Farmington Square Medford

The Alleged Victim (AV) relies on the facility for care and is care planned for staff assistance for bathing, dressing and toileting. On or about June 3, 2025, AV was observed limping, appeared to be uncomfortable while ambulating, and told staff they were in pain and thought they fell. AV was given pain medication, and it was documented that AV had bruising on both elbows. On or about June 7, 2025, AV was observed to be unstable and struggling to take steps, and staff discovered a dark purple bruise on AV's hip and buttocks. AV was sent to the hospital due to left hip pain. According to an investigation, there was no interim service plan (ISP) created to monitor AV for pain and discomfort between June 3, 2025, and June 7, 2025, and no bruising was documented during that time despite care staff helping AV with daily dressing and a shower. The facility failed to provide appropriate services, to include properly care planning and/or implementing interventions, change of condition monitoring and timely medical treatment, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility for his or her safety and has known exit seeking behaviors. On or about May 23, 2025, and then again on June 3, 2025, AV was found outside the locked facility alone, unbeknownst to facility staff inside the cottage where AV resides. The facility repeatedly failed to provide a safe environment, which is a violation of resident’s rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility for care, is known fall risk, and is known to have a diagnosis that affects AVs memory. According to an investigation, between March 21, 2025 and May 17, 2025, AV had multiple falls, some resulting to injury to include pelvic fractures, pelvic bleeding and a mass, ankle fracture, and a head injury. Despite AV continuing to fall, and the facility being aware of AVs lack of cognition, the facility failed to implement a higher level of care for resident safety. The facility failed to provide appropriate services according to AV’s needs, regarding care planning, safety checks and monitoring, causing repeated unreasonable discomfort, 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 and have a history of conflict and physical altercations with each other. AV has a history of entering other residents’ rooms, which results in physical altercations. On or about April 25, 2025, and again on May 7, 2025, AV and W1 got into physical altercations when AV entered W1’s room, resulting in injury to include skin tears on the arm and hand. The facility failed to provide appropriate services, to include care planning and/or implementation of effective interventions to address both AVs and W1s interpersonal conflict and behaviors, and provide a safe environment for AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Both the Alleged Victim (AV) and Witness 1 (W1) rely on the facility for care and have a history of conflict and physical altercations with each other. On or about April 14, 2025, W1 went into AV's bathroom when AV was on the toilet and got into a physical altercation, resulting in a skin tear to AV's hand. The facility failed to provide appropriate services, to include implementation of interventions, medication administration, and to provide a safe environment for AV, causing AV unreasonable discomfort, 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 and have a history of conflict and physical altercations with each other. W1 has a history of entering other residents rooms, which results in physical altercations. On or about February 10, 2025, AV and W1 got into a physical altercation when W1 was attempting to enter AV's room, resulting in W1 punching AV in the head and arms. The facility failed to provide appropriate services, to include care planning and/or implementation of effective interventions to address both AVs and W1s interpersonal conflict and W1's behaviors, and provide a safe environment for AV, causing AV unreasonable discomfort, 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, has a seizure disorder, and ambulates independently with a walker. According to documentation, despite the facility being aware of AV's seizure disorder for approximately two years, seizure management/safety precaution education training was not presented to staff until March 8, 2025. Between July 26, 2024, and March 8, 2025, AV had multiple falls, some due to AV's seizure disorder, resulting in injury to include skin tears, bruising, head injuries and hospitalizations. The facility failed to provide appropriate services according to Alleged Victim’s needs, regarding care planning, safety checks and monitoring, which caused repeated unreasonable discomfort and hospitalization, 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. WI is known to have inappropriate sexual behaviors with residents, including AV. AV and W1 were care planned for staff to intervene and redirect if AV and W1 went into AV or W1’s room together. According to an investigation, on or about February 21, 2025, facility staff found W1 in AV’s room having a sexual interaction. AV was crying, experienced pain, and was sent to the hospital. The facility failed to provide a safe environment for AV by failing to protect AV from W1's sexualized behavior, which is a violation of resident rights, is neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility for his/her care. Witness 1 (W1) is known to have aggressive behaviors, wanders into other resident’s rooms, and has history of resident-to-resident altercations. According to an investigation, between approximately December 16, 2024, and March 11, 2025, AV and W1 had multiple resident-to-resident incidents when W1 wondered into AV’s room. AV received injuries, including skin tears and experienced repeated unreasonable discomfort. The facility failed to provide a safe environment for AV by failing to protect AV from W1's aggressive behavior by properly care planning, which is a violation of resident rights, is neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility to provide a safe environment, and to provide oversight and care. According to an investigation AV was involved in at least six resident to resident altercations from February 19, 2025, through May 7, 2025. The facility failed to implement meaningful interventions to AV's care plan to keep AV safe which is a violation of resident rights and is neglect of care which constitutes abuse.

The Alleged Victim (AV) relies on the facility to provide care. According to an investigation, between December 2, 2024, and January 21, 2025, AV had five injuries of unknown origin and were related to unwitnessed falls. The facility failed to implement meaningful interventions to AV's care plan to prevent AV from falling. This is a violation of resident rights and is considered neglect which constitutes abuse.

The Alleged Victim (AV) relies on the facility for his/her care. Witness 1 (W1) has a history of resident-to-resident altercations. According to an investigation, on or about November 27, 2024, W1 grabbed AV’s arm, which resulted in AV hitting back at W1. Soon after facility staff separated AV and W1, AV and W1 re-approached each other and W1 grabbed AV’s neck and pushed AV against the wall. AV had red marks on his/her neck and experienced pain and emotional discomfort. The facility failed to provide a safe environment to AV and appropriately care plan for W1’s known behaviors, which is a violation of resident rights, is neglect of care which constitutes abuse.

The Alleged Victim (AV) relies on the facility to provide behavioral support interventions and a safe environment. According to an investigation, the AV had multiple altercations with Witness 9 (W9). On or about November 1, 2024, the AV was involved in an altercation with W9. The AV was struck in the face causing bleeding. The facility failed to appropriately implement behavior interventions for the AV and W9, placing the AV at risk of harm, which is a violation of resident’s rights, is neglect of care, and constitutes abuse.

Alleged Victim (AV) relies on the facility for care and to administer his/her medications. On or about October 31, 2024, Alleged Perpetrator 2 (AP2) was training a new employee, Witness 4 (W4), to pass medications when W4 administered AV another resident's medications. According to an investigation, AP2 was not sure where W4 was in their training and was not watching W4 to ensure medications were administered according to their physician order. After AV was given the wrong medications, AV was nonresponsive and had a faint/weak pulse and was transported to the hospital. AP2 neglected AV by failing to ensure medications were given as ordered, which is a violation of resident rights, is neglect of care and constitutes abuse. The facility failed to provide appropriate services, to include a safe medication administration system, oversight of medication training, and that physician orders were carried out as prescribed, which is a violation of resident rights, is neglect of care and constitutes abuse.

The AV relies on the facility for care, to include medication administration. According to an investigation, AV has multiple physician orders for blood sugar regulating medication and there were inconsistencies in their administration. On or about September 25, 2024, AV had an extremely elevated blood sugar reading, resulting in AV being sent to the hospital for treatment. The facility failed to ensure medications were administered as ordered, 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, gets frequent urinary tract infections (UTIs), and has a history of being resistant to care. According to an investigation, AV's UTI's correlate to when AV is left in soaked briefs. On or about September 25, 2024, EMS was called to transport AV to the hospital for a blood sugar issue and it was documented that AV was wet and saturated in urine before leaving the facility, and was ultimately diagnosed with a UTI. The facility failed to provide appropriate services according to AV’s needs, regarding implementation of care, which is a violation of resident rights and dignity, is considered neglect of care and constitutes abuse

The Alleged Victim (AV) is known to wander into other resident’s rooms and is care planned to be redirected. On or about July 13, 2024, AV wandered into Witness 1’s (W1) room. W1 shoved AV out of W1’s room, resulting in a bruise on AV’s finger. The facility failed to follow AV’s care plan and/or properly plan care, 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. Witness 1 (W1) is known to have inappropriate behaviors. According to an investigation, on multiple occasions, W1 was found alone in a bedroom with AV, resulting in unreasonable discomfort. The facility failed to provide a safe environment to AV and appropriately care plan for W1’s known behaviors, which is a violation of resident rights, is neglect of care which constitutes abuse.

The Alleged Victim (AV) is a known exit seeker and wandered and has a history of elopement. On or about April 12, 2024, AV exited the locked facility without knowledge of the staff. No staff know how AV got out of the facility. AV was found almost a half a mile away from the facility sitting on the ground in a parking lot. The facility failed to provide a safe environment, allowing AV to exit the facility without their knowledge, placing AV at risk for harm. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about February 10, 2024, the Alleged Victim (AV) and Witness #1 (W1) engaged in an altercation where W1 pushed and punched AV in the back of his/her head. AV complained of pain to his/her head. The facility's failure to provide a safe environment 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 1 (W1) to supervise W1 to ensure they do not wander into other resident rooms and redirect them if they do. The failure resulted in W1 wandering into the Alleged Victim’s (AV) room causing a resident-to-resident altercation and W1 slapping the AV in the face, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide medical treatment for the Alleged Victim’s (AV) medical conditions, by not applying compression stockings to relieve swelling of the legs, nor timely applying medication for his/her rash. The failure resulted in AV’s condition worsening and was sent to the hospital for treatment of these conditions, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #1 (W1) has a history of wandering into other residents rooms. W1 has multiple altercations with residents and at least 11 instances of wandering into other residents rooms over a two month period. On or about April 12, 2022, W1 wandered into the Alleged Victim's (AV) room and an altercation occurred, in which W1 punched AV and AV punched W1 back, placing both residents at risk for harm. The facility's failure to provide a safe environment is a violation of resident rights, is considered neglect of care and constitutes abuse.

Based on interview and record review, the facility failed to immediately report abuse, suspected abuse, or injuries of unknown cause to the Department, AAA, or law enforcement. The facility’s failure is a violation of Oregon Administrative Rules.

The facility allegedly failed to provide service for the Alleged Victim. An investigation determined this is a violation of Oregon Administrative Rules.

The facility allegedly failed to provide oversight and monitoring of change of condition. An investigation determined this is a violation of Oregon Administrative Rules.

Alleged Victim (AV) relies on the facility for his/her care, and is care planned to have toileting assistance. On or about March 26, 2025, Alleged Perpetrator #2(AP2) was assisting AV to the restroom and left AV unattended. AV fell off the toilet and sustained bruises on AV’s left collar and right/hip butt area and complained of pain in the right leg when moved. AP2 failed to follow the care plan, 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, which is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) relies on the facility for daily care including cueing and redirection for memory loss. According to an investigation, on or about March 3rd, 2025, the Alleged Perpetrator 2 (AP2) threw water on the AV causing emotional distress and harm. The AP2’s actions are a violation of resident rights and constitutes abuse. The facility failed to protect the AV from emotional abuse, which is a violation of resident’s rights, is 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 staffed 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 Alleged Victim (AV) relies on the facility for his/her care. According to an investigation, on or about September 15, 2024, Alleged Perpetrator 2 (AP2) made inappropriate verbal comments to the Alleged Victim (AV) on multiple occasions, which resulted in the AV experiencing unreasonable discomfort and loss of personal dignity. AP2’s actions are a violation of resident rights, are considered neglect of care, and constitutes verbal/emotional abuse. The facility failed to protect the AV from verbal/emotional abuse, which is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) relies on the facility for his/her care. According to an investigation, on or about September 15, 2024, the Alleged Perpetrator 2 (AP2) took inappropriate video(s) of the AV and posted them on AP2’s social media platform, resulting in significant emotional discomfort and harm, significant loss of personal dignity, and is a serious violation of resident rights for the AV. AP2’s actions are a violation of resident rights, are considered neglect of care, and sexual abuse. The facility failed to protect the AV from sexual abuse, which is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) relies on facility staff to ensure resident’s rights. The AV has an intimate relationship with another resident in the facility. According to an investigation, on or about September 17, 2024, it was discovered the Alleged Perpetrator 2 (AP2) had made videos of the AV being intimate with their partner without their permission. In the video, AP2 is heard shaming, taunting, and embarrassing the AV. AP2’s actions are considered verbal and emotional abuse and constitutes abuse. The facility did not keep AV free from verbal and emotional abuse, which is a violation of Oregon Administrative rules.

The Alleged Victim (AV) relies on the facility for his/her care. According to an investigation, on or about September 17, 2024 it was discovered, the Alleged Perpetrator 2 (AP2) recorded the AV without their consent while making derogatory and demeaning comments to the AV. The AP2 posted the videos on their social media platform. The AP2s actions resulted in the AV experiencing unreasonable discomfort and loss of personal dignity. The AP2’s actions are a violation of resident rights, considered verbal and emotional abuse, and constitute abuse. The facility did not keep AV free from verbal and emotional abuse, which is a violation of Oregon Administrative rules.

On or about December 23, 2022, the Alleged Perpetrator (AP2) filmed a video the of the AV and can be heard using derogatory names toward him/her; and threatening to physically harm AV. AP2’s actions are considered verbal/emotional abuse. The facility failed to protect AV from verbal/emotional abuse, which is a violation of Oregon Administrative Rules.

The Alleged Perpetrator #2 (AP2) has demonstrated being short with residents in the past and the Alleged Victim (AV) in particular. AP2 yelled at and made derogatory statements to AV, making AV feel sad and cry. AP2's actions are a violation of resident rights, are considered neglect of care and constitute verbal and emotional abuse. The facility failed to protect AV from verbal and emotional abuse, which is a violation of Oregon Administrative Rules.

The facility failed to keep all equipment in good repair

The facility failed to assist residents with bathing, personal hygiene, dressing and undressing, and toileting, which is a violation of Oregon Administrative Rules.

The facility failed to exercise reasonable precautions against any condition that may threaten the health, safety, or welfare of the residents, which is a violation of Oregon Administrative Rules.

The facility failed to develop and implement a policy that addresses the safekeeping of residents' possessions, which is a violation of Oregon Administrative Rules.

The facility failed to keep all interior materials and surfaces clean, which is a violation of Oregon Administrative Rules.

The facility failed to keep residents medical and other records confidential which is a violation of Oregon Administrative Rules.