Crystal Terrace Memory Care

Alleged Victim (AV) had an extensive fall history and was a high fall risk. On or about November 20, 2025, during weekly skin monitoring, it was discovered that AV had two new marks of discoloration to the back of AV's hand and lower forearm. One was on the top of AV's right hand measuring 0.5 cm x 0.5 cm, red/purple in color, and the skin was intact. Another was to the lower right forearm measuring approximately 2 cm x 1 cm, purple/brown in color. Respondent failed to provide a safe environment for AV, and to ensure the safety of AV. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

Alleged Victim (AV) relies on the facility for his/her care. On or about November 5, 2025, AV was found to have a 2.5 cm long skin tear on his/her right forearm while being assisted with a shower by staff. AV has a history of scratching his/her skin and had varying complaints of itchy skin on or about October 6, 2025, however, there were no new interventions on AV’s care plan. Respondent failed to care plan around AV’s skin issues, and to ensure the safety of AV. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

Alleged Victim (AV) has a known history of falls. On or about November 5, 2025, AV sustained a fall which resulted in discoloration to AV’s right elbow and discoloration area to the right forearm. AV had previously fallen on five (5) occasions between September and October 2025. Respondent failed to implement meaningful interventions for falls, to ensure the safety of AV. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

Alleged Victim (AV) relies on the facility for transfers, ambulation, toileting, and bathing due to AV’s inability to follow directions and resistance. On or about November 4, 2025, at around 11:00 AM, staff observed scattered discoloration/bruising on AV’s left posterior upper arm near the elbow while assisting AV to the bathroom. The pattern of discoloration appeared consistent with fingertip marks. Respondent failed to use proper transfer technique of linking arms or allowing AV to grasp staff, not grabbing the bicep or upper arm, and to ensure the safety of AV. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

Alleged Victim (AV) relies on the facility for his/her care needs. AV was found to have a new area of skin impairment on 9/17/2025 located on the right gluteal cleft measuring approximately .3cm x .3cm, purple in color, fluid filled, and not open. AV was prescribed a barrier cream, which was inconsistently documented as administered, with limited applications recorded in September 2025 despite daily orders. There were discrepancy and lack of clarity in medication orders and documentation regarding which skin treatments were to be applied and when. Respondent failed to implement a safe medication administration system, and to ensure the safety of AV. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

Alleged Victim (AV) has a known history of skin breakdown. On or about September 15, 2025, AV was found to have an open area of skin on h/h left buttocks near the gluteal cleft measuring approximately 2cm x 1.9cm that was red and leaking bodily fluid. The surrounding tissue on both buttocks was red and irritated. The wound appearance was consistent with a pressure-related or friction-related injury. Respondent failed to report that AV had open skin area and skin monitoring was discontinued despite AV’s documented history of recurring skin breakdown, and to ensure the safety of AV. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

Alleged Victim (AV) has a known history of falls. On or about September 14, 2025, AV fell and sustained injuries to his/her face as a result of the fall. The only intervention documented was for AV’s injuries to be monitored and new medication was ordered. Some witnesses did not know what AV’s needs and service plan consisted of despite consistently providing care to AV. Respondent failed to implement meaningful interventions for falls, to ensure the safety of AV. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

Alleged Victim (AV) has a known history of falls. On or about October 3, 2025, AV once again sustained a fall. AV has a prior fall on or about September 18, 2025, however, there was no temporary safety plan dated September 18, 2025, after AV’s fall. On or about October 1, 2025, it was documented by hospice that AV had increased disorientation and increased agitation. Respondent failed to provide a safe environment to AV, and to ensure the safety of AV. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

Alleged Victim (AV) was a high fall risk. Between July 2025 and August 2025, AV sustained seven (7) falls. On or about September 09, 2025, AV was found on his/her hands and knees and had some red discoloration to his/her knees. As a result of this fall, AV sustained skin tear to his/her bottom lip. The facility failed to provide a safe environment to AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) was a 2-person assist with most of his/her care, AV is no longer able to safely self-propel using his/her assistive walking device. On or about September 03, 2025, AV had injuries to his/her left arm of unknown origin. Despite AV having a 1-1 caregiver at all times, AV sustained a skin tear to his/her left arm that was of unknown origin. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) was a 2-person assist with most of his/her care, AV is no longer able to safely self-propel using his/her assistive walking device. On or about September 19, 2025, AV had once again an injury to his/her right forearm of unknown origin. Despite AV having a 1-1 caregiver at all times, AV sustained a skin tear to his/her left arm that was of unknown origin. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) was a 2-person assist with most of his/her care, AV is no longer able to safely self-propel using his/her assistive walking device. On or about September 21, 2025, AV had injuries to his/her right thumb and hand that were from unknown origin. AV had an injury to the left hand that was from unknown origin. This was the third incident of injuries of unknown origin to AV within the month of September 2025. The facility failed to provide a safe environment for AV leading to AV sustaining injuries of unknown origin, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) had a history of small discolorations on the arms. AV is care planned to be a two-person assist with transfers. On or about August 27, 2025, AV had areas of discoloration to both of his/her elbows that were from unknown origin. On or about September 2, 2025, AV had injuries of unknown origin to his/her right hand and wrist. The facility failed to provide a safe environment to AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) was known to have sensitive gums that were prone to bleeding, AV is also care plan to be a one-person assist with oral care. On or about August 7, 2025, AV's gums were bleeding due to the lack of oral care. Facility staff were not consistently providing oral care to AV. The facility failed to follow the care plan around AV’s oral care, which is a violation of resident rights, is neglect of care and constitutes abuse.

The Alleged Victim (AV) has a history of pressure sores. On or about August 31, 2025, AV was found to have a pressure sore on his/her buttocks with blood present in his/her brief. On or about September 2, 2025, AV had a stage 2 wound on his/her buttocks. Medical staff were not made aware of AV's wound, and no care was provided to the wound to ensure that it didn't worsen. Respondent failed to ensure staff advised medical staff of a change of condition and provide services to AV. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

The Alleged Victim (AV) has a history of pressure sores. On or about August 31, 2025, AV was found to have a pressure sore on his/her buttocks with blood present in his/her brief. On or about September 2, 2025, AV had a stage 2 wound on his/her buttocks. On or about September 11, 2025, AV's wound was larger. No new interventions were put into place to reduce the risk of further wound worsening. Respondent failed to ensure interventions were put into place to decrease the worsening of AV wound, or to ensure AV would not have new wounds. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

Alleged Victim (AV) was listed as a two person assist in ambulation and unable to ambulate on his/her own per the care plan. AV is listed as independent with call system but also lists AV cannot use the call system. AV had four (4) falls in July of 2025. On or about August 27, 2025, AV was found on the floor with an injury to his/her right hip/upper thigh. The facility failed to care plan and mitigate AV’s risk of falls, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. On or about June 15, 2025. AV developed a blister to his/her right lower leg. AV was known not to sleep in recliner and known to constantly sit in common area chair. AV was taken to urgent care by facility staff on June 17, 2025, for blister to his/her leg. AV was given an antibiotic, recommended to have compression stockings and elevate legs. AV continued to have blistering/wound on his/her right leg through the month of June, July and August of 2025. As a result, AV had to be admitted to the hospital due to an infection on his/her leg which had become worse. The facility failed to proper care and interventions to prevent further decline to AV’s wound, which is a violation of resident rights, is neglect of care and constitute abuse.

Alleged Victim (AV) had recent history of falls leading up to the fall which occurred on or about August 19, 2025. On or about August 19, 2025, AV fell in the common area. AV was sitting in a chair and napping off and on during the day. AV was noticed to be off baseline earlier in the day. As a result of the fall, AV sustained a head injury. Respondent failed to provide a safe environment for AV. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i)(ii).

Alleged Victim (AV) has a known history of falls. On or about August 14, 2025, AV was found on the floor on his/her hands and knees in his/her room. AV had previously fallen on or about July 2nd, 16th, 21st, 23rd, 2025 and on August 6, 2025. One of those falls resulted in a laceration to AV’s face. Respondent failed to provide a safe environment for AV, and to ensure the safety of AV. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

Alleged Victim (AV) has a known history of falls. On or about July 2025, during a 2-person assisted transfer, AV fell in the shower. On or about August 6, 2025, AV fell during an assisted shower, hit his/her head and was diagnosed with a concussion as a result. Respondent failed to provide a safe environment during showers, and to ensure the safety of AV. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

Alleged Victim (AV) relies on the facility for his/her care and is a full assist with his/her care. On or about September 20, 2025, AV had discolorations to his/her arms and hands that were of unknown origin. AV was not capable of hurting his/her self. Respondent failed to provide a safe environment during showers, and to ensure the safety of AV. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

Alleged Victim (AV) was at high risk for skin impairments/bruising easily as evidenced by type 2 diabetes with insulin dependence, age, limited mobility due to history of stroke and AV took a blood thinner daily. Between June 11, 2025, and June 26, 2025, AV was noted to have discolorations on both of AV’s hands, right thigh, right toes, right wrist and right forearm. On July 3, 2025, and July 8, 2025, AV was noted to have an increase in discolorations to AV’s upper extremities, and AV was noted to bruise easily due to aspirin and blood thinning medication. On or about July 11, 2025, AV had bruising near AV’s left elbow measuring 1 cm x 1 cm, AV was not able to communicate how the bruising happened. The facility failed to provide a safe environment for AV, which lead AV to sustain bruising, which is a violation of resident rights, is neglect of care and constitutes abuse.

Witness 1 (W1) was known to facility staff to have aggressive behaviors towards both facility staff and other residents. W1 is care planned to have known behaviors around the chair that he/she liked to sit in. W1 was known to be possessive over a certain chair in the common area of facility. On or about August 3, 2025, W1 grabbed Alleged Victim (AV) by the shoulder because AV would not get out of a chair that AV was sitting in. As a result of the altercation, AV suffered shoulder pain from the incident. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) has a known a history of falls. AV fell on or about July 31, 2025, and hit AV's head. AV had prior fall on or about July 24, however, there were no new interventions for this fall. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. On or about August 3, 2025, AV was found sitting on the floor and AV's walker was tipped over. Once again, there were no new interventions added due to AV’s falls, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim’s (AV’s) care plan states AV required standby assistance with dressing and AV is a 1-person assist for bathing. On or about May 30, 2025, AV's POA informed the facility he/she didn't want to continue showering AV. Facility made no changes to AV's care plan or TSP in regard to AV's POA no longer being a good intervention to assist in showering AV. On or about June 15, 2025, at around 12:17 a.m., AV developed a blister to h/h right lower leg. The facility was not taking care of AV's leg issues which had become worse by developing a blister which popped. The facility was not changing AV's bandage, it was being left soiled, and AV had to be transported the hospital for care. The facility failed to provide wound care to AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) has a known history of falls. AV requires the use of walker when ambulating, per his/her service plan. Several facility staff stated AV's walker was having issues on or about July 24, 2025, and one facility staff stated they filled out a piece of paper regarding one of the incidents and documented about the walker issue. There were no documents showing AV's walker issues. On or about July 24, 2024, at approximately 3:00 a.m., AV had an unwitnessed fall that resulted in injury. AV had a recent fall earlier that morning that resulted in injury. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) had falls prior to the update of his/her service plan on July 16, 2025, but the service plan stated no falls in the fall history. On or about May 29, 2025, AV was found with an injury to his/her forehead and elbow area. AV was sent to the ER for the injury. On or about June 12, 2025, AV had an unwitnessed fall, however there was no other documentation or interventions for this fall. On or about July 2, 2025, AV had a fall according to a TSP, however there was no incident report or narrative charting describing the incident or interventions. On or about July 23, 2025, AV was seen in the emergency room for a fall that resulted in a cut on h/h eyebrow. The facility failed to care plan and mitigate AV’s risk of falls, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) was on a puree food and thickened liquid diet per his/her care plan. The facility has a history of not following diet restrictions. On or about June 27, 2025, the facility received instructions from PCP to continue to offer diet of pureed food with nectar thickened liquids due risk of aspiration. As of July 16, 2025, AV was being served ice cream as part of his/her diet under the misimpression that it qualifies as a thickened liquid which place AV at risk of aspiration. On or about July 22, 2025, facility staff attempted to give an ice cream sandwich. Two weeks prior to the incident with AV, facility staff tried to serve chicken salad to mechanical soft residents. The facility failed to assure AV’s care plan was being followed, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) was on a puree food and thickened liquid diet per his/her care plan. AV has chewing difficulty and has a diagnosis of Dysphagia. As of July 16, 2025, AV was being served ice cream as part of his/her diet under the misimpression that it qualifies as a thickened liquid. AV has also been receiving water which has placed AV is risk of aspiration. The facility failed to assure AV’s care plan was being followed, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim’s (AV’s) care plan notes he/she is independent with ambulation, is known to refuse showers, and staff must attempt a change of face if AV refuses and has confusion as well as hallucinations. On or about July 13, 2025, AV was found to have a wound and the bandage was soiled. Facility staff did not notify any other staff, begin a TSP or initiate alert charting. It was unknown what caused the injury to AV or when. AV's wound smelled horrible, and the bandage was stuck to the skin and appeared to be growing onto the bandage. The facility failed to care plan around AV’s refusal to showers and to provide appropriate care around the wound that was found, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim’s (AV’s) care plan states staff are supposed to redirect AV as needed when in other residents' personal space and staff are supposed to ensure safety of Witness 1 (W1) or others if W1 becomes agitated. On or about July 6, 2025, W1 pushed AV after AV was touching W1's hair. On or about July 7, 2025, AV reached into W1's walker basket. W1 reached over and slapped AV's left arm. AV and W1 had a previous altercation. The facility failed to assure AV’s care plan was being followed by not keep AV and W1 separated, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) required caregiver to be right next to him/her at all times. This was due to AV experiencing frequent falls and behaviors such as flailing his/her arms. AV was a total assist in all areas of care and could not do anything for him/herself. AV had been placed on a 1:1 caregiver status since April 1, 2025. On or about June 20, 2025, AV was found to have dark red discolorations to the top of his/her left forearm. The facility failed to provide a safe environment for AV, which resulted in skin injuries, which is a violation of resident rights, is neglect of care and constitutes abuse.

The Alleged Victim (AV) is cognitively impaired and requires staff monitoring in common areas and outside. On or about June 15, 2025, AV suffered an unwitnessed fall outside that resulted in AV suffering a fractured clavicle, which caused pain and unreasonable discomfort. Staff were unaware that AV was outside alone for approximately 20 minutes. Respondent failed to ensure staff followed the service plan to ensure AV's safety. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

Alleged Victim (AV) had a progressive brain disorder that gradually destroys memory, thinking and other cognitive functions. In late 2024, AV developed a sore on AV's bottom while living in another facility. Facility was aware of this history, but staff were not aware. On or about June 3, 202025, it was discovered that AV had open areas to AV's buttocks. The facility did not put any interventions in place to prevent sores from developing. The facility should have put interventions in place to prevent wounds on AV's buttocks. AV was scheduled to be showered 2 times per week by 1-person as a total assist; the person was to wash AV's entire body, peri area and face/head as needed. Staff were supposed to complete shower sheets for everyone to document any skin issues. Witness 3 (W3) did not assess AV's skin in the shower; AP1 staff was supposed to do that. AV frequently refused showers. Staff were to call W3 when AV refused to shower after 3 times with change of face. W3 would come in to encourage AV when W3 was available per the Service Plan, but staff would go 3 to 4 weeks without contacting W3. The facility failed to follow the Service Plan around AV’s shower needs, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care needs. AV was found with discolorations to his/her right arm. On or about June 2, 2025, AV's right hand had 6 scattered discolorations in irregular shaped circle-like marks. The sizes and descriptions of the discolorations on AV's right hand were: 0.8 cm red and round, 2 cm dark red/blue and round, 1 cm red and round, 2 cm dark red/blue and round, 1 cm red and round, and 0.4 cm red and round. The top of AV's right wrist had 3 spots of discoloration: 0.7 cm, 0.7 cm, and 0.3 cm all of which were round and light red in color. The upper right forearm near AV's elbow had one 0.6 cm red discoloration, which was round in appearance. It was unknown how the discolorations were caused. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) had extensive fall history since the beginning of 2025. AV had a history of significant injuries from falls like breaking his/her wrist, tearing an arm muscle, and discolorations to his/her eyes. AV had incident reports for falls on or about May 27, 2025, May 5, 2025, and April 20, 2025. AV was seen ambulating through the community right before the fall on May 31, 2025. As a result, AV sustained a fall in the dining room area. The fall was heard by facility staff members that were not in the room. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) is a known fall risk resident. On or about May 30, 2025, during a fire drill AV fell and landed on h/h face, hands and knees. AV had 2 previous falls one on April 17, 2025, and May 6,2025. No new interventions were implemented after the previous falls or the fall on May 30, 2025, to prevent future falls. As a result of the May 30, 2025, fall, AV sustained a swollen wrist. The facility failed to provide a safe environment to AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

On or about May 7, 2025, the Alleged Victim (AV) was found to have bruising on his/her hands. AV is impulsive, has a history of falls and is impulsive without safety awareness. AV had been observed by staff to bump into walls and corners. No interventions were put into place to reduce AV running into walls and corners. On May 7, 2025, an intervention was put into place for staff to redirect AV if seen bumping into walls. Respondent failed to have interventions in place to reduce AV's risk of bruising. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

On or about May 28, 2025, the Alleged Victim (AV) was found to have bruising on his/her hands, wrist and forearm. AV is impulsive, has a history of falls and is impulsive without safety awareness. AV had been observed by staff to bump into walls and corners. An intervention was put into place to reduce AV running into walls and corners on May 7, 2025, however, that intervention was closed on May 12, 2025, and staff were not aware of interventions in place to reduce AV's risk for bruising. Respondent failed to have interventions in place to reduce AV's risk of bruising. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

Alleged Victim (AV) relies on the facility for his/her care. On or about May 7, 2025, it was noted that AV had 2 open areas on the left buttocks. Assessment noted redness to center of buttocks measuring 6 cm by 6 cm, macerated areas to left buttocks, 2 small open area 1 cm by 0.7 cm round in appearance and also a macerated line/scabbed area 1.5 cm long and about 0.5 cm thick. The facility failed to properly plan care and prevent AV from getting skin breakdowns, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. On or about May 6,2025, staff were mopping the floor in the common area, the floor was wet, and AV slipped and fell. The facility failed to provide a safe environment for AV, which exposed AV to risk of harm, which is a violation of resident right, is neglect of care and constitutes abuse.

On or about May 5, 2025, the Alleged Victim (AV) was found with a .4 cm sore on his/her buttocks. AV was care planned to be changed every two hours and were supposed to place a pressure reducing cushion under AV to alleviate pressure on the area. Staff did not follow AV's care plan as AV was found multiple times caked in bowel and urine. Respondent failed to ensure staff followed the care plan. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

Facility staff were to provide Alleged Victim (AV) two-person assistance for all ambulation. On May 3, 2025, AV was in AV's wheelchair. An in-home agency (IHA) staff and facility staff walked with AV back to AV's room. The facility staff briefly left Witness 5 (W5) while W5 wheeled AV into AV's room and closed the room door. AV stood up from AV's wheelchair and grabbed the IHA staff by the shoulder. AV became dead weight and W5 assisted AV to the ground. AV’s care plan stated that staff were to be present at all times to ensure AV’s safety. The facility failed to follow the care plan around two-person assist for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. On or about May 2, 2025, AV invaded Witness 1’s (W1's) space, causing AV to get pushed. On or about April 11, 2025, W1 swatted at AV's hand after AV walked up behind/to the left of W1 and reached for a playing card. Staff were to help redirect AV away from W1 if AV was observed to be in W1's personal space to reduce the risk of physical altercations. However, staff were distracted and did not notice AV getting close to W1. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. On or about April 30, 2025, Hospice staff discovered bruising on both of AV's legs. AV also had red spot bruises on the top of both of AV's hands and right upper arm. AV used a hospital bed with half rails for turning and repositioning due to immobility/pain, and general decline. AV was to have both left and right half side bed rails, placed in full up and locked position while in bed. However, the side rails could increase the risk of skin tears, limb discoloration or dismemberment, suffocation and death. There were no interventions to prevent/decrease the risk of skin tears and limb discoloration, which is a violation of resident rights, is neglect of care and constitutes abuse.

The Alleged Victim (AV) and Witness #1 (W1) have a history of altercations. W1 was care planned for staff to limit the amount of people around W1 to decrease altercations with others. On or about April 30, 2025, W1 yelled "shut up" to AV and then kicked AV in the shin, causing a bruise. The facility failed to ensure staff followed the service plan and ensure the safety of AV. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

Witness #5 was care planned to ensure he/she was keeping distance from other residents while using his/her walker. On or about April 24, 2025, W5 ran over AV's foot with his/her walker, causing a bruise and unreasonable discomfort. The facility failed to ensure staff followed the service plan and ensure the safety of AV. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

Alleged Victim (AV) relies on the facility for his/her care. Between March 6, 2024, and April 16, 2025, AV had up to 33 scabs on AV's upper and lower extremities ranging from 0.2 cm to 2.5 cm in diameter. On April 29, 2025, AV had an open sore on AV's shoulder. The skin around the sore was red. As a result, AV's sore was measured at 1.5 cm by 1 cm and had redness surrounding it that was 7 cm long by 3 cm wide. The facility failed to put new interventions into place that were effective to prevent AV from picking at AV's skin which more likely than not, caused the sore and placed AV at risk of serious harm, which is a violation of resident rights, is neglect of care and constitutes abuse.

The Alleged Victim (AV) is care planned for a mechanical soft diet. On or about April 16, 2025, AV was given a banana nut muffin, which is not categorized as mechanical soft. AV having this type of food places AV at risk for serious harm of choking. The facility's failure to ensure AV received meals as outlined in his/her care plan constitutes abuse by neglect as defined by OAR 411-020-0002(1)(b)(A)(ii).

Witness 1 (W1) has a known history of aggressive behaviors. On or about April 11, 2025, at approximately 11:30 am, Alleged Victim (AV) was walking into the dining room, AV walked by W1 and reached out for one of W1’s cards and W1 slapped AVs hand and yelled “no.”. AV was care planned to be redirected when he/she was observed to be in W1’s personal space to reduce the risk of physical altercations. There is no indication that the interventions were being followed to redirect AV away from W1 during the incident on April 11, 2025. The facility failed to follow the care plan, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim’s (AV’s) care plan notes he/she is incontinent of bladder and occasionally incontinent of bowel. On or about March 25, 2025, AV was found in a soaking wet brief and facility staff believed AV had not been assisted in a timely manner. On or about April 05, 2025, at 7:00 pm, AV was once again covered in loose, dry, old-looking bowel movement (BM). Facility staff believed AV had not been assisted in a timely manner. The facility failed to provide service to AV around incontinent care, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim’s (AV’s) care plan states AV required multiple total-assist brief changes every day. On or about April 5, 2025, AV had dry bowel movement stuck to AV’s skin and the skin was red. Recent prior history indicates that on or about March 24, 2025, AV was found wet and had bowel movement that appear old. On or about April 2, 2025, AV has loose stools. The facility failed to follow the care plan, which resulted in AV having been found with bowel on him/her on several occasions, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) is care planned to be a total assist with his/her care needs; AV is also a two-person assist with toileting. On or about April 2, 2025, AV was found to have a 0.5 cm by 1 cm open area on his/her left buttocks. On February 27, 2025, it the shower sheet, it was documented that AV had an open pressure sore on his/her buttocks and “very very red” in his/her peri area. There was no temporary service plan or incident report for the open sore on February 27, 2025. The facility failed to proper plan care and follow wound care around AV’s know open pressure sore, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) is care planned to be a two-person assistance with toileting. On or about April 5, 2025, AV had been left soiled and the open area in his/her buttocks and had been bleeding. There was no documentation on AV’s care plan on how often he/she was to be checked on or toileted. The facility failed to follow the care plan around AV’s toileting care needs, which is a violation of resident rights, is neglect of care and constitutes abuse.

Between January 6th to 29th, 2025, Alleged Victim (AV) had 13 falls. AV’s one-on-one was removed on March 31, 2025. On or about April 1, 2025, at approximately 10 am, AV was found on AV’s falls mat because AV tried to get up by AV’s self. The facility acknowledged AV’s fall could have been avoided with one-on-one care, it was not a good idea to remove AV’s one-on-one because AV could decide to get up and fall. The facility failed to provide service for AV by failing to assure the necessary supervision to prevent AV from falling, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) has a known history of falls. On or about March 27, 2025, Alleged Perpetrator 2 (AP2) directed a care conference for AV at the facility. AV’s service plan and changes in level of care were reviewed. Those present agreed to attempt to decrease 24-hour one-on-one care to 15-minute checks from 6:00am to 6:00pm. On or about April 1, 2025, at approximately 10:00am, AV was found on AV’s fall mat, AV tried to get up by AV’s self. Based on AP2’s position at the time of the incident, AP2 was responsible to make decisions about care for AV. AV’s family was “really advocating” for AV not to be on one-on-one. AP2 failed to provide a safe environment to AV, which is neglect of care and constitutes abuse. The facility failed to assure AV received a safe environment, which is a violation of resident rights, is neglect of care and constitutes abuse.

The Alleged Victim (AV) requires assistance with transfers, repositioning and ambulation, and is to be checked on every 15-30 minutes for safety. AV suffered two falls within a little over a week, causing unreasonable discomfort to AV. The facility failed to ensure staff understood AV's needs and ensure AV's care plan was updated with interventions to ensure AV's safety. The facility's actions constitute abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

The Alleged Victim (AV) has a known fall history. On or about March 26, 2025, AV suffered a fall which caused unreasonable discomfort. The facility did not implement interventions after AV's fall on March 14, 2025. The facility failed to properly care plan for AV's needs and ensure AV's safety from falls. The facility's actions constitute abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

The Alleged Victim (AV) has a known fall history. On or about April 3, 2025, AV suffered a fall which placed AV at risk for serious harm. AV suffered 4 falls from March 14, 2025, through April 3, 2025. The facility failed to provide supervision for AV to prevent further falls. The facility's actions constitute abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

The Alleged Victim (AV) has a known fall history. On or about April 7, 2025, AV suffered a fall which placed AV at risk for serious harm. AV suffered 5 falls from March 14, 2025, through April 7, 2025. The facility failed to provide supervision for AV to prevent further falls. The facility's actions constitute abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

Alleged Victim (AV) is care planned to be on mechanical soft diet. On or about March 24, 2025, at around 3:00 pm, AV was served cut up corn dogs with ketchup. It was well known to staff that AV was on the mechanical soft diet. The facility failed to follow the care plan, which is a violation of resident rights, is neglect of care and constitutes abuse.

According to the documentation, the facility failed to follow the diet orders for the Alleged Victim (AV) by providing them food that is deemed a choking hazard. The AV is on a mechanical soft diet due to their history of chocking on food. On or about March 24, 2025, the facility provided a corn dog cut into pieces as a snack. Staff members were not trained to know what is considered mechanical soft foods. Staff also stated the AV has been given similar foods in the past that do not follow their mechanical soft diet texture. The facility’s failure to provide a mechanical soft diet to the AV who is at risk of choking is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) is care planned to be on a mechanical soft diet. On or about March 24, 2025, at around 3:00 PM, AV was served a cut up corn dog with ketchup. It was well known to staff that AV was on his/her mechanical died. AV was served the cut-up corn dog as AV had difficulty swallowing and was a choking risk due to a medical condition. the facility failed to assure the care plan was followed, around AV’s mechanical soft diet, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) has a known history of falls. On or about March 7, 2025, AV fell after having a behavior episode and being given medication which was known to make him/her dizzy. As a result of the fall, AV was complaining that his/her head was hurting. The facility failed to put appropriate and/or sufficient interventions into place to address AV’s falls despite the history of dizziness and unsteadiness when walking, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. On or about January 15, 2025, AV’s doctor noted AV’s coccyx wound was a “healed pressure sore still considered stage 1 due to redness.” Between February 11th through the 19th, 2025, AV’s skin was noted to be clear. On or about March 2, 2025, staff reported AV had redness/sore on AV’s left buttocks. On or about March 12, 2025, AV had blanchable redness to buttocks with 1 cm long open area to coccyx. Staff believed AV was supposed to be checked every two hours and were supposed to toilet AV every two hours, but not all staff changed AV every two hours. AV developed a sore as a direct result of AV not being toileted or repositioned as often as AV needed, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) has a known history of verbal and physical aggression. Since October 24, 2024, to February 24, 2025, AV has been involved in seven (7) reported resident to resident altercations where he/she has been the aggressor. The facility was aware that AV had aggressive behaviors but had not implemented any interventions to prevent resident to resident altercation. On or about March 7, 2025, AV had an assessment with a Gero-psych Specialist. The facility received the report with recommendations on May 2, 2025, but as of May 8, 2025, the facility had not implemented any pharmaceutical and non-pharmaceutical interventions that were recommended in the report, which is a violation of resident rights, is neglect of care and constitutes abuse.

According to the documentation, the facility failed to implement appropriate interventions for Witness 1’s (W1) known aggressive behavior towards the Alleged Victim (AV). W1 and the AV have a history of resident-to-resident altercations in the past, the most recent being on approximately January 27, 2025. On or about February 24, 2025, W1 pinched the AV’s cheek and scratched it, causing a skin tear. The only intervention in place was to separate W1 from the AV when behaviors were exhibited. The facility’s failure to implement appropriate and progressive interventions for W1’s known aggressive behavior towards the AV is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) was a total assist with most of his/her care needs, and was wheelchair bound. on or about February 16, 2025, AV asked to be toileted, but was refused care and told to wait until after mealtime was over. As a result, AV was denied toileting care, he/she reported feeling uncomfortable while having to wait. The facility failed to assist AV with toileting, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) was known to have severe behavioral issues and incidents of violence at the facility, including attempting and actually hitting staff and residents. On or about February 14, 2025, AV had a major behavioral episode which resulted in AV attempting to hit Witness 2 (W2) and then Witness 5 (W5) being punched in the face. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) has a known history of falls. Between November 2024, through February 2, 2025, AV sustained nine (9) falls, eight (8) of the nine (9) falls occurred in the late afternoon and evening. Six (6) out of the nine (9) falls occurred in common areas while AV was ambulating. On or about February 4, 2025, at around 6:45 pm, AV pushed AV’s walker up against the closed med tech office door and fell. AV hit AV’s forehead on the cushioned part of AV’s walker. The facility failed to mitigate AV’s risk of falls, which is a violation of resident rights, is neglect of care and constitutes abuse.

According to the documentation, the facility failed to implement appropriate interventions for the Alleged Victim’s (AV) known history of unsteady gait and non-compliance with using their call light for assistance for transfers. On or about February 04, 2025, the AV suffered a non-injury fall in the facility. After this fall, the facility implemented 8 safety checks per 12-hour shift on the AV. Approximately three days later, on or about February 07, 2025, the AV was put in bed for a nap at approximately 1:30 pm. Around 3:00 pm, staff checked on the AV and found them sitting on the floor next to their bed, complaining of back pain. There is no documented evidence the facility implemented appropriate interventions for the AV’s increase in falls, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) is known to be a high fall risk. Between January 26th through 28th, 2025, AV had four (4) falls. On the incident report dated January 26, 2025, it was noted that the fall could have been avoided with possible 1-1 care for AV, which meant that the facility was aware of the proper intervention but failed to implement it. AV was not place on a change in condition or 1-1 care until January 31, 2025, after falling nine (9) times in January 2025. The facility failed to provide AV with adequate supervision which resulted in AV falling multiple times and placed AV at risk of serious harm, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) is known to be a high fall risk. Between January 28th and 29th, 2025, AV had two (2) falls. Witnesses were under the impression that AV was independent with his/her ambulation despite the frequent falls. AV’s 1-1 caregivers were not told that AV’s care consisted of or what care to provide to AV to prevent falls. The facility failed to put appropriate and/or sufficient interventions into place to address AV’s falls, which placed AV at risk of harm, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) had a history of wandering the community and exit seeking. On or about February 5, 2025, AV expressed wanting to go into the common area but was told by staff that he/she was not allowed due to AV requiring 2-people with him/her all the time. On or about February 13, 2025. AV was once again not allowed to leave his/her bed due to AV requiring 2-people to help ambulate. AV was involuntary secluded to his/her room and was not allowed to go into the common area on two occasions, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) had a history of wandering the community and exit seeking. AV was chemically sedated by the facility staff with medication causing AV to sleep more than usual. After a meeting with the facility, it was discovered that at some point at the end of 2024, the facility had switched AV’s scheduled behavior medication to PRN. The medication change had not been approved by AV’s doctor. In January 2025, AV was given PRN pain medication on 7 different occasions on top of his/her scheduled pain medication which was 3 times a day. In January 2025, AV was given PRN anxiety/behaviors medication 8 different occasions on top of his/her scheduled medication which were 3 times a day. The facility failed to provide a safe medication administration system for AV, which put AV in risk of harm, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim was a partial assist for meals and required constant reminders and prompting throughout meals to eat. It was discovered that AV was not given appropriate meals or fluids which led to him/her losing weight. AV’s care plan dated November 21, 2024, noted significant weight loss. It was visibly noticeable for staff that AV was losing wight. The facility failed to provide AV with appropriate meals or fluids which led AV to lose wight resulting in physical harm to AV and created risk of serious harm, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. On or about January 6, 2025, AV was found on the floor in AV's room, AV was on AV's bottom. On January 16, 2025, AV was found on the floor in AV's room, AV was on AV's bottom. On or about January 20, 2025, AV was found on the floor in AV's bathroom. AV was on AV's bottom with AV's head resting on the toilet seat. On or about January 21, 2025, AV had two falls. One was an assisted fall by AP1 staff. There was no information for the 2nd fall. On or about January 24, 2025, AV slid out of bed in-between 15-minute checks. AV was found on the floor. The facility failed to provide a safe environment to AV, which place AV in risk of harm, which is a violation of resident rights, is neglect of care and constitutes abuse.

According to the documentation, the facility failed to properly care plan appropriate interventions for Witness 1 (W1) for their known aggressive and repeated verbal and physical altercations with other residents. On or about January 27, 2025, W1 started yelling at the Alleged Victim (AV) then kicked them in both of their lower extremities, causing pain and unreasonable discomfort. On or about January 21, 2025, AV and W1 were involved in previous physical altercation causing pain and emotional distress. There is no documented evidence the facility implemented interventions after the first incident between W1 and the AV 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 properly care plan interventions for Witness 1’s (W1) known aggressive behaviors towards other residents. On or about January 21, 2025, W1 and the Alleged Victim (AV) were involved in a resident-to-resident altercation. W1 hit the AV in the arm in a common area which caused pain and unreasonable discomfort. The AV was visibly distraught after the incident and expressed a negative emotional response after the incident. W1 was care planned to remove them from the environment after they had expressed aggressive behavior or verbally abused other residents. There was no documented evidence the facility properly care planned progressive interventions to prevent resident-to-resident altercation for W1, 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 20, 2025, AV was found on the floor in his/her bathroom. AV was on his/her bottom with his/her head resting on the toilet seat. AV suffered bruises after his/her fall. Respondent failed to properly care plan to reduce AV's risk of falls, placing AV at risk for harm. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

Alleged Victim (AV) has a known history of falls. Between October 9, 2024, to December 25, 2024, AV sustained seven (7) falls, some resulted in injuries. On or about January 15, 2025, a resident came up to staff and said that AV was on the ground and had fallen. AV was found lying on the floor. The facility failed to provide AV with adequate supervision which resulted in AV falling multiple times which resulted in an injury to AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) has a history of agitation/aggressiveness with staff and residents. Between November 14, 2024, to January 10, 2025, AV either punched or chocked or hit 21 residents, caregiver or providers. There are 21 temporary service plans created by the facility between November 16, 2024, to January 14, 2025, out of the four (4) created on January 7, 2025, one (1) plan was blank, two (2) plans created for aggressive behaviors- listed only report if sad or agitate- no interventions. The facility failed to properly plan care around AV’s known behaviors, which puts residents in risk of harm, and which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim’s (AV’s) care plan indicated that he/she needed to puree food as ordered and thickened liquids related to the diagnosis of difficulty swallowing. On or about January 2, 2025, it was discovered that AV was given soft food instead of pureed food as ordered by AV’s doctor. The facility failed to follow the care plan around AV’s proper diet and drink textured, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim’s (AV’s) care plan stated that AV was on a regular diet, but under AV's meal plan it said AV was on a mechanical soft diet. AV's care plan signed on January 7, 2025 - assisted daily living stated AV was "independent' in meals; however, under the needs and services "meals" section it stated AV was a "partial assist." Effective November 15, 2024, AV was put on a mechanical soft food diet. On January 20, 2025, AV was eating an egg in the dining area when AV began choking and gasping for air. Staff performed the Heimlich on AV until AV threw up pieces of egg and began breathing. AV had stopped breathing a second time and staff administered CPR until paramedics arrived. The facility failed to follow the care plan around AV’s diet needs, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) was documented to be a fall risk. Between November 21, 2024, to January 1, 2025, AV sustained nine (9) falls. The interventions for AV falling were increased safety checks and encourage call light use. Despite AV continuously falling, there were no new interventions placed. Facility documents and narrative charting was inconsistent on number of checks per shift, it lists either eight (8) checks or 12. The facility failed to provide AV with adequate supervision which resulted in AV falling multiple times, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) was documented to be a fall risk. Between January 2nd, to the 9th, 2025, AV sustained two (2) falls. AV had prior falls going back to November 2024. As a result of the two falls, AV experienced pain to his/her right leg and pain on his/her back and red marks to his/her body. Even after these two (2) new falls, there were no updates to AV’s temporary service plan. The facility failed to care plan around AV’s known risk of falls, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) was documented to be a fall risk. On or about January 16, 2025, AV sustained a fall and as a result, AV complained of pain in his/her hips, elbow, head and left groin area pain. On or about January 17, 2025, AV continued to complain of pain in his/her left groin area as a result to the fall from the previous day. The facility failed to care plan around AV’s continued risk of falls, which lead AV to sustain injury followed up with pain, which is a violation of resident rights, is neglect of care and constitutes abuse.

Between December 26th to December 28, 2024, Alleged Victim (AV) has approximately four (4) falls. On or about December 26, 2024, AV sustained a fall which led to a hospital visit. The facility did not create a temporary service plan to address the fall AV had on December 26, 2024, the two (2) falls AV had on December 27, 2024, and the one (1) fall on December 28, 2024, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) is known to be a fall risk. ON or about December 31, 2024, AV was found on his/her knees leaning over his/her bed and complaining of pain. AV had prior fall during the month of December 2024, however, there was no clear care planning for AV’s known history of falls. The facility failed to provide AV with adequate supervision which resulted in AV falling multiple times and experienced unreasonable discomfort, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility to administer his/her medication. On or about December 2024, the facility overmedicated AV using the liquid narcotic so much more than AV’s previous living arrangement. The facility used the narcotic because it was more convenient to use, and it worked quickly. AV had an escalation in use of the narcotic. AV was given the narcotic a total of 19 times in December 2024. There were two (2) other “as needed” medications available for AV; 1 was for agitation and the other was for pain. Those were given to AV a total of three (3) times in December 2024. The facility failed to provide a safe medication administration system for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) has a known history of falls. On or about December 20, 2024, AV sustained two (2) falls. AV was in his/her wheelchair before the first fall occurred at approximately 6:00 am. AV was in his/her wheelchair before the second fall occurred. As a result of the falls, AV was observed to have redness on the back of his/her head and on his/her right shoulder. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) has a known history of falls. On or about December 21, 2024, AV sustained a fall. AV was sitting in the common area of the facility in a recliner. AV got up from the recliner and fell backwards into a decorative tree. AV sustained an abrasion to his/her elbow as a result from the fall. The facility failed to care plan and mitigate AV’s known history of falls, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care needs. AV had an injury to his/her right foot. AV had been seen with discoloration first on or about December 20, 2024. There was swelling and discoloration of the skin that appeared to be blue and purple in color on and after December 20, 2024. AV had noted pain and redness in his/her right foot the night of December 17, 2024. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitute abuse.

Witness 1 (W1) is known to not like people in his/her personal space and does not like people touching him/her and his/her stuff. On or about December 19, 2024, W1 broke Alleged Victim’s (AV’s) cup of water in AV’s hand and W1 kicked AV in the left leg, causing AV to lose his/her balance and falling to the ground. AV and W1 have had four (4) altercation since October 27, 2024. The facility failed to provide a safe environment for AV by failing to provide AV with adequate supervision which resulted in AV being at risk of serious physical harm from another resident, which is a violation of resident rights, is neglect of care and constitutes abuse.

The facility has knowledge that prior to moving into the facility, Alleged Victim’s (AV’s) gait was declining. AV had approximately 13 falls between August 7, to November 14, 2024. On or about November 15, 2024, AV went to sit in a chair in the common area: the chair slid out and AV fell. On or about November 23, 2024, AV once again had a fall when he/she tried to get up from a chair into AV’s wheelchair. AV lost his/her footing/slipped and fell on AV’s bottom. The facility failed to put interventions into place that prevented AV from falling, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) has a known history of falls, which prior fall in the facility. On or about December 17, 2024, AV fell backwards, hitting AVs heard on a planter box in front of the bathroom. Staff were not given a lot of information about AV’s history and/or his/her care needs even though the facility had knowledge. The facility failed to put interventions into place that prevented AV from falling, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility to administer his/her medication. On or about November 12, 2024, an antipsychotic was prescribed to AV in anticipation of AV being moved to help AV cope with the change. On or about December 9, 2024, it was discovered that the facility was not administering AV’s antipsychotic medication properly. AV was supposed to be getting a total of 75 mg every time it was administered, but AV was only getting 50 mg. The facility failed to provide a safe medication administration system for AV by failing to monitor AV when there was a medication change, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. On or about December 19, 2024, AV was placed in a recliner in the common area with his/her legs/feet up and AV’s wheelchair out of AV’s reach. AV constantly tired to get out of the recliner and staff were not paying attention to AV. The facility failed to protect AV from involuntary seclusion by involuntary secluding AV in a recliner, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. Between September 19th through December 11th, 2024, AV was involved in seven (7) resident-to-resident altercations. Four of the altercations resulted in AV being hit by another resident. Temporary care plan had been entered for altercations and/or aggressive behaviors with repeated interventions that had previously failed. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Witness 1 (W1) is known to have ongoing aggressive behaviors/altercations in-between the altercation involving Alleged Victim (AV). on or about December 8, 2024, staff heard screaming. They found W1 sitting on to of AV. AV was punching W1 and W1 was punching AV back. AV and W1 has been involved in prior physical altercations, which puts residents in risk of harm. The facility failed to implement proper interventions and/or monitoring for resident behaviors, which is a violation of resident rights, is neglect of care and constitutes abuse.

Witness 1 (W1) is known to have ongoing aggressive behaviors/altercations. On or about December 10, 2024, Alleged Victim (AV) was hit by W1 were once again in a resident-to-resident altercation, in which W1 hit AV in the chest. Staff heard a smack sound and saw W1 trying to smack AV for a second time during this altercation. There is a prior history of resident-to-resident altercation, which have become physical, between AV and W1. Even after this altercation, the interventions in the Temporary Care Plan (TCP) were not changed/updated, AV’s Service Plan was also not changed/updated to protect AV from future physical resident to resident altercations, which is a violation of resident rights, is neglect of care and constitutes abuse.

Between September 19th, to November 6, 2024, Alleged Victim (AV) had at least six (6) behavioral episodes with staff that involved: yelling, grabbing a staff member by the neck, hitting the back of a staff member’s head, and pulling a staff member’s hair until it fell out. Between that time frame, AV was also combative with cares, AV hit, punched, pinched, bit during cares. On or about December 8, 2024, staff heard screaming. They found AV was sitting on top of Witness 1 (W1). AV was punching W1 and W1 was punching AV back. As a result of the altercation, AV sustained bruises on his/her arms. Throughout off of AV’s altercation/behaviors, the interventions in the Temporary Care Plans (TCP’s) were not changed/updated, and neither was AV’s Service Plan, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) is care planned to have the facility ensure safety of other residents/staff if AV becomes agitated by removing them from the environment. AV requires extensive redirection for violent aggressive acts toward staff and other residents. On or about December 7, 2024, AV and Witness 1 (W1) were in an altercation that led AV to being hit in the left arm by W1. W1 went up to AV to talk, W1 was up in AV’s face/space trying to talk to AV when W1 got frustrated with AV. AV hit W1 on the right arm and W1 hit AV on the left arm. AV has a known history of altercations. The facility failed to assure the care plan was followed, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. On or about December 7, 2024, AV and Witness 1 (W1) were in an altercation that led AV to being hit in the arm. AV went up to W1 to talk, AV was up in W1’s face/space trying to talk to W1. W1 got frustrated with AV and then hit AV on the right arm and AV hit W1 on the left arm. W1 has a history of prior resident to resident altercations. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. Between November 16th, through the 20th, 2024, AV has five (5) altercations with either staff and/or other residents due to his/her behaviors. On or about November 22, 2024, AV assaulted Witness 1 (W1). AV put W1 into a choke hold and refused to let go. As a result, staff had to call the police. The facility failed to put appropriate and/or sufficient interventions into place to address AV’s aggressive/violent acts, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. On or about November 22, 2024, AV was assaulted by Witness 1 (W1). W1 put AV into a choke hold and refused to let go. W1 has a history of prior altercations due to his/her behaviors. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

The Alleged Victim (AV) is a known fall risk and had suffered previous falls with and without injury. On or about November 18, 2024, staff responded to AV's call light and found AV on the floor sitting position, with his/her back to his/her bed. AV was a one-person assist with transfers, however, there was no documentation indicating how staff were to implement it. AV tied to get up on his/her own and ambulate, which caused many of AV's falls. Respondent failed to implement interventions to reduce AV's risk of falls and ensure staff were aware how to enact the interventions that were in place. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

Alleged Victim (AV) relies on the facility for his/her care. On or about October 9, 2024, AV sustained a fall which resulted in AV receiving an injury to his/her right eye and eyebrow. AV fell during a fire drill/evacuation drill. AV did not have his/her walker with him/her during the drill. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) has a known history of falls. On or about December 6, 2024, AV was found on the floor by the bed when staff were doing rounds/check. Interventions in place had not changed between any of AV’s noted incidents. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) has a known history of falls. On or about December 22, 2024, AV was found on the floor in the common area with an injury above his/her left eye. Interventions in place had not changed between any of AV’s noted incidents. The facility failed to care plan around AV’s know history of falls, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) has a known history of falls. On or about December 25, 2024, AV was found on the floor in the common area with no injuries. AV was believed to be dehydrated and dizzy prior to the incident. As a result, AV said that his/her head hurt. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) was a known fall risk with four (4) previous falls. On or about November 25, 2024, at approximately 6:30pm, staff heard a thud and AV was found, alone, on the floor exiting the common bathroom. The facility failed to provide a safe environment for AV, which is a violation of resident right, is neglect of care and constitutes abuse.

Alleged Victim (AV) was a known fall risk with three (3) previous falls. On or about November 24, 2024, AV fell in his/her bathroom which resulted in redness and pain to the back of AV’s head. AV’s updated care plan and TSP were inconstant as to what care staff were to do to prevent falls. The facility failed to care plan and mitigate AV’s known risk of falls, which is a violation of resident right, is neglect of care and constitutes abuse.

Alleged Victim (AV) is known to be a fall risk. Between September 15th thru November 16, 2024, AV had three (3) falls. On or about November 16, 2024, AV fell in the hallway which resulted in AV receiving a laceration above his/her left eyebrow and a broken right thumb. The facility failed to provide a safe environment for AV, which is a violation of resident right, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. On or about September 30, 2024, AV was found on the floor next to his/he bed in the fetal position. Prior to September 30th, 2024, AV had a fall on September 19, 2024, outside of AV’s bedroom, and on August 5, 2024, AV was found on the floor next to AV’s bed. There were concerns that AV’s bed was not adequate for AV as it was tall, which sat higher off the ground. AV’s bed also made it hard to assist AV with transfer. The facility was aware AV’s bed was a concern and a fall risk to AV, but no action was taken. The facility failed to care plan and mitigate AV’s risk of falls, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. Per facility documentation, AV had falls on or about August 9th, 23rd, September 12th and 13th, 2024. Despite these four (4) falls in just over a month, witnesses described AV as not having a significant fall history. The facility failed to care plan and mitigate AV’s risk of falls, which is a violation of resident rights, is neglect of care and constitutes abuse.

The Alleged Victim (AV) is a known fall risk. Between September 6, 2024, and September 23, 2024, AV suffered 8 falls. On or about September 27, 2024, AV was found on the floor of another resident's room. AV suffered a large bump to the back of his/her head and complained of pain. Respondent failed to implement meaningful interventions for falls, to ensure the safety of AV. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

The Alleged Victim (AV) is a known fall risk. Between September 6, 2024, and September 23, 2024, AV suffered 8 falls. On or about October 29, 2024, AV was found on the floor of his/her room on the fall pad next to his/her bed. AV did not suffer any injury; however, AV was placed at risk for harm. Respondent failed to implement meaningful interventions for falls, to ensure the safety of AV. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

Alleged Victim (AV) was care planned to be independent with his/her ambulation and transfer. On or about August 26, 2024, AV was observed to have injuries to his/her head and hand which was documented as an unwitnessed injury fall. The investigation for AV’s injuries was never completed by the facility to determine how AV sustained the injury. AV’s care plan was also not updated to show his/her as a fall risk despite having a fall history related to his/her gait/balance. The facility failed to care plan around AV’s gait/balance, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) is known to be a fall risk. AV sustained falls on or about September 12th, 18th, and 19th, 2024, which placed AV in risk of harm. No new interventions were place in order to prevent AV from sustaining new falls. The facility failed to properly care plan and mitigate AV’s risk of harm, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim’s (AV’s) care plan states he/she is a full assist. Between August 2nd, thru September 11, 2024, AV had approximately 11 falls at the facility which resulted in AV’s pain and injury. On or about August 6, 2024, AV sustained a fall resulting in an abrasion above AV’s right eye bleeding. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. On or about July 23, 2024, Alleged Victim (AV) was sitting at the dinner table when W1 walked up to AV and punched AV on the left cheek. Between July 22nd and October 1, 2024, Witness 1 (W1) was involved in seven (7) altercations with staff and other resident. This altercation sometimes culminated in W1 striking other residents. The facility failed to provide a safe environment for AV, leading to AV sustaining an injury, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) had a progressive brain disorder that caused memory loss, confusion and other cognitive decline. Between May 15, 2024, and June 22, 2024, AV fell seven (7) times. Four (4) of the seven (7) falls resulted in injury to AV including skin tears to different body parts. Facility staff needed to be outside when there was a resident in the wander yard that was a fall risk. On June 20, 2024, at 12:00 pm, AV fell in the wander yard. There was no facility staff present. On July 18, 2024, AV was found lying on the sidewalk outside. There was no indication if where any staff was out with the AV when he/she was found lying on the sidewalk. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) is known to be a fall risk. Between March 25, 2024, through July 16, 2024, AV had six (6) falls, two were with injuries. The facility had interventions in place, however, none of those interventions prevented AV from sustaining continues falls. The facility failed to properly care plan and mitigate AV’s risk of falls, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care needs. AV had a wound on his/her buttock/hip that was getting worse and worse due to poor care by staff. AV’s wound became green in color. The facility failed to provide wound care for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Witness #1 (W1) is known to have behaviors and engage in altercations with residents. W1 is to be monitored by staff and redirected if W1 has symptoms of behaviors. On or about February 23, 2024, W1 punched the Alleged Victim (AV) in the forehead and nose, resulting in swelling and redness. W1 hadn't taken his/her behavioral medication that day as he/she was very agitated. W1's care plan didn't entail any individualized or updated interventions for staff to follow. The facility's failure to properly care plan placed AV at risk for harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about February 18, 2024, the Alleged Victim (AV) received medication that belonged to another resident. Receiving another resident's medication placed AV at risk for serious harm, including low heart rate, cardiac arrest and serious bleeding. The facility failed to contact AV's primary care physician regarding this error, placing AV at risk for serious harm. The facility's failure to ensure AV's physician was contacted placed AV at risk for serious harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) is care planned to be a full assist with toileting, ambulation, transfers, and repositioning. Between October 26, 2023, through January 1, 2024, AV had at least six (6) falls, some of which resulted in injury. The facility failed to provide a safe environment for AV, which resulted in injury, which is a violation of resident rights, is neglect of care and constitutes abuse.

Witness #1 (W1) is known to have altercations with residents and was care planned for staff to observe W1 for aggressive behaviors. On or about December 1, 2023, W1 punched the Alleged Victim (AV) in the head, causing bruising to his/her face and a neck sprain. The facility's failure to implement meaningful interventions to ensure the safety of residents is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to follow Witness #1’s (W1) care plan to be monitored and redirected due to behaviors and aggression. On or about November 23, 2023, W1 and the Alleged Victim (AV) were both observed in an agitated state, when W1 grabbed AV’s wrist and wouldn’t let go, causing AV increased agitation and bruising to AV’s wrist. 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 facility failed to implement interventions or appropriately care plan for Witness #1’s (W1) known behaviors. On or about November 23, 2023, W1 punched AV in the face, causing AV a facial bruise and for AV to be withdrawn. 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 facility failed to implement interventions or appropriately care plan for Witness #1’s (W1) known behaviors. On or about September 29, 2023, W1 grabbed ahold of the Alleged Victim (AV) arm and then punched AV in the face, cutting AV’s lip. 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 facility failed to implement meaningful, effective interventions or appropriately care plan for Witness #1’s (W1) known behaviors. According to an investigation, on or about October 1, 2023, there was a physical altercation between W1 and the Alleged Victim (AV), where AV was found on the floor, bleeding from the mouth with W1 standing over them yelling. 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 facility failed to implement meaningful, effective interventions or appropriately care plan for Witness #1’s (W1) known behaviors. On or about September 24, 2023, there was a physical altercation between W1 and the Alleged Victim (AV). According to an investigation, W1 pushed AV to the ground, resulting in redness to AV’s back and neck as well as a scratch on AV’s chest. 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.

Between August 18 and October 1, 2023, Alleged Victim (AV) had been involved in six (6) altercations with staff and other residents. These altercations sometimes culminated n AV being struck by other resident or striking his/her head on objects in the process. On or about October 1, 2023, AV was found in another resident’s room and was standing over the resident yelling. The other resident was found bleeding from his/her mouth. Despite the interventions being ineffective, the Temporary Care Plans with the same interventions were re-issued over and over again. The facility failed to provide proper intervention for AV, which lead AV to get into physical altercations with other residents, which is a violation of resident rights, is neglect of care and constitutes abuse.

The facility failed to provide a safe medication system and provide mood stabilizing medications to Witness 1 (W1) per physician’s orders. W1 did not receive their mood stabilizing medication for approximately 11 days/doses due to it being “unavailable”. On or about September 23, 2023, W1 walked up to the Alleged Victim (AV) in a common area of the facility and slapped them across the face and then verbally threatened them, causing AV 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 facility failed to implement interventions or appropriately care plan for Witness #1’s (W1) known behaviors. On or about September 2, 2023, the Alleged Victim (AV) patted W1 on the back and W1 responded by punching the AV. 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.

AV had a known history of skin issues and was care planned for staff to observe for skin breakdowns. AV refused care on multiple occasions when the facility staff attempted to assist AV with his/her Activities of Daily Living and the facility failed to appropriately care plan or add appropriate interventions for these behaviors. As a result, AV had poor hygiene which caused AV to suffer skin breakdown and sustained a UTI, which is a violation of resident rights is neglect of care and constitutes abuse.

On or about January 7, 2023, the Alleged Perpetrator 2 (AP2) made inappropriate verbal comments toward Alleged Victim (AV) causing AV to cry, stay in his/her room and not eat. AP2 is responsible for verbal/emotional abuse. According to documentation, AP2 made verbal comments to residents repeatedly, despite being previously reported to the facility management. The facility failed to protect AV from inappropriate verbal comments made by AP2 and the failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about January 7, 2023, the Alleged Perpetrator 2 (AP2) cussed at and yelled at the Alleged Victim (AV) which resulted in AV crying and causing emotional harm. AP2 is responsible for verbal abuse. The abuse by AP2 continued to occur for months, despite being reported to the facility management. The facility failed to protect AV from inappropriate verbal comments made by AP2 and 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 needs. AV fell on September 16th, 17th and again on November 16th, 2022, some resulting in injury to include skin tears and abrasions. The facility failed to properly care plan, implement additional interventions, and/or provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Based on interviews and record review, conducted during a site visit on 02/12/26-02/13/26, the facility's failure to have written, resident specific parameters and document non-pharmacological interventions prior to administering psychotropic medication was substantiated, which is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during a site visit on 02/12/26-02/13/26, the facility’s failure to ensure an RN assessment was completed for all residents with a significate change of condition, an RN monitored resident condition and an RN participated on the service planning team or review the service plan within 48 hours was substantiated, which is a violation of Oregon Administrative Rules.

Based on observation, interview, and record review conducted during a site visit on 02/12/26-02/13/26, the facility’s failure to take reasonable precautions against any condition that might have threatened the health, safety, or welfare of residents was substantiated. The facility’s failure to prevent physical contact between Residents constituted an immediate threat to resident's health and safety, which is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during a site visit on 02/12/26-02/13/26, the facility’s failure to ensure the implementation of services was substantiated, which is a violation of Oregon Administrative Rules.

Based on interviews and record review conducted during a site visit on 03/05/26, the facility’s failure to ensure that medication and treatment orders are carried out as prescribed was substantiated

Based on observation, interview, and record review, the facility failed to comply with change of condition and monitoring requirements was substantiated. The facility’s failure is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during a site visit on 10/21/25, the facility’s failure to carry out medication and treatment orders as prescribed was substantiated, which is a violation for Oregon Administrative Rules.

The facility failed to ensure the implementation of services. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to comply with change of conditions and monitoring requirements. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to have service plans reflective of the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. An investigation determined this is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during a site visit on 10/21/25, the facility’s failure to carry out medication and treatment orders as prescribed was substantiated, which is a violation of Oregon Administrative Rules.

The facility failed to have service plans reflective of the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. An investigation determined this is a violation of Oregon Administrative Rules.

Alleged Victim (AV) relies on the facility to administer his/her medication. On or about August 10, 2025, AV was administered insulin incorrectly by Alleged Perpetrator 2 (AP2). AP2 received online training and in-person supervision for AP2's position. AP2 was delegated to administer insulin on August 7, 2025. On August 10, 2025, the parameters for administering AV's insulin were not followed by AP2. AP2 failed to provide a safe medication administration system to AV, which is neglect of care and constitutes abuse. The facility failed to assure AV received a safe medication administration system, which is a violation of Oregon Administrative Rules.

The facility failed to carry out medication and treatment orders as prescribed. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to immediately report abuse and suspected abuse. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to carry out medication and treatment orders as prescribed. An investigation determined this is a violation of Oregon Administrative Rules.

The facility allegedly failed to take reasonable precautions against any condition that might have threatened the health, safety, or welfare of residents. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

The facility failed to provide records to the Department upon request in accordance with OAR 411-054-0105(1)(a).

The facility failed to provide records to the Department upon request in accordance with OAR 411-054-0105(1)(a).

The facility failed to provide records to the Department upon request in accordance with OAR 411-054-0105(1)(a).

The facility failed to provide records to the Department upon request in accordance with OAR 411-054-0105(1)(a).

The facility failed to provide records to the Department upon request in accordance with OAR 411-054-0105(1)(a).

The facility failed to provide records to the Department upon request in accordance with OAR 411-054-0105(1)(a).

The facility failed to provide records to the Department upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide records to the Department upon request in accordance with OAR 411-054-0105(1)(a), which is a violation of Oregon Administrative Rules.

The facility failed to provide records to the Department upon request in accordance with OAR 411-054-0105(1)(a), which is a violation of Oregon Administrative Rules.

The facility failed to provide records to the Department upon request in accordance with OAR 411-054-0105(1)(a).

The facility failed to provide records to the Department upon request in accordance with OAR 411-054-0105(1)(a).

The facility failed to provide records to the Department upon request in accordance with OAR 411-054-0105(1)(a).

The facility failed to provide records to the Department upon request in accordance with OAR 411-054-0105(1)(a).

The facility failed to provide records to the Department upon request in accordance with OAR 411-054-0105(1)(a).

The facility failed to provide records to the Department upon request in accordance with OAR 411-054-0105(1)(a), which is a violation of Oregon Administrative Rules.

The facility failed to provide direct care staff sufficient in numbers to meet the scheduled and unscheduled needs of each resident in accordance with OAR 411-054-0070(1); Per complaint the facility has been consistently understaffed and taking staff from night shift to cover staffing on the ALF side, which is a violation of Oregon Administrative Rules.

The facility failed to carry out medication and treatment orders as prescribed. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide records to the Department upon request in accordance with OAR 411-054-0105(1)(a), which is a violation of Oregon Administrative Rules.

The facility failed to provide records to the Department upon request in accordance with OAR 411-054-0105(1)(a), which is a violation of Oregon Administrative Rules.

The facility failed to provide records to the Department upon request in accordance with OAR 411-054-0105(1)(a), which is a violation of Oregon Administrative Rules.

The facility failed to provide records to the Department upon request in accordance with OAR 411-054-0105(1)(a), which is a violation of Oregon Administrative Rules.

The facility failed to provide records to the Department upon request in accordance with OAR 411-054-0105(1)(a), which is a violation of Oregon Administrative Rules.

The facility failed to provide records to the Department upon request in accordance with OAR 411-054-0105(1)(a), which is a violation of Oregon Administrative Rules.

The facility failed to provide records to the Department upon request in accordance with OAR 411-054-0105(1)(a), which is a violation of Oregon Administrative Rules.

The facility failed to provide records to the Department upon request in accordance with OAR 411-054-0105(1)(a), which is a violation of Oregon Administrative Rules.

The facility failed to provide records to the Department upon request in accordance with OAR 411-054-0105(1)(a), which is a violation of Oregon Administrative Rules.

The Facility failed to comply with safe medication administration or treatment practices as required by OAR 411-054-0055 (1)(f), per complaint that resident missed doses of prescribed medications, which is a violation of Oregon Administrative Rules.

The facility failed to provide modified special diets that are appropriate to residents' needs and choices in accordance with OAR 411-054-0030(1)(a)(A); per complainant, a resident was served a regular textured diet when their diet order is mechanical soft food, which is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) relies on the facility to manage his/her medications. According to an investigation, on or about March 11, 2025, the Alleged Perpetrator 2 (AP2) took the medications of the AV and instructed facility staff to administer the medication to Witness 1 (W1), another resident. AP2's actions are a violation of resident rights, considered financial exploitation and theft, and constitutes abuse. The facility did not keep AV free from financial exploitation, which is a violation of Oregon Administrative rules.

The facility failed to administer the resident’s medication as order by their physician as required by 411-054-0055(1)(f). Per complainant resident was given another residents medication without physicians orders, which is a violation of Oregon Administrative Rules.

The facility failed to provide qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident in accordance with OAR 411-054-0070; per a complaint staff leave during the night and do not respond to residents, which is a violation of Oregon Administrative Rules.

The facility failed to carry out medication orders as prescribed in accordance with OAR 411-054-0055(1)(f); per a compliant a resident did not receive his/her behavior medication from 02/13/25 - 02/16/25, which is a violation of Oregon Administrative Rules.

The facility failed to carry out medication orders as prescribed in accordance with OAR 411-054-0055(1)(f); per complaint that resident did not receive his/her 8:00 pm medication on 02/11/25, which is a violation of Oregon Administrative Rules.

The facility failed to have a safe medication and treatment systems in accordance with OAR 411-054-0055(1); Per complaint unlicensed direct care staff accepted a verbal order and provided the resident a medication that they had on their list of allergies, which is a violation of Oregon Administrative Rules.

The facility failed to carry out medication orders as prescribed. An investigation determined this is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during a site visit on 02/20/25, it was confirmed the facility failed to carry out medication and treatment orders as prescribed, which is a violation of Administrative Rules.

Based on interview and record review, conducted during a site visit on 02/20/25, it was confirmed the facility failed to keep an accurate MAR and TAR for all medications and treatments administered by the facility, which is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during a site visit on 02/20/25, it was confirmed the facility failed to carry out medication and treatment orders as prescribed, which is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during a site visit on 02/20/25, it was confirmed the facility failed to carry out medication and treatment orders as prescribed, 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.

Based on interview and record review, conducted during a site visit on 02/20/25, it was confirmed the facility failed to carry out medication and treatment orders as prescribed, which is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during a site visit on 02/20/25, it was confirmed the facility failed to carry out medication and treatment orders as prescribed, which is a violation of Oregon Administrative Rules.

The facility failed to carry out medication and treatment orders as prescribed in accordance with OAR 411-054-0055(1)(f); per complainant, a resident missed his/her weekly medication multiple days because the facility did not have the medication on hand, 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 develop, maintain, and implement an Acuity Based Staffing Tool in accordance with OAR 411-054-0037(1-7); complaint on staffing. Qualifies for ABST review, which is a violation of Oregon Administrative Rules.

The facility failed to carry out medication and treatment orders as prescribed in accordance with OAR 411-054-0055(1)(f); per complaint resident was not given blood pressure medication for 19 days, which is a violation of Oregon Administrative Rules.

The facility failed to carry out medication orders as prescribed in accordance with OAR 411-054-0055(1)(f); per complaint that the facility failed to administer medication as ordered, which is a violation of Oregon Administrative Rules.

Alleged Victim (AV) relies on the facility for all care needs. On or about April 6, 2024, during shift change, night shift informed day shift that AV had a swollen, purple foot and that AV complained of pain. Staff suspected the foot was broken. Staff requested AV be sent to the hospital, but Alleged Perpetrator 2 (AP2) denied the request because the facility was short-staffed that day. AP2 directed staff to put AV in a recliner and elevate AV’s foot. AV went back and forth between wanting to go and not wanting to go to the hospital, however, per facility’s policy, the facility does not wait for permission from a resident or responsible party to send a resident to the hospital. AP2 said they would try to get a hold of someone to take AV to the hospital but AP2 never did. AP2 failed to provide service for AV but not getting AV to the hospital in a timely manner, which is neglect of care and constitutes abuse. The facility failed to assure AV received proper service, which is a violation of Oregon Administrative Rules.

Alleged Victim (AV) relies on the facility for all care needs. On or about April 6, 2024, during shift change, night shift informed day shift that AV had a swollen, purple foot and that AV complained of pain. Staff suspected the foot was broken. Staff requested AV be sent to the hospital, but Alleged Perpetrator 2 (AP2) denied the request because the facility was short-staffed that day. AP2 directed staff to put AV in a recliner and elevate AV’s foot. AV could not get out of the recliner on his/her own that day and AV winced and grimaced a lot throughout the day. AV was eventually sent to the hospital where it was determined he/she had a broken foot. AP2 failed to protect AV from involuntary seclusion, which is neglect of care and constitutes abuse. The facility failed to protect AV from involuntary seclusion, which is a violation of Oregon Administrative Rules.

On or about February 18, 2024, the Alleged Victim (AV) was given medication that belonged to another resident. Alleged Perpetrator #2 (AP2) went to the medication cart and grabbed medication for a different resident and gave it to AV. AV was placed at risk of serious harm from receiving another residents medication. The next day, AV was reported to have been incontinent of bowel and was lethargic. AP2's actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility's failure to provide a safe medication administration system is a violation of Oregon Administrative Rules.

Alleged Victim (AV) is wheelchair-bound and requires full assist with mobility and transfers. On or about November 2, 2023, it was decided to keep AV’s wheelchair away from AV to keep him/her from attempting to self-transfer. Alleged Perpetrator 3 (AP3) decided to keep AV’s wheelchair away from AV, however, keeping AV’s wheelchair away from AV was a restraint. AP3 failed to protect AV from involuntary seclusion, which is neglect of care and constitutes abuse. The facility failed to assure AV was protected from involuntary seclusion, which is a violation of Oregon Administrative Rules.

On or about May 1, 2023, the Oregon Health Authority reported to the Department that Respondent failed to comply with weekly reporting requirements of vaccinated individuals, residents and staff, to the proper authority as required by law. This failure has been ongoing from April 1, 2023, to April 30, 2023, for a total of 30 days.

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 have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules.

On or about July 1, 2022, the Oregon Health Authority reported to the Department that Respondent failed to comply with weekly reporting requirements of vaccinated individuals, residents and staff, to the proper authority as required by law. This failure has been ongoing from June 1, 2022 to June 30, 2022, for a total of 30 days.

The facility failed to carry out medication orders as prescribed, which is a violation of Oregon Administrative Rules.

On or about December 13, 2021, Alleged Perpetrator #2 (AP2) failed to administer the Alleged Victim's (AV) blood pressure medication, placing AV at risk for harm. AP2's failure is a violation of resident rights, is 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.