Clatsop Care Memory Community

The Alleged Victim (AV) and Witness #1 (W1) rely on the facility for their care. AV has a history of attempting to go into W1’s room and staff have had to separate AV and W1 multiple times for being too close. W1 has documented history of attempting to get “feely” with other residents. Despite these multiple previous interactions, there were no safety interventions in place to ensure resident safety. According to an investigation, on or about, September 17, 2025, W1 was found in the dining room with his/her hands down the AV’s pants, resulting in a loss of personal dignity. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility for his or her safety and has known exit seeking behaviors. On or about September 7, 2025, the facility received a call informing them AV was outside the locked facility, unbeknownst to facility staff. AV was standing on the side of a busy highway attempting to hitchhike, placing AV at risk for serious harm. According to an investigation, this is the second time AV has been let out of the facility by visitors. The facility failed to provide a safe environment, which is a violation of resident’s rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) and Witness 1 (W1) rely on the facility for care and safety. W1 has a known and documented history of unwanted sexual touching. On or about May 19, 2025, W1 walked up and groped AV's chest from behind, causing AV agitation as noted by AV yelling, swiping things off the counters and tables and trying to hit other residents. On or about June 18, 2026, care staff heard AV yelling and found AV sitting on W1's lap with W1's hands up AV's shirt. The facility failed to provide appropriate services, to include implementing effective interventions and /or properly care planning to address W1's behaviors and provide a safe environment for AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse as defined by OAR 411-020-0002(1)(b)(A)(i).

The Alleged Victim (AV) relies on the facility for a safe environment. Witness 1 (W1) has a known history of aggressive sexual behaviors with both residents and staff with multiple incidents of inappropriate sexual behavior documented. There were not interventions to address W1’s behaviors. According to an investigation, on or about, January 31, 2025, the AV was found on the ground with W1 in between their legs attempting to remove the AV’s pants, resulting in serious risk of harm and loss of personal dignity. 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) relies on the facility for their care. AV is known to go into other resident’s rooms. Witness 1 (W1) has a history of aggressive behaviors and is known to become upset when other residents enter their room. The AV and W1 have a history of a resident-to-resident altercation where the AV was found on the floor in the hall outside of W1’s room. According to an investigation, on or about, December 21, 2024, W1 was yelling at AV and the AV was heard yelling “no no no” and was observed to fall to the ground into the hall from W1’s room, posing a serious risk of harm. The facility failed to ensure a safe environment for AV and appropriately care plan for AV and W1’s known behaviors, which is a violation of resident rights, is considered neglect of care, and constitutes abuse.

The Alleged Victim (AV) is a known fall risk. On or about September 2, 2024 around 2:30 pm, AV had an unwitnessed fall, resulting in a large cut on AV's thumb and pain in AV's shoulder. AV was taken to the hospital where it was discovered AV had a dislocated shoulder and required stitches to AV's thumb. During the investigation it was discovered that prior to this fall, AV experienced other recent falls where no interventions were put in place. The facility failed to implement interventions and/or appropriately care plan for AV, which is a violation of resident rights is neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility for care. Witness 1 (W1) has a history of aggressive behavior resulting in physical altercations and has a history of possessive behaviors regarding Witness 2 (W2). On or about August 6, 2024, W1 and W2 were sitting in the lobby, when AV approached and sat down next to W2. W1 told AV they couldn't sit there and punched AV in the back multiple times as AV was walking away. The facility failed to provide appropriate services, to include care planning and/or implementation of effective interventions to address W1's behaviors and provide a safe environment for AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Both the Alleged Victim (AV) and Witness 1 (W1) rely on the facility for care. W1 has a recent history of hitting other residents. On or about March 7, 2024, W1 wandered into AV's room and hit AV with a hairbrush, causing a bruise. The facility failed to provide services, to include implementing interventions to address W1 aggressive behaviors and provide a safe environment for AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to care plan appropriate interventions for Witness 1’s (W1) known behaviors. The failure resulted in W1 having repeated resident to resident altercations with the Alleged Victim (AV). On or about February 04, 2024, W1 was seen hitting and yelling at the AV in the hallway, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relied on the facility for care and had a history of falls. According to an investigation, on or about January 23, 2024, AV had an unwitnessed fall in their room, resulting in a scraped arm/shoulder. The facility failed to properly care plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse as defined by OAR 411-020-0002(1)(b)(A)(i).

The Alleged Victim (AV) relies on the facility for care. Between June 26, 2023, and November 11, 2023, AV had multiple falls, some with injury to include redness, lacerations, abrasions, and bruises. According to an investigation, after AV's repeated falls, there were no interventions added to prevent AV from falling. The allegation that an unknown Alleged Perpetrator 2 (AP2) physically abused AV by dropping them while toileting, was investigated and wrongdoing was unable to be determined. The facility failed to properly care plan, which is a violation of resident’s rights, is neglect of care, and constitute abuse.

According to the documentation, the facility failed to properly care plan for the Alleged Victim’s repeated falls. The failure resulted in the AV suffering a fall and fractured his/her wrist, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) and Witness 1 (W1) both rely on the facility for their care. W1 has a history of aggressive behaviors resulting in numerous physical altercations with staff and other residents. According to an investigation, on or about May 25, 2023, W1 was upset and having a disagreement with staff in the facility hallway. AV walked by the incident and looked over to see what was going on. W1 reached over and hit AV, causing AV to yell and staff to intervene. A red mark was observed on AVs back as a result of the incident. The facility failed to implement interventions and/or appropriately care plan for W1's known behaviors and provide a safe environment for AV, causing 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 monitor Witness 1 (W1) as outlined in their care plan to prevent behaviors. The failure resulted in a resident-to-resident altercation where W1 hit the Alleged Victim (AV) in the face, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to monitor Witness 1 (W1) as outlined in their care plan to prevent behaviors. The failure resulted in a resident-to-resident altercation where W1 hit the Alleged Victim (AV) in the stomach, 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 Witness 1’s (W1) behaviors and resident to resident altercations. The failure resulted in W1 wandering into the Alleged Victim’s (AV) room and pushing the AV down causing an injury, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is care planned to be redirected away from opposite sex staff, to avoid his/her spouse, Witness #1 (W1) from becoming upset and acting out against AV. On or about March 9, 2023, AV was visiting with another resident of the opposite gender when W1 found AV and proceeded to choke AV, causing AV to be visibly shaken from this event. The facility failed to follow the care plan to ensure AV's safety, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #1 (W1) has known behaviors of inappropriately touching other residents. On or about January 20, 2023, W1 grabbed the Alleged Victim's (AV) breast, and AV said no and hit W1's hand. The facility failed to properly care plan for known behaviors, 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 the Alleged Victim (AV) and Witness #1 (W1) by not monitoring them when they are together. The failure resulted in W1 touching AV in a sexual manner causing emotional harm. 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 altercations with residents and is care planned to receive one to one supervision. On or about December 23, 2022, the Alleged Victim (AV) and W1 were sitting in the dining room. W1 grabbed AV by the arm and slapped AV cross the face. The facility's failure to ensure supervision and follow the care plan is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) and Witness #1 (W1) have had previous altercations with each other. On or about December 4, 2022, AV and W1 were overheard arguing in the hallway. W1 was found to have AV's hair in his/her hand and pulling him/her to the ground. AV had several scratch marks on his/her face and a bite mark on his/her arm. 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) are known to have altercations. AV and W1 were overheard arguing in the hallway. W1 slapped AV in the face. W1 had been on one to one monitoring, however, W1 was released from monitoring when this incident happened. 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) relies on the facility for his/her care and has a history of repeated falls. On or about August 31, 2022, AV was found to have extensive bruising and swelling on AV’s chest and armpit and shoulder. AV was sent to the hospital where it was discovered AV had a fracture of two ribs. Progress Notes indicated AV had fallen recently, but there was no follow-up after the note was entered. The facility failed to implement interventions and/or appropriately care plan related to AV’s safety and history of falls, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is a known fall risk. On or about January 14, 2022, AV was found in his/her closet sitting on his/her bottom. Later in the day, AV was noticed to have a swollen knee and was sent to the emergency room and diagnosed with a fractured knee. The facility failed to properly care plan to reduce the risk of falls suffered by AV. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.