Emerson House Portland

The Alleged Victim (AV) relies on the facility for his/her care. AV has known visual deficits and has a history of unwitnessed falls that occurred in AV’s room. According to an investigation, between August 19, 2025, and August 27, 2025, AV complained of pain and AV’s hip area appeared swollen. AV was sent to the hospital where AV was diagnosed with a fracture and a blood clot in the hip area. The facility failed to appropriately plan care and/or implement interventions to mitigate the risk of injury, which is a violation of resident rights, is neglect of care which constitutes abuse.

The Alleged Victim (AV) relies on the facility for care, supervision, and safety. On or about August 26, 2025 , facility staff discovered AV was missing from the facility. According to an investigation, AV had left the facility, seemingly through an unlocked/unlatched courtyard gate, and walked approximately 4 blocks down a busy road to a local gas station/ convenience store. It is estimated AV was outside of the locked facility for approximately 15 minutes. The facility failed to provide appropriate services, regarding care planning and resident safety, which placed AV at risk of harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Both the Alleged Victim (AV) and Witness 1 (W1) rely on the facility for care. The AV has a history of wandering the halls of the facility. W1 has a history of aggressive behaviors resulting in resident-to-resident physical altercations and is known to be territorial of his/her room. W1 is care planned for staff to redirect residents away from W1's door. On or about October 2, 2024, AV was walking down the hall and when they were close to W1's room, W1 pushed the AV down. The facility failed to provide services, implement interventions and / or follow W1 care plan and provide a safe environment for AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility for care and medication management. According to an investigation, AV’s prescription eye drops were not refilled on a consistent basis between January 2024, and September 2024. Based on the last refill date and the physician order, AV would have run out of their eye drops on approximately May 27, 2024. Despite the facility marking the medication administrator records that the drops were given, AV’s prescription drops were not administered between approximately May 27, 2024 and September 3, 2024, resulting in the AV having blurry vision and pressure build up behind their eyes. The facility failed to administer medication according to physician order and provide a safe medication system, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility for his/her care and is known to have exit seeking behavior. According to an investigation, on or about July 10, 2024, AV eloped out an unsecured door that maintenance workers had been using, posing a risk of harm. The facility failed to provide a safe environment, 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 2’s (W2) known aggressive behaviors. On or about June 15, 2024, the Alleged Victim (AV) was found in their room cleaning blood from their head. The AV was able to articulate W2 was angry with them and a suspected resident to resident altercation took place, causing the injury. The AV was sent to the hospital and needed three staples to close the wound. There were no service plan updates or interventions for W2’s known behaviors and resident to resident altercations, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to follow the care plan for Witness 7 (W7) by not monitoring them for their known behavior of wandering and getting in resident-to-resident altercations. On or about May 23, 2024, W7 was witnessed leaving the Alleged Victim’s (AV) room. The AV was found on the floor and had a laceration on their head which was actively bleeding. The facility staff admitted they could not account for W7 as outlined in their care plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to follow the care plan for Witness 7 (W7) by not monitoring them for their known behavior of wandering and getting in resident-to-resident altercations. On or about May 23, 2024, W7 was witnessed leaving the Alleged Victim’s (AV) room. The AV was found on the floor and expressed pain on their head due to the resident to resident altercation. The facility staff admitted they could not account for W7 as outlined in their care plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility to for care and supervision. The AV is a known fall risk. According to an investigation, on or about May 10, 2024, AV was found by facility staff sitting awake on the edge of the bed with injuries to AV’s face, head and hand. 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.

Alleged Victim (AV) relies on the facility for his/her care, is a high fall risk, and is care planned to have a fall mat in place when in bed. On or about April 7, 2024, facility staff were alerted that AV had fell out of bed by a facility visitor. AV was unresponsive and had a laceration above their eyebrow that was bleeding, requiring AV to be transported to the hospital for stitches. According to an investigation, it was not common knowledge that AV required a fall mat, and there was no fall mat in place or in AVs room prior to the fall. The facility failed to provide services, implement interventions and / or follow AV care plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to provide a safe medication administration system to the Alleged Victim (AV). The failure resulted in the facility not administering the AV’s Thyroid medication from approximately February 21, 2024, through March 15, 2024, putting them at risk of harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to properly care plan for Witness 2’s (W2) known behaviors towards the Alleged Victim (AV). On or about March 18, 2024, Witness 4 (W4) and Witness 5 (W5) heard yelling coming from the AV’s room. Upon arrival, W4 and W4 saw W2 choking the AV. W$ and W5 intervened, separated the residents and evaluated the AV for injuries, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility for care, requires 2-person assistance with transfers, and is non ambulatory. According to an investigation, AV was care planned for assistance with transfers using a Hoyer lift, but staff continued to use a sit to stand device to transfer AV, resulting in numerous injuries and repeated unreasonable discomfort. The facility failed to provide services, to include following AV's care plan and monitoring AV for safety, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to administer The Alleged Victim’s (AV) seizure medication as prescribed by their primary care physician. The failure resulted in the AV to not be administered their full dose of seizure medication on or about January 22, 2024, which placed them at risk for seizure, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility for his/her care, is a known fall risk, and is care planned for assistance with dressing. According to an investigation, on more than on occasion AV was found with inappropriate clothing or footwear, placing AV at risk for falls. The facility failed to ensure the care plan was followed, which is a violation of resident rights, is neglect of care, and constitutes abuse.

The Alleged Victim (AV) relies on the facility to oversee their medication administration. According to an investigation, the facility did not administer AV’s opioid patch for pain control on more than one occasion, resulting in AV suffering repeated physical pain. The facility failed to ensure medications were given as ordered, which is a violation of resident rights, is neglect of care and constitutes abuse.

According to the documentation, the facility failed to follow the care plan for Witness 1 (W1) to observe the resident when they are in common areas due to history of resident-to-resident altercations. The failure resulted in W1 pushing the Alleged Victim (AV) in their wheelchair and let go. This caused AV to crash into a table resulting in a skin tear to the AV’s hand which required stitches, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to properly care plan for the Alleged Victim’s (AV) known behavior of wandering into resident rooms. The failure resulted in the AV to wander into Witness 1’s room (W1) upsetting them causing an altercation between the two residents. The AV sustained a bump on their eyebrow and a bruise on their left eye, 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 appropriate interventions for Witness 1’s (W1) known behaviors which result in resident-to-resident altercations. On or about November 24, 2023, W1 wandered into the Alleged Victim’s (AV) room and upon exiting, got into a physical altercation with the AV. W1 was witnessed pushing the AV down in the hallway and was then separated by facility staff. Facility staff evaluated the AV for injury and called EMS to take them to the hospital for assessment. The AV sustained a hip fracture which required surgery to fix, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to follow the Alleged Victim’s (AV) service plan by leaving them alone in their room while in their wheelchair. The failure resulted in the AV to attempt to self-transfer causing the AV to fall and fracture their hip, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to ensure newly prescribed medication was at the facility at the time the Alleged Victim (AV) was admitted back to the facility from the hospital. The failure resulted in the AV to miss doses of a heart medication and cough medication putting the AV at risk for potential harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility to oversee their medication administration. According to an investigation, from approximately April 6, 2023, to October 23, 2023, AV was given an incorrect dosage of AV’s seizure medication, putting AV at risk of serious harm. The facility’s failure to implement a safe medication administration system, which is a violation of resident rights, is neglect of care and constitutes abuse.

On or about January 6, 2022, Alleged Perpetrator #2 (AP2) was working the overnight shift. The Alleged Victim (AV) was to be checked multiple times through the night to assist with toileting and ensure that his/her incontinence briefs were dry. AP2 failed to check AV after 1:30 AM, resulting in AV contracting a yeast infection in his/her groin area. AP2's actions are a violation of resident rights, are considered neglect of care and constitutes abuse. The facility failed to ensure AP2 was following the care plan and had prior issues with AP2's work ethic and failed to ensure proper supervision, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about January 6, 2022, Alleged Perpetrator #2 (AP2) was working the overnight shift. The Alleged Victim (AV) was to be checked multiple times through the night to assist with toileting and ensure that his/her incontinence briefs were dry. AP2 failed to check AV after 1:30 AM, resulting in AV being found with his/her incontinence brief soaked, along with all his/her bedding, causing unreasonable discomfort. AP2's actions are a violation of resident rights, are considered neglect of care and constitutes abuse. The facility failed to ensure AP2 was following the care plan and had prior issues with AP2's work ethic and failed to ensure proper supervision, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about December 31, 2021, the Alleged Victim (AV) was found on the floor in a fetal position after getting up from his/her wheel chair, moving to the glass door and suffering a fall. Staff assisted AV back into his/her wheelchair, but did not notice any injury to AV at the time. AV showed no signs of wanting to walk or get out of his/her wheel chair after the incident. On January 4, 2022, the facility sent AV out for an X-ray, which determined that AV had a fractured pelvis from the fall on December 31, 2021. The facility failed to intervene when AV's condition changed, leaving AV in unreasonable discomfort. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to consistently staff to the levels, intensity and qualifications indicated by the Acuity-Based Staffing Tool (ABST). Inconsistencies were identified between the staffing schedule and the data produced by the ABST. Facility was not staffing to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to reflect the resident's needs as identified in the evaluation. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to have an Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population, their needs, and all required Activities of Daily Living (ADL). Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. Facility was not staffing to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to develop, maintain, and implement an Acuity Based Staffing Tool. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to consistently staff to the levels, intensity and qualifications indicated by the Acuity-Based Staffing Tool (ABST). Inconsistencies were identified between the staffing schedule and the data produced by the ABST. Facility was not staffing to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules.

The facility allegedly 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 comply with delegation and teaching requirements. The facility’s failure is a violation of Oregon Administrative Rules.

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

The facility failed to implement and maintain an Acuity-Based Staffing Tool. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to develop, maintain, and implement an Acuity Based Staffing Tool. The facility’s failure is a violation of Oregon Administrative Rules.

The facility allegedly failed to administer medication as ordered for the Alleged Victim. An investigation was inconclusive if abuse occurred. The failure is a violation of Oregon Administrative Rules.

The facility failed to develop, maintain, and implement an Acuity Based Staffing Tool. An investigation determined this is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) relies on the facility for care, is a fall risk, and although AV is independent with ambulation, AV is care planned for staff to monitor AV when ambulating. On or about January 20, 2025, at approximately 2:30 am, AV was found on the floor of another residents room, bleeding from a head wound that resulted in AV being transferred to the hospital for treatment. According to the investigation, the Alleged Perpetrator 2 (AP2) had previously been given a written warning for sleeping while on duty and when staff found AV on the floor, AP2 was asleep in a chair in an area of the facility they were not supposed to be in. The AP2 failed to provide services, to include following AV's care plan and monitoring AV for safety, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to ensure the care plan was being followed and that there were qualified and awake care staff , which is a violation of Oregon Administrative Rules.

The facility’s failure to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident and to complete or update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly as required. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to develop, maintain, and implement an Acuity Based Staffing Tool. An investigation determined this is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during a site visit on 06/11/25, the facility’s failure to complete an Acuity-Based Staffing Tool (ABST) evaluation before a resident moved in was substantiated for 1 of 1 sampled resident. The facility’s failure is a violation of Oregon Administrative Rules.

Based on interview and record review, the facility failed to provide records to the Department upon request. The facility’s failure is a violation of Oregon Administrative Rules.

Based on interview and record review, the facility failed to provide records to the Department upon request. The facility’s failure is a violation of Oregon Administrative Rules.

Based on interview and record review, the facility failed to provide records to the Department upon request. The facility’s failure is a violation of Oregon Administrative Rules.

On or about September 01, 2024, the Oregon Health Authority (OHA) 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 01, 2024, through August 31, 2024, for a total of 92 days. The Department sent a letter to you in July 2024, which informed you of the failure to report for previous days, and that if you did not report to OHA by August 31, 2024, you would be receiving a penalty in the amount of $250.00. The facility has failed to comply with this request for the month of August 2024, resulting in a Civil Penalty.

The facility failed to consistently staff to the levels, intensity and qualifications indicated by the Acuity-Based Staffing Tool (ABST). Inconsistencies were identified between the staffing schedule and the data produced by the ABST. Facility is not currently staffing to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

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. Corrective Action taken on related allegation.

The facility failed to consistently staff to the levels, intensity and qualifications indicated by the Acuity-Based Staffing Tool (ABST). Inconsistencies were identified between the staffing schedule and the data produced by the ABST. Facility is not currently staffing to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

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

The facility failed to provide services to ensure the Alleged Victim’s (AV) medications/treatment orders were carried out as prescribed. There was no observable or documented evidence of a negative outcome. The 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.

The facility failed to ensure all equipment necessary for the health, safety, and comfort of the resident was clean and in good repair. 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.

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 a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated, or discontinued medications administered. The facility’s failure is a violation of Oregon Administrative Rules.

According to the documentation, the Alleged Perpetrator 2 (AP2) failed to protect the Alleged Victim (AV) from financial exploitation. On or about May 8, 2024, AP2 was seen on video taking out the AV’s narcotic medication from the cabinet and taking cups of water from the sink to where the medication was. Test of the AV’s medication revealed all the narcotic medication was replaced with water, which is a violation of resident rights and is considered financial abuse. The facility failed to provide a safe environment which is a violation of Oregon Administrative Rules.

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 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.

According to the documentation, the Alleged Perpetrator (AP2) failed to protect the Alleged Victim from verbal abuse. The failure resulted in the AP2 standing over the AV and talking loudly to them, causing them to cry which is a violation of resident rights and is considered verbal abuse. The facility failed to protect the AV from verbal abuse which is a violation of Oregon Administrative Rules.

The facility failed to provide meaningful activities that promote or help sustain the physical and emotional well-being of residents. An investigation determined a licensing violation or abuse occurred.

The facility failed to ensure if the direct care staff person's duties include the administration of medication or treatments, appropriate facility staff must document that they have observed and evaluated the individual's ability to perform safe medication and treatment administration unsupervised. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to protect the Alleged Victim from financial exploitation. On or about April 21, 2022, it was discovered that the Alleged Victim's (AV) debit card was used in two different locations, two different days. Alleged Perpetrator #2 (AP2, Unknown) is responsible for taking AV's debit card. AP2's actions are a violation of resident rights, are considered neglect of care and constitute financial abuse. The facility's failure is a violation of Oregon Administrative Rules.