McMinnville Memory Care

The facility failed to implement fall interventions and appropriately care plan related to the Alleged Victim's (AV) fall history. On or about August 4, 2024, AV got upset, began yelling and staff were unable to calm AV. AV got out of his/her wheelchair, tried to walk and fell. AV landed on his/her left side and had extreme pain and was given a PRN narcotic pain medication as a result of the pain due to the fall. On August 5, 2024, AV's pain level was so high AV could not handle being touched. AV was diagnosed with a broken hip after X-rays were taken. The facility's failure to properly care plan for AV's high fall risk resulted in AV experienced continued extreme pain and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On June 4, 2024, ODHS Adult Protective Services (APS) initiated investigation #00334771 and issued a written investigation report, which is incorporated here by reference. Alleged Victim (AV) and Witness 1 (W1) both lived at Respondent’s facility at time of incident. On May 31, 2024, a resident-to-resident altercation occurred at the facility involving the Alleged Victim (AV) and Witness 1 (W1). Based on facility documentation and interviews, in response to AV spitting on the floor, W1 physically assaulted AV by knocking AV down, kneeling on AV’s chest, and punching AV in the chest and abdomen. AV sustained a head injury and sent to the hospital for treatment due to bleeding and discomfort. Based on facility documentation and interviews, AV was care planned for staff to maintain constant visual supervision in common areas to prevent altercations, due to AV's known impulsive behavior. At time of incident, facility staff failed to follow AV's care plan which led to the altercation between AV and W1 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 or about May 15, 2024, W1 punched Alleged Victim (AV) in the face and pushed AV to the ground, after AV relieved himself/herself on W1's door. AV and W1 have a history of resident-to-resident altercations with each other. Prior to this altercation, W1 was seen following AV and threatening AV. After the altercation, AV was spitting up blood and transported to the ER. AV was diagnosed with a facial contusion. The facility's failure caused 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 related to the Alleged Victim’s (AV) known history of falls. On or about April 23, 2024, AV had an unwitnessed fall while trying to change his/her clothing without staff assistance. AV had a large red and purple bruise on his/her upper back as a result of the fall. Based on facility documentation, AV has a history of falls which included multiple falls within a short period of time of February 13, 2024, and March 19, 2024. The failure resulted in AV experiencing several unwitnessed falls, causing unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to appropriately monitor Witness 1 (W1) according to his/her known behavior and prior altercations. On or about January 30, 2024, W1 got upset that Alleged Victim (AV) was being too loud. W1 then got out of his/her wheelchair and hit AV hard on his/her right arm and right ear. Based on facility documentation and interviews, W1 is to be removed from situations that are overstimulating or when the environment is loud. At time of incident, AV was banging his/her cups and had been doing so for a while. The facility failed to remove W1 from the loud environment prior to W1 getting emotionally triggered and acting out in aggression. The facility's 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 provide appropriate supervision related to the Alleged Victim’s (AV) known history of falls. The failure resulted in AV experiencing a fall on or about September 16, 2023, causing AV unreasonable discomfort. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and provide appropriate supervision related to the Alleged Victim’s (AV) known history of falls. Based on facility documentation and interviews, AV fell on August 27, 2023, September 4, 2023, and September 6, 2023, and facility failed to implement interventions to prevent future falls after each of these falls occurred. The facility's failure resulted in AV experiencing several falls, causing AV unreasonable discomfort which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide appropriate services according to the Alleged Victim’s (AV) hygiene care needs. The facility's failure resulted in AV not receiving assistance with bathing, washing, and other hygiene activities as care planned. The facility's failure caused AV unreasonable discomfort and a loss of personal dignity, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide appropriate services according to the Alleged Victim’s (AV) toileting and wound care needs. Based on facility documentation and interviews, AV has pressure sores on his/her buttocks. AV was observed being left in wet and/or soiled briefs for extended periods of time and has been observed as completely soaked or soiled after night shift. The failure resulted in AV experiencing unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately monitor Witness 1 (W1) according to his/her known behavior and prior altercations. On or about August 5, 2023, W1 slapped Alleged Victim's (AV) hand during an argument unreasonable discomfort to the AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about June 13, 2023, Witness 1 (W1) punched Alleged Victim (AV) twice in the upper left arm causing AV unreasonable discomfort. According to facility documentation and interviews, the facility failed to implement appropriate interventions and failed to appropriately monitor W1 according to his/her known behavior and prior altercations. 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. The failure resulted in a physical altercation on or about June 11, 2023, in which W1 squeezed Alleged Victim's (AV) upper left arm and hit AV in the back of the head 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 Alleged Victim (AV) according to his/her known behavior and prior altercations. The failure resulted in a physical altercation between Witness 1 (W1) and AV on or about June 4, 2023, in which AV squeezed W1's hand and would not let go so W1 bit AV's hand. The facility put an Interim Service Plan in place after this incident, directing staff to keep AV and W1 separated. On June 5, 2023, AV held onto W1's walker and would not let go in which W1 hit AV on his/her hand and yelled "let it go". The facility's failure to provide a safe environment for AV and W1, caused unreasonable discomfort and emotional harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately monitor Witness 1 (W1) according to his/her known behavior and prior altercations. The facility's failure resulted in a physical altercation between W1 and Alleged Victim (AV) on or about May 29, 2023, in which W1 shoved AV in a dispute over the common area couch, causing unreasonable discomfort to the AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to appropriately monitor Witness 1 (W1) related to his/her known behaviors. On or about May 20, 2023, W1 and Alleged Victim (AV) had a resident-to-resident altercation in which W1 squeezed AV's hand hard causing unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about February 17, 2023, the Alleged Victim (AV) fell from his/her wheelchair while left unattended in the facility’s communal room. AV had been moved to that area by staff during dining room cleaning. While unsupervised, AV fell from the wheelchair and struck his/her head on the floor, resulting in a laceration under the right eye, a rug burn on the right side of the forehead, and a cervical fracture. AV was transported to the emergency department for evaluation and treatment. AV passed away on February 20, 2023. Facility documentation and interviews show that between August 19, 2022, and February 17, 2023, a period of seven months, AV experienced fourteen falls. These repeated falls caused multiple injuries, including rug burns, skin tears, and reported pain involving the head, shoulders, and arms. Documentation further indicates that AV slipped from the wheelchair on at least six occasions during this period. Although staff discussed possible fall-prevention interventions, such as using a lap buddy or a specialized wheelchair, there was no documented evidence that these were implemented. The facility failed to put effective interventions in place to prevent AV from repeatedly sliding or falling from the wheelchair which contributed to AV’s fall on February 17, 2023, that resulted in serious injuries which is a violation of resident rights, is considered neglect of care which constitutes abuse.

The facility failed to provide a safe medication administration system to ensure The Alleged Victim’s (AV) medications were administered as ordered. Based on facility documentation and interviews, AV was not administered any of his/her medication for three to four days after moving into the facility on January 5, 2023. AV was transported to the hospital on January 10, 2023, where it was discovered that AV had a stroke. AV takes blood thinner medication to prevent a stroke and facility failed to give AV his/her blood thinner medication as ordered. The failure resulted in unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide appropriate services according to the Alleged Victim’s (AV) peri-care needs. AV is incontinent of the bladder and has a history of urinary tract infections. According to facility documentation and interviews, AV was left in soiled briefs for long periods of time and staff failed to document peri-care assistance. The facility's failure to clean and/or dry AV's body parts wetted or soiled by incontinence caused AV unreasonable discomfort and placed AV at risk for a potential urinary tract infection, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide appropriate services according to the Alleged Victim’s (AV) peri-care needs. According to facility documentation and interviews, AV was left in soiled briefs for long periods of time causing a rash on his/her groin area due to being wet. The facility's failure resulted in AV’s condition worsening 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, causing unreasonable discomfort to the Alleged Victim (AV), which is a violation of resident rights, is considered neglect of care and constitutes abuse. As the new owner of this facility, you are responsible for correcting any deficiencies which pre-date your ownership. You must correct violations which occurred under previous ownership, as directed by the Department. You will not be responsible for paying civil penalties incurred by previous owner(s). However, if you fail to correct identified deficiencies within the specified time you may be subject to aggravated civil penalties.

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 and causing unreasonable discomfort to the Alleged Victim (AV), which is a violation of resident rights, is considered neglect of care and constitutes abuse. As the new owner of this facility, you are responsible for correcting any deficiencies which pre-date your ownership. You must correct violations which occurred under previous ownership, as directed by the Department. You will not be responsible for paying civil penalties incurred by previous owner(s). However, if you fail to correct identified deficiencies within the specified time you may be subject to aggravated civil penalties.

The facility failed to implement interventions and appropriately monitor Witness 1 (W1) and Alleged Victim (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. As the new owner of this facility, you are responsible for correcting any deficiencies which pre-date your ownership. You must correct violations which occurred under previous ownership, as directed by the Department. You will not be responsible for paying civil penalties incurred by previous owner(s). However, if you fail to correct identified deficiencies within the specified time you may be subject to aggravated civil penalties.

The facility failed to implement interventions and appropriately monitor Witness 1 (W1) and Alleged Victim (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. As the new owner of this facility, you are responsible for correcting any deficiencies which pre-date your ownership. You must correct violations which occurred under previous ownership, as directed by the Department. You will not be responsible for paying civil penalties incurred by previous owner(s). However, if you fail to correct identified deficiencies within the specified time you may be subject to aggravated civil penalties.

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 unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse. As the new owner of this facility, you are responsible for correcting any deficiencies which pre-date your ownership. You must correct violations which occurred under previous ownership, as directed by the Department. You will not be responsible for paying civil penalties incurred by previous owner(s). However, if you fail to correct identified deficiencies within the specified time you may be subject to aggravated civil penalties.

The facility failed to implement interventions and appropriately monitor Witness 1 (W1) and Alleged Victim (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. As the new owner of this facility, you are responsible for correcting any deficiencies which pre-date your ownership. You must correct violations which occurred under previous ownership, as directed by the Department. You will not be responsible for paying civil penalties incurred by previous owner(s). However, if you fail to correct identified deficiencies within the specified time you may be subject to aggravated civil penalties.

Witness #1 (W1) is known to have sexualized behaviors towards residents. On or about October 2, 2021 and again on December 12, 2021, W1 touched the Alleged Victim (AV) inappropriately. The facility failed to have appropriate interventions in place to assure the safety of AV. The facility's actions are a violation of resident rights, are considered neglect of care and constitute abuse.

The Alleged Victim (AV) was a new resident to the facility on October 15, 2021. AV suffered four falls from October 16, 2021 to October 19, 2021. Only one intervention was put into place after the first fall AV suffered. AV fell three more times without any new interventions to alleviate his/her falls. During the last three falls, AV suffered a cracked knee, sprained wrist and bruising to his/her right hand, causing unnecessary pain and suffering. The facility failed to properly care plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

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.

Based on interview and record review, conducted during an investigation on 08/21/26, the facility’s failure to complete, update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly, and use the results of an ABST to develop and routinely update the facility's posted staffing plan was substantiated. Findings include but are not limited to: The facility’s census was 45. A review of the facility’s last ABST evaluation update per resident indicated 3 of 45 residents had not been updated quarterly as required as of 03/25/25. A review of the facility’s ABST care times as of 03/25/25 indicated: · For Day shift, 47.75 hours, or a minimum of 6.5 direct care staff; · For Swing shift, 40.14 hours, or a minimum of 5.5 direct care staff; and · For Night shift, 13.82 hours, or a minimum of 2 direct care staff. The facility’s posted staffing plan indicated: · For Day shift, 7 direct care staff; · For Swing shift, 5 direct care staff; and · For Night shift, 3 direct care staff. The facility's posted staffing plan did not meet/exceed the ABST minimum hours required. The findings were reviewed with and acknowledged by Staff 1 on 08/21/26. The facility’s failure to complete or update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly as required and use the results of an ABST to develop and routinely update the facility's posted staffing plan is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during an investigation on 08/21/26, 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, complete or update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly as required, and use the results of an ABST to develop and routinely update the facility's posted staffing plan was substantiated. Findings include, but are not limited to: The facility’s census was 45. A review of the facility’s last ABST evaluation update per resident indicated 4 of 45 residents had not been updated quarterly as required as of 03/20/25. A review of the facility’s ABST care times as of 03/20/25 indicated: · For Day shift, 47.66 hours, or a minimum of 6.5 direct care staff; · For Swing shift, 40.02 hours, or a minimum of 5.5 direct care staff; and · For Night shift, 13.82 hours, or a minimum of 2 direct care staff. The facility’s posted staffing plan indicated: · For Day shift, 7 direct care staff; · For Swing shift, 5 direct care staff; and · For Night shift, 3 direct care staff. The facility's posted staffing plan did not meet/exceed the ABST minimum hours required. The facility’s staffing schedule, dated 03/20/25, indicated the facility was not staffing to its posted staffing plan for 1 of 3 shifts reviewed. The findings were reviewed with and acknowledged by Staff 1 on 08/21/26. 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, complete or update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly as required and use the results of an ABST to develop and routinely update the facility's posted staffing plan is a violation of Oregon Administrative Rules.

The facility allegedly failed to ensure the implementation of services. An investigation determined this is a violation of Oregon Administrative Rules.

Alleged Perpetrator 2 (AP2) had a verbal altercation with Alleged Victim (AV) while working as AV's caregiver, in which AP2 yelled at AV, called AV derogatory names, used profanity toward AV, and ridiculed AV. After this altercation, AV felt their environment was hostile and AV was uncomfortable being around AP2. AP2's actions is considered verbal/emotional abuse. The facility failed to provide a safe environment for AV which is a violation of Oregon Administrative Rules.

The facility failed to provide direct care staff sufficient in number to meet the scheduled and unscheduled needs of the residents. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to implement safe medication and treatment administration systems. An investigation determined this is a violation of Oregon Administrative Rules.

The allegation that the facility failure to exercise reasonable precautions against any condition that may threaten the health, safety, or welfare of residents per OAR 411-054-0025(4) as stated in complaint that staff are not wearing masks, not washing hands between resident care, and leaving dirty briefs on the floor was verified.

The allegation that the facility failed to keep all interior and exterior materials and surfaces clean for the health, safety, and comfort of the residents, in accordance with OAR 411-054-0200(4)(i). Per complaint that dirty laundry and soiled briefs are left on the floors in the rooms was verified.

The facility failed to have sufficient staff to meet the scheduled and unscheduled needs of the residents, which is a violation of Oregon Administrative Rules.

The facility failed to keep the facility free of offensive odors, which is a violation of Oregon Administrative Rules.

The facility failed to exercise reasonable precautions against any condition that may threaten the health, safety, or welfare of the residents, which is a violation of Oregon Administrative Rules.

The facility failed to provide housekeeping services as required, which is a violation of Oregon Administrative Rules

The facility failed to have sufficient staff to meet the scheduled and unscheduled needs of the residents, which is a violation of Oregon Administrative Rules.