Kinsington Oak Grove

The Alleged Victim (AV) relies on the facility to provide a safe environment. According to an investigation AV was struck in the head and neck by Witness 1 (W1) while facility staff watched W1 approach AV and strike them in the head. Both AV and W1 have a history of behaviors and resident-to-resident altercations, but the facility failed to implement interventions to keep AV safe. This is a violation of resident rights and constitutes neglect, which is abuse.

The Alleged Victim (AV) relies on the facility for care and to provide a safe environment. According to an investigation, Witness 1 (W1) and AV engaged in three resident to resident altercations from June 7, 2025, through June 11, 2025, and W1 was not administered their cognitive impairment behavioral medication from June 6, 2025, through June 8, 2025. The facility failed to implement any non-medication interventions to mitigate AV and W1 from having continued resident to resident altercations, which is a violation of resident rights and is neglect, which constitutes abuse.

The Alleged Victim (AV) relies on the facility to provide care and services. According to an investigation, AV's care plan states that AV has a history of falls and interventions were implemented to help mitigate AV from falling. One of the interventions was that AV was to have a bed alarm in place and working when AV is in bed. On or about May 12, 2025, AV was found on the floor of AV's room and had suffered an unwitnessed fall. The facility failed to follow the care plan, and the bed alarm was not in place at the time AV was found on the floor, which is a violation of resident rights, is neglect of care which constitutes abuse.

The Alleged Victim (AV) relies on the facility for care and services. According to an investigation, AV suffered a fall on or about May 5, 2025 and the facility did not put interventions in place or update the care plan with interventions for AV falling. AV continued to show signs of pain as noted by facility staff. AV suffered another fall on May 14, 2025, which resulted in a bilateral hip fracture. The facility failed to implement safety measures to help mitigate AV from falling, which is a violation of resident's rights, is considered neglect and constitutes abuse.

The Alleged Victim (AV) relies on the facility to provide care and a safe environment. According to an investigation, on or about 04/03/2025 AV suffered an unwitnessed fall that resulted in a traumatic head injury. AV had a history of falls prior to the fall on 04/03/2025 and the facility failed to implement progressive interventions to mitigate AV from falling, which is a violation of Oregon Administrative Rule, is considered neglect which constitutes abuse.

On or about March 22, 2025, Witness #1 (W1) pinched the Alleged Victim (AV) on the wrist, causing a bruise. W1 is care planned for multiple interventions to avoid altercations, such as medication, change of face, redirect to an activity, take a walk or offer a snack or comforting object. W1 was not given his/her medication to assist with mood modification, or offered a snack or activity to re-direct him /her after having behaviors. The facility's failure to follow W1's care plan is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) and Witness #1 (W1) have a history of multiple altercations with each other. On or about March 4, 2025, AV and W1 engaged in an altercation where W1 grabbed a teddy bear from AV and slapped AV in the face. Although neither resident was harmed, both were placed at risk for serious harm. Facility staff knew prior to this altercation that these two residents did not get along. According to documentation, there were no temporary service plans in place for AV or W1 to mitigate the risk of altercations with each other. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is a known fall risk, as AV's family advised the facility upon move in that AV had suffered falls at his/her previous placement. AV suffered three falls over 4 days. AV was sent to the hospital a few times after the falls. AV did not have a fall mat, bed alarm or chair alarm to alert staff of falls. AV is one person assist with transfers and one person assist with moving through the cottage in his/her wheelchair. The facility's failure to ensure AV's safety while ambulating is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) has a history of wandering into other residents rooms. AV has been involved in multiple altercations due to wandering into others rooms. On or about December 8, 2024, AV walked into Witness #1's (W1) room and W1 led AV out of his/her room. W1 held onto AV's wrists, stomped on AV's foot and punched AV before being separated by staff. The facility's failure to ensure interventions were appropriate to reduce the risk of altercations 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 frequent safety checks, toileting care 6 times per shift, standby assist for transfers and have a pressure pad alarm in place while AV was in bed. On or about November 4, 2024, at approximately 1:20 am, another resident alerted staff that AV had fallen. AV suffered two abrasions to his/her back during the fall. AV's last safety check was performed at 12:00 am. AV's pressure pad alarm was not in place and did not alert staff to AV being up. 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) was ill and had agreed to stay in his/her room to avoid others getting sick. AV is care planned for his/her needs at meal time, due to AV's weakness from being ill. Staff were to cue AV to eat, assist AV to sit up to eat, take away old food, offer snacks and hydration and provide basic care to AV. On or about October 17, 2024, at 10:15 AM, AV was found in his/her room by staff, half off the bed, with AV's dinner tray from the night before, on the table next to AV. AV didn't eat his/her dinner on October 16, 2024, and was not served breakfast on October 17, 2024, nor was AV offered any snacks or liquids in between this time. Alleged Perpetrator #2 (AP2), Alleged Perpetrator #3 (AP3), Alleged Perpetrator #4 (AP4) and Alleged Perpetrator #5 (AP5, unknown) all were working during this time and did not check on AV from October 16 ,2024 at approximately 5:00 PM until AV was found by another staff at 10:15 AM the next day. AV went at least 23 hours without food or hydration, placing AV at risk for harm. AP2, AP3, AP4 and AP5's failure to follow the care plan is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility's failure to ensure that facility staff followed the care plan is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to appropriately care plan and implement interventions for the Alleged Victim (AV) to reduce the risk of falls. Over the course of two months, AV suffered multiple falls, with and without injury, leading to repeated unreasonable discomfort and pain. The facility failure is a violation of resident rights, are considered neglect of care and constitute abuse.

The Alleged Victim (AV) has had multiple unwitnessed falls. AV has suffered approximately 18 falls within the last 5 months. Three of AV's falls resulted in significant injury and change of condition. The results of AV's falls included 21 stitches on his/her lower left leg, a large bruise to AV's back and showing signs of confusion, and dizziness and shortness of breath, in which AV was sent to the local hospital. The facility's failure to ensure AV's safety 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 a history of falls with and without injury. On or about September 10, 2024, AV had an unwitnessed fall in his/her room, where he/she appeared to try to use his/her bedside table to get out of bed and suffered a fall, causing a skin tear to his/her elbow, an abrasion to his/her shoulder and AV complained of pain in his/her back and knee. AV's bed alarm was pushed to the side and did not register AV getting out of bed. The facility's failure to adequately care plan regarding AV's falls caused unreasonable discomfort, 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 a history of falls with and without injury. On or about September 29, 2024, AV had an unwitnessed fall in his/her bathroom, suffering a skin tear to his/her upper arm. AV's pressure pad alarm was not on at the time of the fall, therefore staff were not alerted that AV was out of bed. The facility's failure to ensure AV's pressure alarm was on placed AV at risk for serious harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is a known fall risk. AV has suffered 5 falls between July 31, 2024 and September 10, 2024. AV is care planned to have a bed alarm. On or about September 10, 2024, AV suffered a fall and was found in the doorway of his/her room. AV did not have a pressure alarm on his bed, so staff were not notified that AV was out of his/her bed. The facility's failure to follow the care plan, to have a bed alarm in place, 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) and Witness #1 (W1) engaged in multiple altercations between July 2024 and October 2024. W1 is care planned to have safety checks six times per shift and AV every 2-3 hours. AV and W1 were to be kept separated and to monitor W1 for increased agitation, aggression and emotional outbursts. The facility's failure to ensure resident safety and ensure care plans are being followed is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) has been involved in multiple altercations and is known to target residents. AV and Witness #1 (W1) engaged in multiple altercations from July 2024 to October 2024. Interventions in place were to keep AV and W1 separated and later to keep AV separated from W1 at all times. The facility's failure to ensure AV and W1 were kept separated caused AV physical harm, 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 engaging in altercations. On or about July 14, 2024, W1 and AV engaged in an altercation where W1 jabbed or hit AV in the torso. Neither resident was injured. On the same day, staff were instructed to monitor AV's whereabouts and for staff to monitor W1 for behaviors, monitor his/her whereabouts when agitated and complete frequent safety checks. On or about July 20, 2024, AV and W1 engaged in an altercation where W1 hit AV and then followed AV and staff to AV's room where W1 forcefully pushed and pulled AV into his/her room. The facility's failure to provide a safe environment placed AV at risk for serious harm. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to properly care plan appropriate interventions for Witness 1’s (W!) known behaviors resulting in resident-to-resident altercations. On or about May 23, 2024, the Alleged Victim (AV) reported to care staff that W1 had touched them inappropriately in the groin. There was no documented evidence the facility implemented appropriate interventions to prevent W1 from instigating resident to resident altercations, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to properly care plan appropriate interventions for the Alleged Victim (AV) history of resident-to-resident altercations with Witness 1 (W1). From approximately March 02, 2024, through April 05, 2024, AV and W1 were involved in approximately four physical altercations. The failure to properly care plan appropriate interventions to prevent physical altercations resulted in multiple physical altercations between the AV and W1, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to properly care plan appropriate interventions to prevent physical altercations between the Alleged Victim (AV) and Witness 1 (W1). On or about April 10, 2024, the AV and W1 were involved in a physical altercation causing a skin tear to the AV. The AV and W1 had a history of physical altercations and there was no documented evidence of appropriate intervention to mitigate the altercations, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to properly care plan appropriate interventions for the Alleged Victim’s (AV) known behaviors resulting in resident-to-resident altercations. From approximately December 03, 2023, through April 05, 2024, AV was involved in approximately five resident to resident altercations with no interventions put in place to prevent AV’s known behaviors, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to implement appropriate interventions for Witness 1’s (W1) known behavior of wandering into other resident rooms. The failure resulted in approximately nine resident to resident altercations between October 09, 2023, through December 03, 2023, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is known to engage in verbal altercations with staff and other residents and staff are to do safety checks at least one time per shift. Witness #1 (W1) has behaviors and has engaged in altercations with AV in the past. W1 is care planned for safety checks two to three times per shift. On or about October 17, 2023, staff heard a commotion coming from the dining area, staff arrived to find AV on the floor, stating that W1 pushed him/her. AV complained of pain in his/her hip. AV was transported to the hospital where he/she was diagnosed with broken hip. The facility failed to provide documentation that they followed AV or W1's care plan to do safety checks as noted in the care plan. 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 care planned as a two person transfer. On or about August 14, 2023, it was discovered that AV had a bruise on his/her right chest. On or about August 20, 2023, AV was sent to the hospital and was diagnosed with a fractured rib. During the course of the investigation, and based on information from AV, it was determined that AV was transferred by Alleged Perpetrator #2 (AP2) without assistance on or about August 12, 2023, causing AV's fractured rib. Alleged Perpetrator #2 (AP2) failed to follow AV's care plan of using two people to transfer AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility's failure to ensure the care plan was followed is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to ensure a safe medication administration system was in place for the Alleged Victim (AV). The failure resulted in the facility not obtaining medication refills in timely resulting the in the AV to go without multiple medications for an extended period, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to provide a safe medication administration system for the Alleged Victim by not acquiring all of their medication before moving into the facility. The failure resulted in the AV missing approximately 10 days of medication before needing to be treated at a hospital, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to provide peri care for the Alleged Victim (AV). The failure resulted in the AV not receiving peri care on the night of November 14, 2022, through the morning of November 15, 2022, resulting in the AV laying in a urine-soaked bed causing unreasonable discomfort and loss of dignity, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide appropriate assessment, implement interventions, and appropriately care planning related to AV’s repeated falls. The failure resulted in AV experiencing approximately 6 falls, and causing repeated discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to properly care plan and implement interventions for the Alleged Victim (AV) to prevent falls. The failure resulted in AV experiencing four falls, the third fall resulting in skin tears and hip pain, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to documentation, the facility failed to provide a safe medication administration system. The failure resulted in the Alleged Victim (AV) missing approximately four doses of antibiotics between 08/29/2022 through 09/01/2022, for an infection causing unreasonable discomfort, which is a violation of resident rights and is considered neglect of care and constitutes abuse.

According to documentation, the facility failed to provide a safe medication administration system to ensure the Alleged Victim’s medications were administered as ordered. The failure resulted in the Alleged Victim (AV) receiving double doses of two medications causing dizziness and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility for care and services. According to an investigation, Alleged Perpetrator 2 (AP2) used a gait belt to transfer AV, which is not in AV's care plan. The facility had told AP2 that they do not use gait belts, but AP2 continued to use them resulting in AV getting bruised. The facility allegedly failed to follow the care plan. An investigation determined the allegation to be inconclusive. The allegation that AP2 neglected AV was investigated and determined to be substantiated. This is a violation of Oregon Administrative Rule.

The Alleged Victim (AV) relies on the facility to provide care and services. According to an investigation, the facility failed to follow the care plan for AV, which is a violation of Oregon Administrative Rule. The Alleged Perpetrator 2 (AP2) did not follow the care plan for AV which resulted in AV falling and risking physical harm which is a violation of resident rights and is neglect, which constitutes abuse.

The facility failed to provide a safe medication administration system for the Alleged Victim (AV). The failure is a violation of Oregon Administrative Rules. AP2 failed to provide a safe medication administration system for AV. AP2's actions are a violation of resident rights, considered neglect, which constitutes abuse.

The Alleged Victim (AV) relies on the facility to protect the resident from emotional abuse. AV is known to have behaviors with residents and staff and the facility had care planned around those behaviors. According to an investigation on or about March 31, 2025, the Alleged Perpetrator 2 (AP2) threw a beverage at AV after AV threw water at AP2 during a behavioral episode. AP2 failed in their duty of care and protection of AV, which is a violation of resident's rights and constitutes abuse. The facility failed to protect AV from emotional abuse which is violation of Oregon Administrative Rules.

On or about January 2, 2025, Alleged Perpetrator #2 (AP2) posted a video of the Alleged Victim (AV) on social media. Staff are not permitted to use personal cell phones while at work. AP2 took the video of AV with the intention to show other staff AV's behaviors, however, during the video, it appears AP2 is mocking and laughing at AV. Facility staff familiar with AV concluded that AV was upset about the video. AP2's actions are a violation of resident rights, are considered neglect of care and constitute emotional abuse. The facility's failure to ensure AV's rights is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) is a know fall risk and is care planned to be assisted with transfers. On or about November 2, 2024, AV was in the TV room with Alleged Perpetrator #2 (AP2) when AV stood up from his/her wheelchair. AP2 advised AV to sit back down and when AV tried to sit, his/her wheelchair moved and AV fell to the floor. AP2 did not assist AV and did not assure that AV's wheelchair brakes were locked. AP2's failure to follow the care plan and assist AV with a transfer is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility's failure to ensure the care plan was being followed is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) is known to be impatient. AV is a one person assist with transfers. On or about September 25, 2024, AV was being impatient and wanted to go to his/her room. Alleged Perpetrator #2 (AP2) assisted AV to his/her room, where AV requested to be transferred from his/her wheelchair. AP2 did not transfer AV as requested and left AV's room, advising AP2 would return in 5 minutes. After approximately 15 minutes, staff heard AV yelling for help. Staff entered AV's room to find AV on the floor from attempting to self-transfer. AV suffered a bruise to his/her leg/hip area. AP2's failure to provide service as requested to AV placed AV at risk for harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility's failure to ensure AV's safety is a violation of Oregon Administrative Rules.

On or about September 9, 2024, the Alleged Victim (AV) told staff that Alleged Perpetrator #2 (AP2) took his/her phone to replace a battery and never returned it. AP2's actions are a violation of resident rights, are considered neglect of care and constitute financial abuse. The facility's failure is a violation of Oregon Administrative Rules.

On or about August 9, 2024, the Alleged Victim (AV) reported to staff that approximately $8.000.00 in jewelry was stolen from him/her. Alleged Perpetrator #2 (AP2) was questioned by the police and didn't have a consistent story regarding the missing jewelry. AP2 tried to state he/she found the jewelry in another residents room, but later confessed to taking the jewelry from AV. Most of AV's jewelry was returned, however, there was a ring still missing. AP2's actions are a violation of resident rights, are considered neglect of care and constitute financial abuse. The facility's failure is a violation of Oregon Administrative Rules.

According to the documentation, the Alleged Perpetrator (AP2) failed to follow the Alleged Victim’s (AV) service plan when the AV required assistance with transferring. The failure resulted in the AV suffering a fall and received a skin tear, which is a violation of resident rights and is considered abuse. The facility failed to follow the care plan which is a violation of Oregon Administrative rules.

According to the documentation, the Alleged Perpetrator (AP2) failed to protect the Alleged Victim (AV) from verbal abuse. The failure resulted in the AV hearing a derogatory remark made by AP2 resulting in the AV experiencing emotional damage and made them cry, which is a violation of resident rights and is considered verbal abuse. The facility failed to provide a safe environment with is a violation of Oregon Administrative Rules.

According to the documentation, the Alleged Perpetrator (AP2) failed to administer medication as prescribed to the Alleged Victim (AV). AP2 admitted to not administer medications to the AV on or about July 28, 2023, as prescribed, which is a violation of resident rights and is considered abuse. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.

According to the documentation, the Alleged Perpetrator (AP2) failed to administer medication as prescribed to the Alleged Victim (AV). AP2 admitted to not administer medications to the AV on or about July 28, 2023, as prescribed, which is a violation of resident rights and is considered abuse. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.

According to the documentation, the Alleged Perpetrator (AP2) failed to administer medication as prescribed to the Alleged Victim (AV). AP2 admitted to not administer medications to the AV on or about July 28, 2023, as prescribed, which is a violation of resident rights and is considered abuse. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.

According to the documentation, the Alleged Perpetrator (AP2) failed to administer medication as prescribed to the Alleged Victim (AV). AP2 admitted to not administer medications to the AV on or about July 28, 2023, as prescribed, which is a violation of resident rights and is considered abuse. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.

According to the documentation, the Alleged Perpetrator (AP2) failed to administer medication as prescribed to the Alleged Victim (AV). AP2 admitted to not administer medications to the AV on or about July 28, 2023, as prescribed, which is a violation of resident rights and is considered abuse. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.

According to the documentation, the Alleged Perpetrator (AP2) failed to administer medication as prescribed to the Alleged Victim (AV). AP2 admitted to not administer medications to the AV on or about July 28, 2023, as prescribed, which is a violation of resident rights and is considered abuse. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.

According to the documentation, the Alleged Perpetrator (AP2) failed to administer medication as prescribed to the Alleged Victim (AV). AP2 admitted to not administer medications to the AV on or about July 28, 2023, as prescribed, which is a violation of resident rights and is considered abuse. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.

According to the documentation, the Alleged Perpetrator (AP2) failed to administer medication as prescribed to the Alleged Victim (AV). AP2 admitted to not administer medications to the AV on or about July 28, 2023, as prescribed, which is a violation of resident rights and is considered abuse. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.

According to the documentation, the Alleged Perpetrator (AP2) failed to administer medication as prescribed to the Alleged Victim (AV). AP2 admitted to not administer medications to the AV on or about July 28, 2023, as prescribed, which is a violation of resident rights and is considered abuse. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.

According to the documentation, the Alleged Perpetrator (AP2) failed to administer medication as prescribed to the Alleged Victim (AV). AP2 admitted to not administer medications to the AV on or about July 28, 2023, as prescribed, which is a violation of resident rights and is considered abuse. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.

According to the documentation, the Alleged Perpetrator (AP2) failed to administer medication as prescribed to the Alleged Victim (AV). AP2 admitted to not administer medications to the AV on or about July 28, 2023, as prescribed, which is a violation of resident rights and is considered abuse. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.

According to the documentation, the Alleged Perpetrator (AP2) failed to administer medication as prescribed to the Alleged Victim (AV). AP2 admitted to not administer medications to the AV on or about July 28, 2023, as prescribed, which is a violation of resident rights and is considered abuse. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.

According to the documentation, the Alleged Perpetrator (AP2) failed to administer medication as prescribed to the Alleged Victim (AV). AP2 admitted to not administer medications to the AV on or about July 28, 2023, as prescribed, which is a violation of resident rights and is considered abuse. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.

According to the documentation, the Alleged Perpetrator (AP2) failed to administer medication as prescribed to the Alleged Victim (AV). AP2 admitted to not administer medications to the AV on or about July 28, 2023, as prescribed, which is a violation of resident rights and is considered abuse. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.

According to the documentation, the Alleged Perpetrator (AP2) failed to administer medication as prescribed to the Alleged Victim (AV). AP2 admitted to not administer medications to the AV on or about July 28, 2023, as prescribed, which is a violation of resident rights and is considered abuse. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.

According to the documentation, the Alleged Perpetrator (AP2) failed to administer medication as prescribed to the Alleged Victim (AV). AP2 admitted to not administer medications to the AV on or about July 28, 2023, as prescribed, which is a violation of resident rights and is considered abuse. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.

According to the documentation, the Alleged Perpetrator (AP2) failed to administer medication as prescribed to the Alleged Victim (AV). AP2 admitted to not administer medications to the AV on or about July 28, 2023, as prescribed, which is a violation of resident rights and is considered abuse. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.

According to documentation Alleged Perpetrator 2 (AP) failed to remove themselves from an altercation with the Alleged Victim (AV). The failure resulted in AP2 grabbing AV’s wrists and hands and pushing AV, causing bruising and emotional discomfort, which is a violation of resident rights, is 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 failed to carry out medication and treatment orders as prescribed. An investigation concluded a licensing violation occurred.