Cedar Village Memory Care Community

The Alleged Victim (AV) has had previous injuries of unknown cause including bruises, abrasions, skin tears and a fractured ankle. On or about August 18, 2025, AV was found with a swollen and purple ring finger. Staff were not aware of any interventions in place to assure AV's safety from injuries of unknown cause. The facility's failure to ensure AV's safety is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is a known fall risk and has suffered 5 falls between July 29, 2025 and August 18, 2025. On or about August 18, 2025, AV was found lying on the floor in his/her room with no feeling in his/her feet. It appeared that AV tried to use the restroom without his/her assistive device. AV was transferred to the hospital and diagnosed with a fractured toe and a bruise on his/her head. AV was last seen 15 minutes prior to the fall, and requires 1 person assist with transfers and cueing with ambulation. The facility's failure to ensure safety and supervision of AV while transferring and ambulating is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) and Witness #1 (W1) have a history of altercations with each other. On or about August 7, 2025, while wandering the hallway, W1 approached AV and bit AV's finger, causing swelling and bleeding. The facility's failure to provide a safe environment caused AV unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is known to suffer injuries of unknown cause. On or about August 3, 2025, staff found AV in his/her room with multiple bruises on his/her knees. AV's care plan did not include interventions to prevent AV's injuries of unknown origin. The facility's failure to ensure AV was safe from injuries of unknown origin is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) has had previous injuries of unknown cause, such as bruises, abrasions and skin tears. On or about July 18, 2025, AV was found to have a bruise on his/her lower back. It is unknown how the bruise was obtained. The facility failed to have interventions in place for safety of AV from unknown injury. The facility's failure to properly care plan for resident safety is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is a known exit seeker. On or about June 16, 2025, AV exited the memory care and was found outside of the secured area. AV was escorted by staff back to the memory care. Although AV was not harmed during the elopement, AV was placed at risk for harm by being able to exit the secure area. The facility's failure to provide a safe environment is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) and Witness #1 (W1) have a history of altercations. On or about June 7, 2025, W1 tried to grab activity items that AV was playing with. W1 slapped AV in the back of the head, causing AV to complain of pain to the back of his/her head. Staff were to keep AV and W1 six feet from each other. Staff did not try to separate the residents until after W1 slapped AV. The facility's failure to follow the care plan is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) has a history of skin tears of unknown origin in April and May of 2025. On or about June 6, 2025, AV was found with a 2 cm abrasion to his/her lower left forearm of unknown origin. The facility has not put any interventions in place to ensure AV's safety from skin tears. The facility's failure to keep AV safe from skin tears is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) and Witness #1 (W1) have a history of altercations. On or about June 5, 2025, W1 pulled AV's hair, causing AV to scream. AV and W1 were supposed to be kept apart by staff, however, on this date, both residents were in the common area without any staff present. The facility's failure to ensure the safety of residents are a violation of resident rights, considered neglect of care and constitute abuse.

The Alleged Victim (AV) and Witness #1 (W1) have a history of altercations. On or about June 5, 2025, W1 hit AV. There were no injuries and staff separated the residents. The facility failed to provide a safe environment, placing both residents at risk for harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) and Witness #1 (W1) have a history of altercations. On or about May 23, 2025, AV and W1 engaged in an altercation where W1 kicked AV. AV was not harmed, however, AV was placed at risk for harm. The facility failed to put sufficient progressive interventions in place to ensure the safety of AV. 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) was at the hospital and returned to the facility on May 23, 2025. AV was care planned to received a shower or bath two times per week. AV complained that he/she was "stinky" and uncomfortable and didn't like it. The facility did not bathe AV from May 23, 2025 until hospice staff gave him/her a bed bath on May 30, 2025. AV suffered unreasonable discomfort due to not having hygiene care for a week. The facility's failure to provide AV with a bath is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is a known exit seeker. On or about October 15, 2024, AV was found walking outside of the facility. AV left the outdoor memory care area after a fire alarm was accidentally went off, causing all doors to unlock. Staff did not ensure the gates in the outdoor area was secured and AV left the area and was found outside the assisted living facility on the outdoor unsecured patio. On or about November 11, 2024, AV was able to exit the facility through a staff break room, due to the doors of the memory care not latching quickly every time. There was an event at the facility the day of the latest incident. Staff are to monitor AV during events to avoid AV following others out the door. The facility's failure to provide a safe environment is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) and Witness #1 (W1) have a history of altercations. Both residents were care planned to intervene if either resident was found to be having behaviors and for staff to keep these two residents away from each other. On or about October 25, 2024, W1 walked up to AV and scratched AV on the face, while staff watched. The facility's failure to ensure the safety of AV is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) and Witness #1 (W1) have a history of alterations with each other on at least 5 separate occasions. There are no interventions listed on either residents service plans to assist with avoiding altercations with each other. Neither resident was injured in the altercation, however, both residents were placed at risk for harm. The facility's failure to properly care plan is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about October 16, 2024, Witness #1 (W1) was talking to staff in the dining room and turned around and pushed the Alleged Victim (AV), accusing him/her of going into W1's room. AV and W1 have had previous altercations. A review of service plans does not identify that the facility implemented any interventions to decrease altercations between the two residents. The facility's failure to ensure interventions are in place to reduce altercations and harm to residents. This failure constitute abuse by neglect as defined by OAR 411-020-0002(1)(b)(A)(ii).

On or about October 15, 2024, the facility fire alarm system was triggered, causing all memory care doors and gates to unlock. The Alleged Victim (AV) exited through one of the gates in the courtyard of the facility. AV was later found by staff in an unsecured area behind the assisted living portion of the building. AV did not suffer any injury during his/her elopement, however, AV was placed at risk of serious harm. The facility's failure to provide a safe environment is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is a known fall risk and was care planned for six safety checks per shift. On or about March 30, 2024, AV fell in his/her bathroom suffering an abrasion to his/her back and a skin tear. AV's care plan was not updated nor was there any interventions in place to prevent AV from falling again. On or about April 14, 2024, AV suffered another fall in his/her bathroom, resulting in a fractured foot and a fractured arm. The facility's failure to properly care plan is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about September 8, 2023, the Alleged Victim's (AV) family requested that the facility keep Witness #1 (W1) away from AV. On or about September 15, 2023, AV and W1 got into an altercation and staff were reminded to keep monitoring and do frequent checks on W1 and ensure the he/she is not near AV's door. On or about September 16, 2023, W1 and AV were found in front of AV's apartment. They were shaking hands and W1 held on a little tight, AV tried to pull away and W1 became violent. Staff intervened and no injuries were sustained, however, the action placed AV at risk for harm. The facility's failure to ensure proper supervision of W1 placed AV at risk for harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) and Witness #1 (W1) are to be kept apart due to W1 family request. On or about September 15, 2023, facility staff were performing a check on AV and found AV in W1's room. Staff attempted to remove AV from the room, and in the process, W1 scratched AV on the face. The facility failed to provide a safe environment, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #1 (W1) has a history of resident to resident altercations. No interventions were put into place to keep W1 from instigating altercations. On or about August 22, 2023, the Alleged Victim (AV) wandered into W1's room, W1 pushed AV out of his/her room. The facility's failure to provide a safe environment for AV is a risk of serious harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) and Witness #1 (W1) were known to have altercations. Interventions in place were to increase hallway monitoring and encourage activities. On or about August 1, 2023, W1 went into AV's room, AV pushed W1 down and W1 scratched AV, causing two skin tears. Staff were not aware of the interventions in place. The facility's failure to provide a safe environment is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) and Witness #1 (W1) were known to have altercations. Interventions in place were to increase hallway monitoring and encourage activities. On or about August 1, 2023, AV went into W1's room, W1 pushed AV down and AV scratched W1, causing two skin tears. Staff were not aware of the interventions in place. The facility's failure to provide a safe environment placing AV at risk for harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) and Witness #1 (W1) have had multiple altercations in the past. On or about June 16, 2023, AV and W1 engaged in an altercation where W1 was holding AV by his/her wrists and AV was on the floor. Neither resident was harmed, however, both residents were placed at risk for harm. The facility's failure to properly care plan to prevent altercations is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #1 (W1) has a history of altercations, and had an altercation with the Alleged Victim (AV) earlier in the day. On or about March 13, 2023, W1 tried to pull out AV's catheter, causing pain to AV. The facility failed to put interventions in place regarding W1's behaviors to ensure AV's safety. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is a known fall risk and has suffered previous falls. On or about April 25, 2023, AV suffered an unwitnessed fall which resulted in a skin tear to AV's eyebrow. The facility failed to put interventions in place to reduce falls, placing AV at risk for harm. The facility's failure to properly care plan is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #1 (W1) has a history of having altercations and behaviors towards staff and other residents. On or about April 18, 2023, W1 and the Alleged Victim (AV) were yelling at each other and W1 hit AV. The facility failed to provide a safe environment, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is a known fall risk and has suffered multiple falls over the last year. During the month of January 2023, AV suffered three different falls and was sent to the emergency department for evaluation. The facility was to place bed rails in November 2022, however, this has yet to be completed. The facility failed to properly care plan to reduce the amount of AV's falls. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is known to have thin skin and bruise easily. AV has had a previous fall and previous bruising. On or about December 24, 2022, AV's family member noticed a bruise on AV's hip and shoulder. The shoulder bruise appeared to be older than the one on his/her hip. No interventions were put into place after AV's previous fall, nor is there any mention of AV's skin integrity and easily bruising, or direction for staff of how to prevent further bruising for AV. 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) was known to fall and has had at least 15 falls prior to this most recent fall. AV suffered a fall on November 11, 2022, suffering a fracture to his/her nose. The facility failed to properly care plan to decrease AV's amount of falls. The facility failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about September 6, 2022, the Alleged Victim (AV) was found on the floor approximately 12:10 pm when a staff was delivering lunch to the AV in his/her room. AV was trying to go to the restroom when he/she fell. AV pushed the call light approximately 11:30 am to get assistance. No staff responded to AV's call light, so AV attempted to go to the restroom him/herself, and AV fell, causing pain to his/her knees and hip. The facility's failure to answer the call light timely is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about July 7, 2022, the Alleged Victim (AV) eloped from the facility through a gate that was left open by a landscaper. AV was not injured, however, AV was placed at risk for harm. The facility's failure to provide a safe environment is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) has a history of leaving the facility unattended. On or about June 28, 2022, AV left the facility unsupervised and was found in a field about 1 mile from the facility. AV suffered 2 cuts on his/her legs and multiple abrasions. The facility failed to provide a safe environment, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) and Witness #1 (W1) were known to engage in altercations. AV and W1 had engaged in altercations at least 4 times prior to this incident. On or about January 20, 2022, AV and W1 engaged in an altercation where W1 threw water on AV and AV responded by hitting W1 on the back. AV complained of pain in his/her arms after the altercation. The facility's failure to ensure a safe environment and properly care plan to avoid altercations is a violation of resident rights, is considered neglect of care and constitutes abuse.