Battle Creek Memory Care

Alleged Victim (AV) and Witness 1 (W1) live at Respondent’s facility. W1 has history of behavioral disturbances, and resident altercations with AV and other residents, including an incident that occurred before this altercation with AV. On or about September 27, 2025, W1 walked up to AV and a verbal argument occurred, AV hit W1, and W1 hit AV back. The facility failed to develop sufficient interventions after AV and W1 first resident to resident altercation and failed to develop interventions for W1 behaviors, which constitutes abuse by neglect.

Alleged Victim (AV) and Witness 1 (W1) live at Respondent’s facility. W1 has history of behaviors and resident altercations, including an incident that occurred on August 11, 2025. AV's service plan reflects AV gets anxious, needs reorientation, gets standard safety checks 4 times a shift. The facility failed to develop sufficient interventions to address W1 known behaviors and resident altercations to mitigate risks to other residents of the facility. On or about September 26, 2025, W1 walked up to AV and grabbed AV by the back of the neck aggressively. Respondent failed to develop and implement suitable interventions, which constitutes abuse by neglect.

The facility is responsible for administering the Alleged Victim’s (AV’s) prescribed medications. AV had a prescription for an anticoagulant medication to be administered twice daily. Per AV's physician order, the anticoagulant was to be held for 72 hours prior to a scheduled medical procedure, with instructions to resume the regular dosing schedule the day following the procedure. Documentation indicates that the anticoagulant medication was placed on hold on or about April 20, 2025. The procedure was performed on or about April 23, 2025. On or about May 15, 2025, while AV was having breakfast, AV’s family observed facial drooping. AV was transported to the emergency department, where it was determined that AV had experienced a stroke. Subsequent review revealed that AV had not received the prescribed anticoagulant medication from April 20, 2025, through May 13, 2025. 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. An investigation was conducted into the allegation that AP2 failed to ensure a safe medication administration system. The allegation was not substantiated.

Alleged Victim (AV) experiences severe confusion and resides in a secure memory care facility. AV requires frequent redirection due to wandering. Staff are to redirect AV when AV is seen wandering in order to manage wandering and prevent elopement. AV is known to try and open doors to try to find the exit. The evening of May 12, 2025, around 11:54 pm Witness 6 (W6) heard AV yelling, "Help me!" and looking stressed while wandering outside of the facility so W6 called the facility at approximately11:56 pm. Witness 4 (W4) went to the front door, saw AV outside the building, and walked AV back to AV's room. On May 13, 2025, AV was found to have purple discoloration on AV's left forearm. Around the beginning of April, it was reported the back secure door wasn't latching properly and staff performed maintenance. The facility failed to ensure all secure exits were working properly, resulting in AV exiting the facility, and sustained injury, which is a violation of resident’s rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) has history falls and fractures. AV service plan indicates fall risk, low fall risk, AV moved into the facility from skilled nursing due to a fall that had broken AV's hip in 3 locations, and AV is a known fall risk due to a history of falls. AV service plan indicates AV is independent with ambulation with or without assistive device. AV is able to determine the need for the use of h/h walker and may use it as s/he decides. AV is independent with transfers. On or about December 30. 2025, AV slipped in water on the floor of the facility dining area and fell. The water came from a water dispenser placed on a dining area countertop for residents to access fresh water. Prior to AV's fall, facility staff were aware that the water dispensers in use at the facility had no built-in means to prevent overflows, spills, or external condensation from migrating to the floor. As a result of the 12-30-24 fall, AV suffered a fractured right hip, severe pain, and required surgical repair. The facility failed to provide a safe environment, which is a violation of resident’s rights is neglect of care and constitutes abuse.

The Alleged Victim (AV) and Witness #1 (W1) have histories of altercations with other residents. On or about November 8, 2024, W1 tried to enter AV's apartment and AV yelled at W1 not to enter, W1 hit AV in the back of the head. Neither resident was injured in the altercation, however, both were placed at risk for harm. The facility's failure to have progressive interventions in place to prevent W1 from having altercations 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. On or about November 8, 2024, AV tried to enter W1's apartment and W1 yelled at AV not to enter, AV hit W1 in the back of the head. Neither resident was injured in the altercation, however, both were placed at risk for harm. The facility's failure to have progressive interventions in place to prevent AV from having altercations is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) was admitted to the facility with no official Dementia diagnosis and was not allowed to leave on h/h own. AV was first noted to be alert and oriented times 4 on February 13, 2024, AV expressed s/he was too high functioning to be in the facility, is very active person and AV expressed s/he thought about suicide. In or around June/July of 2024 AV was determined to not have dementia. No new guidance was provided to staff regarding AV’s cognitive abilities. AV would make suicidal statements, and no interventions were put into place for AV’s suicidal ideation. AV cried while talking about being in the facility and the lack of freedom that s/he has. The facility failed to confirm a diagnosis of dementia prior to admitting AV into the locked memory care facility, which is which is a violation of resident rights, and Resident services in a memory care community, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) is care planned to be a high fall risk. Between May 2023 through June 2023, AV has sustained approximately eight (8) falls, some resulting in injury. AV had been in a 10 to 15 minutes checks, however, AV was only being checked every two (2) hours. The facility failed to care plan appropriately and implement interventions to mitigate AV’s risk of falls exposing AV to harm, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. AV has sustained falls on or about March 5th and 10th, 2023, in one of those fall they sustained a fracture to their humerus. On or about May 15, 2023, at around 5:30am, AV sustained a fall in their room, as a result AV sustained a bump in their forehead and had swelling and bruising around their eye and temple area. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility to administer his/her medications. On or about May 11, 2023, AV received an order to start an anti-psychotic medication and to stop a PRN narcotic. The facility was handed the new anti-psychotic medication by Witness 1 (W1) on or about May 11, 2023, however, this was not started until June 10, 2023. As a result of AV not getting the anti-psychotic medication timely, AV hallucinated, putting AV is risk of harm. The facility failed to provide a safe medication administration system, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. Since being a new resident, admitted on or about February 21, 2023, AV has fallen on multiple occasion. AV’s interventions are not applicable to AV's falls and AV's safety checks went from 15 minutes to 30 minutes after AV continued to sustained falls. At times, AV did not have any interventions put in place after he/she fell putting AV is risk of harm. The facility failed to provide a homelike environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility to administer his/her medications. On or about March 20, 2023, AV had one dose of their insulin medication missed due to the facility not having the refill. On or about March 21st and 22nd, 2023, AV had two doses of their diabetic medication missed due to pending refill. The facility failed to provide a safe medication administration system for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) does not have a history of resident-to-resident altercations. Witness 1 (W1) has a history of verbal outbursts and is easily redirected. On or about October 3, 2022, W1 was yelling and threatening to beat AV, this happened twice in the morning. On or about October 10, 2022, AV and W1 had a physical altercation in their room, initiated while AV was asleep. On or about October 24, 2022, W1 struck AV in the face and head with a closed fist while AV was in bed. The facility failed to provide a homelike environment for AV, which is a violation of resident is neglect of care and constitutes abuse.

The Alleged Victim (AV) is a known fall risk. AV had multiple previous falls at the facility, with and without injury. On or about August 6, 2024, AV began complaining of pain in his/her leg. On or about August 7, AV was taken to the emergency room where he/she was diagnosed with a femur fracture. The facility's failure to properly care plan to reduce the number of falls AV was sustaining placed AV at risk for serious harm and resulted in a femur fracture. The facility's falure to properly care plan is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) and Witness 1 (W1), have a history of resident-to-resident altercations. Between February 16th, through April 27th, 2022, AV and W1 had four (4) altercations. On or about June 17, 2022, W1 shoved AV to the ground, as a result, AV sustained bruises to the patella, sacrum, and the outer side of his/her elbow. The incident occurred in AV’s room. The facility failed to provide a homelike environment to AV, by allowing the altercations to continue to occur and putting AV in risk of harm, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. On or about June 11, 2022, AV had a fall which resulted in AV being sent to the ER and sustaining a fracture to his/her tibia and fabula. AV returned to the facility on June 11, 2022, and five (5) minutes after returning to the facility, he/she sustained another fall. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility to administer his/her medication. Between June 1st through June 6, 2022, AV missed multiple medication. AV was not given the following medications: Atenolol was missed from 6/2/22-6/5/22, Febuxostat was missed from 6/1/22-6/5/22, Finasteride was missed from 6/1/22-6/6/22, Levothyroxine was missed from 6/3/22-6/6/22, Potassium CHL was missed from 6/1/22-6/6/22, Losartan was missed from 6/4/22-6/5/22. The facility failed to provide a safe medication administration system, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. On or about June 3, 2022, AV was sent to the hospital due to swelling and shortness of breath. AV returned on June 3, 2022, with order to increase his/her Furosemide to 40mg twice daily for next two days. AV was given the increased dose of Furosemide twice on June 4, 2022, but not on June 5, 2022. The order from the doctor was not followed correctly and as a result, AV’s legs were swollen, and he/she did feel “crappy” when the medication was missed. The facility failed to administer medication as ordered, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. On or about June 5, 2022, staff did not lock the door to an office which caused AV to elope the facility when they were not watching. AV left the facility without shoes on and walked near a busy street. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) is a high fall risk. On or about May 28, 2022, staff were assisting AV with toileting when AV sustained a fall and hit his/her head on the toilet seat. As a result, AV sustained a skin tear on his/her left elbow, his/her upper right arm, and his/her left knee. AV sustained a laceration on his/her left temple. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) is a high fall risk and has a history of falls. Between April 8, 2022, through May 18, 2022, AV sustained approximately six (6) falls. On or about May 20, 2022, AV hit his/her head on the table and there were no interventions in place to prevent further falls. The facility failed to care plan appropriately and implement interventions to mitigate AV’s risk of falls, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) is a high fall risk. On or about May 28, 2022, AV sustained a fall that resulted in AV having a lump on his/her forehead. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) has a history of exit seeking behaviors. AV’s April 6, 2022, Service Plan did not include clear interventions designed to prevent AV from eloping from the facility. On or about May 14, 2022, AV eloped from the facility after pushing through a staff member. The facility failed to properly care plan around AV’s known history of exit seeking, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim’s (AV’s) April 6, 2022, Service Plan states AV is a high elopement risk and specifically outlined AV’s exit seeking behaviors, noting that AV would enlist other residents, wait by exit doors, then push past people coming into or exiting the facility. On or about May 14, 2022, AV eloped from the facility with another resident by waiting near the doors, then he/she pushed past a staff member who was opening the door to enter. The facility failed to assure AV’s care plan was being followed in regard to his/her known exit seeking behaviors, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) has known exit seeking behaviors. On or about May 1, 2022, at 2:57 p.m., AV eloped from the facility. AV was outside the facility, walking around the building until 3:27 p.m. AV tried to get back into the building at 3:15 p.m. and 3:24 p.m. The facility failed to provide a safe environment, which is a violation of resident rights, is neglect of care and constitutes abuse.

Witness 1 (W1) has a known history of resident-to-resident altercations. On or about April 4, 2022, W1 was holding onto Alleged Victim’s (AV’s) wheelchair asking AV a question and then got mad and slapped AV in the hand three (3) times. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Witness 1 (W1) has a known history of wandering and going into other resident rooms. On or about April 20, 2022, Alleged Victim (AV) was in his/her room when staff heard a scream and saw W1 gripping AV’s wrist and yelling at him/her. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. Due to AV’s behaviors, he/she must have a 1:1 support in order to get needed dialysis treatment. AV has had increased behavior while attending his/her dialysis appointment, due to these behaviors, the hospital has stated that AV cannot attend appointment without a full-time attendant. The facility has not been providing a staff member to go with AV in order for him/her to go to treatment. The facility failed to provide base care by not assisting with medical needs, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. On or about March 22, 2022, Witness 1 (W1) punched AV in the face when AV decided he/she wanted W1 to leave his/her room. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. On or about April 27, 2022, Witness 1 (W1) hit/slapped AV in the face again. AV and W1 have had several physical resident-to-resident altercations. A temporary service plan from incident date of March 22, 2022, outlined for staff to keep AV and W1 separated. During the incident of April 27, 2022, AV and W1 were sitting with each other at the same table after dinner. The facility failed to follow the service plan, which is a violation of resident rights is neglect of care and constitutes abuse.

Witness #1 (W1) has a history of inappropriate behaviors with other residents. W1 was care planned to have one on one care to prevent his/her inappropriate behaviors with others. On or about March 20, 2022, W1 approached the Alleged Victim (AV) and whispered in his/her ear that he/she would like to go to bed with AV. AV was terrified of W1 and did not want to come out of his/her room, causing unreasonable discomfort. The facility failed to follow the care plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) had multiple falls on or about March 18, 2022, that resulted in injury. 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. On or about March 14, 2022, Witness 1 (W1) put his/her hand on AV’s breast. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. On or about March 12, 2022, Witness 1 (W1) and AV were sitting at the kitchenette counter. When AV walked away, W1 touched AV on the back of his/her thigh below the buttocks. AV reported being scared. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. On or about March 9, 2022, staff reported Witness 1 (W1) was seen touching AV’s breast area under his/her shirt. AV reported that it hurt. On or about March 14, 2022, AV was found in W1’s bed before breakfast with his/her pants down. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

The facility failed to follow the Alleged Victim’s (AV) care plan. AV’S care plan states AV needs cuing for self-care and cleaning. According to documentation AV went without a shower for twelve (12) days. The failure resulted in AV experiencing unreasonable discomfort and a loss of dignity, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) is prescribed medications to reduce AV’s aggressive behaviors. On AV’s Service Plan date April 6, 2022, it required the facility to order AV’s medication in a timely manner. Between February 5th through May 16, 2022, the facility ran out of AV’s medication on more than one occasion. Due to AV being out of his/her medication, he/she had aggression behaviors towards other residents. The facility failed to follow the care plan in regard to ordering medication in a timely manner for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) care plan states he/she may develop exit seeking behaviors. On or about January 21, 2022, AV left the courtyard through an unlocked gate ending up at the apartments behind the facility. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility to provide a safe environment. AV and Witness 1 (W1) have a history of resident-to-resident altercations. On or about January 2, 2022, W1 ran into AV with his/her walker. The facility failed to provide a safe environment, which is a violation of resident rights, is neglect of care and constitutes abuse.

The Alleged Victim (AV) was listed on his/her care plan as independent for mobility and transfers. AV has suffered 5 falls within a one month period preceding his/her fall on December 23, 2021. On or about December 23, 2021, AV suffered a fall where AV fractured his/her wrist and pelvis. The facility failed to properly care plan to ensure AV's safety from falls. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #1 (W1) was care planned with aggressive behaviors and was to be redirected when agitated. On or about November 4, 2021, W1 and the Alleged Victim (AV) had a non-injury altercation where both residents hit each other. The facility failed to follow the care plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) was care planned with aggressive behaviors and was to be redirected when agitated. On or about November 4, 2021, Witness #1 (W1) and the AV had a non-injury altercation where both residents hit each other. The facility failed to follow the care plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is care planned to have assistance with showers. On or about February 11, 2025, Alleged Perpetrator #2 (AP2) was assisting AV with a shower when staff heard AV screaming. Staff entered the room and saw AP2 trying to take off AV's bra, and AV was stating, "stop, you are hurting me". The other staff assisted and got the bra off and then assisted with the shower. AP2 continued to assist and after the shower was brushing AV's hair with a comb, pulling AV's tangled hair through the comb, causing additional pain to AV. AP2's actions are a violation of resident rights, is considered neglect of care and constitutes physical abuse. The facility's failure to assure AV was free from physical abuse is a violation of Oregon Administrative Rules.

On or about August 18, 2024, Alleged Perpetrator #2 (AP2) signed out narcotic medication for the Alleged Victim (AV) and marked in the medication system that the medication was given to AV. AV denies asking for or taking the medication in question. AP2's actions are a violation of resident rights, are considered neglect of care and constitute financial abuse. The facility's failure to protect AV from financial abuse is a violation of Oregon Administrative Rules.

The facility failed to ensure that only individuals with a diagnosis of dementia who are in need of support for the progressive symptoms of dementia for physical safety, or physical or cognitive function may reside in a memory care community. The facility’s failure is a violation of Oregon Administrative Rules.

On or about February 19, 2024, Alleged Perpetrator #2 (AP2) told the Alleged Victim (AV) that he/she would pop AV in the chin if he/she didn't stop what they were doing. AP2 lifted his/her elbow at AV at the time of the statement. AV responded by being verbally combative. AP2's actions are a violation of resident rights, are considered neglect of care and constitute emotional abuse. The facility failure is a violation of Oregon Administrative rules.

The facility failed to implement safe medication and treatment administration systems, which is a violation of Oregon Administrative Rules.

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

The facility failed to exercise reasonable precautions against any conditions that may threaten the health, safety, and welfare of residents, which is a violation of Oregon Administrative Rules.

On or about February 18, 2022, Alleged Perpetrator #2 (AP2) was working outside and was bringing equipment back in and left the gate open in the courtyard. The Alleged Victim (AV) is a known exit seeker and got out of the community through the open gate. AV made it all the way to the bus stop and took a seat on the bus. Facility staff were able to get AV off the bus and back to the community. AV was not harmed, however, AV was placed at risk for harm. AP2's failure to provide a safe environment is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility's failure is a violation of Oregon Administrative Rules.