Guardian Angel Homes Memory Care

The Alleged Victim (AV) relies on the facility for care, has a fall history, and is care planned to have a motion detector on in AV's room and a tab alarm on AV at all times. On or about March 19, 2024, AV fell and was found on the floor of their apartment, resulting in a red mark on the AV. According to an investigation, AV’s tab alarm was not functional due to a battery issue and the motion detector was not facing the AV. The facility failed to provide appropriate services according to Alleged Victim’s needs, regarding care planning, safety checks and monitoring, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately care plan related to the Alleged Victim's (AV) falls. The failure resulted in AV experiencing experiencing multiple falls with injury, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to follow the Alleged Victim's (AV) care plan to ensure a pressure alarm is under him/her at all times. The failure resulted in AV experiencing a fall, causing unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately care plan related to Witness 1's known behaviors and recent altercations. The failure resulted in a physical altercation with the Alleged Victim (AV), causing skin injury and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately care plan related to The Alleged Victim’s (AV) known behaviors and recent increase of altercations. Based on facility documentation and interviews, AV was in three resident-to-resident altercations on or about October 21, 2023, resulting in AV getting physically attacked, causing unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to appropriately monitor Witness 1 (W1) and Alleged Victim (AV) according to their known behaviors. On or about October 9, 2023, AV walked into W1's room and W1 grabbed both of AV's wrists, squeezing them very tight which resulted in an open skin tear for AV. The failure resulted in unreasonable discomfort to the AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement appropriate interventions and provide appropriate supervision related to the Alleged Victim’s (AV) known history of falls. On or about September 9, 2023, AV suffered from a ground level fall that resulted in an abrasion to his/her face. The facility's failure caused AV unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On August 21, 2023, Witness 1 (W1) went into Alleged Victim's (AV) room and hit AV with one of AV's shoes. AV sustained a physical mark on his/her face and had some light bruising on the side of his/her face. Based on facility documentation and interviews, W1 has been physically aggressive with AV before the reported incident. The facility failed to implement interventions and appropriately monitor W1 according to his/her known behavior and prior altercations. The failure resulted in a physical altercation, causing unreasonable discomfort to the AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately monitor Witness 1 (W1) according to his/her known behavior and prior altercations. The facility's failure resulted in a physical altercation between W1 and Alleged Victim (AV) in which W1 hit on AV's forearm, causing unreasonable discomfort to the AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to appropriately monitor Witness 1 (W1) according to his/her known behavior and prior altercations. The failure resulted in a physical altercation between W1 and Alleged Victim (AV) in which W1 punched AV in the back, causing unreasonable discomfort to the AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement appropriate interventions and appropriately monitor Witness 1 (W1) according to his/her known behavior and prior altercations. The facility's failure resulted in a physical altercation on or about June 10, 2023, between W1 and Alleged Victim (AV) in which AV received a large bruise on his/her arm causing AV unreasonable discomfort which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide adequate care and supervision to Alleged Victim (AV) which resulted in a fall that caused AV facial cuts, bruising, and a fractured forearm/wrist. Based on facility documentation and interviews, AV was found on the floor in the hallway in front of his/her apartment. A crevice between the floor in the apartment and the hallway was not covered with a threshold strip and there is a difference in height between the two floors which appears to be a tripping hazard. The facility's failure to provide a safe environment for AV, resulted in AV experiencing unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to appropriately monitor Alleged Victim (AV) and Witness 1 (W1) which resulted in a physical altercation between AV and W1 in which AV was slapped in the face, causing unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately monitor Witness 1 (W1) according to his/her known behavior and prior altercations. The failure resulted in a physical altercation between W1 and Alleged Victim (AV) in which W1 slapped AV's right arm, causing unreasonable discomfort to AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately monitor Witness 1 (W1) according to his/her known behavior and prior altercations. The facility's failure resulted in a physical altercation in which W1 pinched and hit Alleged Victim (AV) on the back of his/her head, causing unreasonable discomfort to the AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately monitor Witness 1 (W1) according to his/her known behavior and prior altercations. The failure resulted in a physical altercation, causing unreasonable discomfort to the Alleged Victim (AV), which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately monitor Witness 1 (W1) according to his/her known behavior and prior altercations. The facility's failure resulted in a physical altercation, causing unreasonable discomfort to the Alleged Victim (AV), which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately monitor the Alleged Victim (AV) according to his/her known behavior and prior altercations. The failure resulted in a physical altercation, causing unreasonable discomfort to both AV and Witness 1 (W1), which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately monitor Alleged Victim (AV) according to his/her known behavior and prior altercations. The failure resulted in a physical altercation, causing unreasonable discomfort to the Witness 1 (W1), which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Perpetrator 2 (AP2) failed to follow Alleged Victim's (AV) care plan which resulted in a fall on November 3, 2022, causing AV unreasonable discomfort. AP2's action is considered neglect of care which constitutes abuse. The facility failed to provide a safe environment for AV which resulted in a fall on November 3, 2022, causing AV unreasonable discomfort. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately care plan after the Alleged Victim (AV) returned to the facility on October 13, 2022, from the hospital for an October 8, 2022 fall that caused AV a broken hip and required surgery. After AV returned to the facility, AV suffered another fall on October 17, 2022, after a fall on October 15, 2022, and after AV returned to the facility on October 13, 2022, from the hospital. The fall on October 17, 2022, resulted in pain and unreasonable discomfort for AV. The facility's failure to provide adequate care and supervision to AV resulted in a risk of serious harm which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately care plan after the Alleged Victim (AV) returned to the facility on October 13, 2022, from the hospital for an October 8, 2022 fall that caused AV a broken hip and required surgery. After AV returned to the facility, AV experienced another fall on October 15, 2022, that resulted in pain and unreasonable discomfort. The facility's failure to provide adequate care and supervision to AV resulted in a risk of serious harm which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately monitor Witness 1 according to his/her known behavior and prior altercations. The failure resulted in a physical altercation and causing unreasonable discomfort to the Alleged Victim, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately monitor Witness 1 according to his/her known behavior and prior altercations. The failure resulted in a physical altercation and causing unreasonable discomfort to the Alleged Victim, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and provide appropriate services related to the Alleged Victim’s (AV) known history of falls. The failure resulted in AV experiencing a fall with injury, causing unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately monitor Witness 2 (W2) according to his/her known behavior and prior altercations. The failure resulted in a physical altercation causing unreasonable discomfort to the Alleged Victim (AV), which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide appropriate supervision to the Alleged Victim (AV) according to his/her needs. The failure resulted in AV eloping the secured building, without staff knowledge, placing him/her at risk of harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately monitor Witness 1 according to his/her known behavior and prior altercations. The failure resulted in a physical altercation and causing unreasonable discomfort to the Alleged Victim, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately monitor Witness 1 according to his/her known behavior and prior altercations. The failure resulted in a physical altercation and causing unreasonable discomfort to the Alleged Victim, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about March 21, 2022, Alleged Victim (AV) and Witness 1 (W1) had a resident-to-resident altercation in which W1 pulled AV up off a couch, walked AV to the hall and hit AV in the mouth twice. Based on facility documentation and interviews, it was determined the facility failed to appropriately care plan and implement reasonable interventions to address W1's aggressive behaviors, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about February 5, 2022, the facility failed to provide adequate care and supervision to Alleged Victim (AV) which resulted in a fall and broken arm. Based on interviews and facility documentation, AV was care planned to have a pressure alarm under him/her as a fall prevention/intervention for AV's high fall risk. At time of incident, AV did not have a pressure alarm under him/her. The facility's failure to follow AV's care plan resulted in AV suffering unreasonable discomfort which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide a safe environment for Alleged Victim (AV) by failing to train Alleged Perpetrator 2 (AP2) on AV's care plan which resulting in a skin tear to AV. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse. The allegation that AP2 neglected AV was investigated and findings determined no wrongdoing by AP2.

The facility failed to protect Alleged Victim (AV) from sexual encounters that involved inappropriate touching by Witness 2 (W2). An investigation determined that the facility failed to put behavioral interventions in place to protect residents from W2's inappropriate behavior which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is a fall risk, has a history of falls, and is dependent on staff to implement fall interventions. According to an investigation, on or about May 6, 2025, AP2 neglected to put the AVs fall mat at the bedside as care planned, after assisting the AV into bed. The AV was found on the floor at their bedside resulting in pain to the right hip and right side of the face. AP2’s actions are a violation of resident rights, considered neglect, and constitutes abuse. The facility failed to ensure care plans were implemented, which violates Oregon Administrative Rules.

The Alleged Victim (AV) relies on the facility to for care and supervision. On or about September 22, 2024, Witness 1 (W1) went into AV’s room and over an hour later, after W1 was observed leaving AV’s room, AV was found on the floor with injuries. According to an investigation, the Alleged Perpetrator 2 (AP2) was in the common area of the facility, on their cell phone and did not look up when W1 walked by and went into AV’s room. AP2 failed to provide adequate supervision for AV and W1, which is neglect of care and constitutes abuse. The facility failed to provide a safe environment, which is a violation of Oregon Administrative Rules.

Alleged Victim (AV) relies on the facility for h/h care. AV has a history of falls. Hospice provided an alarm for AV's bed on or about July 8, 2024. According to AVs care plan, AV is supposed have the the alarm under h/h at all times, bed, wheelchair and recliner. On or about August 4, 2024, Alleged Perpetrator 2 and 3, toileted AV, and placed AV in a recliner in the living room. According to AP1 the camera video footage was viewed, which showed AV trying to get up, and s/he fell to h/h side/back and possibly bumped the back of h/h head. AP2 and AP3 did not take AV's pressure alarm from h/h apartment and did not place the alarm back under AV in the living room. AP2 and AP3 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.

Alleged Perpetrator 2 (AP2) used profanity in conversation with Alleged Victim (AV). Based on facility documentation and interviews, AP2 told AV to leave AP2 alone with a threatening tone using offensive profanity in which AV was observed to be shaking and scared as a result of AP2's actions. AP2's is responsible for verbal abuse. The facility failed to protect AV from inappropriate verbal comments made by staff and the failure is a violation or Oregon Administrative Rules.

The facility failed to implement an approved proprietary Acuity-Based Staffing Tool (ABST). The proprietary currently in use has not been submitted for review and approval by the Department. An investigation determined this is a violation of Oregon Administrative Rules.

Alleged Perpetrator 2 (AP2) made an inappropriate verbal comment in Alleged Victim's (AV) presence. AP2 is responsible for verbal abuse. The facility failed to protect AV from inappropriate verbal comments made by staff and the failure is a violation of Oregon Administrative Rules.

Alleged Perpetrator 2 (AP2) failed to follow Alleged Victim's (AV) care plan which resulted in AV suffering a fall, causing AV unreasonable discomfort. Based on facility documentation and interviews, AP2 failed to assist AV in transferring, ambulating, and following AV's care plan to have AV's pressure alarm in use. AP2's actions is considered neglect of care which constitutes abuse. The facility failed to provide a safe environment for AV which is a violation of Oregon Administrative Rules.

The facility failed to implement an approved proprietary Acuity-Based Staffing Tool (ABST). The proprietary currently in use has not been submitted for review and approval by the Department. An investigation determined this is a violation of Oregon Administrative Rules.

Alleged Perpetrator 2 (AP2) physically abused Alleged Victim (AV) by using physical force against AV which was caused by other than accidental means, which resulted in AP2 throwing water in AV's face as punishment for AV spiting in AP2's face. AP2 is responsible for physical abuse. The facility failed to provide a safe environment for AV which is a violation of Oregon Administrative Rules.

The facility failed to ensure the implementation of services. The facility's failure to properly care plan is a violation of Oregon Administrative Rules.