Cherrywood Memory Care - Revere Court

The Alleged Victim (AV) is a two person assist with transfers and has a history of self transfer. On or about April 17, 2025, AV's motion sensor went off and AV was found on the floor of his/her room next to his/her recliner. AV recently received a new recliner to assist with swelling of his/her legs. AV relies on staff to raise and lower his/her foot rest on the recliner, as well as transfers. The facility failed to properly care plan regarding AV being left in his/her recliner with feet elevated. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about May 15, 2025, the Alleged Victim (AV) was in the common area and had expressed to staff that he/she was wanting to go to bed. AV requires a one person assist with ambulation while using his/her wheelchair. Staff failed to assist AV to his/her room to help him/her into bed, leading to AV being found on the floor in his/her room, just outside his/her bathroom. AV was not harmed, however, AV was placed at risk for harm. The facility's failure to follow the care plan is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about May 28, 2025, the Alleged Victim (AV) and Witness #1 (W1) were arguing in the dining room. Staff observed AV and W1 holding onto the same dining chair when W1 pushed the chair leading to AV experiencing a non-injury fall. W1 has been involved in previous altercations with residents. The facility failed to update W1's care plan or implement interventions to ensure the safety of other residents due to W1's altercations. The facility's failure to properly care plan is a violation of resident rights, is considered neglect of care and constitutes abuse.

Between March 30, 2025, and August 26, 2025, the Alleged Victim (AV) suffered 21 falls, 8 of those falls resulted in injury, with one fall requiring a visit to the hospital. The facility failed to place any interventions in place to reduce the risk of AV's falls.

The Alleged Victim (AV) had cataract surgery on or about January 23, 2025. Upon AV's return, the facility was supposed to perform post operative care for AV, including removing tape from AV's eye and administering eye drops to ensure proper healing. Upon AV's return to the facility, family gave a staff member the post surgery documentation and the eye drops. AV was to have the tape removed from his/her eye and the drops applied 3 to 5 hours after surgery or when AV's eye began to open. AV's surgery was completed at 3:20 pm and AV arrived back at the facility approximately 5:00 pm. AV would have been ready to have the tape removed at approximately 6:20 until 8:20 pm. AV's family called him/her at 7:00 pm and the tape was still on AV's eye. AV stated they were trying to open their eye but could not, as no staff had checked on AV or removed the tape and applied the eye drops. Family came to the facility at 8:00 pm and removed the tape and applied the eye drops for AV as facility staff had not completed it. The facility's failure to ensure a safe medication administration system is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #1 (W1) has a history of altercations and harming other residents. On or about November 19, 2024, the Alleged Victim (AV) pushed his/her walker into W1 and W1 reacted by hitting AV in the face. AV was not harmed, however, the facility's failure placed AV at risk for harm. W1 is to have one to one care while outside of his/her room. W1 did not have one to one care at the time of this incident. 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 altercations and harming other residents. On or about November 19, 2024, Witness #1 (W1) pushed his/her walker into AV and AV reacted by hitting W1 in the face. W1 was not harmed, however, the facility's failure placed W1 at risk for harm. AV is to have one to one care while outside of his/her room. AV did not have one to one care at the time of this incident. The facility's failure to follow the care plan is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #1 (W1) has a history of altercations and physically harming other residents. On or about October 6, 2024, the Alleged Victim (AV) and W1 were in the dining room. W1 slapped AV in the face. W1 is to be on one to one supervision while he/she is not in his/her room. No staff were supervising W1 at the time of the altercation. The facility's failure to provide supervision and a safe environment is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is known to wander into other residents rooms and is care planned to be re-directed when seen trying to enter other residents rooms. On or about September 9, 2024, AV wandered into Witness #1's (W1) room and W1 hit AV on the head. W1's room is to be locked so residents don't wander in. The facility failed to follow the care plan, resulting in AV being hit on the head. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #1 (W1) is known to have violent behaviors towards other residents. On or about May 19, 2024, the Alleged Victim (AV) and W1 were sitting in the living room watching TV when AV made negative comments towards W1, causing W1 to become upset. As W1 was leaving the room, AV made another comment, causing W1 to hit AV on the back of the head. Due to W1's violent behavior, W1 is to have 1 to 1 care when out of his/her room. Staff were too far away to intervene to avoid this altercation. The facility's failure to ensure interventions were effective to keep residents safe from W1's outbursts is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about April 22, 2024, the Alleged Victim (AV) was in the dining area getting ready for a meal. AV pushed another resident to move them. The other resident then hit AV in the face with a coffee cup two different times. AV was not sent out to the hospital at the time of the incident, even though AV is on blood thinners. The next day, AV was complaining of pain, nausea and dizziness. AV's child insisted the facility have an ambulance come and take AV to the hospital. AV was diagnosed with a concussion and severe bruising and swelling. The facility's failure to seek immediate medical attention for AV placed AV at risk for serious harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #1 (W1) has a history of aggressive behaviors and is known to have altercations with other residents. On or about March 28, 2024, the Alleged Victim (AV) was looking for a staff member to give him/her their inhaler and walked to W1's room, looking for a staff member. W1 reached out and pulled AV to the ground, causing AV a wound to his/her head. AV was sent to the hospital where he/she received staples to his/her head. The facility failed to properly care plan and have interventions in place to ensure the safety of AV. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #1 (W1) is care planned to be within arms reach of staff when in the common area of the facility, as W1 has a history of hitting other residents. On or about March 21, 2024, the Alleged Victim (AV) and W1 had a dispute about where they should be sitting in the dining area. W1 struck AV in the chin during the altercation. The facility failed to follow the care plan to ensure W1 was within arms length while in the common area, placing AV at risk of harm. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #1 (W1) has a history of altercations with other residents. Staff are to redirect any residents they observe entering W1's personal space. On or about February 19, 2024, AV approached W1's table and was picking up cups and silverware when W1 hit AV in the mouth. Staff did not redirect AV and put him/her at risk for harm. The facility's failure to protect AV from W1 is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) has a history of altercations with other residents. Staff are to redirect any residents they observe entering AV's personal space. On or about February 19, 2024, a resident approached AV's table and was picking up cups and silverware when AV hit this resident in the mouth. Witness #1 (W1) approached AV and told him/her they should not be hitting others of the opposite sex, and proceeded to hit AV in the eye. AV received a small laceration over his/her eye as a result. Staff did not redirect the other resident or W1. The facility's failure to follow the care plan is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #1 (W1) has a history of an altercation in August of 2023. On or about November 2, 2023, the Alleged Victim (AV) and Witness #1 (W1) engaged in an altercation where AV suffered scratches to his/her arm. The facility failed to properly care plan to reduce resident to resident altercations, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) and Witness #1 (W1) are known to engage in altercations. On or about October 14 2023, AV was pushed by W1 and fell to the floor. ON or about October 15, 2023, staff heard screaming and went to the family room where they saw W1 hitting AV in the head with his/her fists. AV fell to the floor and was sent out to the hospital for evaluation. The facility's failure to properly care plan to reduced the risk of altercations between residents 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 from June 2023 to September 2023. AV was care planned for safety checks every two to three hours, however, due to limited staffing, the safety checks were not regularly completed. The facility's failure to follow the care plan placed AV at risk for serious harm. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) suffered 17 non injury falls between July 22, 2023 and September 11, 2023. AV was not injured in the falls, however, the number of falls placed AV at risk for harm. The facility failed to implement meaningful interventions to alleviate the number of falls. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) takes medication and will sometimes refuse medications due to having behaviors. Alleged Perpetrator #2 (AP2) and Alleged Perpetrator #3 (AP3) have been witnessed forcing AV to take his/her medication by holding his/her arms down and the other would force medications into AV's mouth. The facility administrator had been advised by other staff that AP2 and AP3 were forcing medications on AV by restraining him/her, however, nothing was done about the complaint. AP2 and AP3's actions are a violation of resident rights, is considered neglect of care and constitutes wrongful restraint. The facility's failure to protect AV from wrongful restraint is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately monitor Witness 1 (W1) according to his/her known behavior and prior altercations. The failure resulted in a physical altercation between W1 and Alleged Victim (AV) causing a laceration on AV's forehead in which AV was sent to the hospital for treatment. The facility's failure caused AV unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about August 6, 2022, the facility failed to appropriately monitor Witness 1 (W1) according to his/her known behavior and prior altercations. The facility's failure resulted in a physical altercation in which W1 hit Alleged Victim (AV) on the head with a shower chair. AV was sent to the hospital for treatment requiring stitches to his/her forehead. 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 facility failed to implement interventions and appropriately care plan related to the alleged victim's (AV) fall history. This failure resulted in AV experiencing multiple injury falls, resulting in pain and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to develop, maintain, and implement an Acuity Based Staffing Tool in accordance with OAR 411-054-0037(1-7), which is a violation of Oregon Administrative Rules.

The facility failed to develop, maintain, and implement an Acuity Based Staffing Tool in accordance with OAR 411-054-0037(1-7), which is a violation of Oregon Administrative Rules.

The facility failed to properly staff based on their ABST for 2 of 3 shifts, which is a violation of Oregon Administrative Rules.

The facility failed to provide intermittent direct nursing services in accordance with 411-054-0045(1)(f)(F)

The facility failed to determine and document what action or invention is needed when a resident experiences a short-term change of condition in accordance with 411-054-0040(1)(d), which is a violation of Oregon Administrative Rules.

The facility failed to develop, maintain, and implement an Acuity Based Staffing Tool in accordance with OAR 411-054-0037(1-7), which is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) was care planned to have staff ensure AV was using his/her walker. On or about December 15, 2024, AV was found on the floor in another residents room. AV did not have his/her walker with him/her. Staff failed to follow the care plan to ensure AV's walker was in use. The facility's failure is a violation of Oregon Administrative Rules.

On or about May 8, 2024, Alleged Perpetrator #2 (AP2) tried to force the Alleged Victim (AV) to transfer and accept cares. AP2 had a pattern of being rough with residents. AP2's actions of forcibly transferring AV could have caused harm to AV. AP2's actions are a violation of resident rights, are considered neglect of care and constitutes physical abuse. The facility's failure to protect AV from physical abuse is a violation of Oregon Administrative Rules.

On or about October 25, 2023, the Alleged Victim (AV) was in the hallway without his/her pants on. Alleged Perpetrator #2 (AP2) advised AV he/she couldn't be outside his/her room without pants. AP2 offered to help AV when AV became aggressive. AP2 tried to stop AV from leaving his/her room by nudging AV back into his/her room. AV suffered a fall from this nudge, causing a skin tear and a fracture to AV's spine. AP2's actions are a violation of resident rights, are considered neglect of care and constitute physical abuse. The facility's failure to ensure residents safety from physical abuse is a violation of Oregon Administrative Rules.

On or about October 25, 2023, the Alleged Victim (AV) was in the hallway without his/her pants on. Alleged Perpetrator #2 (AP2) advised AV he/she couldn't be outside his/her room without pants. AP2 offered to help AV when AV became aggressive. AP2 tried to stop AV from leaving his/her room by nudging AV back into his/her room, and closing his/her door to try to stop AV from coming out into the hallway. AV tried to open the door, however, AP2 was holding the door closed. AP2's actions are a violation of resident rights, are considered neglect of care and constitute involuntary seclusion. The facility's failure to ensure residents safety from involuntary seclusion is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) is a known fall risk and is known to try to self-transfer. AV is care planned for safety checks every two three hours. Staff checked on AV at midnight and Alleged Perpetrator #2 (AP2) checked on AV at 3:00 am and should have checked AV's brief at that time. At approximately 6:00 am on September 11, 2023, AV was found on the floor of his/her room, and his/her brief was soaked. AV was not injured, however, AV did suffer unreasonable discomfort from being on the floor for an unknown amount of time and being soaked. AP2 did not check AV after 3:00 am and had given agency staff a list of residents, stating that AV was independent. No residents within the facility are independent. AP2's actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility's failure to ensure AV was care for properly is a violation of Oregon Administrative Rules.

The facility failed to fully implement and update an Acuity Based Staffing Tool (ABST) in accordance with OAR 411-054-0037, which is a violation of Oregon Administrative Rules.