Firwood Gardens RCF

The Alleged Victim (AV) relies on the facility to provide a safe environment. According to an investigation, AV has a history of trying to elope from the facility. On or about May 28, 2025, AV was able to push through a door and exit the facility. When AV was outside, AV attempted to go into traffic multiple times. The facility had to call law enforcement to try and keep AV out of traffic, and AV was taken by law enforcement to the hospital. The facility failed to provide a safe environment for AV, which is a violation of resident's rights and is neglect of care which constitutes abuse.

The Alleged Victim (AV) relies on the facility to provide a safe environment. According to an investigation, on 3/27/25 AV was able to exit from their secured unit and go into an unsecured area of the facility. The facility failed to ensure that the exit door was functioning properly, allowing AV to gain access to a stairwell, which is a violation of resident rights and considered neglect of care which constitutes abuse.

The Alleged Victim (AV) has a history of leaving the facility unattended. Ln or about November 28, 2024, AV was seen exiting the emergency door exit around 3:00 pm. AV was brought back inside by staff. At approximately 4:30 pm, AV was found in the unsecured area of the facility. AV had re-entered the facility after eloping from the locked unit. AV was redirected back to the memory care. The facility failed to provide a save environment, placing AV at risk for harm. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility to provide a safe environment. According to an investigation AV had a resident-to-resident altercation on or about August 13,2024 and the facility created a temporary service plan to keep AV and Witness 1 (W1) away from each other. On August 15, 2024, there was another resident-to-resident altercation, and the facility staff were not following the temporary service plan. The facility failed in providing a safe environment for AV, which is a violation of resident rights and is neglect, which constitutes abuse.

The Alleged Victim (AV) is dependent on the facility to meet his/her safety needs and has a history of attempting to elope from the secured unit. According to an investigation, on or about June 11, 2024, AV eloped from the secured unit by exiting through a window. The facility failed to ensure AV's service planned need for supervision was provided and provide a safe environment for AV, placing AV at risk of serious harm, which is a violation of resident rights, is neglect of care which constitutes abuse.

The Alleged Victim (AV) is dependent on the facility to meet his/her safety needs and has a history of attempting to elope from the secured unit. According to an investigation, on or about June 10, 2024, AV eloped from the secured unit by exiting through an unlocked courtyard gate. The facility failed to ensure AV's service planned need for supervision was provided and provide a safe environment for AV which is a violation of resident rights, placing AV at risk of serious harm, is neglect of care which constitutes abuse.

The Alleged Victim (AV) had a history of elopement and exit seeking behaviors. AV is care planned for staff to redirect AV away from the doors when he/she is guarding the doors. According to an investigation, on or about August 23, 2023, AV attempted to elope from the facility around 2:15 pm, then continued to sit near the door waiting for staff to exit. At approximately 2:40 pm, AV exited the memory care unit, went into the dining area of the residential care facility, and exited the doors to the unsecured smoking area. The facility failed to follow AV’s care plan when staff failed to redirect AV away from the doors, placing AV at risk for serious harm. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) had exit seeking behaviors and a history of elopement, including the previous day. According to an investigation, on or about August 13, 2023, AV eloped from the facility on two occasions, placing AV at risk for serious harm. At approximately 10:00am, it was discovered that AV eloped the facility when staff noticed AV in the back of the parking lot. AV was returned to the facility and at approximately 10:45am, it was discovered that AV was not in the facility again. AV was found by staff down the street, off facility grounds. Staff discovered that one of the doors at the back of the facility, leading to the outside, had a malfunctioning lock. 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) had exit seeking behaviors, a history of elopement, and was care planned for hourly checks. According to an investigation, on or about August 12, 2023, AV was discovered missing around 4:15pm-4:30pm, with 2:00pm being the last time staff saw AV. Video footage showed AV leaving through a gate at 2:10pm and was found by a bus driver when AV was still on the bus at the end of the line. When AV was returned to the facility, between approximately 9:10pm – 9:30pm, he/she had a cut above his/her eye that was bleeding. 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) had a history of elopement and exit seeking behaviors. The facility failed to provide a safe environment. According to an investigation, on or about May 21, 2023, a staff member saw AV by the bus station after AV had followed another resident’s family member out the door, placing AV at risk for serious harm. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) had a known elopement risk. The facility failed to provide a safe environment. According to an investigation, on or about March 22, 2023, AV eloped from the facility. AV was found outside the facility next to the garbage cans, placing AV at risk for harm. Staff discovered the entrance door to the facility unit was not secured. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to follow the care plan and provide appropriate services according to the Alleged Victim (AV)'s needs relating to toileting, personal hygiene, hearing aids, and compression socks, which resulted in AV experiencing unreasonable discomfort and a loss of personal dignity. This failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide appropriate services according to resident needs. The Alleged Victim’s (AV) call lights were not being answered in a timely manner and AV’s care plan was not being followed, relating to frequent checks, housekeeping, and toileting, which resulted in AV experiencing unreasonable discomfort and a loss of dignity. These failures are a violation of resident rights, is neglect of care which constitutes abuse.

According to an investigation, on multiple occasions, the call light system the Alleged Victim (AV) used was not working properly and AV was unable to call for help and/or to request as needed pain medication, resulting in AV experiencing increased pain. The facility failed to provide appropriate services according to AV’s needs and to respond in a timely manner, which caused repeated unreasonable discomfort, is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is care planned to be supervised when leaving the community. On or about, June 23, 2022, Law Enforcement contacted the facility about AV being lost and confused in the community. The facility failed to follow the care plan, which allowed the AV to leave the facility his/her own, leaving AV at risk for harm. The facility’s failure is a violation of resident rights, is neglect of care which constitutes abuse.

AV has a history of frequent infections and skin breakdowns, and is care planned for two showers a week. According to an investigation, there were only three documented showers for AV in the month of June 2022, due to lack of staff. AV experienced unreasonable discomfort and a loss of personal dignity. The facility failed to follow AV's care plan, which is a violation of resident's rights, is considered neglect of care and constitutes abuse.

According to an investigation, on or about April 27, 2022, the Alleged Victim (AV) reported that money was stolen out of his/her room. The facility failed to respond to AV's complaint, investigate, and assure AV had a safe place to store his/her belongings. AV experienced emotional discomfort and on or about May 16, 2022, AV filed a grievance. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about December 30, 2021, the facility conducted an audit on Alleged Victim's (AV) narcotic pain medication count and it was discovered that Alleged Perpetrator 2 (AP2) diverted AV's narcotic pain medication on or about December 13, 2021. AP2's actions is considered financial exploitation which constitutes abuse. The facility failed to provide a safe medication administration system which resulted in theft of AV's narcotic pain medication. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about December 30, 2021, the facility conducted an audit on Alleged Victim's (AV) narcotic pain medication count and it was discovered that Alleged Perpetrator 2 (AP2) diverted AV's narcotic pain medication on or about December 13, 2021. AP2's actions is considered financial exploitation which constitutes abuse. The facility failed to provide a safe medication administration system which resulted in theft of AV's narcotic pain medication. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

An unknown Alleged Perpetrator 2 (AP2) used a rice sock to treat Alleged Victim's (AV) discomfort with his/her abdominal wound. Based on interviews and facility documentations, it was determined that the rice sock treatment was not in AV's care plan/medical orders for use as relief for AV's abdominal pain. AP2 failed to provide basic care and/or services to maintain the health and safety of AV which resulted in a burn to AV's abdomen. AP2's actions are considered neglect of care which constitutes abuse. Based on interviews and facility documentation, multiple care staff knew about the rice sock and used it on an ongoing basis for relieving AV's abdominal pain. The facility failed to appropriately care plan for AV's wound care which resulted in a burn to AV's abdomen which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about November 5, 2021, Alleged Perpetrator 2 (AP2) wrongfully restrained Alleged Victim (AV) by inappropriately restraining AV in his/her wheelchair by using a gait belt to strap AV to his/her wheelchair for AP2's convenience. AP2's actions is considered wrongful restraint which constitutes abuse. 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 allegation that Alleged Perpetrator 3 (AP3) wrongfully restrained AV was investigated and found no wrongdoing by AP3.

The facility failed to develop, maintain, and implement an Acuity Based Staffing Tool. This is a violation of Oregon Administrative Rule.

The facility failed to ensure when a resident experienced a short-term change of condition that weekly progress was noted until the condition resolved. This is a violation of Oregon Administrative Rule.

The facility failed to provide records to the Department upon request which is a violation of Oregon Administrative Rule.

The facility failed to develop, maintain, and implement an Acuity Based Staffing Tool which is a violation of Oregon Administrative Rule.

The facility failed to develop, maintain, and implement an Acuity Based Staffing Tool which is a violation of Oregon Administrative Rule.

The facility failed to provide records to the Department upon request which is a violation of Oregon Administrative Rule.

Based on interview and record review, conducted during a site visit on 04/24/25, the facility’s failure to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident was substantiated. The facility’s posted staffing schedule indicated: For the residential care facility, for day and evening shifts, there were 2.5 caregivers and one medication aide, and for night shift, one caregiver and one medication aide; For the memory care, for day and evening shifts, there were 2.5 caregivers and one medication aide, and for night shift, one caregiver and one medication aide; and For specific needs contract residents, for day and evening shifts, the ratio was one staff for four residents, and for night shift, the ratio was one staff for six residents. The facility staff schedule for 03/27/25 indicated the facility was not staffed according to their posted staffing plan for two of nine shifts, of the time reviewed. It was determined the facility’s failure to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident was substantiated.

Based on interview and record review, conducted during a site visit on 04/24/25, it was determined the facility failed to accurately capture care time and care elements that staff were providing to each resident as outlined in each individual service plan for 1 of 2 sampled residents (# 1). The facility utilized the ODHS ABST and had a census of 76. Resident 1’s service plan, dated, 03/26/25, and ABST profile (undated) indicated: -Resident 1 required one-person physical assistance with changing incontinence products. The ABST profile had no time assigned for this task. Resident 1 required partial assistance and repetitive verbal cues to dress upper body and required staff assistance to dress lower body. The ABST profile had no time assigned for this task. Staff 7 stated Resident 1 could feed him/herself, but everything else s/he depended on care staff for. Staff changed his/her briefs, assisted with dressing, showering, and support with medication. It was determined the facility failed to accurately capture care time and care elements that staff were providing to each resident as outlined in each individual service plan for Resident 1. An investigation determined this is a violation of Oregon Administrative Rules.

Based on observation, interview, and record review, conducted during a site visit on 04/24/25, the facility’s failure to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident was substantiated. The facility’s census for the residential care facility was 52, including 15 residents served by the specific needs contract. The facility’s census for the memory care was 30. The facility’s posted staffing schedule indicated: For the residential care facility, for day and evening shifts, there were 2.5 caregivers and one medication aide, and for night shift, one caregiver and one medication aide; For the memory care, for day and evening shifts, there were 2.5 caregivers and one medication aide, and for night shift, one caregiver and one medication aide; For specific needs contract residents, for day and evening shifts, the ratio was one staff for four residents, and for night shift, the ratio was one staff for six residents. A review of the specific needs contract, dated 05/06/24, indicated for day and evening shifts, the facility must have four direct care staff while at full contract capacity (15 residents), and for night shift, the facility must have three direct care staff when at full contract capacity. On 02/24/25, the facility was at capacity for specific needs contract residents. A review of the staff schedule, dated 02/18/25 through 02/24/25, indicated: For the resident care facility, the facility was not staffed to their posted staffing plan for 14 of 21 reviewed shifts. For the memory care, the facility was not staffed to their posting staffing plan for three of 21 reviewed shifts. For the specific needs contract, the facility was not staffed to their posted staffing plan or contract for five of 21 reviewed shifts. It was determined the facility’s failure to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident was substantiated. An investigation determined this is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) relies on the facility staff for behavior management and requires interventions. According to an investigation, on or about November 13th, 2024, Alleged Perpetrator 2 (AP2) was reported to verbally abuse the AV, screaming and using aggressive body language. AP2's actions caused the AV emotion distress. AP2’s actions are a violation of resident rights, considered verbal abuse, and constitutes abuse. The facility did not keep AV free from verbal abuse, which is a violation of Oregon Administrative rules.

The facility failed to fully implement and update an acuity-based staffing tool which is a violation of Oregon Administrative Rule.

The Alleged Victim (AV) relies on the facility to meet his/her daily needs. According to an investigation, on or about June 6, 2024, the Alleged Perpetrator 2 (AP2) failed to follow proper procedures when he/she did not ensure the doors to the secured unit closed behind them when leaving the unit, resulting in AV exiting the secured area and exposing AV to potential harm. AP2's actions are considered neglect and constitutes abuse. The facility failed to provide a safe environment, which violates Oregon Administrative Rules.

On or about January 5, 2024, the Alleged Victim (AV) returned from the hospital. Upon his/her return, he/she found that some envelopes with cash in them had been ripped open and approximately $80.00 was taken from AV's room. Alleged Perpetrator #2 (AP2, Unknown) took the money, which is a violation of resident rights, is considered neglect of care and constitutes financial abuse. The facility's failure to keep AV safe from financial abuse is a violation of Oregon Administrative Rules.

According to investigation, on or about July 22, 2023, the Alleged Perpetrator 2 (AP2) was verbally aggressive towards Alleged Victim (AV), which caused AV emotional distress and loss of personal dignity. AP2’s actions are a violation of resident rights, are considered neglect of care and constitutes verbal abuse. The facility failed to protect AV from verbal abuse, which is a violation of Oregon Administrative Rules.

According to an investigation, on or about July 22, 2023, Alleged Perpetrator 2 (AP2) hit the Alleged Victim (AV) on the back while AV was walking away from AP2, which resulted in red mark on AV's back and significant loss of personal dignity. AP2’s actions are a violation of resident rights, are considered neglect of care and constitutes physical abuse. The facility failed to protect a resident from physical abuse which violates Oregon Administrative Rules.

According to an investigation, on or about July 22, 2023, Alleged Perpetrator (AP2) attempted to prevent the Alleged Victim (AV) from communicating from another facility staff member by blocking AV multiple times and putting his/her feet in front of AV's, to prevent AV from walking away, resulting unreasonable discomfort and serious loss of personal dignity. AP2’s actions are a violation of resident rights, are considered neglect of care and constitutes involuntary seclusion. The facility failed to protect a resident from involuntary seclusion, which violates Oregon Administrative Rules.

The facility failed to provide direct care staff sufficient in number to meet the scheduled and unscheduled needs of the residents. Facility was not staffing to the levels as indicated by the ABST. Upon Department review on December 15, 2022, the facility is back in compliance and no corrective action will be issued.

The facility failed to have an Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their needs. 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. Upon Department review on December 15, 2022, the facility is back in compliance and no corrective action will be issued.

The facility failed to have enough staff to meet the scheduled and unscheduled needs. An investigation determined this is a violation of Oregon Administrative Rules.

The facility allegedly failed to assist the Alleged Victim with toileting. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to have a policy in place to prevent the safekeeping of resident's possessions. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to administer the resident ' s medication as ordered by their physician. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to have enough staff to meet the scheduled and unscheduled needs. An investigation determined this is a violation of Oregon Administrative Rules.

The facility allegedly failed to assist the Alleged Victim with toileting. An investigation determined no licensing violation or abuse occurred.