Fircrest Senior Living

On or about May 12, 2025, the Alleged Victim (AV) was calling for assistance and no staff showed up to assist. AV was having shortness of breath and couldn't get anyone to assist him/her. AV has a whistle, but can't always use the whistle to call for staff. AV is in a contracted bed, where there is to be 2 staff at all hours of the day, and to be near these rooms to assure staff get assistance they need. On this day, the staff scheduled for this area were not in the area, as they were assisting in the assisted living side of the building due to short staff. The facility's failure to staff appropriately and ensure resident services as needed is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #1 (W1) is care planned to be on one to one supervision due to wandering into other residents rooms. On or about March 10, 2025, W1 wandered into the Alleged Victim's (AV) room and grabbed AV's arm, causing a skin tear. Facility staff who were to be watching W1 went to break and did not advise other staff that someone needed to supervise W1, allowing W1 to enter AV's room. The facility's failure to follow W1's care plan is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) and Witness #1 (W1) have a history of resident to resident altercations. On or about December 15, 2024, AV approached W1 to shake his/her hand, W1 pushed AV, causing AV to fall. AV suffered a laceration above his/her eye. The facility failed to have interventions in place to ensure the safety of residents. This failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #1 (W1) is known to wander. On or about December 4, 2024, W1 wandered into the Alleged Victim's (AV) room. AV found W1 standing over his/her spouse and asked W1 to leave. W1 and AV engaged in a physical altercation where AV received a minor laceration and a skin tear to his/her face. The facility's failure to provide a safe environment is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about December 4, 2024, the Alleged Victim (AV) wandered into Witness #1's (W1) room. W1 found AV standing over his/her spouse and asked AV to leave. W1 and AV engaged in a physical altercation where W1 received a minor laceration and a skin tear to his/her face. AV stated they were punched in the face, however, didn't show any injuries. 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) wears geri sleeves, which are supposed to be changed daily and removed at bedtime. AV's care plan does not provide staff with information regarding AV's geri sleeves. AV needs full assistance with dressing daily and showering twice a week. On or about November 15, 2024, staff noted that AV's geri sleeve was bunched up and stuck to AV's skin. The sleeve had to be soaked to be removed from AV's arm. Once removed, it was noted that AV had a stage 4 sore under the geri sleeve, in the pit of AV's elbow. AV's last shower was noted to be on November 9, 2024.

The Alleged Victim (AV) is care planned to be positioned in bed in the center of the bed, to avoid AV falling from the bed. On or about November 15, 2024, AV was found on the fall mat next to his/her bed. No injuries were identified at the time of the fall, however, in January of 2025, AV was sent out to the hospital for a spot on AV's head that could have been an old injury. 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) had been involved in previous sexual assault by Witness #1 (W1). AV was to be on one to one supervised care around the clock to ensure his/her safety, as well as 15 minute checks to ensure his/her whereabouts. On or about June 4, 2024, staff found AV standing fully clothed in W1's shower. W1 was also in the bathroom. Alleged Perpetrator #2 (AP2) was the staff that was supposed to be on one to one care for AV at the time of the incident. AP2 left AV alone while AV was sleeping, thinking they could take a break During this time is when AV was found in W1's room. AP2's failure to provide one to one care to AV placed AV at risk for harm. AP2's actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility's failure to ensure staff followed AV's temporary service plan in a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about June 2, 2024, the Alleged Victim (AV) was found lying on Witness #1's (W1) bed. AV was fully clothed, however, W1 had his/her pants partially down and W1 was touching him/herself. Both residents were re-directed. These two residents had been found together other times and AV was on one to one care beginning May 31, 2024, however, leadership at the facility didn't actually place any one staff member in charge of AV's one to one care, therefore, it was not being completed, allowing this incident to occur. The facility failed to protect AV from further attempted sexual assault by W1. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is known to wander and lay down on other residents beds when tired. On or about May 30, 2024, staff found the AV in Witness #1's (W1) bed. AV was not wearing any clothes, however W1 still had his/her clothes on. On or about May 31, 2024, staff found AV naked on W1's bed and W1 was also naked. W1 was holding AV's legs up, attempting to engage in a sexual act. AV repeatedly stated he/she was scared after the incident. The facility failed to put a safety plan in place after the incident for AV or W1 and failed to send AV out for a Sexual assault exam or any medical attention until 5 days after the incident. The facilities failure to put interventions in place for known sexualized behaviors by W1 placed AV at risk of serious harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is known to wander. Witness #1 (W1) has a history of being aggressive towards residents and staff and is to keep his/her door locked while he/she is inside. On or about May 27, 2024, W1 pushed AV to the ground after AV wandered into W1's room. AV was not injured, however, AV was placed at risk of harm due to the facility not providing adequate supervision of AV and W1. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is diabetic and also has a diagnosis of dementia. On or about February 15, 2023, AV had his/her right great toenail removed by his/her podiatrist. AV was treated with antibiotics and daily wound care and his/her removal of the toenail resolved by March 22, 2023. On or about April 9, 2023, care staff noted that AV's toe had turned black. AV was sent to the hospital and his/her toe was amputated. AV was care planned to have his/her feet checked during showers by staff. There is no documentation that shows that AV's feet were checked by staff at any time, although AV was care planned for this action. The facility's failure to follow AV's care plan and provide oversight and monitoring of AV's condition is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to properly care plan for Alleged Victim (AV) which resulted in AV being sent to the hospital for treatment. Based on an investigation, AV moved into the facility on October 20, 2022 in which AV did not have any wounds or skin issues at time of admittance to the facility. After admittance to the facility, AV showed signs of failure to thrive and the facility sent AV to the hospital for treatment on November 8, 2022. At time of admittance to the hospital, AV was found to have several pressure wounds, severe dehydration, and severe infection with his/her urinary tract. An investigation determined that facility failed to develop and/or maintain a comprehensive care plan for AV's care needs which included interventions for AV's refusal of care. The facility's failure caused AV unreasonable discomfort which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness 1 (W1) is care planned with aggressive behaviors and frequent agitation and had an increase of altercations prior to incident. On or about December 11, 2021, Alleged Victim (AV) and Witness 1 (W1) had an injury altercation which resulted in AV getting lacerations to his/her arms and face. The facility's failure to provide a safe environment for AV which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) and Witness 1 (W1) are known to have resident-to-resident altercations. W1 is care planned to be redirected whenever he/she enters the room of other residents. On or about December 6, 2021, AV and W1 entered the room of another resident in which the other resident became upset and started yelling at AV and W1 to get out. W1 responded to the matter by becoming upset and punching AV in the face and giving him/her a black eye. The facility failed to provide AV a safe environment which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide appropriate documentation when requested, which is a violation of Oregon Administrative Rules.

The facility failed to provide appropriate documentation when requested, which is a violation of Oregon Administrative Rules.

The facility failed to provide appropriate documentation when requested, which is a violation of Oregon Administrative Rules.

The facility failed to provide appropriate documentation when requested, which is a violation of Oregon Administrative Rules.

The facility failed to provide appropriate documentation when requested, which is a violation of Oregon Administrative Rules.

The facility failed to provide appropriate documentation when requested, which is a violation of Oregon Administrative Rules.

The facility failed to provide documentation as requested, which is a violation of Oregon Administrative Rules.

The facility failed to provide appropriate documentation when requested, which is a violation of Oregon Administrative Rules.

The facility failed to provide appropriate documentation when requested, which is a violation of Oregon Administrative Rules.

The facility failed to provide appropriate documentation when requested, which is a violation of Oregon Administrative Rules.

The facility failed to provide appropriate documentation when requested, which is a violation of Oregon Administrative Rules.

The facility failed to provide appropriate documentation when requested, which is a violation of Oregon Administrative Rules.

The facility failed to provide appropriate documentation when requested, 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 in accordance with OAR 411-054-0036(2); per a report of a serious event, which is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) is care planned to be transferred with a gait belt. On or about September 16, 2025, Alleged Perpetrator #2 (AP2) transferred AV from the toilet using a bear hug type transfer, causing AV pain in his/her ribs. AV was transferred to the hospital and diagnosed with fractured ribs. AP2's actions are a violation of resident rights, are considered neglect of care and constitute abuse. The faciilty's failure to ensure the care plan was followed 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 ensure reasonable precautions must be exercised against any condition that may threaten the health, safety, or welfare of residents in accordance with OAR 411-054-0025(4); per complaint that a window was missing a window lock blocker and a resident eloped, 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), which is a violation of Oregon Administrative Rules.

On or about June 9, 2025, Alleged Perpetrator #2 (AP2) was inappropriately dressed, wearing a really low cut shirt. The Alleged Victim (AV) commented to AP2 that he/she was inappropriately dressed and AP2 commented to AV, "Do you like what you see?" and advised AV that his/her significant other would beat AV up. AP2 left the facility and while driving away, yelled cuss words at AV and signed an explicit finger gesture to AV. AP2's actions are a violation of resident rights, are considered neglect of care and constitute verbal / emotional abuse. The facility's failure to protect AV from verbal / emotional abuse is a violation of Oregon Administrative Rules.

On or about November 2, 2024, the Alleged Victim (AV) was dispensed medication at 8:00 PM by a facility staff member where the staff member did not observe AV take the medication. On or about November 3, 2024 at 5:30 AM, AV ended up taking the medication as it was laying on AV's bookshelf. The facility's failure to ensure a safe medication administration system is a violation of Oregon Administrative Rules.

The facility failed to fully implement and update an acuity-based staffing tool in accordance with OAR 411-054-0037, which is a violation of Oregon Administrative Rule.

The Alleged Victim (AV) is scheduled to receive two showers per week, however, AV is only receiving one shower per week. At times, AV will refuse showers, however, the facility is sometimes short staffed, not allowing for AV to have his/her shower twice a week. The facility's failure to ensure proper staffing is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) was resting in his/her room. Alleged Perpetrator #2 (AP2) badgered AV repeatedly to get out of bed and stated to him/her to not be lazy and get moving. AV was uncomfortable being called lazy and thought they had done something wrong by resting in their room. AP2's actions are a violation of resident rights, are considered neglect of care and constitute mental abuse. The facility's failure is a violation of Oregon Administrative Rules.

The facility failed to development and implement a policy for the referral of residents who may be victims of acute sexual assault to the nearest trained sexual assault examiner within 86 hours per complaint that the facility failed to follow proper procedure for possible incidents of sexual assault. The facility's failure is a violation of Oregon Administrative Rules.

The licensee failed to monitor each resident consistent with his or her evaluated needs and service plan per a complaint the facility was to provide one-on-one supervision for the safety of a resident and failed to do so, which is a violation of Oregon Administrative Rules.

The facility failed to be to provide effective administrative oversight over the operation of the Memory Care Community per the severity of citations confirmed during a site visit on 06/05/24, which is a violation of Oregon Administrative Rules.

The facility failed to ensure the facility RN is notified of nursing needs per complaint the facility RN was not notified of a resident incident, which is a violation of Oregon Administrative Rules.