Arbor Oaks Terrace Memory Care Residence

The Alleged Victim (AV) is a known fall risk, has an unsteady gait and experiences weakness and balance issues. On or about February 9, 2026, AV suffered two falls in his/her room. On fall resulted in hitting AV's head and tailbone. AV's falls are mostly from AV trying to self-transfer. Implemented interventions have not been successful in reducing AV's falls. Respondent failed to ensure interventions were appropriate and successful in reducing AV's risk of falls. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

The Alleged Victim (AV) has a history of falls and has been in physical therapy. On or about February 6, 2026, AV fell in his/her room and had crawled out into the hallway to find staff for assistance. AV did not find anyone to assist him/her, as there were not staff available near AV's room due to short staffing at the facility. AV suffered a goose egg to his/her head and was sent to the hospital for evaluation. Respondent failed to ensure the proper number of staff were working to meet the scheduled and unscheduled needs of the residents were met, causing unreasonable discomfort to AV. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

The Alleged Victim (AV) and Witness #1 (W1) have a history of altercations. On or about February 5, 2026, W1 and AV engaged in an altercation where W1 hit AV during snack time. W1 had been showing signs of agitation that day and staff are to monitor W1 when he/she is agitated and redirect from AV. W1 was redirected after the altercation, not prior. Respondent failed to ensure staff intervened to reduce the risk of altercations with residents, placing residents at risk for harm. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(ii).

The Alleged Victim (AV) was a known fall risk and had suffered falls recently. On or about January 26, 2026, AV suffered a fall while getting out of bed to close his/her door. AV is known to transfer without asking for assistance, although interventions in place are to remind AV to request assistance. Two hour safety checks were in place, however, this intervention is not adequate, as AV continues to fall, placing AV at risk for harm. Respondent failed to ensure new interventions were created to ensure AV's safety from falls. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(ii).

The Alleged Victim (AV) has had previous falls with injury. Interventions put into place are not effective to reduce AV's falls. On or about January 22, 2026, and January 24, 2026, AV suffered falls without injury, however, AV was placed at risk for harm. Respondent failed to ensure proper care planning to reduce the risk of falls. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

The Alleged Victim (AV) was a known fall risk and had suffered falls recently. On or about January 19, 2026, AV suffered a fall from his/her wheelchair and suffered a skin tear to his/her arm. AV is known to transfer without asking for assistance, although interventions in place are to remind AV to request assistance. Interventions in place were repetitive with no new interventions created, placing AV at risk for harm. Respondent failed to ensure new interventions were created to ensure AV's safety from falls. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

The Alleged Victim (AV) was a known fall risk and had suffered falls between December 5, 2025, and January 15, 2026. On or about January 22, 2026, AV was found to have bruising on AV's forehead and right forearm. AV had suffered a fall on January 15, 2026, and it would appear these bruises were from that fall. AV is independent with ambulation with the use of a walker and transfer assistance by staff. An intervention of physical therapy was listed for a couple of AV's falls, however, no physical therapy had been started. Respondent failed to ensure new interventions were implemented to ensure AV's safety from falls. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

The Alleged Victim (AV) has a catheter and has been diagnosed with multiple urinary tract infections and one bout of sepsis throughout 2025. Staff are to ensure that AV's catheter is changed once per month. AV went a couple of months in 2025 without a catheter change. AV has a history of refusing catheter care and the only intervention in place was to apply a change of face or wait a few minutes and try again. AV suffered unreasonable discomfort due to not getting complete catheter care. Respondent failed to ensure appropriate interventions were in place to ensure timely catheter care was completed. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

The Alleged Victim (AV) is a known fall risk and has suffered multiple falls with and without injury between October 25, 2025, and November 13, 2025. AV's service plan was not updated to reflect AV's pattern of falls. Interventions were created after October 7, 2025, to include cuing, reminding the resident to call for assistance, however, upon investigation, no call light or pendant was seen near AV to be able to call for assistance from staff. Respondent failed to ensure proper care planning and meaningful interventions what would reduce AV's risk of falls. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

On or about November 9, 2025, the Alleged Victim (AV) was found to have three very large water blisters on his/her legs. Alleged Perpetrator #2 (AP2) was notified by staff of the blisters but did not take any actions for AV's wounds. On or about November 15, 2025, AV was sent to the hospital for evaluation of the blisters and prescribed medication and advised to follow up with AV's physician. AV's physician saw AV on November 17, 2025, and called home health, as the facility failed to contact home health to come in to complete wound care. AP2's actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility's failure to ensure AV received proper nursing services is a violation of 411-020-0002(1)(b)(A)(i), which constitutes abuse by neglect.

The Alleged Victim (AV) is a known fall risk and suffered 6 falls between August 24, 2025, and October 7, 2025. On or about October 7, 2025, AV suffered a fall while trying to transfer out of his/her bed, where he/she was found on the floor, sustaining a skin tear to his/her elbow. AV was on frequent checks and interventions in place were for reminders to call for assistance and to use his/her assistive device when ambulating. There was not appropriate staffing during overnight shifts to ensure the safety of all residents.

The Alleged Victim (AV) moved into the facility on or about October 1, 2025. AV was listed as independent with ambulation and transfers. AV suffered three falls within the first week of being at the facility, two of the falls resulted in injuries to AV's head. On or about October 7, 2025, AV was sitting in the dining room and stood up from the table and fell backwards, hitting his/her head. AV went on to have another fall on October 24, 2025, resulting in another head injury. The facility's failure to ensure person centered interventions and supervision lead to AV having multiple falls, which constitutes neglect by abuse, as outlined in OAR 411-020-0002(1)(b)(A)(i).

The Alleged Victim (AV) and Witness #1 (W1) have been involved in previous altercations with each other and an interim service plan was in place to redirect the two when they are in the common area together. On or about September 14, 2025, AV and W1 were walking together and W1 back handed AV on the side of his/her head. There were no witnesses to this altercation, however, W1 reported to staff that he/she hit AV. The facility failed to follow the interventions in place to reduce altercations between AV and W1. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is a known fall risk and has suffered 9 injury falls in 4 months, resulting in skin tears, bumps to the head and bruising. On or about September 7, 2025, AV was found on the floor by staff at approximately 3 AM, with scratches down his/her back. AV's interim service plans do not have specific interventions to prevent AV from suffering falls. The facility's failure to properly care plan to prevent falls is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is a known fall risk and suffered 6 falls between August 14, 2025 and September 6, 2025. On or about September 6, 2025, AV suffered a fall where he/she was found on the floor, sustaining a laceration to his/her head and shoulder pain. AV was on 15 minute checks and interventions in place were for reminders to call for assistance and to use his/her assistive device when ambulating. There were not enough staff on overnight shifts to ensure the safety of all residents. The facility's failure to ensure proper staffing and properly care plan for AV is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is a known fall risk and suffered 10 falls between June 2025 and August 2025. After July 29, 2025, AV suffered 3 falls where no new interventions were put into place to reduce AV's risk of falls. On or about August 6, 2025, AV was found on the floor of his/her room with blood on his/her face. AV was sent to the emergency room where it was determined that AV suffered a fractured nose. The facility's failure to properly care plan to reduce the risk of falls is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is a known fall risk and has suffered 16 falls between April 2025 and June 2025. On or about June 24, 2025, AV was found on the floor next to his/her bed with an end table on top of his/her chest. AV suffered a bump on the head, a skin tear to his/her elbow and redness to his/her back. The facility failed to implement new interventions to reduce AV's risk of falls. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #1 (W1) has known aggressive and combative behaviors and is care planned to have cueing and redirection during meal times, as W1 is known to get up and take other residents plates. On or about June 20, 2025, W1 took another residents plate at meal time and the Alleged Victim (AV) attempted to remove the plate from W1 and W1 responded by slapping AV. AV was not injured, however, AV was placed at risk for harm. Facility staff did not intervene timely to ensure the safety of other residents. The facility's failure to follow W1's care plan is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is a known fall risk and has suffered falls with significant injury in the past. On or about May 18, 2025, AV had an unwitnessed fall in his/her room, which resulted in a large bump to his/her head. At the time of the fall, AV was stand by assist with ambulation with the use of his/her walker or cane. AV was on two hour safety checks and was known to attempt to walk without assistance or use of the walker or cane. The facility's failure to ensure proper interventions were in place to reduce AV's risk of falls is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is a known fall risk and has suffered falls with significant injury in the past. On or about May 17, 2025, AV had an unwitnessed fall in his/her room, which resulted in a broken finger. At the time of the fall, AV was stand by assist with ambulation with the use of his/her walker or cane. AV was on two hour safety checks and was known to attempt to walk without assistance or use of the walker or cane. The facility's failure to ensure proper interventions were in place to reduce AV's risk of falls is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) had suffered falls on April 5, 2025, and April 10, 2025. On April 10, 2025, fall, AV suffered a broken hip and upon his/her return from the hospital, AV was unable to ambulate without staff intervention. AV repeatedly tried to walk without staff assistance. On or about April 11, 2025, AV suffered another fall and was in a lot of pain. AV was sent back out to the hospital and diagnosed with a fractured rib. Respondent failed to implement meaningful interventions to reduce AV's risk of falls. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

The Alleged Victim (AV) is to receive as needed medication when he/she does not have a bowel movement for two days. On or about March 12, 2025, through a medication audit, it was discovered that AV did not have a bowel movement from March 4, 2025 to March 8, 2025, causing unreasonable discomfort. The facility's failure to follow AV's care plan is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) and Witness #1 (W1) have a history of altercations with each other. Staff are to monitor AV and W1 for agitation and redirect when necessary. On or about September 28, 2024, AV and W1 were in the dining area when W1 slapped AV in the face. No staff were present during the altercation, but heard AV screaming and arrived to separate the two residents. The facility's failure to ensure resident safety is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #1 (W1) is known to be anxious and agitated at times. Between September 1, 2024 and September 17, 2024, W1 experienced 8 episodes of anxiousness and confusion. On or about September 22, 2024, W1 pushed the Alleged Victim (AV) during an altercation, causing AV to fall and hit his/her head on the wall. AV was transported to the hospital where he/she received 3 staples to close the wound on his/her head. The facility's failure to ensure a safe environment is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #1 (W1) is known to have behaviors and altercations. W1 has been involved in approximately 8 altercations in 2024. On or about September 13, 2024, W1 was in the hallway and was upset. The Alleged Victim (AV) walked past W1 and W1 pushed AV to the ground unprovoked by AV. AV was not injured, however, AV was placed at risk for harm. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is a known fall risk and has suffered two falls recently. On or about August 23, 2024, AV was found on the floor of his/her room, bleeding from his/ her nose. AV was sent out to the hospital and was diagnosed with a broken nose. AV complained of pain on his/her face from the fall. On or about October 15, 2024, AV suffered another fall, complaining of pain. AV was sent out to the hospital and evaluated for a closed fractured nasal bone, injury to the head and contusion to right shoulder. AV complained of pain for two days after the incident. The facility failed to put interventions in place to keep AV safe from falls. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) and Witness #1 (W1) have a history of altercations. On or about August 17, 2024, AV wandered into W1's room and both residents began to hit each other. Staff were able to separate the two and remove AV from W1's room. Failure to have appropriate interventions placed both residents at risk for harm. The facility's failure to ensure resident safety from altercations is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) and Witness #1 (W1) have a history of altercations. On or about August 17, 2024, W1 wandered into AV's room and both residents began to hit each other. Staff were able to separate the two and remove W1 from AV's room. Failure to have appropriate interventions placed both residents at risk for harm. The facility's failure to ensure resident safety from altercations is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) moved into the facility in July 2024. AV was a known fall risk and had a previous fall at home where AV suffered a fractured hip. AV suffered approximately 5 falls between August 18, 2024 and October 17, 2024. On or about August 28, 2024, AV suffered a fall in which AV hit his/her head and was bleeding. AV was sent out to the hospital and was diagnosed with a fractured hip requiring surgery. The facility's failure to properly care plan for AV's risk of falls is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about July 17, 2025, the Alleged Victim (AV) was in the spa bath without facility staff supervision. Witness #1 has a history of behaviors and altercations with other residents. (W1) tried to remove AV from the spa bath, as AV shouldn't have been in there alone. W1 grabbed a hold of AV, and gripped him/her with their fingernails, causing a scratch and torn skin to AV's arm. The facilities failure to ensure supervision of both W1 and AV, causing harm to AV. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) and Witness #1 (W1) have a history of altercations. On or about May 28, 2024, W1 had been involved in an altercation and staff were instructed to keep W1 away from others and to not leave W1 unsupervised in the common area. On or about May 29, 2024, staff heard screaming and ran to the common area to find W1 lying on the floor in front of AV. AV had suffered a skin tear to his/her right hand. The facility's failure to ensure supervision of W1 is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) and Witness #1 (W1) have a history of altercations. On or about May 28, 2024, AV had been involved in an altercation and staff were instructed to keep AV away from others and to not leave AV unsupervised in the common area. On or about May 29, 2024, staff heard screaming and ran to the common area to find AV lying on the floor in front of W1. AV had suffered a lumbar strain and a bruise to his/her right knee. The facility's failure to ensure supervision of AV to prevent him/her from falling is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) and Witness #1 (W1) have histories of altercations with other residents and each other. On or about May 28, 2024, AV and W1 engaged in an unwitnessed altercation where AV suffered a bruise to his/her head and W1 suffered redness and scratches to his/her face and neck. The facility failed to provide a safe environment, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) and Witness #1 (W1) have had previous altercations. On or about May 16, 2024, AV and W1 engaged in an altercation where W1 hit AV with a doll. Neither resident suffered any injury, however, the facility's failure to ensure proper care planning and interventions were in place, placed AV at risk for harm. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) and Witness #1 (W1) have had previous altercations. On or about May 16, 2024, AV and W1 engaged in an altercation where AV hit W1 with a doll. Neither resident suffered any injury, however, the facility's failure to ensure proper care planning and interventions were in place, placed AV at risk for harm. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) and Witness #1 (W1) have had previous altercations. On or about May 7, 2024, AV and W1 engaged in an altercation where W1 slapped AV in the neck, causing a red mark. The facility failed to ensure the safety of AV, placing him/her at risk of harm. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) and Witness #1 (W1) have been involved in multiple altercations. On or about May 6, 2024, AV and W1 engaged in an altercation where W1 grabbed onto AV's arm, causing a skin tear. The facility failed to properly care plan to reduce the risk of altercations, placing residents at risk of harm. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is known to exit seek. AV was transferred from an unlocked facility due to wandering and exit seeking. Facility staff were called on or about April 20, 2024 and advised that AV was outside of the building. AV had opened a window and kicked out the screen and exited the building through a window and was seen by staff at a neighboring building. Facility staff retrieved AV and brought him/her back to the building without injury, however, AV was placed at risk for harm. The facility's failure to provide a safe environment is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about March 12, 2024, Witness #1 (W1) and the Alleged Victim (AV) engaged in an altercation. W1 and AV have had previous altercations. Neither resident suffered any injury during the altercation, however, failure to ensure interventions were enacted placed both residents at risk for harm. The facility's failure to ensure residents safety is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) and Witness #1 (W1) have engaged in previous altercations. On or about March 11, 2024, AV and W1 engaged in an altercation where W1 pushed AV down onto the floor. AV sustained scratches to his/her hand from the thumb to the wrist. The facility failed to implement interventions to reduce altercations. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) and Witness #1 (W1) were known to engage in altercations. On or about March 2, 2024, AV and W1 engaged in an altercation where W1 pulled on AV's scarf, causing AV's head to go to W1's lap, causing suffocation of AV. AV suffered a scrape to his/her face. The facility's failure to properly care plan to reduce the altercations between AV and W1 is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) and Witness #1 (W1) have a history of altercations. AV and W1 entered into an altercation on March 2, 2024 where W1 hit AV in the head approximately 4 times. AV and W1 engaged in another altercation where W1 pulled AV's hair and grabbed AV's wheelchair. The facility failed to provide a safe environment, placing residents at risk for harm. The facility's failure to provide a safe environment is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about February 29, 2024, the Alleged Victim (AV) suffered a fall in his/her room, and had suffered a previous fall on February 23, 2024. The facility call system was not working on February 29, 2024, and it is unknown when AV was last checked on or how long AV was on the floor calling for help. AV was not injured in this fall, but being on the floor for an unknown amount of time caused AV unreasonable discomfort. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about February 29, 2024, the Alleged Victim (AV), Witness #1 (W1) and Witness #2 (W2) were involved in an altercation. AV and W1 were engaging and W2 attempted to separate the two. AV grabbed W2 by the arms and W2 slapped AV in the face. All three residents have a history of altercations. AV had been involved in 9 altercations since January 2024, Interventions have not been person centered or new. The facility's failure to properly care plan to ensure AV's safety is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about February 29, 2024, Witness #1 (W1), Witness #2 (W2) and the Alleged Victim (AV) engaged in an altercation. All three residents are known to have altercations in the past. While the three residents were engaging, AV received a skin tear on his/her right hand. The facility failed to implement meaningful interventions to prevent altercations involving these three residents, placing residents at risk for harm. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV), Witness #1 (W1) and Witness #2 (W2) all have a history of altercations. On or about February 29, 2024, the three engaged in an altercation. W2 received a skin tear on his/her hand. The facility failed to properly care plan and have meaningful interventions in place to reduce altercations with these three residents, leaving them at risk for harm. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about January 25, 2024, the Alleged Victim (AV) was short of breath and needing his/her inhaler and staff could not find it. AV's inhaler was received at the facility and checked in by Alleged Perpetrator #2, however, it is unknown where the inhalers went. The intake process for the medications did not have a multi-person check for the medications and inventory was not completed by the Registered Nurse. AV did not have his/her inhaler when necessary, which placed AV at risk for harm. The facility failed to provide a safe medication administration system, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about January 25, 2024, it was discovered that the the Alleged Victim (AV) was missing his/her inhaler and staff could not find it. AV's inhaler was received at the facility and checked in by Alleged Perpetrator #2, however, it is unknown where the inhaler went. The intake process for the medications did not have a multi-person check for the medications and inventory was not completed by the Registered Nurse. AV did not receive his/her inhaler, which was purchased and sent to the facility. The facility failed to provide a safe medication administration system, causing a financial loss to AV, which is a violation of resident rights, is considered neglect of care and constitutes financial abuse.

On or about January 22, 2024, the Alleged Victim (AV) and Witness #1 (W1) engaged in an altercation when AV said hello to W1, W1 slapped AV on the arm. AV did not suffer any injury, however, AV was placed at risk of harm. W1 was agitated and W1 is care planned to have interventions when W1 is having behaviors. Staff did not intervene when W1 was having behaviors. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #1 (W1) has a history of altercations. On or about January 22, 202, W1 slapped the Alleged Victim (AV) in the face after AV slapped W1's hand away from his/her dog. The facility failed to properly care plan and have interventions in place to prevent W1 from having altercations with residents, leaving AV at risk for harm. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about January 22, 2024, it was reported by the Alleged Victim's (AV) adult child that AV had a bad rash under his/her breasts, which caused unreasonable discomfort. AV's service plan does not indicate any sort of rash on AV. AV is care planned to have a shower with skin checks. AV's charting notes indicate no skin checks from November 11, 2023 to January 10, 2024. On more than one occasion, AV went almost two weeks without a shower. AV's care plan does not does not have interventions for when AV refuses showers. AV had been prescribed medicated powder to be used under AV's left breast daily. AV had ointment to be used as needed for redness under breasts as well, however, documentation shows no ointment applied to AV in December 2023 or January 2024. The facility's failure to provide hygiene to AV, or provide medicated ointment to area's of redness is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #2 (W2) has a history of being aggressive and having altercations with other residents. On or about January 4, 2024, W2 was seen aggressively pulling on the Alleged Victim's (AV) arm, which resulted in a scratch on AV's arm. The facility failed to monitor, intervene and put interventions in place to keep AV safe. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) and Witness #1 (W1) are known to have altercations with each other and are care planned to be kept separated and observe if one or both become agitated and intervene and redirect from the situation. On or about December 15, 2023, AV was sitting in W1's chair when staff heard yelling and saw W1 walking away from AV. AV had scratches on his/her cheek, neck and arm. W1 may have suffered bruising to his/her arm. The facility's failure to follow the care plan and prevent an altercation is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #1 (W1) has a history of resident to resident altercations. It was determined that W1 exhibits agitation by undressing him/herself. On or about November 7, 2023, W1 engaged in an altercation with the Alleged Victim (AV) where W1 hit AV. W1 was pulling his/her pants down prior to the altercation, and staff failed to redirect W1 away from AV to avoid the altercation. The facility's failure to follow interventions in place is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) and Witness #1 (W1) have a history of altercations with each other. On or about October 25, 2023, staff found W1 holding AV's neck. AV was not harmed, however, both AV and W1 were placed at risk for harm. The facility's failure to ensure the safety of AV and W1 is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) receives his/her medications from facility staff. On or about October 12, 2023, Alleged Perpetrator #2 (AP2) was dispensing medications and failed to follow the care plan to watch AV take his/her medications, which was dissolved in liquid, allowing AV's medication to stay unattended overnight, placing AV at risk of harm for not taking his/her medication and other residents that could have drank AV's medication from the glass. AP2's failure to follow the care plan is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility's failure to provide a safe medication administration system is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) receives his/her medications from facility staff. On or about October 21, 2023, Alleged Perpetrator #3 (AP3) was dispensing medications and failed to follow the care plan to watch AV take his/her medications, which was dissolved in liquid, allowing AV's medication to stay unattended overnight, placing AV at risk of harm for not taking his/her medication and other residents that could have drank AV's medication from the glass. AP3's failure to follow the care plan is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility's failure to provide a safe medication administration system is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #1 (W1) has a history of altercations. On or about October 7, 2023, W1 hit the Alleged Victim (AV) in the face three times and twice on his/her shoulder. The facility failed to properly care plan and have interventions in place to prevent W1 from having altercations with residents, leaving AV at risk for harm. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) was known to have behaviors and was involved in at least 8 altercations between July and September 2022. The facility failed to provide a safe environment for AV by not having enough staff present to ensure AV's safety. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #1 (W1) is known to have behaviors and has been involved in multiple altercations. No interventions were put into place to decrease W1's altercations. On or about July 12, 2022, W1 grabbed the Alleged Victim (AV) when he/she was trying to get off the couch. W1's behavior caused AV to sustain a scrape and a couple bruises. The facility's failure to properly care plan is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is a known fall risk and needs assistance with transfers. On or about August 14, 2024, staff arrived at the building and found AV sitting in a recliner with a chair under the footrest, not allowing AV to put the foot rest down to get up from the recliner. Staff removed the chair to allow AV to get up. The chair under the footrest was placed by Alleged Perpetrator #2 (AP2), who placed the chair to ensure AV would not get up from the recliner and fall while AP2 was assisting with other residents, as there was a shortage of staffing that evening. AP2's action is considered physical restraint for purpose of convenience, which is a violation of resident rights, are considered neglect of care and constitute abuse. The facility's failure is a violation of Oregon Administrative Rules.

The facility failed to ensure that the service plan must reflect the resident's needs per complaint that staff are not assisting the resident with their glasses, and hearing aid, which is a violation of Oregon Administrative Rules.

The facility failed to carry out medication orders as prescribed per complaint that a resident did not receive their scheduled medications, which is a violation of Oregon Administrative Rules.

The facility failed to ensure a resident monitoring and reporting system is implemented 24-hours a day per complaint that staff failed to follow up on a resident's sore timely, which is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) moved into the facility on April 10, 2024. AV had medications that he/she was supposed to be receiving. The facility failed to ensure AV's medications were approved in the medication administration system, which caused AV not to receive his/her medication for four days. The facility's failure is a violation of Oregon Administrative Rules.

The facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to complete quarterly service plans per complaint that there have not been regular quarterly care conferences, and the resident's service plan was not updated quarterly, which is a violation of Oregon Administrative Rules.

The facility failed to ensure the staff person who administered the medication visually observed the resident take his/her medication per complaint that staff did not observe the resident take his/her medication, which is a violation of Oregon Administrative Rules.

The facility failed to schedule and administrator on-site at least 40 hours per week, per complaint the facility did not have an administrator for a week, which is a violation of Oregon Administrative Rules.

The facility failed to prepare and serve meals in accordance with Food Sanitation Rules, per complaint the kitchen was dirty, which is a violation of Oregon Administrative Rules.

The facility failed to provide and document delegation by a RN, per complaint there was no nurse holding delegations for a week, which is a violation of Oregon Administrative Rules.

The facility failed to notify the resident's physician or other practitioner if the resident refuses consent to an order, per a complaint that the resident' refused their medications from 04/23/23 until 05/05/23 and the facility did not notify the resident's physician, which is a violation of Oregon Administrative Rules.

The facility failed to post the Ombudsman notification poster per complaint that the facility does not have Ombudsman information posted anywhere, which is a violation of Oregon Administrative Rules.

The facility failed to implement written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day, per complaint that staff never reported the resident's UTI symptoms to their doctor as planned, and staff are not trained on what urgent health concerns would require the patient to go to the hospital, which is a violation of Oregon Administrative Rules.

The facility failed to ensure the implementation of services, per complaint that staff are not providing the resident stand-by assists for showers at their planned time, which is a violation of Oregon Administrative Rules.

The facility failed to carry out medication orders as prescribed, per complaint the facility discontinued prescribed medication, which is a violation of Oregon Administrative Rules.

The facility failed to ensure a resident was free of retaliation, per complaint the facility raised a resident's rates in retaliation, which is a violation of Oregon Administrative Rules.

The facility failed to implement the resident's right to be given informed choice and opportunity to select or refuse service and to accept responsibility for the consequences. The facility is forcing the resident to wear depends, which is a violation of Oregon Administrative Rules.

The facility failed to investigate and report an incident of abuse or suspected abuse, which is a violation of Oregon Administrative Rules.

The facility failed carry out medications and treatments as prescribed per complaint staff could not locate resident's medications, which is a violation of Oregon Administrative Rules.

The facility failed keep an accurate medication administration record, which is a violation of Oregon Administrative Rules.

On or about June 1, 2022, the Oregon Health Authority reported to the Department that Respondent failed to comply with weekly reporting requirements of vaccinated individuals, residents and staff, to the proper authority as required by law. This failure has been ongoing from May 1, 2022 to May 31, 2022, for a total of 30 days.

On or about May 1, 2022, the Oregon Health Authority reported to the Department that Respondent failed to comply with weekly reporting requirements of vaccinated individuals, residents and staff, to the proper authority as required by law. This failure has been ongoing from April 1, 2022 to April 30, 2022, for a total of 30 days.

The facility allegedly failed to provide a safe medication administration system, which is a violation of Oregon Administrative Rules.