Compass Rose Memory Care

Alleged Victim (AV) lives at Respondent’s facility and relies on the facility staff to provide appropriate supervision and care. AV has a history of falls, including two prior incidents that occurred in July 2025, that resulted in EMS transporting AV to the hospital for evaluation, and an incident on August 10, 2025. However, the facility failed to develop sufficient interventions to mitigate risk of further falls to AV. On or about August 15, 2025, AV was found on the floor of AV's living room on AV's back. AV reported hitting head, and pain at level 9 in back, neck and hip. AV was transported by EMS to the hospital for evaluation. Respondent failed to develop and implement suitable interventions, which constitutes abuse by neglect.

Alleged Victim (AV) lives at Respondent’s facility and relies on the facility staff to provide appropriate supervision and care. AV has a history of falls, including two prior incidents that occurred in July 2025, that resulted in EMS transporting AV to the hospital for evaluation. However, the facility failed to develop sufficient interventions to mitigate risk of further falls to AV. On or about August 10, 2025, AV was found on the floor with a skin tear to right skin fold and redness to right knee. AV also complained of hip pain. Respondent failed to develop and implement suitable interventions, which constitutes abuse by neglect.

Alleged Victim (AV) lives at Respondent’s facility and relies on the facility staff to provide appropriate supervision and care. AV has a history of falls, including an incident that occurred on July 22, 2025, that resulted in EMS transporting AV to the hospital for evaluation. However, the facility failed to develop sufficient interventions to mitigate risk of further falls to AV. On or about July 30, 2025, AV fell and was found in the same location on the floor as the prior fall on July 22, 2025. AV reports pain in back and head, EMS transported AV to the hospital for evaluation. Respondent failed to develop and implement suitable interventions, which constitutes abuse by neglect.

Alleged Victim (AV) is a resident of AP1 and relies on AP1 staff for AV's basic care and safety needs. AV likes to walk and has wandering behaviors. AV's Care Plan dated on or about May 7, 2025, indicates AV has a fall history, however there is inconsistency as it also notes AV is not a fall risk. AP1 staff are to be aware where AV is and provide safety checks to make sure AV is safe and accounted for, AV requires frequent supervision and redirection due to wandering, AV cannot be left unassisted, AP1 staff to provide daily redirection when AV is wandering in order to help keep AV safe. On or about July 29, 2025, AP1 staff heard a scream and found AV on the floor in the hallway. AV had a bloody nose, a skin tear on the bridge of AV's nose, swollen lips, and a bruise above AV's right eye. AV was transported to the emergency room for assessment and treatment. The facility failure to follow AV's care plan, providing AV supervision and leaving AV unassisted, resulted in an injury fall, which is a violation of resident’s rights is neglect of care and constitutes abuse.

Alleged Victim (AV) lives at Respondent’s facility and relies on the facility staff to provide appropriate supervision and care. AV has a history of falls, including an incident that occurred on July 4, 2025. However, the facility failed to develop sufficient interventions to mitigate risk of falls to AV. On or about July 22, 2025, AV lost balance and fell, when attempting to reach for something resulting in AV hitting h/h head and complaining of back pain. EMS transported AV to hospital. Respondent failed to develop and implement suitable interventions, which constitutes abuse by neglect.

The Alleged Victim (AV) has a history of physical altercations with other residents. AV's interventions for this behavior include staff monitoring and to redirect AV to another area of the community if becoming agitated, and to spend time with AV. On or about December 27, 2024, AV was standing in front of the television, blocking others view, causing Witness #1 (W1) to push AV out of the way, causing AV to fall. W1 and AV were seen in the common area prior to the altercation, and staff could have predicted AV standing in front of the TV, as this action has caused multiple altercations. 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 December 16, 2024, W1 approached the Alleged Victim (AV) and tried to take his/her coffee. AV told W1 to go away and W1 became aggressive, hitting AV in the elbow with his/her cane. AV was uninjured during the altercation, however, the facility's failure to follow the interventions in place for W1 and to supervise W1, placed AV at risk for harm. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) relies on facility staff to ensure that AV's personal care, safety, and supervision requirements are met. AV has been complaining of pain in AV's teeth for over a year. The only documented attempt of scheduling a dentist appointment was on October 26, 2023. There is no further documentation regarding AP1's attempt in finding AV a dentist in the area. The facility failed to assure that a dentist provided dental care in the event dental pain, as timely as required by the resident's oral condition.

The Alleged Victim (AV) relies on the facility for care and has a history of falls. According to an investigation, on or about March 18, 2024, AV had an unwitnessed fall, resulting in bruising to AVs face, orbital socket, and hand, and a bleeding head wound. The AV was taken to the hospital for treatment that included closing the head wound with glue. The facility failed to implement interventions to mitigate AV’s increasing fall risk, 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 care. According to an investigation, on or about March 11, 2024, AV was in pain and did not receive ordered pain medication. The facility failed to administer medication as ordered, 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 in the last few months. On or about February 12, 2024, the Alleged Victim (AV) suffered a fall and was found on the floor with a laceration to his/her head. AV was sent out to the emergency department and received staples to his/her head. AV's care plan was not updated after his/her multiple falls to include clear direction to staff regarding AV's transfer and ambulation requirements after his/her change of condition. The facility's failure to have oversight and monitoring of AV's change of condition 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 within the prior month. AV is care planned as independent in mobility and transfers, even though he/she has suffered multiple falls. On or about January 6, 2024, AV suffered a fall and was sent out to the hospital for evaluation. AV returned with a closed head injury. The facility's failure to properly care plan to reduce AV's risk for falls 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) relies on the facility for care and has a history of falls. According to an investigation, on or about November 11, 2023, AV had an unwitnessed fall. AV hit their head and leg and were transported to the hospital for treatment. The facility failed to implement interventions to mitigate AV’s increasing fall risk, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility for care and has a history of falls. According to an investigation, on or about November 12, 2023, AV had an unwitnessed fall, resulting in a leg injury. The facility failed to implement interventions to mitigate AV’s increasing fall risk, 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, however, AV's care plan lists AV as independent in transfers and ambulation. On or about October 7, 2023, AV suffered an unwitnessed fall and was transported to the emergency room where he/she was diagnosed with a fractured hip. The facility's failure to ensure interventions were appropriate and properly care plan to reduce falls is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) had a known history of wandering into other residents’ rooms. Witness 1 (W1) has a history of being protective of his/her things and not wanting others in his/her room. On or about September 18, 2023, AV went into W1’s room, resulting in W1 punching AV in the back. The facility failed to effectively care plan and/or implement interventions to keep AV safe, which is a violation of resident rights, is neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility for catheter care. According to an investigation, the facility failed to provide appropriate services, relating to catheter treatment, which resulted in unreasonable discomfort and loss of personal dignity. The facility failed to follow AV's care plan, which is a violation of resident's rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions or appropriately care plan for Witness #1’s (W1) known behaviors. This failure resulted in W1 grabbing the Alleged Victim (AV) on or about January 11, 2023 and throwing him or her to the ground, placing AV at risk for harm. 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.

Alleged Victim (AV) relied on the facility for his/her care and their Service Plan stated if they are resistant/combative with care to leave and re-approach later. On or about January 6, 2023, the Alleged Perpetrator 2, 3, and 4 (AP2, AP3, AP4) were tasked with showering the AV due to fecal incontinence. AV was resistant to care and had not allowed staff to change his/her brief for approximately 5 days. While AP2 was getting the shower ready, the Alleged Perpetrator 3-4 (AP3-4) forced AV into the bathroom to take a shower. AV was observed to be screaming and resistant to care as they were brought to the shower and an old wound opened and started bleeding during the event. During an investigation it was discovered that AP3 and AP4 were not properly trained regarding caring for residents, and therefore AP3 and AP4 allegations were not substantiated. AP2 is not substantiated due to their limited involvement. The facility failed to provide services, to include ensuring AV’s Service Plan was followed and that staff were properly trained, which is a violation of resident rights, is neglect of care which constitutes abuse as defined by OAR 411-020-0002(1)(b)(A)(i).

The Alleged Victim (AV) relied on the facility for care. Between approximately January 1, 2023, and January 5, 2023, AV would not allow staff to assist them with brief or clothes changes or showering, resulting in AV developing skin breakdown and irritation. The facility failed to provide appropriate services, to include following the care plan and/or implementation of effective interventions which is a violation of resident rights, is considered neglect of care and constitutes abuse as defined in OAR 411-020-0002(1)(b)(A)(i).

Witness #1 (W1) and Alleged Victim (AV) have history of sexually inappropriate behaviors with other residents and each other. W1 and AV have interventions in place regarding their inappropriate behaviors that include redirection and supervision. On or about November 04, 2022, documentation indicates W1, and AV engaged in inappropriate sexual behaviors with each other. The facility failed to appropriately adjust care plans and implement reasonable interventions to address W1s and AVs continued inappropriate behaviors with each other, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide a safe medication administration system to ensure the Alleged Victims (AV) medication orders were administered as prescribed. The AV is frequently out of the facility and on multiple occasions did not receive h/h medication as scheduled placing AV at risk of serious harm. The facility failed to appropriately implement a plan for medication management while AV was out of the facility, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) is a high fall risk and has history of falls. AV is care planned as independent with ambulation, using an assistive device. On or about August 23, 2022, and August 26, 2022, AV fell resulting in h/h being sent to the Emergency room (ER) due to swollen, painful knees and having difficulty standing and transferring. AV returned from the ER with a diagnosis of joint effusion and wearing a knee brace immobilizer. The facility failed to appropriately care plan and implement reasonable interventions to address AV’s increasing and ongoing falls, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about August 26, 2022, Alleged Victim (AV) was in the kitchen area getting napkins, as AV consistently wipes h/h mouth due to a physical condition. Alleged Perpetrator 2 (AP2) was witnessed using a wrongful restraint on AV by wrapping h/h arms around AV from behind and attempted to remove napkins from AV’s pocket. AV struggled to get free from AP2, resulting in AV becoming frustrated and upset. AP2’s actions are considered a wrongful use of a restraint and constitutes abuse. The facility failed to provide a safe environment, oversight, and monitoring of AP2, and the facility failed to complete a background check on AP2, which is a violation of resident rights, is neglect of care as and constitutes abuse.

The facility failed to implement interventions and appropriately care plan regarding Alleged Victim’s (AV) known fall risk. AV had multiple documented falls between May 29, 2022, and August 22, 2022, some resulting in injury including but not limited to a head injury, skin tears, abrasions and bruising. The facility failed to implement interventions to mitigate AV’s increasing fall risk, 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/her care, to include transportation to and from medical appointments. On or about August 15, 2022, the AV had an appointment with his/her physician for a scheduled procedure. The AV was transported to the medical appointment by the facility bus and arrived late to their appointment and was unable to be seen by the physician, making AV have to reschedule their procedure for approximately two (2) months. The facility failed to provide services and timely transportation for AV’s medical appointment, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide a safe medication administration system to ensure the Alleged Victims (AV) medication orders were administered as prescribed. On multiple occasions, it was discovered that AV did not receive h/h medications and/or did not receive medications in a timely manner, resulting in AV becoming agitated and having verbal outburst. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide appropriate services and care plan according to the Alleged Victim’s (AV) needs. On or about July 16, 2022 the Alleged Victim (AV) had a fall that resulted in a fractured finger. There is no documented evidence that the facility was following the care plan, which stated to monitor AV’s skin at least one (1) time per day and report any discoloration, bumps or lumps, or that the facility placed additional interventions in place after the fall. The failure caused AV unreasonable discomfort, 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. On or about July 16, 2022, AV had a fall, resulting in a fractured finger which required surgery to correct. The facility failed to manage, schedule and follow through with AVs outside providers for treatment. The facility failure to provide timely medical treatment caused AV unreasonable and ongoing pain, discomfort, and emotional hardship, which is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility for his/her care. AV has a history of placing foreign objects in h/h brief. On or about June 19, 2022, AV was found to have foreign objects in AV’s brief, causing AV to go to the hospital, placing AV at risk for serious harm. The facility failed to appropriately care plan and implement reasonable interventions to address AV's behaviors which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On approximately May 21, 2022, and again on May 24, 2022, the Alleged Victim (AV) was not administered his/her pain patch and was displaying physical signs of pain (increased agitation and restlessness). The facility failed to provide a safe medication administration system, which is violation of resident’s rights, is considered neglect of care and constitutes abuse.

On or about May 2, 2022, the Alleged Victim (AV) had a unwitnessed fall resulting in a head injury, and AV was sent to the hospital for treatment two days later, on May 4, 2022. AV’s Service Plan indicates AV is a known fall risk, uses assistive devices (walker and wheelchair), requires assistance with transfers and ambulation escorts, but also states AV is independent with ambulation. The facility failed to implement interventions and care plan to appropriately address AV’s increasing fall risk, 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 regarding Alleged Victim’s (AV) known fall risk. On or about April 21,2022, AV was found on the floor and was sent to the hospital for elbow pain and a head laceration. The facility failed to implement interventions to mitigate AV’s increasing fall risk, which caused repeated unreasonable discomfort, is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his or her care and has a history of falls and behaviors. On or about April 20, 2022, AV was wanting to get up from a chair and AP2 was reportingly arguing with AV and pulling AV’s belt to get AV to sit back down. AP2 was heard telling AV they would not help AV if they fell and then AP2 walked away, resulting in AV falling onto the floor. Facility staff did not call emergency services and reported the fall as noninjury despite staff stating AV hurt his or her elbow and applied an ice pack. The facility and AP2 failed to provide services, which is a violation of resident rights, is neglect of care and constitutes abuse.

The facility failed to implement interventions or appropriately care plan for the Alleged Victim’s (AV) and Witness #1’s (W1) known behaviors, which resulted in a resident-to-resident interaction between W1 and AV on or about April 10, 2022, causing a loss of personal dignity and risk of serious harm. 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) moved into the facility on or about March 2, 2022, and the facility did not start administering AV’s medications until approximately noon on March 15, 2022. AV missed multiple doses of all ordered medications which included a blood pressure lowering medication, which put AV at risk of serious harm. The facility failed to provide a safe medication administration system to ensure AV’s medications were administered as ordered. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately care plan regarding Alleged Victim’s (AV) known fall risk. AV fell on or about February 22, 2022, resulting in a head injury and AV being transferred to the hospital for treatment. The facility failed to implement person centered interventions to mitigate AV’s increasing fall risk, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide a safe medication administration system to ensure Alleged Victim’s (AV) pain medication was given as ordered and as needed. The AV missed multiple doses of pain medication between approximately February 14, 2022, and February 21, 2021, which caused AV repeated unnecessary discomfort. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. AV had a fall on or about January 1, 2022, and again on or about January 7, 2022, with at least one resulting in injury. The facility failed to provide documentation that interventions were put in place and that AV was care planned to mitigate AV’s increasing fall risk, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide appropriate services and care plan according to the Alleged Victim’s (AV) needs. The Alleged Victim (AV) had approximately twenty-three (23) documented falls between February 2, 2021, and December 8, 2021, some resulting in injury, a 25.4-pound weight loss in six (6) months, and on or about December 24, 2021 AV had a severe infection in the lungs, bed sores on AV's bottom and heels and a genital injury. The facility failed to provide appropriate services to respond to AV’s change of conditions, which caused repeated unreasonable discomfort, 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. On or about December 22, 2021, Alleged Victim was administered another resident’s medication and soon after AV experienced elevated blood pressure and was transferred to the hospital for treatment. The facility failed to provide a safe medication administration system, which is a violation of resident rights, is neglect of care and constitutes abuse.

The Alleged Victim (AV) was care planned to be assisted with toileting. On or about December 12, 2021, AV was found soiled in urine and the condition of his/her room was unsanitary. Due to a lack of appropriate staffing, AV’s care plan was not followed, leaving AV at risk for harm. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

AV experienced approximately eight falls from September 5, 2021, to December 4, 2021. On or about, December 7, 2021, AV went to the hospital and was diagnosed with a blood clot. It was also discovered during the investigation, that AV's care plan was not being followed relating to medication, housekeeping and toileting due to a lack of staffing. The facility failed to provide appropriate services according to resident needs. These failures are a violation of resident rights, is neglect of care which constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. AV had eleven falls between June 1, 2021, and November 28, 2021. Based on interviews and facility documentation, eight of the eleven falls resulted in emergency medical treatment with the fall on November 28, 2021, causing AV a head injury. The facility failed to appropriately care plan and implement proper interventions to mitigate AV's fall risk. This failure is a violation of resident rights, is neglect of care which constitutes abuse.

The facility failed to provide appropriate services according to the Alleged Victim (AV)'s needs, relating to change of condition when AV experienced a physical decline. AV experienced unreasonable discomfort and a loss of personal dignity, which is a violation of resident rights, is neglect of care which constitutes abuse.

On or about November 17, 2021, it was determined that the facility failed to provide adequate services and care for Alleged Victim’s (AV) catheter treatment and facility also failed to maintain cleanliness and safety as directed in AV’s care plan. The facility failure to follow AV's care plan, which is a violation of resident's rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. AV had fourteen falls between August 11, 2021, and November 9, 2021. The facility failed to properly care plan for AV's fall risk and on or about, November 14, 2021, AV had another fall where AV experienced pain. This failure is a violation of resident rights, is considered neglect of care which constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. AV had thirteen falls between August 11, 2021, and November 7, 2021. The facility failed to properly care plan for AV's fall risk and on or about, November 9, 2021, AV had another fall where AV was sent to the hospital for a head injury that required staples. This failure is a violation of resident rights, is neglect of care which constitutes abuse.

The facility failed to provide appropriate health assessment, oversight, and monitoring when AV’s medical condition changed which resulted in AV experiencing an untreated decline in his/her condition and AV not receiving timely medical treatment. AV was sent to the hospital on or about, November 2, 2021, where he/she was diagnosed with cellulitis. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) was care planned to be assisted with toileting. On or about October 31, 2021, AV was found saturated in urine. Due to a lack of appropriate staffing, AV’s care plan was not followed, leaving AV at risk for harm. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to carry out medication and treatment orders as prescribed. The facility's failure is a violation of Oregon Administrative Rules.

The facility failed to implement resident rights per HCBS rules. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to ensure the resident's HCBS right to choose a roommate. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide a lockable door. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide Transportation for medical services. An investigation determined this is a violation of Oregon Administrative Rules.

Alleged Perpetrator 2 (AP2) failed to provide a safe medication administration system to Alleged Victim (AV). AP2 did not clarify the medication order prior to faxing them to AV's pharmacy, AV's medication was discontinued, the original ordered was a PRN. When AP2 re-ordered the medication it was written as a scheduled medication. AV suffered three falls in a 24-hour period after receiving four doses of a medication. AP2's actions are considered neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.

The facility failed to ensure that residents may not enter a room through another resident's bedroom. The facility’s failure is a violation of Oregon Administrative Rules.

On or about April 5, 2023, the Alleged Perpetrator #2 (AP2), placed a wheelchair and pillow against the Alleged Victim's (AV) bed in an attempt to prevent them from falling out of bed. AP2 did not follow state guidelines for resident rights/treatment and no restraints, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to ensure the residents rights/treatment was being followed, which is a violation of Oregon Administrative rules.

On or about April 5, 2023, the Alleged Victim (AV), fell out of bed. The Alleged Perpetrator #2 (AP2), found AV on the floor, and instead of providing assistance to AV, AP2 placed a pillow under AV's head and a blanket on them and left AV on the floor. AV was on the floor for approximately 15-20 minutes until another staff member came back from lunch and called 911. AV was taken to the hospital due to a head hematoma. AP2 failed to provide services to AV, which is considered neglect of care and constitutes abuse. The facility failed to ensure care was completed which is a violation or Oregon Administrative rules.

The allegation that the facility failed to exercise reasonable precautions against any condition that may threaten the health, safety, and welfare of residents in accordance with OAR 411-054-0025(4). Per a complaint that staff are not using masks, screening staff/visitors, and following recommended COVID precaution practices was verified.

The facility failed to provide a safe medication administration system to ensure the Alleged Victim’s (AV) medications were administered as ordered. There was no observable or documented evidence of a negative outcome. The failure is a violation of Oregon Administrative Rules.

The facility allegedly failed to protect the Alleged Victim from inappropriate sexual contact. An investigation determined no abuse occurred. The facility failed to retain resident records, provide documents upon request, and ensure service plans are reflective of residents needs which is a violation of Oregon Administrative Rules.