Brookdale Geary Street Memory Care

According to the documentation, the facility failed to provide a safe environment for the Alleged Victim (AV) who has a known history of exit seeking. On or about July 13, 2025, an outside vendor was provided the door access code so they could go in and out of the secured facility. When the vendor was leaving, the AV followed them out of the facility. The AV was located approximately 15-30 minutes later about a block away. The failure to provide a safe environment led to the AV leaving the secured memory care unattended, creating a risk of harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to follow the care plan for Witness 1’s (W1) known behaviors resulting in resident-to-resident altercations. W1 was care planned to have a 1:1 care giver due to their history of resident-to-resident altercations. On or about February 16, 2025, W1’s 1:1 caregiver stepped away from W1 to help a community member but kept W1 in line of sight. W1 then got up from the table and engaged in an altercation with the Alleged Victim (AV) pushing them down and causing them to hit their head. The AV’s head was swollen, and the next day had bruising to their head. The facility failed to ensure the service plan for W1 was being followed, resulting in an altercation and the AV to suffer pain and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to properly care plan appropriate interventions for the Alleged Victim’s (AV) known history of falls with injury. On or about February 14, 2025, the AV was found on the floor in a community bathroom. The AV had a wound to their head which needed immediate medical attention. The AV was sent to the hospital by EMS where they received stitches to close the wound. The facility failed to properly care plan appropriate interventions to prevent the AV from falling, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to properly care plan for the Alleged Victim’s (AV) known history of falls with injury. On or about January 10, 2025, the AV suffered an unwitnessed fall in their bedroom and suffered a scrape to their right shoulder. They AV has had numerous falls with and without injury and have been identified as a fall risk. There is no documented evidence the facility attempted progressive fall interventions to prevent the AV from sustaining falls, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to implement appropriate interventions for Witness 1’s (W1) known history of physical altercations towards other residents. on or about December 21, 2024, W1 threatened the Alleged Victim (AV) and both we separated. Approximately 10 minutes later, W1 instigated a physical altercation with the AV and punched them in the face. The AV sustained a bruise to their eye and a skin tear to their arm. The facility failed to implement interventions to prevent the physical altercation instigated by W1, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to appropriately care plan appropriate interventions for Witness 1’s (W1) known behaviors towards other residents. On or about August 14, 2024, W1 and the Alleged Victim (AV) were involved in a resident-to-resident altercation. During this altercation, W1 admitted to biting the AV on the stomach and pinching their arm, causing a skin tear and bruising. W1 has a history of resident-to-resident altercations with other residents. There was no documented evidence the facility care planned progressive interventions to prevent further altercations which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to follow the care plan to put on non-skid socks or shoes for the Alleged Victim’s (AV) known fall risk. From approximately July 22, 2024, through August 02, 2024, the AV experienced approximately three falls. The interventions implemented was to ensure the AV was always wearing shoes or non-slipped socks to prevent falls. On or about August 13, 2024, the AV was in the dining room folding laundry in the dining room wearing one non-slip sock and one regular sock. The AV then slipped and fell, causing hip pain. The AV was sent to the hospital for evaluation. The AV sustained a fractured hip which required surgery, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to provide a safe environment for the Alleged Victim (AV) by ensure they could not exit the locked memory care facility. The AV is documented to have exit seeking behavior and is diagnosed with cognitive impairment and limited orientation to place and time. On or about August 07, 2024, the AV was seen in the parking lot by an outside provider. The AV was able to be redirected back into the facility. The failure to provide a safe environment for the AV placed them at risk for harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to properly care plan appropriate interventions to prevent Witness 1 (W1) and the Alleged Victim (AV) from engaging in physical altercations together. The AV and W1 have a history of physical altercations between each other. both care plans tell staff to keep these two separated. On or about August 24, 2024, facility staff witnessed W1 kick the AV in the shins, causing pain and unreasonable discomfort. the service plan does not address appropriate interventions to prevent these two resident from engaging in physical altercations. The lack of interventions resulted in the physical altercation which left the AV in pain and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to properly care plan appropriate interventions for the Alleged Victim (AV) for their frequent falls. On or about July 20, 20204, the AV was found in their room after a suspected fall. The facility conducted an investigation and determined the cause of the fall was due to the AV wearing shoes that did not fit them and did not belong to the AV. The intervention put into place was to have staff ensure the AV is wearing proper foot ware. On or about July 21, 2024, the AV was found on the floor in the hallway. An investigation determined the AV was wearing the same shoes that did not fit the AV which caused the fall the previous day. The facility failed to remove the shoes that did not belong to AV which caused the falls causing a skin tear and pain and or unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to appropriately care plan for Witness 1’s (W1) history of resident to resident altercations. On or about June 09, 2024, W1 was involved in a resident to resident altercation where W1 was heard telling the AV “I did not hit you, I pushed you down.” On or about July 09, 2024, the Alleged Victim (AV) was in the hallway standing in W1’s door way. W2 then grabbed them and physically moved them out of the way causing the AV emotional harm. There was no documented evidence of interventions implemented for res to res altercations and behaviors after the incident on approximately 06/09/2024, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to provide a safe medication administration system for the Alleged Victim (AV) by not administering medications as prescribed. Between approximately May 05, 2024, through May 14, 2024, the AV was not given their scheduled antipsychotic medication approximately 5 times, causing increased confusion, unsteady gait, increased heart rate and blood pressure, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to provide a safe environment for the Alleged Victim (AV) to ensure they did not leave the secured facility unsupervised. On or about May 13, 2024, at approximately 630 in the morning, the AV was found outside the secured facility in the parking lot and was escorted back into the facility. Staff were unaware the AV exited the facility unsupervised and was unsure how they were able to exit the facility, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to provide a safe environment for the Alleged Victim (AV) to ensure they did not leave the secured facility. On or about May 08, 2024, at approximately 2:30 in the afternoon, the AV was in the hallway outside of the secured facility. The Av was seen approximately 10 minutes prior to being found outside the secured doors of the facility, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to implement appropriate interventions on the Alleged Victim’s (AV) service plan for their known behaviors. Between approximately March 04, 2024, and April 09, 2024, Witness 1 (W1) and the AV were involved in approximately three physical altercations leading to injuries such as bruising. There was no documented evidence appropriate interventions were placed to prevent resident to resident altercations, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to implement appropriate interventions for recent falls with injury for the Alleged Victim (AV). On approximately February 21, 2024, and February 27, 2024, the AV suffered two falls while attempting to self-transfer. As a result of these unwitnessed falls, the AV suffered skin abrasions and bruising to their knees. After these two injury falls, there was no documented evidence the facility implanted new interventions to ensure the AV’s safety with transfers. On or about April 08, 2024, the AV suffered another fall attempting to self-transfer resulting in a fractured femur, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to properly care plan appropriate interventions for Witness 1’s (W1) known behavior towards other residents. W1 has had multiple resident to resident altercations in the past. On or about March 31, 2024, the Alleged Victim (AV) and W1 were involved in a resident to resident altercation in which W1 grabbed the AV’s wrists and instilled fear in the AV. There was no documented evidence the facility implemented interventions for W1 to prevent future altercations with the AV. On or about April 01, 2024, W1 was seen dragging the AV through the halls by their wrist, causing bruising and unreasonable discomfort. The facility failed to update the W1’s care plan with appropriate interventions to ensure the AV’s safety, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is a known fall risk, and primarily falls while in his/her room and is on frequent checks with staff. On or about March 10, 2024, AV fell while transferring from his/her wheelchair to his/her bed. AV was sent to the emergency room where he/she was diagnosed with four fractured ribs. The facility's failure to ensure sufficient interventions were in place to ensure AV's safety from falling is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to follow the care plan for Witness 1 (W1) to prevent their known behaviors towards other residents. in January of 2024, the facility updated W1’s service plan to have staff escort them to and from the dining room to prevent them from going into other resident’s rooms. On or about March 06, 2024, W1 left the dining room unassisted and entered the Alleged Victim’s (AV) room. W1 then rammed the AV with their wheelchair, yelled at and grabbed the AV by the arm. The facility failed to follow the care plan for W1, causing physical and emotional harm, 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 the Alleged Victim’s (AV) fall history. On or about October 8, 2023, AV suffered an unwitnessed fall, resulting in AV breaking two ribs. The failure resulted in AV experiencing pain and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to documentation, the facility failed to implement interventions and appropriately care plan related to the Alleged Victim’s (AV) fall history. On or about August 9,2023, AV suffered an unwitnessed fall, resulting in AV an injury to h/h head. The failure resulted in AV experiencing pain and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about December 25, 2022, Alleged Perpetrator 2 (AP2) failed to follow The Alleged Victim (AV) is care planned to be checked on every two hours. According to documentation AP2 let AV go out onto the secured courtyard unattended. The failure resulted in AV being found approximately five hours later cold and wanting to come inside and experiencing pain and unreasonable discomfort. AP2's actions is a violation of resident rights, is considered neglect of care and constitute abuse. The facility failed to ensure care plans were followed, which is a violation of Oregon Administrative Rules.

On or about November 03, 2022, the facility failed to appropriately care plan and provide care for the Alleged Victim (AV) after he/she entered the facility. According to documentation no evaluation shows that AV should be in a memory care, AV was misplaced in a memory care and was unable to leave the facility because of the misplacement. The failure resulted in AV experiencing unreasonable discomfort and a loss of dignity. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to Provide a safe environment for The Alleged Victim (AV). On or about August 17, 2022, AV went outside on the courtyard, and was checked on every twenty (20) minutes. At the second check AV was warm to the touch and unresponsive. Resulting in AV having to go to the emergency room for treatment for dehydration. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to documentation, On or about April 09, 2022, the facility failed to follow The Alleged Victim (AV) temporary care plan for frequent checks due to AV being a high fall risk. The failure resulted in AV being found on the floor with an injury to his/her head. The facility failed to ensure care plans were followed which is a violation of resident rights, is considered neglect of care and constitute abuse.

On or about April 09, 2022, Alleged Perpetrator 2 (AP2) failed to follow The Alleged Victim (AV) temporary care plan for frequent checks due to AV being a high fall risk. The failure resulted in AV being found on the floor with an injury to his/her head. The facility failed to ensure care plans were followed, which is a violation of Oregon Administrative Rules.

The facility failed to implement interventions and appropriately care plan related to the Alleged Victim’s (AV) fall history. The failure resulted in AV experiencing injury and unreasonable discomfort, 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 (W1) known inappropriate behaviors. On or about March 26, 2022, W1 had inappropriate contact with the Alleged Victim (AV) causing a loss of personal dignity, which is a violation of resident rights, is considered neglect of care which constitutes abuse

The facility failed to implement interventions and appropriately care plan related to the Alleged Victim’s (AV) fall history. The failure resulted in AV experiencing injury and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility to ensure a safe environment. AV has a history of resident-to-resident altercations. On or about December 16, 2021, Witness 1 (W1) sustained a bruise from AV, during the altercation in the TV room. The facility failed to ensure a safe environment for AV. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility to ensure a safe environment. Witness 1 (W1) has a history of resident-to-resident altercations. On or about December 16, 2021, AV sustained a bruise from W1, during the altercation in the TV room. The facility failed to ensure a safe environment for AV. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about November 23 ,2021 The facility failed to implement interventions and appropriately care plan related to the Alleged Victim’s (AV) fall history. The failure resulted in AV experiencing an injury to h/her head, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about November 13, 2021, the facility failed to implement interventions and appropriately care plan related to the Alleged Victim’s (AV) fall history. The failure resulted in AV bruising h/her forehead from a fall in the dining, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to put effective interventions for the Alleged Victim (AV) known behaviors. AV is known for taking food off other resident's plates. The failed resulted in Witness 1 (W1) hitting AV and AV experiencing unreasonable discomfort, which is a violation of residents rights, is considered neglect of care and constitutes abuse.

On or about November 07 ,2021, the facility failed to implement interventions and appropriately care plan related to the Alleged Victim’s (AV) fall history. The failure resulted in AV experiencing a witnessed fall hitting h/her head, 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 (W1) known behaviors. On or about October 27, 2021, W1 was found inappropriately touching the Alleged Victim (AV) causing a loss of personal dignity, which is a violation of resident rights, is considered neglect of care which constitutes abuse.

The facility failed to properly administer the Alleged Victim’s (AV) medications. According to documentation, AV experienced agitation and unreasonable discomfort. The Facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.

The facility failed to implement interventions and appropriately care plan related to Witness 1’s (W1) known behaviors. On or about October 15, 2021, W1 was found inappropriately touching the Alleged Victim (AV) causing a loss of personal dignity, which is a violation of resident rights, is considered neglect of care which constitutes abuse.

The facility failed to provide documentation upon request which is a violation of Oregon Administrative Rules.

The facility failed to develop a service plan by a Service Planning Team consisting of the resident, the resident's legal representative, any person of the resident's choice, the facility administrator or designee and at least one other staff person who is familiar with, or who is going to provide services to the resident in accordance with OAR 411-054-0036(5); per complaint the resident nor their family were involved in creating the initial care plan.

The facility failed to fully implement an Acuity-Based Staffing Tool (ABST). Time and frequency were unable to be determined by the facility's current internal assessment tool for all required 22 ADLs with staff time required to complete the care needs. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to fully implement an Acuity-Based Staffing Tool (ABST). Time and frequency were unable to be determined by the facility's current internal assessment tool for all required 22 ADLs with staff time required to complete the care needs. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to fully implement an Acuity-Based Staffing Tool (ABST). Time and frequency were unable to be determined by the facility's current internal assessment tool for all required 22 ADLs with staff time required to complete the care needs. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to fully implement and update an acuity-based staffing tool. An investigation determined a licensing violation or abuse occurred.

Facility failure to keep an accurate Medication Administration Record (MAR) accordance with OAR 411-054-0055(2); per complaint that a resident received PRN medication however had been entered into MARs as scheduled medication.

The facility failed to fully implement and update an acuity-based staffing tool in accordance with OAR 411-054-0037.

The facility failed to fully implement and update an acuity-based staffing tool. An investigation determined a licensing violation or abuse occurred.

The facility failed to fully implement an Acuity-Based Staffing Tool (ABST). Time and frequency were unable to be determined by the facility's current internal assessment tool for all required 22 ADLs with staff time required to complete the care needs. An investigation determined this is a violation of Oregon Administrative Rules.

According to the documentation, the Alleged Perpetrator 2 (AP2) failed to protect the Alleged Victim (AV) of verbal and emotional abuse. On or about December 06, 2023, AP2 was clearing plastic cups off the table and the AV wanted to keep them. AP2 continued to clean the cups up and the AV grabbed onto the AP2. AP2 responded by yelling a profanity at the AV. A few moments after this incident, AP2 was seen mocking the AV, which is a violation of resident rights and is considered verbal and emotional abuse. The facility failed to provide a safe environment which is a violation of Oregon Administrative Rules.

According to the documentation, the Alleged Perpetrator 2 (AP2) and Alleged Perpetrator 3 (AP3) failed to protect the Alleged Victim (AV) from physical abuse. On or about October 17, 2023, the AV was partially nude walking through common areas of the facility. AP2 grabbed the AV’s arms and forced them to sit in a chair to attempt to get a brief on the AV. After the AV refused and got visibly upset, AP2 and AP3 took the AV by their arms to attempt to force the AV into their room. A Med Tech saw AP2 and AP3 physically forcing the AV to move and instructed them to let go of the AV immediately, which is a violation of resident rights and is considered physical abuse. The facility failed to provide a safe environment which is a violation of Oregon Administrative rules.

The facility failed to ensure that the glass and area surrounding the fireplace must not exceed 120 degree Fahrenheit in accordance with OAR 411-054-0200(8)(c) per complaint that the top section of the metal care near the vent for the fireplace was exceptionally hot.

The facility failed to provide three daily nutritious, palatable meals with snacks available seven days a week in accordance with OAR 411-054-0030(1)(a) per complaint that lunches are late and the food is cold.

The facility failed to provide a daily program of social and recreational activities that are based upon individual and group interests, physical, mental, and psychosocial needs, and creates opportunities for active participation in the community at large in accordance with OAR 411-054-0030(1)(c).

The facility failed to have a full time administrator scheduled to be on-site in the facility at least 40 hours per week in accordance with OAR 411-054-0065(1).

The facility failed to provide three daily nutritious, palatable meals with snacks available seven days a week in accordance with OAR 411-054-0030(1)(a) per complaint that the facility is not providing meals when a resident is toileting, out of the facility, or sleeping.