Violations

Substantiated violations listed are either a substantiated instance of abuse or a licensing violation. Open investigations and complaints that are being appealed by the provider are not listed. This section of the website displays substantiated licensing violation history back to 2010.

Violations
Date Date From To	Provider ID Provider ID	Name Name	Provider type Provider type AFH ALF NF RCF	Report number Report number	Allegation Allegation Exceeded license capacity Failed to address resident's behavior Failed to adequately care plan related to falls Failed to adequately plan discharge Failed to administer medication as ordered Failed to administer ordered medication Failed to answer call light in a timely manner Failed to assist with ambulation or mobility Failed to assist with dressing or grooming Failed to assist with eating Failed to assist with toileting Failed to assist with transfer Failed to assure a qualified caregiver was present Failed to assure adequate food supply Failed to assure adequate supply or equipment Failed to assure dental treatment Failed to assure food safety Failed to assure physician services Failed to assure proper hydration Failed to assure resident rights Failed to assure resident was safe Failed to assure that a qualified caregiver was present Failed to assure timely medical treatment Failed to care plan in accordance with assessment Failed to communicate necessary information Failed to comply with a final order Failed to comply with move-out, transfer or discharge requirements Failed to comply with nursing delegation requirement Failed to control pests Failed to cooperate with an investigation Failed to demonstrate financial solvency Failed to follow care plan Failed to have medication available Failed to hire according to administrative rules Failed to intervene when resident's condition changed Failed to investigate injury of unknown origin to rule out abuse Failed to keep medication record current or accurate Failed to keep resident record current or accurate Failed to maintain a safe physical environment Failed to maintain functional door alarm or call system Failed to make facility or resident records accessible Failed to meet the scheduled and unscheduled needs of residents Failed to notify family Failed to notify family of suspected abuse Failed to obtain a facility license Failed to obtain an exception or waiver Failed to obtain appropriate consultation Failed to obtain medical order Failed to obtain medication order Failed to perform adequate screening or assessment Failed to properly admit or re-admit Failed to properly plan care Failed to properly post and maintain daily staffing documentation Failed to properly secure or store medication Failed to properly use restraint Failed to protect resident from corporal punishment Failed to protect resident from financial exploitation Failed to protect resident from inappropriate sexual contact Failed to protect resident from involuntary seclusion Failed to protect resident from mental or emotional abuse Failed to protect resident from physical abuse Failed to protect resident from rape Failed to protect resident from rough treatment Failed to protect resident from verbal abuse Failed to provide a homelike environment Failed to provide a safe medication administration system Failed to provide a therapeutic diet Failed to provide appropriate activities Failed to provide appropriate housekeeping services Failed to provide appropriate pain control Failed to provide appropriate skin care Failed to provide appropriate staffing Failed to provide assistive devices Failed to provide infection control Failed to provide inservice Failed to provide medical treatment as ordered Failed to provide or assist with hygiene Failed to provide or maintain resident care equipment Failed to provide oversight and monitoring of change of condition Failed to provide peri care Failed to provide proper food/nutrition Failed to provide rehabilitative services Failed to provide safe environment Failed to provide sanitary food service conditions Failed to provide service Failed to provide social services Failed to provide transportation for medical or social purposes Failed to report potential or suspected abuse Failed to report vaccination status Failed to staff as indicated by ABST Failed to submit timely or adequate staffing documentation Failed to update staffing plan based on ABST Failed to use an ABST Failed to use restraint properly Failure to provide a system that prevents theft or misuse of medication Falsified records Retaliated against resident/complainant	Type Type Abuse: Abandonment Abuse: Financial abuse Abuse: Financial Exploitation Abuse: Involuntary Seclusion Abuse: Neglect Abuse: Physical Abuse Abuse: Restraints Abuse: Sexual Abuse Abuse: Verbal Abuse Abuse: Verbal/Mental abuse Abuse: Wrongful Restraint Licensing Violation
12/5/2016	38E075	Tierra Rose Care Center	NF	CO17260	Failed to assure resident rights	Abuse: Neglect
8/12/2022	38E075	Tierra Rose Care Center	NF	OR0003496606	Failed to provide appropriate skin care	Licensing Violation
9/26/2020	38E075	Tierra Rose Care Center	NF	OR0002713501	Failed to administer medication as ordered	Licensing Violation
5/12/2011	38E075	Tierra Rose Care Center	NF	OR0000688103	Failed to notify family	Abuse: Neglect
5/12/2011	38E075	Tierra Rose Care Center	NF	OR0000688102	Failed to provide appropriate skin care	Abuse: Neglect
3/5/2010	38E075	Tierra Rose Care Center	NF	OR0000576600	Failed to provide service	Abuse: Neglect
1/10/2019	38E075	Tierra Rose Care Center	NF	OR0001707404	Failed to provide appropriate pain control	Abuse: Neglect
9/1/2020	38E075	Tierra Rose Care Center	NF	OR0002624700	Failed to intervene when resident's condition changed	Licensing Violation
1/10/2019	38E075	Tierra Rose Care Center	NF	OR0001707403	Failed to provide proper food/nutrition	Abuse: Neglect
2/5/2019	38E075	Tierra Rose Care Center	NF	OR0001744600	Failed to assure resident was safe	Licensing Violation

47750 records found | Page 778 of 4775

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