Boone Ridge Memory Care

Alleged Victim (AV) relies on the facility for h/h care. AV has a history of falls, is considered a high fall risk and had 7 falls since May 2025. On or about August 12, 2025, AV fell and complained of pain and guarding and swelling of AV's wrist. AV was transported to the hospital and diagnosed with a fracture wrist. At the time of AV's fall on August 12, 2025, interventions in place were not effectively preventing AV from falling and injuring AV's self; AV had falls on July 2, 2025, and August 1, 2025, with no new fall interventions added. The facility failure to adjust the service plan after each fall, lead to continued falls and injury, which is a violation of resident

Both the Alleged Victim (AV) and Witness 1 (W1) have documented cognitive decline. AV and W1 have a history of resident-to-resident altercations—both with each other and with other residents. W1 is known to become triggered when other residents enter or pass through W1’s personal space, including residents walking past W1’s doorway. AV is known to ambulate frequently throughout the facility when awake. Following an altercation between AV and W1 on or about July 26, 2025, the following interventions were implemented: staff are to ensure AV remains in a common area away from W1’s apartment, staff are to redirect AV if observed walking near or past W1’s room. Despite these interventions, on or about August 1, 2025, AV was walking down the hallway when W1, who was standing in the doorway of their room, reached out and struck AV’s right shoulder with the side of a closed fist. The facility failed to maintain a safe environment, provide adequate oversight, and follow the interventions in place for AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) and Witness 1 (W1) are residents of a locked memory care facility and rely on AP1 for a safe environment and their care needs. W1 has a history or resident-to-resident altercations. On or about July 3, 2025, W1 and AV were involved in a resident-to-resident altercation, W1 was sitting on the bench in front of W1's room, as AV walked by W1, W1 swung W1's cane out at AV. Interventions put into place, staff to be aware of the incident and observe report any additional interaction between AV and W1. On or about July 26, 2025, W1 left W1's room, walked down the hall, and W1 hit h/h cane against AV's walker and cheek. The facility failed to adjust the service plan for W1 leading to continued aggressive behavior, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) has had 10+ falls between October 2024 and January 26, 2025. AV's service plan dated on or about January 13, 2025, notes AV is a low fall risk and should be checked on 2x per shift and staff are to assist AV into h/h recliner after meals. AV fell on or about December 14, 2024, Staff did not transfer AV into the recliner after the meal. Interventions noted are to again have staff assist AV to recliner after meals and place non-skid strips in front of recliner. Non-skid strips were not in the incident report and not added in front of AV's recliner by observation of investigator. AV fell on December 20, 2024, intervention was to ensure AV has shoes on. AV fell on December 21, 2024, AV was not wearing proper shoes. AV fell on January 4, 2025, and was sent to the ER due to pain in hip/ribs. No new interventions noted. AV fell on January 8, 2025, and had slippers on, not proper shoes. No new interventions noted. AV fell on January 26, 2025, and was sent to the ER with a wound above left eyebrow that was bleeding. The facility failed to appropriately care plan and implement reasonable interventions to address AV’s falls, and failed to follow interventions that were in place, which is violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) has a history of multiple falls due to self-transfers, and forgets s/he is unable to transfer and h/h own. On or about March 8, 2025, AV fell and broke h/h wrist and hit h/h head. AV was not wearing shoes at the time of the fall which is a previous intervention. AV's service plan doesn't include previous months interventions and lists AV as a minimal risk for falls. Staff are not aware of fall interventions, who is supposed to implement them, and staff were unsure if fall interventions were being implemented or not. The facility failed to provide a safe environment and appropriately care plan and implement reasonable interventions to address AV’s falls, which is violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is care planned to be assisted with dressing. on or about September 23, 2024, AV dressed him/herself and was walking and turned around and lost his/her footing and fell. AV was wearing mismatched shoes, causing him/her to fall. The next day, AV's wrist was swollen and was taken to the hospital and it was determined AV suffered a fractured wrist. Facility staff failed to follow AV's care plan by not assisting AV with getting dressed. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) has a history of seizures and recurring falls. AV's service plan dated on or about July 2, 2024, indicates AV is a 2-person transfer, is ambulatory and loves moving around and going for walks and dancing. On or about September 14, 2024, AV had a seizure and fell, resulting in blunt head trauma, a forehead laceration requiring staples and a cut on the inside of h/h mouth. No additional interventions were put into place after this incident. On or about September 22, 2024, AV fell from a standing position resulting in AV being sent to the hospital and diagnosed with blunt head trauma, and two fractured fingers. Intervention put in place frequent checks, make sure AV uses toilet frequently. AV had two additional falls on September 23, 2024, and it is noted AV has been a lot weaker and not stable on h/h feet without assistance. Interventions to keep AV in areas where AV can be checked on frequently, complete safety checks at beginning end and least six times between. AV was found on the ground by h/h bed on or about September 29, 2024. It is noted AV has a change in mobility status, intervention put in place motion pad brought in by family. On or about October 01, 2024, AV was found on the ground next to the bathroom. Interventions put into place, staff to check 4x a shift to ensure AV is in h/h wheelchair. On or about October 5, 2024, AV was found on the ground in front of h/h wheelchair. The wheelchair had the footrest on at the time of incident. AV had 6 falls between September 14, 2024 to October 5, 2024, AV was 2-person transfer prior to the falls, interventions put into place after AV falls, 1-person assist with gait belt, and with ambulation staff to walk right next to h/h and hold h/h hand or arm to help provide some support, and if not walking safely encourage to sit in wheelchair, chair or bed. Complete frequent safety checks, and a motion mat was ordered however it does not indicate if this motion mat was implemented, as AV had several falls after with no mention of alarm notification, or if motion mat was in place. The facility failed to provide a safe environment, appropriately care plan and implement reasonable interventions to address AV’s ongoing falls, which is violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) has a history of seizures and is prescribed medication for this disorder. Facility is responsible for ordering, storing and administering AV's medications. On or about August 7, 2024, AV was prescribed an increase to a current medication that is an anticonvulsant used to treat seizure disorders, but AV did not receive the increased dose until September 12, 2024. On or about September 14, 2024, AV had a seizure in the dining area falling out of h/h chair, hitting h/h head resulting in a severe head injury requiring hospital visit and staples. The facility failed to administer medication as ordered failed to provide a safe medication administration system, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) was scheduled for surgery on or about September 4, 2024, and had doctor's orders to not eat after midnight before the surgery. Witness 6 (W6) was given the doctor's orders regarding AV's fasting for surgery. When a resident has doctor's orders or change of condition, a temporary care plan would be created and put in a book for all staff to observe, but this was not done. AV was reported as having breakfast that morning before going in for surgery. AV was at serious risk of aspiration during surgery by not following doctor's orders to fast before surgery. The facility failed to properly plan care and provided interventions appropriate to keep AV from eating prior to surgery, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about August 13, 2024, the Alleged Victim (AV) was found on his/her bathroom floor after an unwitnessed fall, resulting in a scalp laceration that required hospitalization and staples. Based on facility documentation and interviews, AV had a documented history of falls, including 11 falls between June 19, 2024, and August 9, 2024, two of which resulted in head injuries. The facility's lack of appropriate oversight and care planning regarding AV's known fall risk, caused AV continued pain and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) was discharged from the hospital on or about November 05, 2023, with two (2) PRN pain medications. On or about November 06, 2023, AV was limping around and experiencing pain. AV was not given a dose of either PRN pain medication until November 07, 2023, resulting in AV experiencing unreasonable discomfort. The facility failed to administer medication as ordered, which is a violation of resident rights is considered neglect of care and constitutes abuse.

The facility failed to provide assistance with bathing to the Alleged Victim (AV). Approximately in May 2023 there is only documentation of staff showering AV two times, and approximately in August 2023 there is no documentation of AV being showered between 08/03/23 and 08/28/23 resulting in AV experiencing unreasonable discomfort, and redness on h/h head from itching. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) service plan: AV will sometimes refuse care, or gets angry when staff try and help h/h in the evening. On a scheduled medications for behaviors. AV requires minimal assistance. Mobility: Minimal Assistance 2 person. AV ambulates independently with walker, sometimes forgets walker. AV requires staff assistance with bathing twice weekly in the evenings. Staff will need to turn on the shower, assist AV getting h/h clothes off, hand h/h soapy washcloth and have h/h wash all areas that s/he can, assist AV with the shampoo and have h/h scrub and rinse h/h hair, help get completely dry, assist with putting clothing on. AV will sometimes refuse to take h/h shower or get really upset when staff is trying to shower h/h. If this occurs, make sure AV is in a safe area and walk away and try again at a later time. On or about September 17, 2023 AV had become agitated after a shower and began to walk out of the shower. AP2 turned to get AV a towel, AV lost AV's balance and stumbled backwards. AP2 attempted to assist AV and catch AV's balance but AV began to slip causing AV and AP2 to fall backwards. AV fell on top of AP2. EMTs took AV to the hospital and AV was diagnosed with a hip fracture. The facility failed to properly care plan and have clear instructions for staff, which resulted in serious harm to AV, which is a violation of resident’s rights is neglect of care and constitutes abuse.The allegation that AP2 failed to provide supervision or safety for AV, was investigated and the determination was not substantiated.

Alleged Victim (AV) has a history of wandering into other residents’ rooms, resulting in physical altercations. AV is service planned for staff to redirect AV out of resident rooms, and keep doors locked of the rooms near AV room unless the resident requests their room not be locked. On or about January 23, 2023, AV wandered into Witness 1 (W1) unlocked room, where a physical altercation took place resulting in AV sustaining a skin tear to AV arm. The facility failed to appropriately adjust care plan and implement reasonable interventions to address AVs continued wandering into other residents unlocked rooms and keep AV safe, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) has a history of wandering into other residents rooms. Witness 1 (W1) and AV have history of past physical resident-to-resident altercations. On or about December 29, 2022, AV wandered into W1’s room and W1 hit AV in the eye. AV was visibly scared, upset and in pain. The facility failed to appropriately adjust care plans and implement reasonable interventions to address AVs wandering and resident altercations between W1 and AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to ensure supervision and staff support regarding known behaviors related to Witness #1 (W1). An incident occurred between W1 and the Alleged Victim (AV) where W1 hit AV in the face. The facility's failure to provide a safe environment is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #1 (W1) has a history of aggressive behaviors towards staff and residents. On or about September 07, 2022, Alleged Victim (AV) and W1 had a verbal altercation that turned physical. W1 grabbed AV by the arm leaving a red mark. The facility failed to appropriately care plan and implement reasonable interventions to address W1’s increasing and ongoing behaviors, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) has history of wandering the facility. Witness 1 (W1) has history of aggression, and resident-to-resident altercations. On or about September 05, 2022, AV was wandering the halls. AV and W1 were seen by a visitor with hands on each other, W1 pushed AV causing AV to fall on the floor hitting h/h head. AV sustained a bump on h/h head and complained of pain. The facility failed to appropriately care plan and implement reasonable interventions to address AV’s wandering, and W1 aggressive behaviors, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about August 26, 2022, the Alleged Victim (AV) was found on the restroom floor, crying and complaining of pain. AV was sent out to the Emergency Room and was diagnosed with multiple, inoperable, pelvic fractures. AV returned from the hospital and suffered two more falls, causing unreasonable discomfort. The facility failed to properly care plan after a significant change of condition, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #1 (W1) has a history of behaviors, including aggression, screaming, verbal abuse, and hitting. On or about July 27, 2022, W1 was showing signs of aggression towards other staff and residents. W1 slapped Alleged Victim (AV) on the face leaving a red mark. The facility failed to properly plan care and provided interventions appropriate to mitigate W1 aggressive behaviors towards other residents which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about July 26, 2022, the Alleged Victim (AV) was found in another residents room with a laceration to the back of his/her head from a fall. AV was sent to the Emergency Room where he/she received stitches. AV is care planned to be redirected by staff when wandering into other residents rooms. AV was seen wandering by staff prior to the incident, however, AV was not redirected and was in the other residents room for at least 7 minutes. The facility failed to follow the care plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) has a history of wandering around the facility and entering other residents’ rooms. On or about June 20, 2022, AV wandered into Witness 1 (W1) room, W1 reported she/he tried to get AV out and AV fell and hit head causing a cut above AVs eyebrow. The facility failed to properly plan care and provided interventions appropriate to mitigate AV ongoing wandering, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to properly care plan and implement reasonable interventions that would mitigate Alleged Victim (AV) from falling. AV fell twice while attempting transfer on or about May 07, 2022, and again on or about May 09/, 2022 sustaining a broken arm. 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 between August 2021, and November 2021, AV suffered 10 falls, resulting in pain and injuries from bruises to lacerations and fractures. On or about November 15, 2021, AV fell from bed, resulting in a fractured nose and a laceration to his/her face, which required stitches. This fall was the third fall for AV within 30 days. The facility's failure to ensure AV was safe from falls is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to have an Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population, their needs, and all required Activities of Daily Living (ADL). Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. Facility was not staffed to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to have an Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population, their needs, and all required Activities of Daily Living (ADL). Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. Facility was not staffed to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to have an Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population, their needs, and all required Activities of Daily Living (ADL). Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. Facility was not staffed to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to have an Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population, their needs, and all required Activities of Daily Living (ADL). Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. Facility was not staffed to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to have an Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population, their needs, and all required Activities of Daily Living (ADL). Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. Facility was not staffed to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to have an Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population, their needs, and all required Activities of Daily Living (ADL). Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. Facility was not staffed to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to have an Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population, their needs, and all required Activities of Daily Living (ADL). Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. Facility was not staffed to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to develop, maintain, and implement an Acuity-Based Staffing Tool (ABST). During the review, inconsistencies were identified, and the facility was not staffing according to the levels indicated by the ABST or the posted staffing plan for the date reviewed, March 24, 2026. The investigation determined that this constitutes a violation of Oregon Administrative Rules.

The facility failed to develop, maintain, and implement an Acuity-Based Staffing Tool (ABST). During the review, inconsistencies were identified, and the facility was not staffing according to the levels indicated by the ABST or the posted staffing plan for the date reviewed, July 26, 2025. The investigation determined that this constitutes a violation of Oregon Administrative Rules.

The facility failed to develop, maintain, and implement an Acuity-Based Staffing Tool (ABST). During the review, inconsistencies were identified, and the facility was not staffing according to the levels indicated by the ABST or the posted staffing plan for the date reviewed, June 6, 2025. The investigation determined that this constitutes a violation of Oregon Administrative Rules.

Witness #1 (W1) has history of being protective of h/h room, especially when other residents go near it. W1 service plan indicates staff are to redirect others away from W1's room. Alleged Victim AV is a wanderer into other resident’s rooms and when s/he needs to use the bathroom. AV service plan indicates staff are to keep an eye on AV and redirect h/h to h/h room if s/he is in other resident’s room. On or about March 25, 2025, AV went into W1's room uninvited which upset W1, so s/he started to hit AV with h/h cane. AV had no redness, bruising or pain due to this incident. Facility failed to follow AV and W1 Care plan which is a violation of Oregon Administrative Rules.

Alleged Victim (AV) relies on the facility for h/h care and for a safe environment. AV has a history of refusing medication, getting upset and refusing care when s/he does not know what is going on. AV has interventions in place for this behavior that include telling AV what will be happening before care is done. AV has PRN medication for aggressive behavior, and prior to administration staff are to attempt at least two interventions. On or about August 1, 2023, no interventions or attempt was made to give AV h/her medications prior to AV’s PRN medication and scheduled medications being crushed and placed in a syringe with liquid. AV was lying on h/h own bed, when on two (2) attempts Alleged Perpetrator’s #2, #3, #4 and #5 (AP2, AP3, AP4, and AP5) entered AV’s room and restrained AV while AP2 forcibly held AV’s head to administered AV’s medications. AP2 held AV’s nose closed and covered AV’s mouth to physically interfere with AV’s ability to breathe and expel the liquid medication. AP2, AP3, AP4 and AP5 all received training regarding wrongful use of physical restraints, and AP2 received training regarding physical abuse. AP2’s actions of holding AV’s nose and mouth closed are a violation of resident’s rights, are considered neglect of care and constitute physical abuse. AP2, AP3, AP4 and AP5’s actions are a violation of resident rights, are considered neglect of care and constitute wrongful use physical restraint. The facility failed to ensure AV had a safe environment and was protected from physical abuse, and wrongful use of restraint which is a violation or Oregon Administrative Rules.

Alleged Victim (AV) relies on the facility for h/h care and for a safe environment. AV has a history of refusing medication, getting upset and refusing care when s/he does not know what is going on. AV has interventions in place for this behavior that include telling AV what will be happening before care is done. AV has PRN medication for aggressive behavior, and prior to administration staff are to attempt at least two interventions. On or about August 1, 2023, no interventions or attempt was made to give AV h/her medications prior to AV’s PRN medication and scheduled medications being crushed and placed in a syringe with liquid. AV was lying on h/h own bed, when on two (2) attempts Alleged Perpetrator’s #2, #3, #4 and #5 (AP2, AP3, AP4, and AP5) entered AV’s room and restrained AV while AP2 forcibly held AV’s head to administered AV’s medications. AP2 held AV’s nose closed and covered AV’s mouth to physically interfere with AV’s ability to breathe and expel the liquid medication. AP2, AP3, AP4 and AP5 all received training regarding wrongful use of physical restraints, and AP2 received training regarding physical abuse. AP2’s actions of holding AV’s nose and mouth closed are a violation of resident’s rights, are considered neglect of care and constitute physical abuse. AP2, AP3, AP4 and AP5’s actions are a violation of resident rights, are considered neglect of care and constitute wrongful use physical restraint. The facility failed to ensure AV had a safe environment and was protected from physical abuse, and wrongful use of restraint which is a violation or Oregon Administrative Rules.

Alleged Victim (AV) relies on the facility for h/h care and for a safe environment. AV has a history of refusing medication, getting upset and refusing care when s/he does not know what is going on. AV has interventions in place for this behavior that include telling AV what will be happening before care is done. AV has PRN medication for aggressive behavior, and prior to administration staff are to attempt at least two interventions. On or about August 1, 2023, no interventions or attempt was made to give AV h/her medications prior to AV’s PRN medication and scheduled medications being crushed and placed in a syringe with liquid. AV was lying on h/h own bed, when on two (2) attempts Alleged Perpetrator’s #2, #3, #4 and #5 (AP2, AP3, AP4, and AP5) entered AV’s room and restrained AV while AP2 forcibly held AV’s head to administered AV’s medications. AP2 held AV’s nose closed and covered AV’s mouth to physically interfere with AV’s ability to breathe and expel the liquid medication. AP2, AP3, AP4 and AP5 all received training regarding wrongful use of physical restraints, and AP2 received training regarding physical abuse. AP2’s actions of holding AV’s nose and mouth closed are a violation of resident’s rights, are considered neglect of care and constitute physical abuse. AP2, AP3, AP4 and AP5’s actions are a violation of resident rights, are considered neglect of care and constitute wrongful use physical restraint. The facility failed to ensure AV had a safe environment and was protected from physical abuse, and wrongful use of restraint which is a violation or Oregon Administrative Rules.

Alleged Victim (AV) relies on the facility for h/h care and for a safe environment. AV has a history of refusing medication, getting upset and refusing care when s/he does not know what is going on. AV has interventions in place for this behavior that include telling AV what will be happening before care is done. AV has PRN medication for aggressive behavior, and prior to administration staff are to attempt at least two interventions. On or about August 1, 2023, no interventions or attempt was made to give AV h/her medications prior to AV’s PRN medication and scheduled medications being crushed and placed in a syringe with liquid. AV was lying on h/h own bed, when on two (2) attempts Alleged Perpetrator’s #2, #3, #4 and #5 (AP2, AP3, AP4, and AP5) entered AV’s room and restrained AV while AP2 forcibly held AV’s head to administered AV’s medications. AP2 held AV’s nose closed and covered AV’s mouth to physically interfere with AV’s ability to breathe and expel the liquid medication. AP2, AP3, AP4 and AP5 all received training regarding wrongful use of physical restraints, and AP2 received training regarding physical abuse. AP2’s actions of holding AV’s nose and mouth closed are a violation of resident’s rights, are considered neglect of care and constitute physical abuse. AP2, AP3, AP4 and AP5’s actions are a violation of resident rights, are considered neglect of care and constitute wrongful use physical restraint. The facility failed to ensure AV had a safe environment and was protected from physical abuse, and wrongful use of restraint which is a violation or Oregon Administrative Rules.

Alleged Victim (AV) relies on the facility for h/h care and for a safe environment. AV has a history of refusing medication, getting upset and refusing care when s/he does not know what is going on. AV has interventions in place for this behavior that include telling AV what will be happening before care is done. AV has PRN medication for aggressive behavior, and prior to administration staff are to attempt at least two interventions. On or about August 1, 2023, no interventions or attempt was made to give AV h/her medications prior to AV’s PRN medication and scheduled medications being crushed and placed in a syringe with liquid. AV was lying on h/h own bed, when on two (2) attempts Alleged Perpetrator’s #2, #3, #4 and #5 (AP2, AP3, AP4, and AP5) entered AV’s room and restrained AV while AP2 forcibly held AV’s head to administered AV’s medications. AP2 held AV’s nose closed and covered AV’s mouth to physically interfere with AV’s ability to breathe and expel the liquid medication. AP2, AP3, AP4 and AP5 all received training regarding wrongful use of physical restraints, and AP2 received training regarding physical abuse. AP2’s actions of holding AV’s nose and mouth closed are a violation of resident’s rights, are considered neglect of care and constitute physical abuse. AP2, AP3, AP4 and AP5’s actions are a violation of resident rights, are considered neglect of care and constitute wrongful use physical restraint. The facility failed to ensure AV had a safe environment and was protected from physical abuse, and wrongful use of restraint which is a violation or Oregon Administrative Rules.

Alleged Victim (AV) returned to the facility with wound care instructions on or about June 16, 2023. AV's wound care instructions: keep biopsy site dry for 24 hours after procedure, after 24 hours you may shower and allow soapy water to run over biopsy site. Change bandage 1-2 times a day with Vaseline and a new bandage until healed up. Witness #2 (W2) discovered the biopsy wound on or about June 21, 2023, and no wound care instructions had been added to AV progress note, MAR, or TSP. W2 did not see infection and no doctor follow up was needed. Wound care instructions entered late into AV progress note on or about June 21, 2023. The facility failed to properly provide wound care to AV as ordered by medical provider after a surgical procedure. The facility failed to carry out Treatment administration as order which is a violation of Oregon Administrative Rules