspection
    Found a failure to provide a safe medication and treatment administration system.
    • Licensing—Failed to provide a safe medication administration system
    18 Feb 2020Inspection
    Found a violation for not providing a safe and homelike environment.
    • Licensing—Failed to provide a homelike environment
    12 Feb 2020Abuse: Neglect
    Found that care providers failed to provide a needed service, leading to skin breakdown and pain for a resident.
    • Abuse—Failed to provide service
    01 Nov 2019Inspection
    Investigated a space-related complaint and found that resident units did not meet the minimum size and bed-spacing requirements.
    • Licensing—Failed to assure resident rights
    01 Nov 2019Inspection
    Confirmed a violation of residents' rights by not allowing residents to choose a roommate when sharing a bedroom.
    • Licensing—Failed to assure resident rights
    06 Sept 2019Inspection
    Investigated the matter and confirmed a failure to safeguard resident possessions under applicable rules.
    • Licensing—Failed to provide safe environment
    12 Jul 2019Abuse: Neglect
    Investigated and found a failure to provide a safe medication administration system, constituting neglect and abuse.
    • Abuse—Failed to provide service
    17 May 2019Abuse: Neglect
    Investigated found that the provider failed to provide services and an appropriate care plan for a resident with a history of falls, resulting in a fall and a wrist fracture; a fine was assessed.
    • Abuse—Failed to provide service
    07 Apr 2019Abuse: Neglect
    Identified a failure to provide necessary health and safety services, with a substantiated finding. A $188 fine was assessed.
    • Abuse—Failed to properly plan care
    21 Dec 2018Inspection
    Found a deficiency in providing ADL assistance; residents were left in soiled briefs for over 3 hours.
    • Licensing—Failed to provide peri care
    08 Dec 2018Abuse: Neglect
    Found neglect related to medication administration that resulted in harm or unreasonable discomfort to a resident.
    • Abuse—Failed to provide a safe medication administration system
    08 Dec 2018Abuse: Neglect
    Determined neglect occurred, failing to provide basic care and services that maintain health and safety, creating risk of serious harm.
    • Abuse—Failed to provide a safe medication administration system
    12 Oct 2018Abuse: Financial abuse
    Determined that abuse occurred and was substantiated. Verbal, emotional, and physical abuse of a resident was substantiated.
    • Abuse—Failed to protect resident from rough treatment
    04 Aug 2018Abuse: Neglect
    Identified neglect related to incontinence and hygiene, creating risk of serious harm; a $500 fine was assessed.
    • Abuse—Failed to provide service
    04 Aug 2018Inspection
    Found a failure to report suspected abuse, with a $750 fine assessed.
    • Licensing—Failed to report potential or suspected abuse
    15 Mar 2018Abuse: Neglect
    Found neglect resulting in a fatal fall due to insufficient monitoring; a $2,500 fine was assessed.
    • Abuse—Failed to properly plan care
    25 Nov 2017Abuse: Neglect
    Found that a safe environment was not provided, which led to inappropriate contact between residents.
    • Abuse—Failed to provide safe environment
    02 Aug 2017Inspection
    Investigated and substantiated a failure to provide a safe environment, leading to multiple resident-to-resident altercations.
    • Licensing—Failed to properly plan care
    22 Jun 2016Abuse: Neglect
    Concluded that a safe environment was not provided to a resident, resulting in harm.
    • Abuse—Failed to provide safe environment
    21 Jun 2016Abuse: Neglect
    Found that a resident was not protected, indicating a failure to provide a safe environment.
    • Abuse—Failed to provide safe environment
    07 May 2016Inspection
    Found a failure to provide a secure environment.
    • Licensing—Failed to provide safe environment
    28 Dec 2015Inspection
    Concluded there was inadequate supervision to protect a resident from elopement.
    • Licensing—Failed to provide safe environment
    02 Dec 2015Abuse: Neglect
    Investigated a neglect allegation and found deficiencies in care planning that contributed to a resident-to-resident sexual incident.
    • Abuse—Failed to care plan in accordance with assessment
    16 Aug 2015Inspection
    Investigated the allegation of an unsafe environment. The violation was substantiated.
    • Licensing—Failed to provide safe environment
    19 Jun 2015Inspection
    Found a resident safety deficiency where staff failed to monitor a resident, resulting in an unsafe situation.
    • Licensing—Failed to assure resident was safe
    16 Jun 2015Abuse: Neglect
    Concluded that supervision was inadequate, resulting in a resident-to-resident situation.
    • Abuse—Failed to follow care plan
    04 Apr 2015Abuse: Neglect
    Investigated an allegation of neglect and found a failure to protect the resident from harm.
    • Abuse—Failed to provide safe environment
    22 Jan 2015Abuse: Neglect
    Investigated and found that the facility failed to provide a safe environment.
    • Abuse—Failed to provide safe environment
    17 Feb 2014Abuse: Neglect
    Investigated a complaint of neglect and found a failure to address a resident's behavior and to prevent a resident-to-resident altercation.
    • Abuse—Failed to address resident's behavior
    05 Nov 2013Abuse: Neglect
    Investigated an allegation of neglect related to failing to assess and intervene when a resident's condition changed. Findings indicated failure to assess and intervene appropriately and timely.
    • Abuse—Failed to intervene when resident's condition changed
    02 Jul 2013Inspection
    Found a failure to provide a safe environment for a resident. The issue was categorized as a licensing violation.
    • Licensing—Failed to provide safe environment
    29 Mar 2013Inspection
    Investigated and found that needed medical supplies were not provided as ordered.
    • Licensing—Failed to provide medical treatment as ordered
    06 Mar 2013Inspection
    Investigated the allegation of failing to provide a safe environment and found that the failure to assess and intervene resulted in a resident-to-resident altercation.
    • Licensing—Failed to provide safe environment
    21 Dec 2012Abuse: Neglect
    Found that care was not provided as required, resulting in a resident fall with injuries.
    • Abuse—Failed to follow care plan
    31 May 2012Inspection
    Determined that a resident's rights were not protected.
    • Licensing—Failed to assure resident rights
    02 Feb 2010Inspection
    Investigated and found a failure to treat residents with respect and dignity, related to resident rights.
    • Licensing—Failed to assure resident rights

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