Klamath Falls Senior Living

The Alleged Victim (AV) and Witness 1 (W1) both rely on the facility for care. W1 has a documented history of inappropriate sexual behavior with other residents and is care planned to be escorted any time they are outside of their room. According to an investigation, on or about January 1, 2026, W1 attempted to coerce AV into their room and then sat outside AV's room for days waiting for them to enter the common area. AV was emotionally distressed and stayed inside their room with the door locked for multiple days, to ensure W1 was not outside. The facility failed to provide service, to include following the care plan and/or implementing interventions to mitigate W1 known behaviors and ensure AV's safety, causing AV emotional distress and placing AV at risk for harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse as defined by 411-020-0002(1)(b)(A)(i)(ii).

The Alleged Victim (AV) and Witness 1 (W1) rely on the facility for care, and W1 has a history of inappropriate behavior and comments to facility staff and residents. On or about August 11, 2025, W1 and AV were alone in AV's room when W1 touch AV inappropriately in a sexual manner. AV attempted to pushed W1's hand away, but was unable to say anything and AV stated they were "frozen" and wasn’t sure what to do. According to in investigation, these are behaviors that were known to the facility prior to W1 moving in. The facility failed to provide appropriate services, to include implementing effective interventions and /or properly care planning to address W1's behaviors and provide a safe environment for AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relied on the facility for care and was a known fall risk. According to an investigation, during August 2025, AV experienced approximately eight (8) falls, some resulting in injury to include skin tears, and AV hitting their head requiring a hospital visit. Interventions remained largely reminders and checks, but often lacked defined frequency or consistency. Staff were uncertain regarding how often the checks were actually performed. On or about August 30, 2025, after hearing a loud bang, AV was found on the ground with skin tears to the right hand and left knee. The facility failed to put effective, person-centered interventions in place after repeated falls, which is a violation of resident rights is neglect of care and constitutes abuse as defined by OAR 411-020-0002(1)(b)(A)(i)(ii).

The Alleged Victim (AV) relies on the facility for his/her care and has a history of falls and recent cognitive decline. On or about May 3, 2025, AV had a fall in their room resulting in a left hip fracture that required surgery. According to an investigation, after a recent injury fall, the facility added interventions that were already in place to the care plan. The facility failed to provide appropriate services, to include care planning and/or implementation of effective interventions to mitigate AV’s increasing fall risk and provide a safe environment for AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relied on the facility for care and was a known fall risk. AV was care planned for standby assist with ambulation and transfers and was a total assist with toileting. According to an investigation, on or about March 4, 2025, AV fell while attempting to use the restroom, resulting in a head injury, swelling and bruising. The facility failed to provide appropriate services, to include proper care planning and/or the implementation of effective interventions and resident monitoring, resulting in unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse as defined by OAR 411-020-0002(1)(b)(A)(i).

The Alleged Victim (AV) relies on the facility to provide appropriate care and services. The AV has a history of falls, a history of not using their call light, as well as a health issue that causes AV to become dizzy at times. According to an investigation, between December 30, 2024, and January 28, 2025, AV suffered three falls, resulting in multiple injuries, including back pain, head injury and discoloration to his/her wrists and forearm. The facility failed to ensure the care plan was followed and/or implement interventions to mitigate AV’s increasing fall risk, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility to provide appropriate care and services. The AV has a history of falls, a history of not using their call light, and has a health issue that causes AV to become dizzy at times. According to an investigation, between February 2, 2025, and February 4, 2025, AV suffered three falls, resulting in multiple injuries, including back pain and a head injury. The facility failed to ensure the care plan was followed and/or implement interventions to mitigate AV’s increasing fall risk, resulting in repeated 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 assistance with their medications, has been on oxygen at night for approximately 6 years, and has a history of confusion when ill or oxygen is low. There is no mention of AV requiring oxygen in AV's care plan, and a no oxygen orders on the Medication Administration Record (MAR) until January 2025. AV was placed on alert charting on approximately December 17, 2024, due shortness of breath (SOB) and weakness with little to no specific interventions. During the time AV was on alert charting for SOB and weakness, AV's oxygen saturations were only taken 6 times out of 77 charting notes. On or about December 19, 2024, AV went to the hospital due to AV's oxygen levels being in the 70's and returned home with an as needed nebulizer treatment. According to an investigation, AV was not receiving their nebulizer treatment after return from the hospital due to the need for AV to request it, which AV was not doing due to their confusion. On December 31, 2024, AV's POA took AV to see their physician and the nebulizer treatment was changed to scheduled rather than as needed. AV started improving shortly after. The facility failed to provide services, to include implementing effective interventions and/or properly care planning and ensuring a safe medication system, which is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility for his/her care and has a history of falling, especially when AV is not feeling well. On or about December 18, 2024, fell out of his/her recliner and had to call staff for help. According to an investigation, despite the facility being aware that AV was at an increased risk of falls when not feeling, no additional interventions were put in place to ensure AV's safety. The facility failed to provide services, to include implement effective interventions to mitigate AV’s falls and monitoring AV for safety, resulting in a risk for harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relied on the facility for care, was a fall risk due to poor judgement and prior fall history, was care planned for four (4) safety checks per shift and also was documented as independent with short distance ambulation and transfers. According to an investigation, facility staff were not checking on AV frequently because AV was independent. In October 2024, after a previous fall, AV's physician had ordered physical and occupational therapy but there is no documentation this occurred. On or about December 19, 2024, AV was found on the floor next to the head of AV's bed with AV's back to the wall and did not respond when staff asked what happened. AV was sent to the hospital approximately three (3) days later, on December 22, 2024, and was diagnosed with a left hip fracture that required surgical intervention. The facility failed to provide appropriate services according to AV’s needs, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relied on the facility for care and was service planned to be checked on two times per shift and for their briefs to be changed two times while asleep, to prevent soiled bedding. AV had a history of UTIs. On or about December 17, 2024, AV was found lying in bed, soaked in urine. Facility staff was not sure when the last time AV was checked on, and AV stated they had been needing help for 4 hours. According to an investigation, AV's room smelled strongly of urine. Document review revealed AV refused care often but there were no interventions put in place regarding refusal behaviors. The facility failed to provide appropriate services, to include following the care plan and/or implementation of effective interventions, and resident monitoring, placing AV at risk for recurring UTIs and skin breakdown, 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 is a known fall risk, with an extensive recent history of falls. AV is care planned for staff to check on AV eight times per shift for safety due to fall risk and wandering requiring redirection. According to an investigation, on or about November 16, 2024, AV fell and was on the floor in pain. The last documented time staff checked on AV was approximately 13 hours earlier. The facility failed to provide appropriate services according to Alleged Victim’s needs, regarding implementation of services, safety checks and monitoring, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility for his/her care, has a history of seizures, and is a known fall risk. According to an investigation, AV is a total assist for seizure disorder and confusion, and AVs Service Plan states most of AV’s falls are seized related. Between September 25, 2024, and October 30, 2024, AV is documented to have gone to the hospital approximately three (3) times for a fall or a seizure that resulted in injury to include head hematomas and lacerations. The facility failed to implement interventions or appropriately care plan, to mitigate the risk of injury due to AV's increase in seizures and falls, which is a violation of resident rights, is neglect of care which constitutes abuse.

The Alleged Victim (AV) relies on the facility for his/her care. AV has a history of refusing care and known to be incontinent and remain his his/her soiled clothing/briefs, resulting in AV being diagnosed with a UTI on multiple occasions and loss of personal dignity. The facility failed to provide appropriate services for AV’s needs, including care planning and lack of instruction, which is a violation of resident rights, is neglect of care which constitutes abuse.

The Alleged Victim (AV) relies on the facility for his/her care. According to an investigation, AV experienced approximately four unwitnessed falls between July 2, 2024, and September 28, 2024, resulting in pain, contusion to AV’s left hip and unreasonable discomfort. The facility failed to appropriate care plan and provide services according to the Alleged Victim (AV)'s needs, relating to falls and lack of appropriate interventions, which is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility for his/her care. The Alleged Victim (AV) was care planned for assistance with transferring, toileting, and dressing. AV was known to have a sore on his/her buttock area. According to an investigation, AV was found soaked in urine multiple occasions and often left in his/her recliner for long periods of time without being repositioned, resulting in unreasonable discomfort, lack of dignity and placing AV at risk of serious harm. The facility failed to follow AV’s care plan, due to lack of staffing, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility for his/her care. The AV is care planned for assistance with transferring and toileting and to be checked on eight times per shift, including night shift. According to an investigation, on or about October 11, 2024, AV used the call button and when staff took too long to respond, AV transferred themselves and attempted to self-toilet which resulted in AV urinating in his/her pants. AV experienced unreasonable discomfort and a lack of personal dignity. It was also discovered that AV’s care plan was not being followed regarding safety checks. The facility failed to provide appropriate services according to resident needs, as it relates to care plan not being followed, and call light not being answered in a timely manner, which is a violation of resident rights, is neglect of care which constitutes abuse.

The Alleged Victim (AV) relies on the facility for his/her care. The AV is care planned for assistance with transferring and toileting and to be checked on eight times per shift, including night shift. According to an investigation, on or about September 28, 2024, AV transferred themselves out of his/her powered wheelchair, resulting in AV hitting his/her head. The facility failed to provide appropriate services according to Alleged Victim’s needs, relating to care planning and lack of appropriate interventions and/or call light not being answered in a timely manner, which is a violation of resident rights, is neglect of care which constitutes abuse.

The Alleged Victim (AV) is a known fall risk with a history of falls. According to an investigation AV experienced multiple falls between July 1, 2024, and October 12, 2024, which resulted in repeated unreasonable discomfort, including back and hip pain, injury to his/her left elbow, and head injuries. The facility failed to provide appropriate services according to Alleged Victim’s needs, relating to care planning and lack of appropriate interventions, to mitigate the risk of injury due to AV's increase in falls, which is a violation of resident rights, is neglect of care which constitutes abuse.

The Alleged Victim (AV) relies on the facility for his/her care. AV is care planned for total assistance for toileting and staff to check on AV multiple times per shift to ensure AV is dry. AV is known to be resistant to being changed or showered and is care planned for staff to document, perform weekly skin checks and report any changes in skin condition to RN and Physician. According to an investigation, AV was sitting in soiled briefs and clothing daily, resulting in redness, skin injury and toilet paper residue on AV’s skin. The facility failed to follow the care plan, which is a violation of resident rights, is neglect of care which constitutes abuse.

The Alleged Victim (AV) relies on the facility for care. The facility manages AV's oxygen supply to include ordering as well as setting up AV with portable oxygen devices so AV can be in the common areas of the facility. According to an investigation, multiple times the facility staff were not completely turning off the portable canisters after use and staff were often increasing AV's oxygen flow to 4 L/min, despite a physician order for only 2 L/min. This resulted in AV running out of oxygen in the portable canisters, causing AV distress and requiring AV to be confined in their room until new canisters were delivered. The facility failed to provide appropriate services, regarding care planning and oxygen orders, which caused unreasonable discomfort and AV distress, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility for his/her care, has a history of urinary incontinence and has a catheter. On or about October 3, 2024, Alleged Perpetrator 2 (AP2) was notified that AV pulled his/her catheter out. AP2 took no action. Many hours later AV was complaining of lower back, abdominal, and genitalia pain and was transported to the hospital for care. AP2’s actions are considered neglect of care and constitutes abuse. It was also determined that the facility failed to ensure AP2 had been properly trained in all areas of their job duties, posing a serious risk of harm to AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility for his/her care and has a dementia diagnosis. According to an investigation, AV pulled their catheter out on or about October 3, 2024 and was sent to the hospital for treatment, where a new catheter was placed. AV's care plan was updated to remind AV not to pull the catheter out but lacked clear instruction on how and when to issue reminders. Then, on or about October 7, 2024, AV, once again pulled their catheter out resulting in AV being sent back to the hospital for treatment. The facility failed to properly care plan resulting in repeated unreasonable discomfort, which is a violation of resident rights, is neglect of care which constitutes abuse.

The Alleged Victim (AV) relies on the facility for his/her care. According to an investigation, AV was left sitting in urinated clothing for long periods of time, resulting in AV getting a rash in his/her groin area and causing unreasonable discomfort and lack of dignity. Witnesses indicated that facility staff were not aware that AV had a rash on his/her groin area. The facility failed to provide appropriate services for AV’s needs, including care planning and lack of instruction, which is a violation of resident rights, is neglect of care which constitutes abuse.

The Alleged Victim (AV) relies on the facility for his/her care. AV was known to use his/her wheelchair as a walker and was unstable on his/her feet. According to an investigation, AV experienced approximately four unwitnessed falls between August 29, 2024, and September 25, 2024, resulting head injuries and unreasonable discomfort. The facility failed to provide appropriate services according to Alleged Victim’s needs, relating to care plans and lack of appropriate interventions and instructions, to mitigate the risk of injury due to AV's increase in falls, which is a violation of resident rights, is neglect of care which constitutes abuse.

The Alleged Victim (AV) is care planned for two-person transfers and on-person assist for ambulation. AV is known to not like to rely on facility staff to help with transfers or ambulation and forgetting to use his/her call button. According to the investigation, AV had approximately six falls between June 28, 2024, and October 17, 2024, while attempting to self-transfer, resulting in some injuries, including a pelvic rami fracture, a concussion and multiple skin injuries. The facility failed to provide appropriate services according to resident needs, relating to care planning and lack of appropriate interventions, to mitigate falls and self-transferring, which is a violation of resident rights, is neglect of care which constitutes abuse.

The Alleged Victim (AV) relies on the facility for his/her care. The Alleged Victim (AV) was care planned for assistance with transferring, reposition, toileting, and total assistance for dressing. AV had a pressure sore that that fluctuated in severity. According to an investigation, AV was found soaked in urine by multiple staff members on many separate occasions due to lack of staffing, resulting in unreasonable discomfort, lack of dignity and placing AV at risk of serious harm. The facility failed to follow AV’s care plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) has an unsteady gait and is a known fall risk with a history of falls. AV had a injury fall on or about August 1, 2024, and although was on alert, there were no interventions added to AVs care plan. According to an investigation, on or about September 11, 2024, AV fell and hit their head, requiring an emergency department visit and 17 stiches. The facility failed to provide appropriate services according to Alleged Victim’s needs, regarding care planning, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility for his/her care. AV is known to have a history of urinary tract infections (UTI’s) and bladder incontinence. AV was care planned for total assistance with toileting, showering, dressing, and housekeeping, occasional assist with ambulation, and standby assist with transfers. According to an investigation, on or about August 25, 2024, at approximately 8:00am, AV was found in another resident’s room in sitting on his/her urine for an extended period. EMS was called and found AV to be hot to the touch, smelling strongly of urine, and was unable to hold a conversation. AV was taken to the hospital for extreme weakness, confusion and diagnosed with a UTI and blood in his/her urine at the hospital. The facility failed to provide appropriate services, related to care planning and following AV’s care plan, which is a violation of resident rights, is neglect of care which constitutes abuse.

The Alleged Victim (AV) relies on the facility for his/her care. The AV is a known fall risk with a history of falls and is known to try and be independent even when he/she is care planned as an assist. AV was care planned to be checked on four times per shift and to be reminded to ask for assistance with transfers when feeling week. According to investigation, on or about August 25, 2024, AV was placed on an interim service plan to help AV with transfers and escorts. On or about August 26, 2024, AV experienced a non-injury fall while trying to use an assisted device by him/herself. On or about September 1, 2024, AV experienced a fall that resulted in a head injury, requiring stiches to repair. AV also had two skin tears to his/her elbow. It was determined that AV pressed his/her pendant for assistance prior to the fall. Staff interviewed indicated there was no consistent checks on AV and/or understanding of AV’s care plan. According to medical records, the stitches on AV’s head were supposed to be in for five to seven days but were still in AV’s head after forty-four days of the incident. The facility failed to provide appropriate services, related to care planning, lack of interventions, and following AV’s care plan, 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 is a known fall risk. AV is documented as being an occasional assist with toileting and for staff monitoring for changes. AV is known to be forgetful. According to an investigation, staff were not provided with direction to check on AV throughout the day and/or frequency they should be monitoring AV. On or about July 17, 2024, AV had a fall off the toilet, resulting in contusions to AV’s face and forehead. The facility failed to provide appropriate services according to Alleged Victim’s needs, regarding care planning, safety checks and monitoring, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility for care, has a documented seizure disorder, and has a recent history of falls. According to an investigation, on or about July 13, 2024, AV had a fall, resulting in a 3 cm laceration above AV's right eye. The facility failed to provide services, to include implementing interventions to mitigate AV’s increasing fall risk and/or to ensure the facility was appropriately staffed, 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 and requires assistance with transfers. On or about July 22, 2024, the Alleged Perpetrator #2 (AP2) assisted AV with a transfer resulting in AV hitting their head on the wall. During the investigation it was discovered that AP2 was partially trained on transfers and AVs care plan was inconsistent regarding AV's care needs. The allegation that AP2 failed to provide basic care and services necessary for AV health and safety was investigated and wrongdoing was unable to be determined. The facility failed to provide appropriate services according to Alleged Victim’s needs, relating to care planning and providing fully trained staff, which is a violation of resident rights, is neglect of care which constitutes abuse.

The Alleged Victim (AV) relies on the facility for his/her care. The Alleged Victim (AV) is a known fall risk with a history of falls. According to AV’s care plan, AV had very poor vision and was unable to see about a foot in front of him/her, but was care planned as independent in ambulation, transfers, and the use of the call button system. AV was known to not use his/her walker in his/her apartment and would ambulate very quickly. Between April 16,2024 and April 18, 2024, AV experienced three falls, resulting in skin tears and repeated unreasonable discomfort. The facility failed to implement interventions or appropriately care plan, to mitigate the risk of injury due to AV's increase in falls, which is a violation of resident rights, is neglect of care which constitutes abuse.

The facility failed to ensure the Alleged Victim's (AV) medication was obtained and administered as ordered post surgery. The failure resulted in AV going back to the ER 3 times between 02/21/24 and 02/27/24, with symptoms and concerns, but there was never a mention around AV not receiving hospital discharge medications. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to follow the Alleged Victim’s (AV) care plan for pain management and failed to administer PRN medication as ordered. The failure resulted in AV experiencing “agonizing” pain and was sent to the hospital, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to assess and intervene according to the Alleged Victim’s change of skin condition. After AV was sent to the emergency room, s/he was diagnosed with a skin infection and was ordered antibiotics. The facility failed to provide a safe medication administration system to ensure AV’s medication was administered as ordered. The failures resulted in ongoing pain and a worsening skin condition, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to ensure staff were monitored and followed facility policy regarding the needs of the Alleged Victim. The failure places residents at risk of serious harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility and AP2 failed to appropriately respond to the Alleged Victim's (AV) change of condition and provide consistent skin assessments and put in interventions around AV's skin breakdown. The failure resulted in AV requiring on-going licensed professional intervention and treatment, 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 AV's dietary needs and risk of choking. The failure to ensure staff were aware, instructed and demonstrated competency to meet AV's needs placed AV at risk of serious harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

AV has a medical condition which requires weekly skin checks and has a history of being non-compliant with receiving facility care. Both the skin checks and non-compliance with care were addressed in AV’s service plan. The facility failed to ensure that the service plan was followed because weekly skin checks were not performed. The facility also failed to appropriately care plan according to AV’s needs and behaviors and provide staff with instructions regarding monitoring and the delivery of services with respect to non-compliance with care because the interventions were limited and not effective. On or about June 4, 2023, staff became aware of AV’s significant change of condition and reported their findings to AP2 that day, and the worsening of his/her condition the following day. However, AP2 failed to properly assess AV's change of condition, provide sufficient instruction on interventions or monitoring, and failed to follow up on AV’s condition according to OAR 411-054-0045(1)(f). On or about June 6, 2023, AV went to his/her doctor related to the significant change of condition and was sent to the hospital, where his/her leg was amputated approximately three (3) days later. The failure of the facility and AP2 to provide basic care and services necessary to maintain the health of safety of AV resulted in permanent loss to AV, which constitutes abuse by neglect as defined in OAR 411-020-0002(1)(b)(A)(i).

On or about mid-afternoon on April 26, 2023, the Alleged Victim (AV) experienced a significant change of condition, exhibiting stoke like symptoms and high blood pressure readings. Facility staff recognized the change of condition and alerted AP2, but did not otherwise take appropriate immediate action. AP2 either did not assess AV or did not perform an adequate assessment in response. AV remained at the facility and continued to exhibit the same symptoms overnight until the facility sent the resident to the hospital the next morning, when it was discovered that the resident had suffered a stroke. The facility failed to provide training or tools for staff to recognize and respond appropriately to medical emergencies related to AV’s symptoms. AP2 was notified of AV’s significant change of condition and failed to properly conduct an assessment according to facility policy and OAR 411-054-0045(1)(f). AP2 advised staff not to call for emergency services and to put AV back to bed. AP2 did not provide staff with instructions for care and/or monitoring AV’s symptoms. The failure of the facility and AP2 to provide basic care and services necessary to maintain the health of safety of AV resulted in permanent loss to AV, physical harm, unreasonable discomfort, and delay that presented a serious risk of harm, which constitutes abuse by neglect as defined in OAR 411-020-0002(1)(b)(A)(i).

According to documentation, the facility and the Alleged Perpetrator 2 (AP2) failed to assure resident rights, when AP2 coerced the Alleged Victim (AV) to shower before his/her appointment after several refusals. AV had already cleansed and prepared his/herself for an appointment and was emotionally upset and embarrassed about being forced to shower because s/he felt they had no choice and having to attend his/her appointment with wet hair. AP2's actions are considered emotional abuse and the facility's failure to ensure resident rights is considered neglect of care and constitutes abuse.

The facility and Alleged Perpetrator 2 (AP2) failed to follow the Alleged Victim's (AV) care plan to provide two-person assistance during transfers. AP2 attempted to transfer AV by him/herself (due to insufficient number of staff available to assist) and AV experienced a fall with injury, which is a violation of resident rights, is considered neglect of care and constitutes abuse by both the facility and AP2.

The facility failed to provide appropriate services and staff instructions according to the AV's needs and his/her CPAP care. The failure resulted in dark matter and particles being found in AV's CPAP machine, which s/he uses for oxygen at night, causing risk of infection and illness, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement appropriate interventions and care plan according to AV's change of condition related to falls. The failure resulted in AV experiencing several injury falls and risk of serious harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide a safe medication administration system to ensure The Alleged Victim’s (AV) medications were administered as ordered. The failure resulted in AV going approximately 5 days without his/her medication causing him/her to have trouble sleeping and experiencing physical pain, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide appropriate oversight of the Alleged Victim's (AV) need for assistance with ambulation. According to documentation, staff were encouraged to "push" AV to walk and use threats to call AV's son if s/he refused. The Alleged Perpetrator 2 (AP2) caused emotional discomfort to the AV by using profanity in his/her presence, threatened to call his/her son, and slammed AV's walker down out of frustration. AP2's actions are considered verbal/emotional abuse. The facility's failure to ensure quality services resulted in AV experiencing emotional discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility and AP2 failed to provide services to the Alleged Victim (AV) according to his/her need. According to documentation, there was confusion amongst staff regarding whether or not they were to assist AV with ambulation/transfers, potential staffing issues and AV's care plan didn't provide clear instruction as to how to support AV with his/her needs. The failure resulted in AV experiencing pain and emotional discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

AV has a history of periodic hip pain and experienced approximately five falls between December 4, 2021 and April 23, 2022. On or around April 19, 2022, AV's hip pain worsened significantly and interfered with AV's ability to ambulate. AV complained of extreme weakness and trouble walking, and was observed walking with a wobble. For subsequent days facility staff documented AV's continued complaints of pain and difficulty ambulating. On April 23 and April 27, 2022, AV fell in the facility. AP2 was notified of these changes and considered them to constitute a significant change of condition as defined in 411-054-0040(1)(b). AP2 failed to assess or appropriately respond to AV's significant change of condition according to 411-054-0045(1)(f) or document any contact with AV's primary care physician--thus suggesting that AV's primary care physician was not contacted. The facility failed to oversee staff and ensure that staff followed the applicable regulations and provided appropriate care. Failure to timely respond to, assess, and follow-up on treatment related to AV's significant change of condition constituted a failure to provide basic care and services as required by rule, resulting in a risk of serious harm to the resident through the continued risk of falls as well as harm to the resident in experiencing ongoing pain. This constitutes abuse by neglect as defined in OAR 411-020-0002(1)(b)(A)(ii).

The facility failed to properly care plan for the Alleged Victim’s (AV) respiratory and pulmonary needs, and to properly assess AV for the ability to self-administer oxygen. The failure resulted in AV ultimately having a significant medical event that required AV to be seen and treated in the emergency room, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement appropriate interventions and care plan according to AV's change of condition related to falls. The failure resulted in AV experiencing approximately four unwitnessed falls causing repeated unreasonable discomfort and risk of serious harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately care plan related to the AV’s fall history, need for skin monitoring and directions on what to do if W2 refuses care. The failure resulted in AV experiencing falls with injury and risk of ongoing harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) had suffered a stroke in the past; On or about March 30, 2022, Witness #2 (W2) was on the phone with AV, when s/he began to exhibit symptoms of slurred speech and incoherence. W2 contacted the facility while remaining on the phone with AV, and requested facility staff check on AV, for signs of a stroke. Alleged Perpetrator #2 (AP2) was at the facility, however, failed to assess or appropriately respond to AV's significant change of condition according to 411-054-0045(1)(f), but requested another staff person check on AV. Staff checked and determined through observation from AV’s door, that AV’s speech was slurred due to holding the phone to his/her face. During night shift, on or about March 30, 2022, Alleged Perpetrator #3 (AP3) noticed AV was acting abnormally and outside of his/her baseline, however, did not consult AV’s service plan, nor request an RN assessment. Upon observing AV the morning of March 31, 2022, day shift staff called emergency services to take AV to the hospital. AV was admitted to the hospital, diagnosed with having suffered a stroke and a Urinary Tract Infection, was septic and hypoxic. The facility failed to appropriately care plan related to AV’s past medical history, describe signs or symptoms for staff to look for, and instructions for a change of condition. The facility's, AP2's and AP3's failures are a violation of resident rights, are considered neglect of care and constitute abuse.

On or about January 3, 2022, AV experienced a change of condition including stomach pain and weakness. Facility staff were aware of AV’s condition and complaints. As AV’s symptoms persisted, AV requested to go to the hospital. AP3 was on shift when AV made the request to be sent to the hospital. AP3 notified AP2, who was not on shift, of AV’s condition and request according to OAR 411-054-0040(1)(b). AP2 and AP3 agreed to offer AV a remedy. However, AP2 failed to properly assess AV's change of condition, provide sufficient instruction on interventions or monitoring, and failed to follow up on AV’s condition according to OAR 411-054-0045(1)(f). AP3 failed to create a temporary service plan for interventions or monitoring after administering a medical remedy according to 411-054-0036(2)(e). Additionally, AV was not sent to the hospital upon AV’s request. AV continued to experience symptoms related to the change of condition, and passed away overnight. Respondent failed to oversee facility staff and ensure that staff followed the applicable regulations and provided appropriate care. Failure to assess, care plan and follow-up on treatment related to AV's change of condition, and failure to honor AV’s request to go to the hospital, constituted a failure to provide basic care and services as required by rule, resulting in a risk of serious harm to the resident. The failure constitutes abuse by neglect as defined in OAR 411-020-0002(1)(b)(A)(ii).

The facility failed to fully implement and update an acuity-based staffing tool. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to immediately report abuse or suspected abuse to the Department, AAA, or law enforcement agency and promptly investigate all reports of abuse and suspected abuse. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to develop and implement a policy for the referral of residents who may be victims of acute sexual assault. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to ensure the staff person who administers the medication must visually observe the resident take the medication. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to ensure service plans were reflective of resident preferences and implemented. The facility’s failure is a violation of Oregon Administrative Rules.

The licensee failed to be responsible for the operation of the facility and the quality of services rendered in the facility. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to ensure residents had the right to a safe and homelike environment. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to develop and implement a policy for the referral of residents who may be victims of acute sexual assault. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to immediately report and investigate abuse and suspected abuse and neglect. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to exercise reasonable precautions against any condition that could threaten the health, safety and welfare of residents. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to ensure service plans were based on evaluations and reflective of the resident's needs and preferences, provided clear direction regarding the delivery of services, were implemented, reviewed and updated and were readily available to staff. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to identify, evaluate, monitor, and document significant change of condition requirements. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

The facility failed to consistently staff to the levels, intensity and qualifications indicated by the Acuity-Based Staffing Tool (ABST). Inconsistencies were identified between the staffing schedule and the data produced by the ABST. Facility was not staffed to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

The facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

The facility failed to consistently staff to the levels, intensity and qualifications indicated by the Acuity-Based Staffing Tool (ABST). Inconsistencies were identified between the staffing schedule and the data produced by the ABST. Facility was not staffed to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

The Alleged Victim (AV) and Witness 1 (W1) both rely on the facility for care. W1 has a documented history of inappropriate sexual behavior with other residents and is care planned to be escorted any time they are outside of their room. According to an investigation, on or about December 31, 2025 AV was inappropriately touched by W1, while at a facility gathering and a again short time later when W1 and AV were in common area hallway leaving the gathering. The next day, January 1, 2026, W1 attempted to coerce AV into their room, and then sat outside AV's room for days waiting for them to enter the common area. The Alleged Perpetrator 2 (AP2) found out about the recent incidents on January 6, 2026, but failed to take any action for approximately 2 days, resulting in emotional harm for AV, as well as placing AV at risk for serious harm. The AP2 knew W1 had a history of inappropriate sexual behavior and failed to ensure staff were following the service plan and/or implement a safety plan for W1's behaviors before or after the incidents on December 31, 2025, and January 1, 2026, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to ensure a safe environment, which is a violation of Oregon Administrative Rules.

Alleged Victim (AV) relies on the facility for his/her care. On or about September 5, 2025, the Alleged Perpetrator 2's (AP2) approached AV in the common area dining room, rubbed AV's arm and kissed AV's forehead, then walked away. According to an investigation, AP2 acknowledged that kissing AV was unprofessional, but AP2 was trying to convey they cared for AV. AP2 actions are considered sexual abuse. The facility failed to provide a safe environment for the AV which is a violation of Oregon Administrative Rules.

The facility failed to provide a safe medication administration system to ensure the Alleged Victim’s (AV) medications were administered as ordered, and documented accurately. The failure is a violation of Oregon Administrative Rules.

Facility failure to provide an Oregon licensed nurse who is regularly scheduled for onsite duties and who available for phone consultation. The facility’s failure is a violation of Oregon Administrative Rules.

Facility failure to provide at least one working elevator. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to fully implement and update an Acuity Based Staffing Tool (ABST). The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to provide an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules.

According to documentation, the Alleged Perpetrator 2 (AP2) failed to follow the Alleged Victim's (AV) care plan and provide appropriate services according to AV's needs. The failure resulted in AV experiencing a loss of personal dignity and risk of harm, which is a violation of resident rights, is considered neglect of care and constituents abuse. The facility failed to protect AV from neglect, which is a violation of Oregon Administrative Rules.

The facility failed to keep the interior free from unpleasant odors and failed to keep interior materials and surfaces clean, which is a violation of Oregon administrative rules.

The facility failed to have the Registered Nurse (RN) assess all residents with a significant change of condition