Emerald Gardens

The Alleged Victim (AV) relied on the facility for care and to manage their personal incidental fund (PIF) money. According to an investigation, on or about December 26, 2025, it was discovered that AV's PIF money was missing approximately $20.00. The facility kept all residents PIF funds in an unlocked box inside a locked office. There were multiple staff that had the code to access the office where the money was held, and the office door was often left open with no staff present. The money was taken by an unknown Alleged Perpetrator #2 (AP2), which is considered financial exploitation and constitutes abuse. The facility failed to protect the resident from financial exploitation, which is a violation of resident rights is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relied on the facility for care and to manage their personal incidental fund (PIF) money. According to an investigation, on or about December 26, 2025, it was discovered that AV's PIF money was missing approximately $20.00. The facility kept all residents PIF funds in an unlocked box inside a locked office. There were multiple staff that had the code to access the office where the money was held, and the office door was often left open with no staff present. The money was taken by an unknown Alleged Perpetrator #2 (AP2), which is considered financial exploitation and constitutes abuse. The facility failed to protect the resident from financial exploitation, which is a violation of resident rights is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relied on the facility for care and to manage their personal incidental fund (PIF) money. According to an investigation, on or about December 26, 2025, it was discovered that AV's PIF money was missing approximately $19.25. The facility kept all residents PIF funds in an unlocked box inside a locked office. There were multiple staff that had the code to access the office where the money was held, and the office door was often left open with no staff present. The money was taken by an unknown Alleged Perpetrator #2 (AP2), which is considered financial exploitation and constitutes abuse. The facility failed to protect the resident from financial exploitation, which is a violation of resident rights is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relied on the facility for care and to manage their personal incidental fund (PIF) money. According to an investigation, on or about December 26, 2025, it was discovered that AV's PIF money was missing approximately $89.79. The facility kept all residents PIF funds in an unlocked box inside a locked office. There were multiple staff that had the code to access the office where the money was held, and the office door was often left open with no staff present. The money was taken by an unknown Alleged Perpetrator #2 (AP2), which is considered financial exploitation and constitutes abuse. The facility failed to protect the resident from financial exploitation, which is a violation of resident rights is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relied on the facility for care and medication management and had a history of recurrent urinary tract infections (UTI). According to an investigation, on or about August 25, 2025, facility staff were told that AV's confusion was worse than normal, and a UTI was suspected. The facility took no action, despite there being a standing physician order that indicates if AV is off baseline the facility should take a urinalysis and start AV on an antibiotic immediately. On August 27, 2025, AV developed a high fever and their pulse was elevated, facility staff gave AV pain medication. On August 28, 2025, AV was unable to take medications, pale, shaking and ultimately not responsive, and was transferred to the hospital. The next morning, August 29, 2025, AV passed away. AV's cause of death was Septic shock due to UTI. The facility failed to provide appropriate services, to include following AV's care plan, following physician orders, and ensuring AV was monitored for a change of condition, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) was a fall risk, had a history of falls, and was care planned for one-on-one caregiving due to high risk of falls. According to an investigation, on or about March 20, 2025, the facility did not have a one-on-one caregiver assigned to the AV. The AV got up got up an ambulated independently and experienced a fall, resulting in a head injury and AV to become unconscious. The facility failed to provide appropriate services, which is a violation of resident’s rights, is neglect of care, and constitutes abuse.

The Alleged Victim (AV) is a known fall risk with a history of falls. According to an investigation the AV experienced multiple falls between January 14, 2025, and March 14, 2025 resulting in pain, injuries, and repeated unreasonable discomfort. AV had another fall on or about March 14, 2025, where they had a skin tear and mark to the left shoulder. The facility failed to provide appropriate services according to AV’s needs, relating to care planning and lack of appropriate interventions, to mitigate the risk of injury due to AV's falls, which is a violation of resident rights, is neglect of care, and constitutes abuse.

The Alleged Victim (AV) was a known fall risk with a history of falls. The facility failed to care plan according to the AV's needs, change of condition, and number of falls. According to an investigation, the AV experienced multiple unwitnessed falls between January 17, 2025, and March 5, 2025, resulting in abrasions, pain, and discomfort. The failure is a violation of resident rights, is considered neglect of care, and constitutes abuse.

The Alleged Victim (AV) was a known fall risk and was care planned for safety checks. On or about July 12, 2024, AV was found on the floor in his/her bathroom by staff at 5:00 am. It is not known how long AV was on the floor, as no staff completed the safety check between midnight and 5:00 am. AV was sent out to the hospital and had sustained a broken nose and a facial laceration in the fall. The facility's failure to follow the care plan is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) has suffered multiple falls at the facility, and a previous fall, he/she broke his/her hip and went to skilled nursing for recovery. AV returned to the facility late November 2023, and continued to suffer falls sporadically. On or about January 7, 2024, staff noticed that AV was more confused and fatigued than normal. At approximately 7:00 pm on January 7, 2024, AV was found on the floor of his/her room, AV had a cut on his/her head, and a laceration on his/her arm. AV was sent out to the hospital and was diagnosed with a broken hip. The facility's failure to provide a safe environment is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is a known fall risk with a history of falls. According to an investigation AV experienced multiple falls between March 16, 2023, and June 12, 2023. AV had another fall on or about June 24, 2023, where he/she had a large hematoma on the left side of his/her head. The facility failed to provide appropriate services according to Alleged Victim’s needs, relating to care planning and lack of appropriate interventions, to mitigate the risk of injury due to AV's increase in falls, which is a violation of resident rights, is neglect of care which constitutes abuse.

On or about January 6, 2023, Witness #1 (W1) punched the Alleged Victim (AV) in the stomach, causing unreasonable discomfort. W1 and AV have a history of altercations and there is a service plan in place to keep these two away from each other. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) and Witness #1 (W1) have interventions in place to re-direct from each other due to altercations. On or about December 17, 2022, staff went into AV's room to change him/her and found W1 hitting AV with his/her cane. The facility failed to provide a safe environment, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #1 (W1) is known to have aggressive behaviors and altercations with the Alleged Victim (AV). Interventions were put into place to keep W1 and AV away from each other. On or about December 12, 2022, W1 hit AV in the stomach on two occasions, causing unreasonable discomfort to AV. The facility failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) was a known fall risk and had a history of multiple falls, with and without injury. On or about December 8, 2022, AV suffered a fall which resulted in bleeding from his/her nose and lip. The facility failed to provide a safe environment, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about October 22, 2022, the Alleged Victim (AV) was found with a skin injury to his/her right shin. This was an unwitnessed injury, however, AV had just gotten a new bed with metal hardware. It is suspected that AV hit his/her leg on the bed, causing the skin tear. The facility failed to provide a safe environment, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is a known fall risk and a history of transferring on his/her own. On or about October 14, 2022, AV fell from his/her recliner. Interventions in place were to put AV in his/her recliner when he/she was in the TV room, however, there was no intervention in place to keep AV from falling out of the recliner. On or about October 19, 2022, AV was placed in the recliner and fell out of the recliner, sustaining a bump on the head and was sent out to the hospital. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about September 8, 2022, the Alleged Victim (AV) fell out of his/her bed, suffering a cut to his/her eyebrow and bruising to his/her back. AV had suffered previous falls on July 22, 2022 and August 25, 2022. The facility failed to implement interventions and appropriately care plan regarding AV's risk of falls. The facility failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #1 (W1) is a known wanderer and is known to get into altercations with other residents. On or about August 17, 2022, W1 wandered into the Alleged Victim's (AV) room and hit AV in the face. The facility failed to provide a safe environment, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #1 (W1) has a history of wandering into residents rooms, aggressive behaviors and hitting others. W1 is care planned to be redirected when wandering in hallways. On or about August 8, 2022, W1 entered the Alleged Victim's (AV) room and hit AV. Staff saw W1 wandering the halls and did not redirect W1. The facility's failure to follow the care plan is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about July 23, 2022, the Alleged Victim (AV) suffered a fall, causing bruising to his/her left arm, pain to his/her leg and a cut to the back of AV's head. The facility failed to follow the care plan to have a fall mat by AV's bed. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) has a history of falls. AV's care plan did not contain interventions designed to prevent falls. On or about July 22, 2022, AV fell outside his/her room, and suffered a scraped knee. The facility failed to properly care plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is a fall risk and has had multiple falls over the past few months. On or about July 3, 2022, AV fell and hit his/her head and was sent to the Emergency Room for evaluation. The facility failed to have new and meaningful interventions to alleviate AV's falls. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #1 (W1) and the Alleged Victim (AV) have had prior altercations in different areas of the facility. The only interventions in place was to keep the two separated in the dining room or common areas. On or about June 12, 2022, W1 wandered into AV's room and punched AV in the face two times. The facility failed to properly care plan, placing AV at risk for harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is a known fall risk and was on wellness checks 4 times per shift. AV fell in his/her room, suffering cuts to his/her eye and nose, as well as bruising to his/her eye. The facility failed to provide a safe environment, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility to manage his/her medications. On or about November 15, 2021, it was reported that AV missed his/her required medication. During the investigation, it was discovered AV missed his/her required medications on multiple occasions in October and November of 2021, which resulted in unreasonable discomfort. The facility failed to provide a safe medication administration system to ensure AV’s medication was available to be administered as ordered. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is a known fall risk with a history of falls. According to an investigation AV fell on or about October 28, 2021, resulting in multiple skin injuries. The facility failed to provide appropriate services according to Alleged Victim’s needs, relating to care planning and lack of appropriate interventions, to mitigate the risk of injury due to AV's increase in falls, which is a violation of resident rights, is neglect of care which constitutes abuse.

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

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

The facility failed to provide records to the Department upon request. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to provide records to the Department upon request. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to provide records to the Department upon request. The facility’s failure is a violation of Oregon Administrative Rules.

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

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

The facility failed to provide records to the Department upon request. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to provide records to the Department upon request. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to provide records to the Department upon request. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to provide records to the Department upon request. The facility’s failure is a violation of Oregon Administrative Rules

The facility failed to provide records to the Department upon request. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to provide records to the Department upon request. The facility’s failure is a violation of Oregon Administrative Rules

The facility failed to provide records to the Department upon request. The facility’s failure is a violation of Oregon Administrative Rules

The facility failed to provide records to the Department upon request. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to provide records to the Department upon request. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to provide records to the Department upon request. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to provide records to the Department upon request. The facility’s failure is a violation of Oregon Administrative Rules.

The facility allegedly failed to assist the Alleged Victim with eating. An investigation determined this is a violation of 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 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.

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.

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 May 14, 2023, two unknown staff members, Alleged Perpetrator #2 (AP2) and Alleged Perpetrator #3 (AP3), were assisting the Alleged Victim (AV) to get up. AP2 and AP3 pulled AV up by his/her hands and weren't able to get AV up, so they placed AV on the ground. AP2 and AP3 then utilized AV's gait belt to help him/her from the floor. AP2 and AP3 did not follow AV's care plan to use the gait belt to transfer AV as required. Pulling AV up by his/her hands caused AV to have bruises on his/her hands. AP2 and AP3's actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility's failure to ensure staff were following the care plan 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.

The facility allegedly failed to provide a working equipment, which is a violation of Oregon Administrative Rules.

On or about June 22, 2022, Alleged Perpetrator #2 (AP2) was passing medications. The Alleged Victim (AV) was in the dining room and was given another residents medication by AP2, which made AV vomit and have diarrhea. AV was sent to the emergency room, where he/she was diagnosed with a drug overdose. 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.