Ascot Park Senior Living

The Alleged Victim (AV) relies on the facility for his/her care. Witness 2 (W2) has a history of wandering and resistive behaviors and is care planned to be redirected with assistance from staff when wandering into other residents’ rooms. According to an investigation, on or about July 07, 2025, W2 wandered into AV's room and got into AV's bed, pushing AV against the wall. W2 was resistive to staff attempts to get out of the bed and W2 remained in bed, resulting in AV experiencing unreasonable discomfort. No interventions were determined to address the behavior. The facility failed to provide a safe environment and properly plan care, which is a violation of resident’s rights, is neglect of care and constitutes abuse.

The Alleged Victim (AV) is care planned as independent with ambulation and does not use an assistive device. The AV has suffered three unwitnessed falls from December 4, 2024, through January 2, 2025, then experienced another fall or about on January 22, 2025. AV was sent to the hospital due to hip and elbow pain. The facility failed to update and implement interventions in AV’s care plan after the falls, which is a violation of resident rights, is neglect of care and constitutes abuse.

The Alleged Victim (AV) is a known fall risk. Between May 23, 2024 and July 13, 2024 AV had approximately five (5) falls with minimal or no interventions put in place. AV has repeatedly fallen out of bed, and at least one occasion is documented to have buttocks/rear pain. The facility failed to implement interventions and/or appropriately care plan for AV’s continued falls, which is a violation of resident rights is neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility for care and for managing AV’s medications. According to an investigation, AV ran out of medication to control high blood pressure and missed all doses between June 2, 2024 and June 20, 2024, causing repeated unreasonable discomfort and placing AV at risk for stroke, heart attack, acute kidney injury, and death. The facility failed to administer medication as ordered and provide a safe medication administration system which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide a safe environment according to AV's needs. The failure resulted in AV experiencing injuries of unknown cause including bruising and skin injuries, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about February 22, 2024, the Alleged Victim (AV) was sent to a medical appointment without staff. AV's physician was not sure why AV was the appointment. On or about February 21, 2024, staff diagnosed AV with shingles and provided medication beginning February 21, 2024. AV's physician stated that AV's shingles were more than a few days old and AV had shingles prior to a day before the physician visit. AV's shower schedule was not followed and dictates that AV did not receive a shower for 6 days from February 14, 2024 to when the shingles were discovered by staff on February 20, 2024 during his/her shower. The facility failed to provide staff and coordinate medical needs for AV, which resulted in a delay of treatment for his/her condition, resulting in pain and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness 1 (W1) relies on the facility for their care and has a history of aggressive behaviors and physical altercations. According to an investigation, on or about November 13, 2023, the Alleged Victim (AV) and W1 got into a verbal confrontation that turned physical where W1 hit AV in the shoulder and AV slapped W1 in response. The facility failed to implement effective interventions and/or appropriately care plan for W1’s known behaviors and provide a safe environment for AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is a known fall risk. On or about November 10, 2023, AV was found on the floor from an unwitnessed fall, was complaining of back pain, and was given an as needed pain medication. According to the investigation, an alarm that the facility was using to alert staff when the AV was getting up had a dead battery. The facility failed to ensure resident safety, which is a violation of resident rights is neglect of care and constitutes abuse.

On or about September 9, 2023, the facility failed to implement interventions or follow Witness #1’s (W1) care plan which states W1 needs 1:1 supervision due to behaviors. The failure resulted in W1 kicking the Alleged Victim (AV) and causing a bruise. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions or appropriately care plan for Witness #1’s (W1) known behaviors. This failure resulted in W1 pushing and grabbing the hands/wrists of the Alleged Victim (AV) on or about March 4, 2022, which caused AV to fall and hurt their back. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions or appropriately care plan for Witness #1’s (W1) known behaviors. This failure resulted in W1 striking and grabbing the hands/wrists of the Alleged Victim (AV) on or about August 6, 2023, which caused unreasonable discomfort. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately care plan related to Witness 1's known behaviors and recent increase of altercations. The failure resulted in multiple physical altercations with staff and other residents, including the incident where s/he kicked the Alleged Victim’s (AV) three times, causing unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility to administer his/her medications. On or about January 22, 2023, the Alleged Perpetrator 3 (AP3) was scheduled to administer AV delegated metabolic medication but left several hours earlier than the medication was scheduled to be given. It is unclear if the medication was administered, as the Medication Administration Record (MAR) was not signed. Not administering the medication or administering the medication and not documenting that it was given placed AV at risk for serious harm. AP3 and the facility failed to provide a safe medication administration system, which is a violation of resident rights, is neglect of care and constitutes abuse.

The facility failed to implement meaningful interventions and appropriately care plan regarding Alleged Victim’s (AV) known fall risk. AV had approximately thirteen (13) documented falls between October 4, 2022, and November 29, 2022, with at least one resulting in injury. The facility failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately care plan regarding Alleged Victim’s (AV) known fall risk and change of AV’s condition. AV had multiple documented falls between September 21, 2022, and November 15, 2022, some resulting in injury including but not limited to a head injury, lacerations, and fracture of nasal bone. The facility failed to implement interventions to mitigate AV’s increasing fall risk, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care and for transferring. On or about August 27, 2022, at 1:45 am, AV pulled his or her call light for assistance. AV was found on the floor in his/her room at approximately 2:20 am on August 27, 2022 from a fall while waiting for staff and sustained a skin tear on his/her right elbow and left palm. The facility failed to follow the care plan which is a violation of resident’s rights is neglect of care and constitutes abuse.

The facility failed to implement interventions or appropriately care plan for Witness #5’s (W5) known behaviors. On or about August 7, 2022, there was an unwitnessed altercation between W5 and the Alleged Victim (AV). AV was found on the floor, complaining of chest and shoulder pain and was sent to the hospital. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) had two falls within 6 months. No interventions were put into place after the falls to ensure AV's safety. AV's care plan and progress notes are inconsistent regarding AV's falls. 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 care planned for assistance with toileting and will use his/her call light to alert staff when assistance is needed. On multiple occasions, AV had to wait more than 20 minutes and one time over an hour for the call light to be answered, causing unreasonable discomfort for AV. The facility's failure to answer the call light in a timely manner is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) resides at the facility and relies on the facility to meet his/her daily needs. AV's service plan identified the need for assistance with toileting and post-toileting hygiene. According to an investigation, on or about August 30, 2025, the Alleged Perpetrator 2 (AP2) neglected AV when AP2 did not assist AV with clothing adjustment following toileting, resulting in AV feeling upset and asking for another care staff. AP2's actions are a violation of resident's rights, are considered neglect of care and constitutes abuse. The facility failed to ensure appropriate care was provided to AV, which is a violation of Oregon Administrative Rules.

Based on an interview and record review conducted during a site visit on 07/30/25, the facility’s failure to exercise reasonable precautions against any condition that may threaten the health, safety, or welfare of residents was substantiated. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to carry out medication and treatment orders as prescribed. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to carry out medication and treatment orders as prescribed.The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to have a safe medication and treatment system. The facility's failure is a violation of Oregon Administrative Rules.

The facility allegedly failed to provide basic care to the Alleged Victim (AV)due to medications being administered incorrectly by the Alleged Perpetrator 2 (AP2). An investigation determined no abuse occurred by the facility and was inconclusive for AP2. Review of the Medication Administration Record (MAR), revealed multiple medication errors, which is a violation of Oregon Administrative Rules.

According to an investigation, the Alleged Perpetrator #3 (AP3) asked the Alleged Victim (AV), via text message, if they could borrow money. On or about August 1, 2024, AV sent AP3 approximately $150.00 via Cash App, which is considered financial exploitation and constitutes abuse. The facility failed to protect AV from financial exploitation which is a violation of Oregon Administrative Rules. Allegations against the Alleged Perpetrator 2 (AP2) were not substantiated.

The facility failed to determine and document what action or intervention is needed if a resident experiences a short-term change of condition. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to immediately notify the Department's Central Office of severe interruption of physical plant services. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to maintain their fire detection and protection equipment. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to carry out medication orders as prescribed. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident in each area. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to carry out medication orders as prescribed. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to quarterly evaluate service plans. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to properly administer the Alleged Victim’s (AV) medications. According to documentation, AV experienced no negative outcome. The failure is a violation of Oregon Administrative Rules.

The facility failed to properly administer the Alleged Victim’s (AV) medications. According to documentation, AV experienced no negative outcome. The failure is a violation of Oregon Administrative Rules.

The facility failed to properly administer the Alleged Victim’s (AV) medications. According to documentation, AV experienced no negative outcome. The failure is a violation of Oregon Administrative Rules.

The facility failed to properly administer the Alleged Victim’s (AV) medications. According to documentation, AV experienced no negative outcome. The failure is a violation of Oregon Administrative Rules.

The facility failed to properly administer the Alleged Victim’s (AV) medications. According to documentation, AV experienced no negative outcome. The failure is a violation of Oregon Administrative Rules.

The facility failed to carry out medication orders as prescribed, 2 resident's medications were missed. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide three daily nutritious, palatable meals with snacks available seven days a week. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to notify the local Department office, or the local AAA, of any incident of abuse or suspected abuse. An investigation determined this is a violation of Oregon Administrative Rules.

Alleged Victim (AV) relies on the facility for his/her care and is care planned to have two people assist with incontinence care. On or about July 22, 2023, AV was found in a decayed incontinence brief lying on a urine soaked mattress. According to an investigation, the Alleged Perpetrator #2 (AP2) did not call float staff to assist the AV with incontinence care and left AV in a wet bed shivering, resulting in a loss of personal dignity and unreasonable discomfort. AP2 failed to follow the care plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to ensure the care plan was being followed, which is a violation of Oregon Administrative Rules.

Alleged Victim (AV) relies on the facility for his/her care. AV is care planned to have standby toileting assistance and is a fall risk. On or about July 21, 2023, Alleged Perpetrator #2(AP2) did not assist AV when toileting and there was a significant amount of urine found on the floor, which placed AV at risk for harm. AP2 failed to follow the care plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to ensure the care plan was being followed, which is a violation of Oregon Administrative Rules.

Alleged Victim (AV) relies on the facility for his/her care. AV is care planned for full assistance with toileting and incontinence care. On or about July 21, 2023, Alleged Perpetrator #2(AP2) failed to ensure necessary and timely incontinence care was provided to AV, resulting in AV found to be “drenched” in urine, causing a loss of personal dignity. AP2 failed to follow the care plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to ensure the care plan was being followed, which is a violation of Oregon Administrative Rules.

• Alleged Victim (AV) relies on the facility for his/her care and is care planned to have two people assist with incontinence care. On or about July 22, 2023, AV was found in a dry brief on a urine soaked bedding. According to an investigation, the Alleged Perpetrator #2 (AP2) did not call float staff to assist the AV with toileting and left AV on a wet bed, resulting in a loss of personal dignity and unreasonable discomfort. AP2 failed to follow the care plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to ensure the care plan was being followed, which is a violation of Oregon Administrative Rules.

• Alleged Victim (AV) relies on the facility for his/her care and is care planned to have two people assist with incontinence care. On or about July 22, 2023, AV was found in a wet bed. According to an investigation, the Alleged Perpetrator #2 (AP2) did not call float staff to assist the AV with incontinence care and left AV on a wet bed, resulting in a loss of personal dignity and unreasonable discomfort. AP2 failed to follow the care plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to ensure the care plan was being followed, which is a violation of Oregon Administrative Rules.

According to the documentation, the Alleged Perpetrator (AP2) failed to follow the care plan by transferring the Alleged Victim by themselves. The failure resulted in the AV falling and sustaining a skin abrasion and bruising, which is a violation of resident rights and is considered physical abuse. The facility failed to follow the care plan which is a violation of Oregon Administrative Rules.

The facility failed to properly administer the Alleged Victim’s (AV) medications. According to documentation, AV experienced no negative outcome. The Facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.

Alleged Perpetrator 2 (AP2) failed to ensure the Alleged Victim’s (AV) medications were administered as ordered. On or about January 22, 2023, AP2 did not administer AV their medications, placing AV at risk for harm. AP2’s actions are a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.

Alleged Perpetrator 2 (AP2) failed to ensure the Alleged Victim’s (AV) medications were administered as ordered. On or about January 22, 2023, AP2 did not administer AV their medications, placing AV at risk for harm. AP2’s actions are a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.

Alleged Perpetrator 2 (AP2) failed to ensure the Alleged Victim’s (AV) medications were administered as ordered. On or about January 22, 2023, AP2 did not administer AV their medications, placing AV at risk for harm. AP2’s actions are a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.

Alleged Perpetrator 2 (AP2) failed to ensure the Alleged Victim’s (AV) medications were administered as ordered. On or about January 22, 2023, AP2 did not administer AV their medications, placing AV at risk for harm. AP2’s actions are a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.

Alleged Perpetrator 2 (AP2) failed to ensure the Alleged Victim’s (AV) medications were administered as ordered. On or about January 22, 2023, AP2 did not administer AV their medications, placing AV at risk for harm. AP2’s actions are a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.

Alleged Perpetrator 2 (AP2) failed to ensure the Alleged Victim’s (AV) medications were administered as ordered. On or about January 22, 2023, AP2 did not administer AV their medications, placing AV at risk for harm. AP2’s actions are a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.

Alleged Perpetrator 2 (AP2) failed to ensure the Alleged Victim’s (AV) medications were administered as ordered. On or about January 22, 2023, AP2 did not administer AV their medications, placing AV at risk for harm. AP2’s actions are a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.

Alleged Perpetrator 2 (AP2) failed to ensure the Alleged Victim’s (AV) medications were administered as ordered. On or about January 22, 2023, AP2 did not administer AV their medications, causing unreasonable discomfort. AP2’s actions are a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.

Alleged Perpetrator 2 (AP2) failed to ensure the Alleged Victim’s (AV) medications were administered as ordered. On or about January 22, 2023, AP2 did not administer AV their medications, placing AV at risk for harm. AP2’s actions are a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.

Alleged Victim (AV) relies on the facility to administer his/her medications. On or about January 22, 2023, the Alleged Perpetrator 2 (AP2) was scheduled to administer all AV evening medications, except those that were delegated to another staff member. AP2 did not administer any medications to AV, placing AV at risk for serious harm. AP2’s actions are a violation of resident rights, are considered neglect of care and constitutes abuse. The facility failed to administer medication as ordered which is a violation of Oregon Administrative Rules.

Alleged Perpetrator 2 (AP2) failed to ensure the Alleged Victim’s (AV) medications were administered as ordered. On or about January 22, 2023, AP2 did not administer AV their medications, causing unreasonable discomfort. AP2’s actions are a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.

On or about January 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 December 1, 2022, to December 31, 2022, for a total of 30 days.

The facility failed to ensure service plans were updated quarterly for 1 of 1 sampled resident, whose service plans were reviewed. The facility’s failure is a violation of Oregon Administrative Rules.

Witness #1 (W1) has a history of aggression towards staff and other residents. On or about April 4, 2022, the Alleged Perpetrator #2 (AP2) saw that W1 was out of bed, however, AP2 assumed that W1 was going back to bed and failed to follow de-escalation protocols put in place for W1. After AP2 walked away from W1, an altercation occurred between W1 and the Alleged Victim (AV), resulting in AV having discoloration to his/her eye and skin tears on his/her hand. AP2 failed to provide a safe environment, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to provide a safe environment, which is a violation of Oregon Administrative Rules.