Jefferson Lodge Memory Care Community

The Alleged Victim (AV) and Witness #1 (W1) have a history of altercations. Interventions included keeping W1 away from others when appearing agitated and to monitor AV when near W1. On or about January 12, 2026, W1 yelled at and pushed AV. Interventions include escorting AV past W1's room, deter residents from standing in W1's doorway and consulting W1's Physician regarding medication to manage W1's behaviors. Respondent failed to ensure supervision to ensure the safety of AV, placing AV at risk for harm. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(ii).

Witness #1 (W1) has a history of initiating altercations and targeting the Alleged Victim (AV). The facility has put some interventions in place to reduce the number of altercations, however, W1 will watch staff and wait until their backs are turned to initiate an altercation. On or about January 12, 2026, AV was kneeling on the floor near W1's room and W1 pushed AV down. AV was not harmed, however, AV was placed at risk for harm. Respondent failed to ensure staff supervision of W1 to ensure the safety of residents. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(ii).

On or about December 15, 2025, the Alleged Victim (AV) was standing in the hall a few rooms away from Witness #1's (W1) room. W1 told AV that he/she was going to "karate chop" AV and then W1 threw his/her hands towards AV's face and made contact when AV brought his/her hands up to defend him/herself. W1 has had similar incidents, as W1 gets agitated by others being in or around W1's apartment. AV was not injured; however, AV was placed at risk for harm. Respondent failed to provide a safe environment for AV. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

On or about December 13, 2025, the Alleged Victim (AV) was crouched in the hall cleaning the carpet near Witness #1's (W1) room. AV called for help and staff observed W1 holding onto AV while hitting him/her. W1 has had similar incidents, as W1 gets agitated by others being in or around W1's apartment. AV suffered pea sized lacerations to his/her face, neck and ear. Respondent failed to provide a safe environment for AV. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

The Alleged Victim (AV) is a known fall risk and is to have a bed alarm turned on during night shift to alert staff if AV is getting up. On or about November 12, 2025, AV was found on the floor in his/her room after he/she fell after getting out of bed. AV's bed alarm either wasn't turned on or wasn't working, placing AV at risk for harm. Respondent failed to provide a safe environment by not ensuring AV's bed alarm was on or working properly. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(ii).

Witness #1 (W1) is known to have aggressive behaviors towards other residents. On or about October 4, 2025, W1 had an altercations with another resident at approximately 3:00 PM and at approximately 3:30 pm, W1 engaged in an altercation with the Alleged Victim (AV). W1 pulled on AV's wheelchair and flicked AV on the cheek. W1 has multiple interventions in place, however, W1 has no known triggers, which makes interventions difficult. Staff are to redirect W1 from other residents to avoid altercations. The facility's failure to ensure oversight of W1 to ensure safety of others 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 altercations. Interventions included keeping W1 away from others when appearing agitated and to monitor W1 when near AV. On or about October 3, 2025, W1 approached AV in the dining room and pushed AV into a table. Staff were present at the time of the incident but did not intervene to keep the residents apart. Respondent failed to ensure staff intervened when W1 and AV were in proximity to avoid an altercation, placing AV at risk for harm. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(ii).

Witness #1 (W1) is known to engage in altercations with other residents. On or about August 17, 2025, W1 attempted to stab the Alleged Victim (AV) in the forearm with a fork. AV suffered pink discoloration to his/her forearm, which dissipated after a short time. W1 had previously been agitated and had two other altercations that same day. Interventions in place for W1 were not successful. The facility's failure to provide a safe environment is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #1 (W1) and the Alleged Victim (AV) have a history of altercations, which occurred on July 3, 2025, July 28, 2025 and July 30, 2025. On or about August 3, 2025, AV was walking down the hallway and W1 was sitting in a chair. W1 got up when he/she saw AV and pushed AV into the wall. After the altercation, AV was found on the floor curled up in a ball due to anxiety and needed as needed medication. 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) is a known fall risk and is care planned for one to one care on all shifts. There is some confusion about AV's one to one care, as some staff mention one to one care is only from 2:00 PM to 10:00 PM, however TSP's claim AV is to be on one to one care all shifts. AV's care plan also indicates AV is to have 3-5 checks per shift and have checks 8 times per shift. On or about August 3, 2025, AV was found on the floor in his/her room, and AV's brief and bed were soaked with urine. The facility failed to follow AV's care plan, resulting in AV being found on the floor and being soaked in urine, 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 for their care. On or about July 22, 2025, an outside care provider watched Witness #4 (W4) wrap a towel around the AV's wrists to restrain his/her arms to keep them from flailing while having his/her hair dried. W4 routinely restrained AV, as staff were advised to check AV after W4 left the facility, to ensure that AV wasn't restrained. On multiple occasions, facility staff found AV restrained with a seatbelt on AV's wheelchair, a safety strap on AV's waist while in bed, or AV's wrists or ankles tied to AV's bed or wheelchair. AV has a history of unintended weight loss, and has lost approximately 20 pounds. AV was care planned to have high calorie pudding, which was often refused by W4. The facility's failure to intervene to ensure the proper care of AV is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about July 18, 2025, at approximately 12:35 AM, the Alleged Victim (AV) was found on his/her fall mat. AV is care planned for safety checks hourly. AV had last been seen at approximately 10:30 PM sitting on the bed with his/her head on the pillow and feet on the floor. AV was not harmed in the fall but was at risk for harm due to failure to follow the care plan for hourly checks. Respondent failed to ensure staff followed the care plan. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(ii).

The Alleged Victim (AV) is care planned to have one to one care during the hours of 2:00 PM to 10:00 PM, due to sun downing, as an intervention for AV's behaviors and fall risk. On or about June 29, 2025, AV was placed into bed too early, approximately 7:00 pm, when AV's typical bed time is 9:00 PM to 10:00 PM. AV did not have a one to one caregiver, as outlined in his/her service plan. On this date, AV suffered a fall and was found on the floor on his/her buttocks. AV was not harmed, however, AV was placed at risk for harm. The facility's failure to follow AV's care plan is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is a known fall risk and is care planned to have staff assist with transferring from the wheelchair to dining room chair. On or about June 19, 2025, AV was found on the floor in the dining room after trying to transfer him/herself from the wheelchair to the dining room chair. AV was not injured in the fall, however, AV was placed at risk for harm. 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) is a known fall risk. On or about May 7, 2025, AV suffered a stroke. AV had suffered falls prior to his/her stroke. On or about May 14, 2025, AV suffered a fall from his/her bedside commode, suffering bleeding and swelling to AV's face, nose and lips. AV had a history of falling from his/her commode in the past. The facility's failure to have interventions in place to ensure AV's safety while using the commode is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is a known fall risk and has suffered multiple falls in March, April and May 2025. AV is care planned to have a pressure alarm beneath him/ her at all times so that staff are alerted when AV gets up. On or about May 8, 2025, AV's pressure alarm was not under him/her as care planned. AV stood up from his/her recliner and fell. The facility's failure to follow the care plan placed AV at risk for harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is care planned to be checked for safety between 3-5 times per shift during the night, as well as have a light on during the night. AV is a 2-3 person transfer. There is no documentation regarding the last item AV was checked for safety. On or about May 8, 2025, AV was found on the floor next to his/her bed. AV suffered a skin tear during the fall. The facility failed to follow the care plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is a known fall risk and has suffered multiple falls in March and April 2025. On or about April 4, 2025, AV suffered a fall in his/her room and was yelling for help. AV was found to have a distended abdomen after his/her fall. AV was sent to the hospital and diagnosed with a fractured rib. The facility's failure to implement meaningful interventions to prevent AV from falling is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about March 6, 2025, the Alleged Victim (AV) was found lying on his/her right side, next to his/her bed. AV suffered a hematoma to the head and discoloration to his/her right arm. AV was on hospice, so hospice was called and it was determined that AV had a broken arm and was given pain medication. AV had a bed alarm on his/her bed, however, it did not notify staff of the fall, as the alarm was not working. 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) and Witness #1 (W1) are known to engage in altercations. AV requires frequent checks and redirection while wandering in the facility. W1 has episodes of agitation and is triggered by loud noises. AV and W1 are to be kept apart as much as possible. On or about December 12, 2024, AV was found on the floor with a chair flipped over next to him/her. W1 was yelling at AV to get up and was raising his/her leg towards AV as if to kick at AV. 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) is a known fall risk and suffered 3 separate falls between November 3, 2024 and November 8, 2024. On or about November 8, 2024, AV was found on the floor after a fall out of his/her bed. AV was taken to the hospital and diagnosed with a fractured femur from falling out of bed. On or about November 4, 2024, interventions for falls occurring on November 3rd and 4th were to change AV to a hospital bed, to reduce AV's falls. On November 8, 2024, at the time of AV's fall, AV was not in a hospital bed. The facility's failure to ensure interventions were appropriate and in place is a violation of resident rights, are considered neglect of care and constitute abuse.

On or about November 3 and November 4, the Alleged Victim (AV) suffered falls, resulting in injuries to his/her head and a skin tear on the right elbow. AV suffered 7 falls between September 23, 2024 and November 8, 2024, 3 of which resulted in injury. The facility failed to properly care plan for the reduction of AV's falls, which 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 altercations and both have interventions in place to reduce altercations. On or about July 30, 2024, AV and W1 engaged in an altercation where the two were squeezing and shaking each other. W1 was on one to one care at the time of the altercation, however, W1's one to one staff was not near W1 and was assisting another staff within line of sight. AV received scratches during the altercation. The facility failed to provide a safe environment for AV by not following W1's service plan. The facility's failure 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 altercations and both have interventions in place to reduce altercations. On or about July 30, 2024, AV and W1 engaged in an altercation where the two were squeezing and shaking each other. AV was on one to one care at the time of the altercation, however, AV's one to one staff was not near AV and was assisting another staff within line of sight. W1 received scratches during the altercation. The facility failed to provide a safe environment for W1 by not following AV's service plan. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) has a history of aggression towards staff and residents. On or about June 29, 2024, Witness #1 (W1) was standing in the hallway talking to another resident and called AV stupid. AV's one to one caregiver got in between AV and W1 but could not separate the two. W1 kicked AV and AV scratched W1's arm and knocked his/her glasses off. W1 and AV suffered a skin tear during the altercation. The facility's failure to provide a safe environment is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #1 (W1) has a history of aggression towards staff and residents. On or about June 29, 2024, the Alleged Victim (AV) was standing in the hallway talking to another resident and called W1 stupid. W1's one to one caregiver got in between W1 and AV but could not separate the two. AV kicked W1 and W1 scratched AV's arm and knocked his/her glasses off. AV and W1 suffered a skin tear during the altercation. The facility's failure to provide a safe environment is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #1 (W1) is known to engage in altercations and has a one to one caregiver. On or about May 23, 2024, the Alleged Victim (AV) walked into another residents room. W1 was sitting on a bench near the room and saw AV and jumped up quickly after AV and hit him/her. Staff were completing shift change and W1 was sitting right with staff, however, they could not stop W1 in time. The facility's failure to provide a safe environment is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #1 (W1) has a history of agitation and alterations. On May 11, 2024, W1 was observed by a staff member to be agitated. The staff member did not notify other staff that W1 was agitated. Later, W1 was observed pulling AV by his/her sweatshirt from the dining area and shoved into his/her room by W1. The facility's failure to ensure the safety of residents 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 alterations. On March 3, 2024 AV and W1 were involved in an altercation where W1 suffered a skin tear. No interventions were put into place after this altercation. On or about May 2, 2024, W1 pushed AV into the door frame of his/her room. AV was calling for help while W1 was yelling at AV and hitting AV in the back. AV tried to get away, W1 grabbed AV's hand, causing a skin tear and a large bruise. The facility's failure to ensure the safety of residents 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. On or about March 17, 2024, W1 struck Alleged Victim (AV) on top of his/her head. Based on facility documentation and interviews, AV got into W1's personal space when AV picked items off of the ground near W1. AV triggered W1 which resulted in a physical altercation. The facility's failure to identify W1's potential trigger and redirect W1 prior to W1 becoming agitated resulted in a physical altercation causing unreasonable discomfort to AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On February 21, 2024, Witness 1 (W1) and Alleged Victim (AV) got into physical altercation in which AV dug his/her nails into W1's left hand resulting in multiple skin tears. W1 then shoved AV which resulted in both residents falling to the ground. AV was taken to the hospital for treatment after this incident and was diagnosed with a fracture of his/her upper left arm. Based on facility documentation and interviews, AV and W1 have a history of altercations with each other, and AV is care planned to be redirected away from W1 due to their history of aggressive behavior towards each other. The facility failed to follow AV's care plan by not keeping AV and W1 separated which resulted in physical harm to AV which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #1 (W1) has an extensive history of resident to resident altercations. On or about February 3, 2024, the Alleged Victim (AV) was sitting on a bench in the hallway when W1 approached AV and got upset over AV's presence. W1 began to yell and threw a cup of water on AV. Staff intervened and directed AV to a quieter area. The facility failed to properly care plan regarding W1's behaviors, 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 facility failed to implement interventions and appropriately monitor Witness 1 (W1) according to his/her known behavior and prior altercations. On or about January 26, 2024, W1 wandered into Alleged Victim's (AV) room without permission. AV yelled for staff to get W1 out of his/her room. W1 pushed AV onto his/her bed and W1 hit AV during the incident which resulted in AV having back pain. Based on facility documentation and interviews, the facility failed to ensure that W1 saw his/her doctor regarding his/her aggressive behaviors as requested by W1's doctor on November 29, 2023, and December 2, 2023. W1 had several resident-to-resident altercations after the facility failed to ensure W1 was seen by his/her doctor on December 2, 2023. The January 26, 2024, incident was preventable and caused 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. On January 16, 2024, W1 and Alleged Victim (AV) had a resident-to-resident altercation resulting in AV falling out of his/her chair, and landing on his/her hands and knees. AV and W1 have a history of engaging in altercations with each other. Based on facility documentation and interviews, the facility failed to protect AV from the risk of physical harm. AV showed signs of being a little anxious after incident. The facility administered AV's PRN medication to help with his/her anxious symptoms. W1 had been showing signs of increased behaviors and refused his/her PRN medication the day of the incident. The facility's failed to protect AV from W1's aggressive behaviors, 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 failure resulted in a physical altercation on or about December 28, 2023, 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. On or about December 24, 2023, W1 walked up to Alleged Victim (AV) and hit AV in the back of the head with three (3) briefs in his/her hand. Based on documentation and interviews, W1 targets AV and staff tries to keep W1 and AV separate. At time of incident, staff were in the area and did not redirect W1 from AV. The facility's failure to redirect W1, caused 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. On or about December 19, 2023, W1 pushed Alleged Victim (AV) and AV fell to the ground, causing AV unreasonable discomfort. Based on facility documentation and interviews, the facility failed to ensure that W1 saw his/her doctor regarding his/her aggressive behaviors as requested by W1's doctor on November 29, 2023, and December 2, 2023. W1 had several resident-to-resident altercations after the facility failed to ensure W1 was seen by his/her doctor on December 2, 2023. The December 19, 2023, incident was preventable and caused 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 failed to appropriately monitor Witness 1 (W1) according to his/her known behavior and prior altercations. On or about December 14, 2023, W1 struck Alleged Victim (AV) on the back of the head, causing AV a headache. The facility's failure to protect AV from W1's known pattern of aggressive behavior, 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. On or about December 5, 2023, W1 became agitated when he/she saw Alleged Victim (AV) and pushed AV into his/her room causing AV unreasonable discomfort. W1 is known to become agitated without warning. The facility's failure to protect AV from W1's aggressive behavior resulted in a physical altercation 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. On or about December 4, 2023, W1 became agitated and pulled Alleged Victim's (AV) wrist. W1 is known to be aggressive and erratic, without visible triggers to his/her behavior. Based on facility documentation and interviews, the facility failed to enforce a previous intervention to redirect W1 away from AV which resulted in the physical altercation, 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 provide appropriate supervision to the Alleged Victim (AV) according to his/her care needs. The facility's failure resulted in AV attempting to elope from the secured building, without staff knowledge. On or about November 30, 2023, AV was found on the floor in the hallway with his/her foot caught in the doorway which leads outside of the facility. AV's nose was bleeding and AV was screaming "I broke my arm". Based on facility documentation and interviews, the door that AV attempted to leave from was left open because someone left a trash bag outside the door which prevented the door from closing securely. As a result of the incident, AV suffered a broken arm, 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. On or about November 28, 2023, W1 slapped Alleged Victim (AV) 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 on or about November 23, 2023, in which W1 punched Alleged Victim (AV) in the face, 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 (W1) according to his/her known behavior and prior altercations. The failure resulted in a physical altercation on or about November 22, 2023, in which W1 slapped Alleged Victim (AV) on his/her face, 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 on or about November 19, 2023 in which W1 smacked Alleged Victim's (AV) left arm, 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 on or about November 19, 2023, in which W1 smacked Alleged Victim (AV) on his/her left shoulder, 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 (W1) according to his/her known behavior and prior altercations. The failure resulted in a physical altercation on or about November 18, 2023, in which Alleged Victim (AV) was found on his/her knees with W1 digging his/her nails into AV's hands 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 on or about November 10, 2023, in which W1 slapped Alleged Victim (AV) on the back of the head, causing unreasonable discomfort to the AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for a safe environment. Witness #1 (W1) has a history of agitation, aggression, and physical behaviors towards other residents. On or about November 04, 2023, W1 had aggressive behavior towards AV, which lead to a resident-to-resident altercation. W1 yelled at AV to stop moving chairs and then kicked AV. The facility failed to provide a safe environment, properly plan care, and provided interventions appropriate to mitigate W1 continued aggressive behaviors towards other residents 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 on or about October 30, 2023, between W1 and Alleged Victim (AV) in which W1 slapped AV, 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 on or about October 28, 2023, in which W1 was found squeezing Alleged Victim's (AV) right thumb and wrist, 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 (W1) according to his/her known behavior and prior altercations. The failure resulted in a physical altercation on or about October 29, 2023, in which W1 hit Alleged Victim (AV) on the neck, causing unreasonable discomfort to the AV, and AV retaliated by grabbing W1's wrist resulting in a small scratch on W1's right wrist. The facility's failure to provide a safe environment is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) and Witness #1’s (W1) have a history of resident-to-resident altercations with other residents and each other. W1 has a history of wandering the community and into other residents’ rooms. W1 requires frequent checks on whereabouts and redirection for safety. On or about October 29, 2023, W1 was trying to get into AV's room, which led to a physical altercation. W1 pushed AV down and then hit AV on the left side of head, resulting in AV having back pain. W1 was seen a few minutes prior to the altercation trying doors and wandering the halls alone. The facility failed to follow care plan, 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. On or about October 29, 2023, W1 and Alleged Victim (AV) got into an altercation in the dining room because AV was sitting in W1's preferred table. W1 tried to remove AV from the chair he/she was sitting in. W1 grabbed AV's wrist resulting in a scratch. AV fought back by hitting and kicking W1. Based on documentation and interviews, W1 has known behavioral issues in the dining room that causes him/her to be aggressive. The intervention put into place after a previous altercation between AV and W1 was not followed. The facility's failure caused unreasonable discomfort to the AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) and Witness #1 (W1) are known to engage in altercations with each other. On or about October 17, 2023, W1 hit AV in the side and pulled his/her blankets off trying to get AV out of bed. The facility's failure to provide a safe environment is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #1 (W1) is known to engage in altercations. On or about October 16, 2023, W1 was walking down the hall and slapped the Alleged Victim (AV) on the side of AV's forehead leaving a red mark and agitating AV. The facility's failure to have interventions in place to reduce W1 altercations placed 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 October 2, 2023, the Alleged Victim (AV) was jiggling the doorknob of another resident when Witness #1 (W1) shoved AV to the ground, causing pain to his/her buttocks. W1 was known to have aggressive incidents with other residents, however, W1's service plan does not mention W1's aggressive behaviors, nor was there any interventions in place to ensure the safety of other residents from W1. The facility's failure to properly care plan regarding W1's aggressive behavior is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about September 29, 2023, Alleged Victim (AV) and Witness 1 (W1) had an altercation in the dining room in which W1 pushed AV to the ground and kicked AV in the lower back. The facility failed to appropriately monitor W1 and AV according to their 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 care plan related to the Alleged Victim's (AV) fall history. The failure resulted in AV experiencing a fall on or about September 28, 2023, resulting in a skin tear to the back of AV's hand that was approximately 3 inches, causing AV unreasonable discomfort 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. Based on facility documentation and interviews, AV moved into the facility on or about June 29, 2023, and AV suffered from approximately 40 falls between June 29, 2023 (AV's move-in date), and September 28, 2023, causing continued unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Between June 8, 2023 and October 1, 2023, the Alleged Victim (AV) suffered approximately 13 falls, resulting in redness, skin tears, bruising to his/her back, swelling to his/her forehead and pain in his/her elbow. Interventions listed during this time were offer assistance, frequent checks, keep AV's walker near, and to have clear pathways. AV continued to have falls with these interventions in place. No new interventions were put into place to assist with keeping AV safe from falls. The facility's failure to properly care plan to ensure AV's safety is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for a safe environment. Witness 1 (W1) and AV are roommates. W1 has a history of being found rummaging through other resident's belongings believing that they belong to W1. AV has complained to multiple staff that W1 is stealing from h/h. The facility failed to address AV concerns and the facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for a safe environment. Witness 1 (W1) and AV are roommates. AV and W1 have history of arguing. AV frequently complains to staff about W1 being mean to AV, and not wanting to live with W1. As a result, to W1 treatment cries, self-isolate and will withdraw from activities that s/he enjoys avoiding W1. The facility failed to address AV concerns and the facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Documentation provided to the department shows Alleged Victim (AV) is scheduled to receive showers (bed baths or sponge baths) twice per week and if AV refuses both showers in a week to notify family member to come in for assistance. Staff to ensure Av’s feet are dry between toes after shower and before assisting to dress. AV received approximately five showers in the month of July 2023. AV received a shower on or about July 19, 2023, complained of feet pain on July 20th and per documentation received h/h next shower on or about July 27, 2023. AV left fourth (4th) toe was noted to have a wound. AV was sent to the hospital on or about July 30, 2023, with an infection that required a surgical amputation of h/h left fourth toe. The facility failed to provide appropriate services according to the AV’s needs, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) moved into the facility on or about July 03, 2023. AV had approximately five (5) falls from about July 06, 2023, to July 30, 2023, resulting in a head injury, AV becoming unresponsive for a brief episode and transported to the hospital, bruising to right shoulder, vertebrae and buttocks, skin tear to the left wrist and pain. The facility failed to provide a safe environment, appropriately care plan, and implement reasonable interventions to address AV’s increasing and ongoing falls, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. AV is a high fall risk with history of prior falls, and a broken clavicle prior to being admitted into facility. AV also uses a prosthesis. AV is care planned to use equipment or device, gait belt and prosthesis for pivot transfers. AV is a 2-person max assist for pivot transfers. AV also is to have a fall mat on the floor when AV is in bed, and make sure bed is lowered. On or about June 29, 2023, AV was found lying on the floor, bed completely elevated and no fall mat. On or about July 08, 2023, AV was found lying on the floor with no fall mat placing AV at risk for serious harm. The facility failed to provide a safe environment and provide appropriate services according to the AV's needs which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) has a history of falls and is a known fall risk. On or about June 24, 2023, AV had a witnessed fall when getting up from his/her wheelchair and ambulating without assistance. AV requires staff assistance to walk or transfer to avoid falls. After AV's fall, he/she was noticed to have a swollen hand. AV was sent to the hospital and suffered and broken hand. The facility's failure to ensure proper supervision to ensure AV was safe from falls is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) and Witness 1 (W1) have history of verbal altercations and aggressive behavior with other residents and each other. On or about April 24, 2023, AV and W1 behaviors escalated from verbal incident to physical incident resulting in injuries. AV sustained swelling to h/h right eye, skin tears to right bicep, and left hand near pinkie finger. W1 sustained skin tear to h/h left hand, and index finger near knuckle. The facility failed to appropriately adjust care plans and implement reasonable interventions to address AVs and W1s continued aggressive behaviors, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) and Witness 1 (W1) have history of verbal altercations and aggressive behavior with other residents and each other. On or about April 24, 2023, AV and W1 behaviors escalated from verbal incident to physical incident resulting in injuries. W1 sustained swelling to h/h right eye, skin tears to right bicep, and left hand near pinkie finger. AV sustained skin tear to h/h left hand, and index finger near knuckle. The facility failed to appropriately adjust care plans and implement reasonable interventions to address AVs and W1s continued aggressive behaviors, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for a safe environment. Witness 1 (W1) and AV have history of aggressive behaviors towards staff and other residents. W1 service plan requires staff to provide 1:1 care to prevent W1 from harming others during episodes of heightened agitation. AV TSP requires staff to monitor non-consensual touching and intervene and redirect when interacting with other residents in a non-consensual manner. On or about April 02, 2023, AV was tugging at W1 and would not stop when W1 asked. W1 threw a cup at AV mouth causing unreasonable pain to AV. The Facility failed to provide a safe environment for AV and failed to follow the interventions and care plans for W1 and AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) and Witness 1 (W1) have history of altercations towards residents, and each other. W1 has history of going into other resident rooms and gets angry if anyone accuses h/h of stealing. AV service plan has interventions for redirecting that is not successful, and W1 has no interventions outlined for altercations. On or about March 18, 2023, AV accused W1 of stealing something from h/h and a physical altercation occurred resulting in AV sustaining a skin tear on h/h left hand and a scraped ankle. The facility failed to appropriately care plan and provided interventions to mitigate AV and W1 from having physical altercations which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for a safe environment. Witness 1 (W1) and AV have history of physical resident-to-resident altercation were W1 struck AV causing a bruise. An intervention was placed for staff to cue residents to not walk so close to others. On or about February 15, 2023, AV tried taking a jacket from W1, W1 struck AV in the face, resulting in AV having a cut on h/h lip and a red nose. The facility failed to appropriately adjust the service plan for W1 to prevent physical altercations with AV, The Facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Witness #1 (W1) is known to have aggressive behaviors with staff and residents. Between December 2022 and February 2023, W1 was documented as having aggressive behaviors with both staff and residents at least 10 times. On or about February 14, 2023, W1 pushed the Alleged Victim (AV) down. When AV stood up after being pushed down, then sat down, AV yelped. W1 had been aggressive with AV in the past, and staff were directed to keep AV and W1 apart. The facility's failure to follow the care plan placed AV at risk for harm. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #1 (W1) is known to engage in altercations with other residents and staff. On or about February 11, 2023, W1 went into the Alleged Victim's (AV) room, and when AV asked W1 to leave, W1 backed AV into a corner and hit AV in the chest, leaving a bruise on AV's chest and back. The facility's failure to properly care plan regarding W1's aggressive behaviors resulted in AV receiving bruises from W1. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) is a high fall risk and has a history of falls occurring while transferring, ambulating and toileting without assistance. AV service plan dated August 01, 2022, indicates AV is to receive assistance with ambulation, transfers and fall prevention as needed, and requires routine toileting assistance. According to interviews and documentation provided during the investigation AV had approximately four falls causing injury to AV prior to the fall on or about February 06, 2023, resulting in a left hip fracture and skin tear to left elbow causing severe pain. The facility failed to appropriately care plan and implement reasonable interventions to address AV’s increasing and ongoing falls, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) has history of aggressive/verbal behaviors and entering other residents’ rooms resulting in physical altercations with residents and staff. AV and W1 have history of prior verbal altercation with threats to punch each other after AV entered W1 room on December 3, 2022. AV is service planned for staff to redirect as an intervention, however, documentation provided to the department indicates AV does not respond to redirection. On or about January 5, 2023, AV knocked on W1 door and pushed h/h way into W1 room. W1 punched AV causing AV to fall, hit h/h head on a bench and was knocked out. AV was not talking or moving to any stimuli, and sustained red mark on chin, head, and an abrasion on h/h leg. AV was transported to the emergency room for medical attention. The facility failed to appropriately adjust AV care plan and implement reasonable interventions to address AVs ongoing behaviors and entering other residents’ rooms, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness 1 (W1) has a history of aggression and altercations with staff and other residents resulting in harm, and injury. Documentation provided to the Department indicates W1s interventions put into place after prior altercations have been monitor and redirection. On or about December 19, 2022, W1 attempted to enter Alleged Victim (AV) room. W1 grabbed AV’s throat, and started choking AV, resulting in AV becoming frightened. The facility failed to appropriately care plan and implement reasonable interventions to address W1s ongoing aggression and behaviors, is violation of resident rights, is considered neglect of care and constitutes abuse.

Witness 1 (W1) has a history of aggression and altercations with staff and other residents resulting in harm, and injury. Documentation provided to the Department indicates W1s interventions put into place after prior altercations have been monitor and redirection. On or about December 11, 2022, W1 walked by Alleged Victim (AV) and pushed AV’s head back, resulting in AV becoming visibly upset. The facility failed to appropriately care plan and implement reasonable interventions to address W1s ongoing aggression and behaviors, which is violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) had approximately Twelve (12) falls in seven (7) months approximately between the months of March 2022 to October 2022, sustaining injuries of skin tears, bruises, and fractured wrist. The facility failed to appropriately care plan and implement reasonable interventions address AV’s increasing and ongoing falls, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) was a known fall risk and suffered multiple falls between August and October 2022. The facility's documentation does not show any interventions put into place to alleviate AV's falls. Many of AV's falls resulted in skin injuries or head injuries. The facility's failure to properly care plan regarding falls is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) and Witness 1 (W1) have a history of aggressive behaviors with other residents and with each other. AV is care planned to have safety check every fifteen (15) minutes. W1 is care planned for one-on-one support or offer activities. On or about October 10, 2022, W1 and AV were involved in an altercation, W1 was hitting AV with a metal water bottle and pulled AV’s hair, resulting in a skin tear to AV’s right arm. The facility failed to appropriately adjust care plans and implement reasonable interventions to address AVs and W1s continued aggressive behaviors. The facility failed to follow AV’s care plan and provide safety checks every fifteen (15) minutes, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #1 (W1) is known to have altercations and between August 1, 2022 and October 2, 2022, W1 was physically aggressive towards others at least 16 times. On or about October 2, 2022, W1 and the Alleged Victim (AV) were caught hitting each other in the dining room. AV was not injured, however, he/she was placed at risk for harm. The facility's failure to properly care plan to address W1's physical behavior is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #1 (W1) is known to have altercations and between August 1, 2022 and October 2, 2022, W1 was physically aggressive towards others at least 16 times. On or about October 2, 2022, W1 pushed the Alleged Victim (AV) to the ground, causing AV to hit his/her head, causing a goose egg sized bump and a bruise. The facility's failure to properly care plan to address W1's physical behavior is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness 1 (W1) has a history of agitation and aggressive behaviors with other residents. W1 has been involved in approximately nine (9) resident-to-resident altercations between August 03, 2022, and September 16, 2022. On or about September 16, 2022, W1 grabbed Alleged Victim (AV) walker, stomped on AV’s foot and shoved AV to the ground, causing AV emotional distress. The facility failed to appropriately adjust W1 care plan and implement reasonable interventions to address W1s continued aggressive behaviors, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to intervene when the Alleged Victim ‘s (AV) condition changed. On or about August 23, 2022, AV was admitted into the facility and was independent with toileting and was able to ambulate with the use of an assistive device. According to documentation AV began to decline, refuse care and was no longer able to meet h/h own care needs. AV was admitted into the hospital on or about September 08, 2022, diagnosed with Stage one pressure sores on h/h right bilateral posterior lower leg, two pressure sores on h/h left bilateral posterior lower leg, stage one pressure sore on h/h coccyx, redness to both of h/h heels, a rash to left groin, and pain in h/h feet. The facilities failure to assess, assist and care plan in accordance with AVs capabilities and needs is a violation of resident rights, is neglect of care and constitutes abuse.

The facility failed to follow the care plan and provide a safe environment for Alleged Victim (AV). Witness 1 (W1) has history of wandering into other residents’ rooms and resident to resident altercations. W1 is care planned to have frequent checks and to keep W1 away from other residents. On or about, September 09, 2022, W1 wandered into AV room. W1 and AV had a verbal confrontation that turned physical. W1 grabbed AVs arm and pushed him/her to the ground resulting in a skin tear to AV. This failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness 1 (W1) has history of combative behaviors and altercations with other residents. W1 is care planed and has interventions in place when agitated. On or about August 26, 2022, W1 became agitated and tried to enter Alleged Victim (AV) room by pushing through the door. W1 hit AV on h/h left cheek and arm, resulting in redness. The facility failed to follow the care plan and interventions to address W1s behaviors, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness 1 (W1) has history of wandering into other residents’ rooms, combative behaviors, and resident to resident altercations. W1 is care planned to keep h/h away from other residents. On or about August 25, 2022, Alleged Victim (AV) yelled at W1 and W1 hit AV on h/h right forearm. The facility failed to follow the care plan which is a violation of resident rights is neglect of care and constitutes abuse.

Witness #1’s (W1) has a history of agitation, combative behaviors, and resident-to-resident altercations. On or about August 17, 2022, W1 slapped Alleged Victim (AV) on the face and tried to grab AV walker. W1 is care planned to be redirected and to keep W1 away from other residents in common arear. The facility only redirected W1 but failed to keep W1 away from other residents in common area. The facility failed to follow care plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness 1 (W1) has a history of agitation and aggressive behaviors with other residents. W1 has been involved in approximately five (5) resident-to-resident altercations between August 03, 2022, and August 16, 2022. On or about August 16, 2022, W1 slapped Alleged Victim (AV) in the face multiple times causing redness to AV face. The facility failed to appropriately adjust W1 care plan and implement reasonable interventions to address W1s continued aggressive behaviors, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for a safe environment. Witness 1 (W1) has history of aggressive behaviors. On or about August 03,2022, Witness 1 (W1) struck AV with pillows, and struck AV on the right side of h/h head leaving a lump. The facility failed to adjust the service plan for W1 leading to continued aggressive behavior. Facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) Slid off the bed on or about May 01, 2022, sustaining skin tear, bruise, and rib fracture. AV Slid off the bed on or about May 17, 2022. The facility failed to appropriately care plan and implement reasonable interventions to address AV’s sliding of the bed, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) is care planned to have Geri-Sleeves on both arms during all waking hours. On or about May 11, 2022, AV was not wearing Geri-Sleeves and sustained a skin tear to h/h right arm while being transferred in a Hoyer Lift. The facility failed to follow the care plan which is a violation of resident’s rights is neglect of care and constitutes abuse.

On or about November 14, 2021, the facility discovered the Alleged Perpetrator 2 (AP2) was administering an excessive amount of PRN Narcotic Medications to Alleged Victim (AV). Based on an investigation, it was determined that (AP2) took AV’s medication, resulting in financial exploitation, by way of theft. AP2’s actions are a violation of resident rights, are considered neglect of care and constitute financial abuse. AP1 failed to ensure adequate supervision, training, and oversight of the medication administration system, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility discovered the Alleged Perpetrator 2 (AP2) was administering an excessive amount of PRN Narcotic Medications to Alleged Victim (AV). Based on an investigation, it was determined that (AP2) took AV’s medication, resulting in AV having pain and preventing h/h from getting up. AP2’s actions and failure to provide a safe medication administration system are a violation of resident rights, are considered neglect of care and constitute abuse. AP1 failed to ensure adequate supervision, training, and oversight of the medication administration system, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility discovered the Alleged Perpetrator 2 (AP2) was administering an excessive amount of PRN Narcotic Medications to Alleged Victim (AV). Based on an investigation, it was determined that (AP2) took AV’s medication, resulting in financial exploitation, by way of theft. AP2’s actions are a violation of resident rights, are considered neglect of care and constitute financial abuse. AP1 failed to ensure adequate supervision, training, and oversight of the medication administration system, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to properly staff to it's posted staffing plan for 2 of 3 shifts, which is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) has a history of falls. On or about October 16, 2025, AV experienced a fall in his/her room. Staff checked AV for injury and returned AV to his/her bed and AV fell asleep. Staff are trained to check vitals after an incident with a resident. Alleged Perpetrator #2 (AP2) did not take AV's vitals after this incident, placing AV at risk for harm. AP2's actions are a violation of resident rights, are considered neglect of care and constitute abuse, as outlined in OAR 411-020-0002(1)(b)(A)(ii). The facility's failure to ensure staff take resident vitals as trained is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) is a 2-person transfer and assistance with toileting. AV is care planned to not be left alone while using the toilet, due to AV being a fall risk. On or about October 1, 2025, Alleged Perpetrator #2 (AP2) and Alleged Perpetrator #3 (AP3) assisted AV to the toilet and then left AV's room. After about 5 minutes, AP2 and AP3 heard a thud and went into AV's room and found AV on the floor of the bathroom. AV suffered redness and bruising to his/her tailbone from the fall. AP2 and AP3's actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility's failure to ensure staff followed the care plan is a violation of Oregon Administrative Rules.

The facility failed to staff according to their posted staffing plan on one shift for one day, on September 22, 2025, which is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) suffered two falls on August 4, 2025 and was sent to the hospital and was found to have a bruise on his/her buttocks. On or about August 4, 2025, it was discovered that Alleged Perpetrator #2 (AP2) had given AV a sedative to calm him/ her down. AV did not have any as needed medication listed as an intervention. AP2 gave the medication for his/her convenience, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility's failure to ensure medication is not used as a restraint is a violation of Oregon Administrative Rules.

The facility failed to carry out medication and treatment orders as prescribed in accordance with OAR 411-054-0055(1)(f); per complaint that residents are not given PRNs when needed and a resident was given an unprescribed medication, 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 was substantiated.

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 was substantiated.

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 was substantiated.

The facility’s failure to complete or update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly as required was substantiated.

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, use the results of an ABST to develop and routinely update the facility’s posted staffing plan, and complete or update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly as required was substantiated.

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, use the results of an ABST to develop and routinely update the facility’s posted staffing plan, and complete or update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly as required was substantiated.

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, use the results of an ABST to develop and routinely update the facility’s posted staffing plan, and complete or update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly as required was substantiated.

The facility’s failure to complete or update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly as required was substantiated.

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, use the results of an ABST to develop and routinely update the facility’s posted staffing plan, and complete or update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly as required was substantiated.

The facility’s failure to use the results of an ABST to develop and routinely update the facility’s posted staffing plan and complete or update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly as required was substantiated.

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, use the results of an ABST to develop and routinely update the facility’s posted staffing plan, and complete or update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly as required was substantiated.

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, use the results of an ABST to develop and routinely update the facility’s posted staffing plan, and complete or update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly as required was substantiated.

The facility’s failure to use the results of an ABST to develop and routinely update the facility’s posted staffing plan and complete or update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly as required was substantiated.

The facility’s failure to use the results of an ABST to develop and routinely update the facility’s posted staffing plan and complete or update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly as required was substantiated.

The facility’s failure to use the results of an ABST to develop and routinely update the facility’s posted staffing plan and complete or update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly as required was substantiated.

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, use the results of an ABST to develop and routinely update the facility’s posted staffing plan, and complete or update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly as required was substantiated.

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, use the results of an ABST to develop and routinely update the facility’s posted staffing plan, and complete or update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly as required was substantiated.

The facility’s failure to complete or update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly as required was substantiated.

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, use the results of an ABST to develop and routinely update the facility’s posted staffing plan, and complete or update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly as required was substantiated.

The facility’s failure to complete or update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly as required was substantiated.

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, use the results of an ABST to develop and routinely update the facility’s posted staffing plan, and complete or update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly as required was substantiated.

On or about March 23, 2025, a semi-nude photo was taken of the Alleged Victim (AV) and uploaded to social media by Alleged Perpetrator #2 (AP2). AP2 violated facility policy and resident rights by taking the photo and posting it to social media. AP2's actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility's failure to ensure AV's safety from having inappropriate photo's taken and posted to social media is a violation of Oregon Administrative Rules.

The facility’s failure to complete or update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly as required was substantiated.

The facility’s failure to complete or update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly as required was substantiated.

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, use the results of an ABST to develop and routinely update the facility’s posted staffing plan, and complete or update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly as required was substantiated.

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.

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 January 23, 2025, Alleged Perpetrator #2 (AP2) was upset and swore while assisting the Alleged Victim (AV) with cares. While AP2 was not speaking to AV, AP2 did make statements including swearing in front of AV, causing AV unreasonable discomfort and experiencing verbal abuse. AP2's actions are a violation of resident rights, are considered neglect of care and constitutes abuse. The facility's failrue to protect AV from verbal abuse is a failure of Oregon Administrative Rules.

On or about January 23, 2025, Alleged Perpetrator #2 (AP2) was upset and swore while assisting the Alleged Victim (AV) with cares. While AP2 was not speaking to AV, AP2 did make statements including swearing in front of AV, causing AV unreasonable discomfort and experiencing verbal abuse. AP2's actions are a violation of resident rights, are considered neglect of care and constitutes abuse. The facility's failrue to protect AV from verbal abuse is a failure of Oregon Administrative Rules.

The Alleged Victim (AV) is care planned to have a fall mat in his/her room to alert staff when and if AV falls, as AV has a history of falls from self-transferring. On or about January 3, 2025, Alleged Perpetrator #2 (AP2) turned off AV's fall mat because it was malfunctioning. AP2's actions resulted in AV suffering a fall and sustaining a bruise to his/her ankle and staff were not aware of the fall. AP2's actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility's failure 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).

On or about December 22, 2024, Alleged Perpetrator #2 (AP2) was assisting the Alleged Victim (AV) with cares when AV became agitated and began yelling at AP2. AP2 pushed AV and poked him/her in the chest, telling AV "you don't do that". Another staff intervened and took over cares of AV. Approximately 15 minutes later, AV was still agitated and followed AP2 into another residents room. AP2 pushed AV out of the room and locked the door behind AV. After AP2 pushed AV out of the room, it was discovered that AV suffered a skin tear due to the interaction. AP2's actions are a violation of resident rights, are considered neglect of care and constitute physical abuse. The facility's failure to protect AV from physical abuse is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) has a history of falls and having ticks and/or spasms. AV was assigned one to one care, to be performed by Alleged Perpetrator #2 (AP2). On or about August 9, 2024, AV was walking down the hall when AV had a spasm and fell. AV landed on his/her wrist and was taken to the hospital and diagnosed with a fractured wrist. AP2 failed to ensure AV's safety while ambulating, as AP2 was not close enough to AV to protect AV from falling. AP2's actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility's failure is a violation of Oregon Administrative Rules.

The facility failed to provide a safe environment which resulted in the Alleged Victim (AV) eloping without injury. The failure is a violation of Oregon Administrative Rules. The allegation that Alleged Perpetrator 2 (AP2) neglected AV was investigated and determined to be not substantiated.

Alleged Victim (AV) relies on the facility for his/her care. AV is care planned to have toileting and incontinence assistance. AV has episodes of resisting ADLs. If AV resists ADLs, staff is to wait 30 minutes and re-try. Use calm and direct language. On or about October 31, 2023, Alleged Perpetrator #2 (AP2) was called to Alleged Victim’s (AV) room to assist two other caregivers in changing AV's brief. AV declined twice became resistant and hit, punched AP2, then attempted to kick AP2 in the face. AP2 reacted by hitting AV. AP2 failed to follow AV's care plan and actions are a violation of resident rights, are considered neglect of care and constitute physical abuse. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to immediately notify the local Department office, or the local AAA, of any incident of abuse or suspected abuse in accordance with OAR 411-054-0028(2)(b) per complaint that the facility failed to report a resident's 34 falls, which is a violation of Oregon Administrative Rules.

Based on observation, interview and record review, during a site visit conducted on 10/03/23, it was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs for residents, which is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

Based on observation, interview, and record review, conducted during a site visit on 10/03/23, it was confirmed the facility failed to provide a daily meal program for nutrition and hydration based upon the resident's preferences and needs available throughout each resident's waking hours.

Based on interview and record review, conducted during a site visit on 10/03/23, it was confirmed the facility failed to immediately notify the local Department office, or the local AAA, of any incident of abuse or suspected.

Based on interview and record review, conducted during a site visit on 10/03/23, it was confirmed the facility failed to carry out medication and treatment orders as prescribed.

Based on observation, interview and record review, during an site visit on 10/03/23, it was confirmed the facility failed to implement service plans that are reflective of resident needs.

ABST Condition #RCFCD23-01393, impending effective November 6, Imposed effective Monday November 13, 2023 no further action required.

It was determined the facility failed to evaluate the resident's health, medical, behavioral or care needs within a reasonable time, but no later than 24 hours after the resident has been deemed ready for discharge.

On or about January 01, 2023, the Oregon Health Authority 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 for a total of 30 days.

On or December 01, 2022, the Oregon Health Authority 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 for a total of 30 days

On or about August 1, 2022, the Oregon Health Authority 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 July 1, 2022 to July 31, 2022, for a total of 30 days.

The Alleged Victim (AV) relies on the facility for his/her care. On or about November 17, 2021, Alleged Perpetrator (AP2) gave AV a picture and AP2 allowed AV to kiss AP2 on the lips. AP2’s actions are a violation of residents rights, are considered neglect of care and constitutes abuse. The facility failed to provide a safe environment which is a violation of Oregon Administrative Rules.

The facility discovered the Alleged Perpetrator 2 (AP2) was administering an excessive amount of PRN Narcotic Medications to Alleged Victim (AV). Based on an investigation, it was determined that (AP2) took AV’s medication, resulting in financial exploitation, by way of theft. AP2’s actions are a violation of resident rights, are considered neglect of care and constitute financial abuse. AP1 failed to ensure adequate supervision, training, and oversight of the medication administration system, which is a violation of resident rights, is considered neglect of care and constitutes abuse.