Mckenzie Living Eugene

Alleged Victim (AV) relies on the facility for his/her care needs. On or about January 27, 2026, at 8:25 PM, AV was being toileted by Alleged Perpetrator 2 (AP2), who did not use a gait belt to assist with the transfer back to AV's mobility device after finishing the task. As AP2 turned around to grab something behind AP2, AV fell backwards and hit AV's head on the floor. AP2 was retrained on transfers and gait belt usage and served a suspension day for not following AV's service plan. AP2 knew AV needed a gait belt for toileting transfers, however, AP2 acknowledged not using the gait belt. AP2 failed to follow the care plan around transfer for AV, which is neglect of care and constitutes abuse. The facility failed to protect AV from financial exploitation, which is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during an investigation on 06/04/26, the facility’s failure to update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly as required was substantiated, which is a violation of Oregon Administrative Rules.

Alleged Victim (AV) relies on the facility for his/her care needs. On or about September 26, 2025, staff found a bruise on AV's right arm. AV stated the bruising was caused by staff pulling AV up and out of bed. Alleged Perpetrator 2 (AP2) was identified as having been responsible for the bruising on AV's arms because of the timing of AV's care, and also because AV and AP2 told staff that AP2 had pulled AV up. AP2 acknowledged that when AP2 lifted AV, AV was unable to help with the transfer motion, therefore AP2 would've supported AV's upper body weight by holding onto AV's arms alone. AP2 failed to provide a safe environment for AV, which is neglect of care and constitutes abuse. The faciality failed to provide a safe environment to AV, 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) per the allegation of a serious event.

The facility failed to comply with Change of Conditions and Monitoring requirements in accordance with OAR 411-054-0040(1-2) per a report of a serious event.

The facility failed to carry out medication orders as prescribed in accordance with OAR 411-054-0055(1)(f) per complaint that a resident was administered another resident's medications, which is a violation of Oregon Administrative Rules.

On or about November 22, 2023, the facility failed to properly administer the Alleged Victim’s (AV) medications. According to documentation, AV experienced no negative outcome. The failure is a violation of Oregon Administrative Rules.

The facility failed to have safe medication and treatment administration systems in place that are approved by a pharmacist consultant, registered nurse, or physician. An investigation determined this is a violation of Oregon Administrative Rules.

Alleged Perpetrator 2 (AP2) failed to ensure the Alleged Victim's (AV) medications were administered as ordered. On or about August 11, 2023, AP2 administered one of AV diabetic medications at the wrong dosage, placing AV at risk for harm. AV was sent to the hospital for monitoring and treatment. AP2's actions are considered neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.

The facility failed to have an Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population, their needs, and all required Activities of Daily Living (ADL). Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. Facility is not currently staffing 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.

Alleged Victim (AV) relies on the facility for his/her care. On or about May 13, 2023, Alleged Perpetrator 2 (AP2) was assisting AV when they got into a verbal exchange, where AP2 spoke to AV inappropriately, which is considered verbal/emotional abuse. The facility failed to protect AV from verbal/emotional abuse which is a violation of Oregon Administrative Rules.

The facility failed to carry out medication and treatment orders as prescribed. An investigation determined licensing violation or abuse occurred.

On or about October 19, 2021, Alleged Perpetrator 2 (AP2) failed to administer medications to Alleged Victim (AV) as ordered by AV's physician. AP2's actions is considered neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system which is violation of Oregon Administrative Rules.