Meadowlark Senior Living

The Alleged Victim (AV) lives at the Respondent’s facility and relies on facility staff to ensure that AV’s basic care, safety, and supervision needs were met. AV has a documented history of urinary tract infections (UTIs), some of which have resulted in hospitalization. AV also exhibits poor gait, generalized weakness, and decreased mobility. According to AV’s service plan, AV has a history of making unsafe decisions, failing to communicate medical information to facility staff, and not following physician orders. AV has a pattern of declining assistance. AV is incontinent of urine and wears incontinence briefs and is able to change these independently. Staff are required to notify the facility nurse of any signs of UTI, including painful urination, foul odor, dark urine, burning with urination, increased confusion, or hallucinations. AV has been known to use multiple pads within the briefs and, on multiple occasions, to remain in feces and urine for extended periods. On or about October 10, 2025, AV was evaluated in the emergency room for altered mental status with hallucinations and was treated for a UTI. The Respondent failed to develop and implement adequate person-centered interventions placing AV at risk of harm. This failure constitutes abuse by neglect.

The Alleged Victim (AV) resides in the Respondent’s facility and depends on staff to meet basic needs and ensure safety. AV has a documented history of falls, including incidents in August and September 2025. AV’s service plan dated on or about August 26, 2025, notes poor gait, weakness, decreased mobility, and use of both a walker and wheelchair. AV utilizes an upright walker within AV’s apartment, requires one-person staff assistance for wheelchair mobility over longer distances, and requires two-person assistance for transfers. On or about August 29, 2025, AV was unable to stand from the wheelchair despite three attempts. On or about September 4, 2025, AV was recertified for physical therapy, AV was assessed as requiring extensive assistance for all transfers and bed mobility and was noted to be non-ambulatory. On or about October 6, 2025, AV self-transferred from the wheelchair to the sink and fell in AV’s bathroom. Following this fall, interventions directed AV to call for assistance and wait for staff before attempting transfers. On or about October 10, 2025, AV sustained an unwitnessed fall in AV’s room. AV reported leaning too far, falling out of bed, and landing on AV’s side next to the bed. AV was not wearing a call pendant and yelled for help. AV sustained injuries to the face, left knee, left arm/elbow, and back of the head. Interventions following this fall included having the family obtain a grabber tool and instructing AV to call staff for assistance. The Respondent failed to develop and implement person-centered interventions sufficient to mitigate the known fall risk to AV. This failure constitutes abuse by neglect.

The Alleged Victim (AV) moved into the facility on November 13, 2024. AV had a history of falls and a medicaid assessment completed in September 2024 determined AV needed substantial assistance with ambulation and transfers. AV was assessed by the facility as minimal under fall evaluation. AV had reported to staff that on November 25, 2024, AV had fallen from his/her bed. On or about November 26, 2024, AV suffered a fall in his/her bathroom, resulting in injuries to his/her head, arms and knees. AV was sent out to the hospital for evaluation. The facility's failure to properly assess and care plan for AV's risk of falls is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) relies on facility staff to administer AV’s medications as prescribed by AV’s provider(s). AV is prescribed an anticonvulsant twice daily. AV missed the evening doses of h/h anticonvulsant From October 12, 2024, to October 15, 2024. AV also missed the morning dose of h/h anticonvulsant on October 15, 2024. October 15, 2024, AV experienced a seizure and went to the hospital for evaluation. As a result of the seizure, AV experienced increased pain, soreness, and tiredness. The facility failed to administer medication as ordered, take appropriate steps in refilling AV’s anticonvulsant medication, which is a violation of resident rights is considered neglect of care and constitutes abuse.

Alleged Victim (AV) relies on AP1 to ensure AV's basic care, safety and supervision requirements are met. AV relies on the facility to order, store and administer h/h medications. AV has a history of seizures, and takes prescribed medication to be administered at 1500 hours daily . On or about the January 14, 2024, AV went without h/h Neurological Medication, and experienced a seizure on January15, 2024. It was determined AV's seizure was likely the result of AV not receiving h/h Medication on January 14, 2024. AP2 works for an agency and not directly for AP1 . AP2 was responsible for providing AV with h/h medications at 1500 hours. AP2 arrived at the facility at approximately 1640 hours due to inclement weather. AP2 could not log into the medication administration system until approximately 1730 hours and no training or explanation of how the medication records system worked was provided to AP2. The allegation that AP2 to failed ensure proper administration of AV's medications as prescribed to AV was investigated and determined to be not substantiated. The facility failed to provide a safe medication administration system, and administer AV's medication as ordered, which is a violation of resident’s rights, is neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility to manage his/her medications. According to an investigation, on or about November 18, 2023, AV requested his/her PRN pain medication. AV did not receive the pain medication for over two hours, which resulted in unreasonable discomfort. The facility failed provide a safe medication administration, which is a violation of resident rights, is 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 provide a safe medication administration system to ensure AV's medications were administered as ordered. According to an investigation, AV did not receive his/her medications according to the doctor’s orders from approximately August 4, 2023, to September 10, 2023, which resulted in AV being sent to the hospital for confusion, lethargy, and mood swings. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) was a known fall risk with a history of falls. The facility failed to provide appropriate services according to the Alleged Victim (AV)'s needs, relating to his/her change of condition, number of falls with lack of appropriate interventions. According to an investigation, AV experienced multiple unwitnessed falls between August 8, 2023, and September 12, 2023, resulting in pain and head injuries. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is a known fall risk with a history of falls. 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. According to an investigation, AV experienced multiple falls between June 1, 2023, and September 14, 2023, which resulted in various abrasions and caused repeated unreasonable discomfort. This failure is a violation of resident rights, is neglect of care which constitutes abuse.

The Alleged Victim has a history of falls when his/her knees give out and is care planned as a high fall risk. The facility failed to appropriately care plan, relating to falls. According to an investigation, or about June 1, 2023, AV experienced a fall when his/her knee gave out, resulting in unreasonable discomfort, including two skin tears. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim has a history of falls and was care planned as a high fall risk. The facility failed to provide appropriate services according to Alleged Victim (AV)'s needs, number of falls with lack of appropriate interventions to mitigate fall risk. Based on an investigation, AV experienced approximately six falls from approximately January 17, 2022, and May 4, 2023, which resulted in repeated unreasonable discomfort, including a skin tear and a hip fracture. The facility's failure 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 AV's medications were administered as ordered. According to an investigation, AV did not receive his/her metabolic medications approximately ten times between April 2, 2023, and May 14, 2023, placing AV at risk for serious harm. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse. The allegation that Alleged Perpetrator 2 (AP2) failed to provide accurate administration of medications was investigated and determined to be Not Substantiated.

The facility failed to provide a safe medication administration system to ensure AV's medications were administered as ordered and to ensure that the Alleged Perpetrator 2 (AP2) was properly trained to pass medications. According to an investigation, on or about February 20, 2023, AV did not receive his/her narcotic pain medication according to the doctor’s orders, which resulted in AV experiencing pain. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) has a known hesitation to call staff when needing assistance and a history of falls. The facility failed to provide appropriate services according to Alleged Victim’s needs, number of falls with lack of appropriate interventions. Based on an investigation, AV experienced multiple unwitnessed falls from December 29, 2022, and February 23, 2023, which resulted in repeated unreasonable discomfort, including a laceration. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to an investigation, on or about January 13, 2023, the facility failed to administer medication as ordered for the Alleged Victim, placing AV at risk for harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The allegation that the Alleged Perpetrator 2 (AP2) failed to provide a safe medication administration was investigated and determined to be not substantiated.

According to an investigation, on or about January 11, 2023, the facility failed to administer medication as ordered for the Alleged Victim, resulting in AV experiencing high blood pressure and a headache for approximately two days, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The allegation that the Alleged Perpetrator 2 (AP2) failed to provide a safe medication administration was investigated and determined to be not substantiated.

AV is a fall risk and was care planned as full-assist with dressing and undressing. The facility failed to provide appropriate services according to Alleged Victim (AV)'s needs, relating to care plan and lack of appropriate interventions. According to an investigation, AV experienced a fall on or about December 23, 2023, when AV reached for his/her clothes to dress him/herself, which resulted in abrasions to AV's arm. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to an investigation, on or about November 28, 2022, Alleged Perpetrator 2 (AP2) gave AV an incorrect dosage of his/her diabetic medication, which resulted in AV experiencing unstable blood sugar, leaving AV at risk for serious harm. The facility and AP2 failed to provide a safe medication administration system, which is a violation of resident rights, is neglect of care and constitutes abuse.

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. Based on an investigation, AV experienced approximately seven unwitnessed non-injury falls between November 11, 2022, and November 27, 2022. On or about November 28, 2022, AV experienced another unwitnessed fall, which resulted in AV sustaining an abrasion to the right side of his/her chin. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) has a history of falls and is a fall risk. The facility failed to appropriate care plan and provide services according to the AV's needs, relating to falls and lack of appropriate interventions. Based on an investigation, on or about November 29, 2022, AV experienced two unwitnessed falls, where AV was found on the bathroom floor, resulting AV experiencing back pain. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide a safe medication administration system. On or about November 22, 2022, AV was administered a medication not prescribed to him/her. AV was sent to the hospital for observation and experienced side effects due to the medication error. The facility’s failure is a violation of resident rights, is neglect of care and constitutes abuse. The allegation that Alleged Perpetrator 2 (AP2) failed to provide appropriate services was investigated and determined no abuse occurred.

The facility failed to implement adequate interventions and provide appropriate supervision related to the Alleged Victim’s (AV) known history of falls. The failure resulted in AV experiencing an unwitnessed fall, that resulted in a head injury, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Under the prior ownership, Alleged Victim (AV) CAPS Assessment dated on or about December 15, 2021, indicates AV experiences paralysis on AV's left side, is a full assist with ambulation, uses a power chair for most ambulation, can walk a little way with the support of a caregiver, is a full assist with transfers, AV's left leg is paralyzed and is unable to use it in transitioning, is a full assist with toileting, and has a history of having several falls and not calling for assistance. AV has impulsiveness and is not cognizant to the safety and help AV requires. AV Service Plan dated on or about May 2, 2022, indicates AV needs constant reminders to use the call, has a hemi-walker and a quad cane that s/he will occasionally use for transfers into h/h wheelchair, uses an electric wheelchair and is independent with transferring into it. AV is independent with mobility with the use of h/h assistive devices and independent in transferring. AV is a high fall risk and has had a few falls in the past couple of months. AV requires extended care with getting dressed and needs assistance in pulling h/h pants up. AV needs occasional monitoring, guidance, or cueing and has some mild confusion and short-term memory loss. Documentation provided during investigation indicates AV had approximately nine (9) falls in approximately five (5) months from approximately March 18, 2022, to September 11, 2022. The falls are reported as AV slipping out of bed, being found on bathroom floor after tripping over powerchair, and slipping out of scooter seat, slipping on bathroom floor not wearing shoes. The CAPS assessment and Care plan are not aligned in AV capabilities and needs. There is no TSP or update to the care noted after each of AV falls. On or about September 11, 2022, AV fell in the bathroom when AV was transferring self from Wheelchair to toilet and lost h/h footing. AV hit AV's left hip and forehead on the wall and was transported to the emergency room. At the time of the incident, the only intervention in place for falls was to take AV's vitals daily. The facility failed to implement interventions and/or appropriately care plan for AV’s continued falls, which is a violation of resident rights is neglect of care and constitutes abuse.

The facility failed to assess, intervene, and monitor the Alleged Victim (AV) when he/she experienced a change of condition. On or about, May 26, 2022, the AV was found outside the assisted living facility. Prior to the incident, AV was exhibiting increased wandering within the facility and experiencing cognitive decline. The facility's failure placed AV at serious risk of harm, which is a violation to resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) has a known history of not being spatially aware of where his/her left arm is in regard to objects around the facility. The facility failed to provide appropriate services according to the Alleged Victim (AV)'s needs, relating to lack of care planning and interventions. On or about April 26, 2022, AV was unable to get through an exterior door before it closed on his/her left hand, which caused the door to pinch AV's finger, resulting in a fracture and requiring stitches. The facility's failure 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 (AV)'s needs, relating to his/her change of condition, increased level of care and number of falls with lack of appropriate interventions. On or about March 29, 2022, AV was transported to the hospital as he/she could not bear weight on one leg as a result of a fall the previous day. At the hospital, AV was diagnosed with a fractured tibia, low potassium levels, and a urinary tract infection. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to protect the Alleged Victim (AV) from theft of property. On or about February 10, 2022, it was discovered that some of AV’s PRN narcotic pills were missing. Based on an investigation, it was determined that Alleged Perpetrator 2 (AP2) signed out medication that was not requested or given to AV, and AP2 took AV’s medication for their own use. AP2 was responsible for financial exploitation, which constitutes abuse. The facility’s failure 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) narcotic medication was properly monitored, which resulted in theft. According to an investigation, Alleged Perpetrator 3 (AP3) was notified about concerns of theft and failed to conduct any audits, which resulted in theft of AV's medication. Alleged Perpetrator 4 (AP4) and Alleged Perpetrator 7 (AP7) failed to ensure adequate oversight of the medication system, which resulted in theft of AV's medication. AP3, AP4, and AP7’s actions are considered neglect and constitutes abuse. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse. The allegation that Alleged Perpetrator 5 (AP5) , Alleged Perpetrator 6 (AP6) and Alleged Perpetrator 8 (AP8) failed to ensure adequate oversight of the medication administration system was investigated, and determined no abuse occurred.

The facility failed to provide a safe medication administration system to ensure the Alleged Victim’s (AV) narcotic medication was properly monitored, which resulted in theft. According to an investigation, Alleged Perpetrator 3 (AP3) was notified about concerns of theft and failed to conduct any audits, which resulted in theft of AV's medication. Alleged Perpetrator 4 (AP4) failed to ensure adequate oversight of the medication system, which resulted in theft of AV's medication. AP3, and AP4’s actions are considered neglect and constitutes abuse. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse. The allegation that Alleged Perpetrator 5 (AP5), Alleged Perpetrator 6 (AP6), Alleged Perpetrator 7 (AP7), and Alleged Perpetrator 8 (AP8) failed to ensure adequate oversight of the medication administration system was investigated, and determined no abuse occurred.

The facility failed to protect the Alleged Victim (AV) from theft of property. On or about February 10, 2022, it was discovered that some of AV’s PRN narcotic pills were missing. Based on an investigation, it was determined that Alleged Perpetrator 2 (AP2) signed out medication that was not requested or given to AV, and AP2 took AV’s medication for their own use. AP2 was responsible for financial exploitation, which constitutes abuse. The facility’s failure 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) narcotic medication was properly monitored, which resulted in theft. According to an investigation, Alleged Perpetrator 3 (AP3) was notified about concerns of theft and failed to conduct any audits, which resulted in theft of AV's medication. Alleged Perpetrator 4 (AP4) failed to ensure adequate oversight of the medication system, which resulted in theft of AV's medication. AP3 and AP4's actions are considered neglect and constitutes abuse. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse. The allegation that Alleged Perpetrator 5 (AP5), Alleged Perpetrator 6 (AP6), Alleged Perpetrator 7 (AP7), and Alleged Perpetrator 8 (AP8) failed to ensure adequate oversight of the medication administration system was investigated, and determined no abuse occurred.

The facility failed to protect the Alleged Victim (AV) from theft of property. On or about February 10, 2022, it was discovered that some of AV’s PRN narcotic pills were missing. Based on an investigation, it was determined that Alleged Perpetrator 2 (AP2) signed out medication that was not requested or given to AV, and AP2 took AV’s medication for their own use. AP2 was responsible for financial exploitation, which constitutes abuse. The facility’s failure 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) narcotic medication was properly monitored, which resulted in theft. According to an investigation, Alleged Perpetrator 3 (AP3) was notified about concerns of theft and failed to conduct any audits, which resulted in theft of AV's medication. Alleged Perpetrator 4 (AP4) and Alleged Perpetrator 7 (AP7) failed to ensure adequate oversight of the medication system, which resulted in theft of AV's medication. AP3, AP4, and AP7’s actions are considered neglect and constitutes abuse. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse. The allegation that Alleged Perpetrator 5 (AP5), Alleged Perpetrator 6 (AP6), and Alleged Perpetrator 8 (AP8) failed to ensure adequate oversight of the medication administration system was investigated, and determined no abuse occurred.

The facility failed to protect the Alleged Victim (AV) from theft of property. On or about February 10, 2022, it was discovered that some of AV’s PRN narcotic pills were missing. Based on an investigation, it was determined that Alleged Perpetrator 2 (AP2) signed out medication that was not requested or given to AV, and AP2 took AV’s medication for their own use. AP2 was responsible for financial exploitation, which constitutes abuse. The facility’s failure 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) narcotic medication was properly monitored, which resulted in theft. According to an investigation, Alleged Perpetrator 3 (AP3) was notified about concerns of theft and failed to conduct any audits, which resulted in theft of AV's medication. Alleged Perpetrator 4 (AP4) failed to ensure adequate oversight of the medication system, which resulted in theft of AV's medication. AP3, and AP4’s actions are considered neglect and constitutes abuse. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse. The allegation that Alleged Perpetrator 5 (AP5), Alleged Perpetrator 6 (AP6), Alleged Perpetrator 7 (AP7), and Alleged Perpetrator 8 (AP8) failed to ensure adequate oversight of the medication administration system was investigated, and determined no abuse occurred.

The facility failed to protect the Alleged Victim (AV) from theft of property. On or about February 10, 2022, it was discovered that some of AV’s PRN narcotic pills were missing. Based on an investigation, it was determined that Alleged Perpetrator 2 (AP2) signed out medication that was not requested or given to AV, and AP2 took AV’s medication for their own use. AP2 was responsible for financial exploitation, which constitutes abuse. The facility’s failure 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) medication was available to be administered as ordered. According to an investigation, Alleged Perpetrator 3 (AP3) was notified about concerns of theft and failed to conduct any audits, which resulted in AV being financially exploited, by way of theft. Alleged Perpetrator 4 (AP4) and Alleged Perpetrator 7 (AP7) failed to ensure adequate oversight of the medication system, which resulted in AV being financially exploited, by way of theft. AP3, AP4, and AP7’s actions are considered neglect and constitutes abuse. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse. The allegation that Alleged Perpetrator 5 (AP5), Alleged Perpetrator 6 (AP6) and Alleged Perpetrator 8 (AP8) failed to ensure adequate oversight of the medication administration system was investigated, and determined no abuse occurred.

The facility failed to protect the Alleged Victim (AV) from financial exploitation. On or about February 10, 2022, it was discovered that approximately 272 narcotic pills were missing. Based on an investigation, it was determined that Alleged Perpetrator 2 (AP2) took AV’s medication for their own use, resulting in financial exploitation, by way of theft. AP2 was responsible for financial exploitation, which constitutes abuse. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) has a history of attempting to leave the facility. According to an investigation, Alleged Perpetrator 2 (AP2) wrongfully restrained the Alleged Victim (AV) by administering sedating medications to keep AV in the facility, placing AV at risk for serious harm. AP2's actions are considered neglect and constitutes abuse. The facility failed to provide a safe environment, which is a violation of resident rights, is neglect of care and constitutes abuse.

The facility failed to provide a safe medication administration system to ensure the Alleged Victim’s (AV) narcotic medication was properly monitored, which resulted in theft. According to an investigation, Alleged Perpetrator 3 (AP3) was notified about concerns of theft and failed to conduct any audits, which resulted in theft of AV's medication. Alleged Perpetrator 4 (AP4) failed to ensure adequate oversight of the medication system, which resulted in theft of AV's medication. AP3, and AP4’s actions are considered neglect and constitutes abuse. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse. The allegation that Alleged Perpetrator 5 (AP5), Alleged Perpetrator 6 (AP6), Alleged Perpetrator 7 (AP7), and Alleged Perpetrator 8 (AP8) failed to ensure adequate oversight of the medication administration system was investigated, and determined no abuse occurred.

The facility failed to protect the Alleged Victim (AV) from theft of property. On or about February 10, 2022, it was discovered that some of AV’s PRN narcotic pills were missing. Based on an investigation, it was determined that Alleged Perpetrator 2 (AP2) signed out medication that was not requested or given to AV, and AP2 took AV’s medication for their own use. AP2 was responsible for financial exploitation, which constitutes abuse. The facility’s failure 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) narcotic medication was properly monitored, which resulted in theft. According to an investigation, Alleged Perpetrator 3 (AP3) was notified about concerns of theft and failed to conduct any audits, which resulted in theft of AV's medication. Alleged Perpetrator 4 (AP4) failed to ensure adequate oversight of the medication system, which resulted in theft of AV's medication. AP3 and AP4’s actions are considered neglect and constitutes abuse. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse. The allegation that Alleged Perpetrator 5 (AP5), Alleged Perpetrator 6 (AP6), Alleged Perpetrator 7 (AP7), and Alleged Perpetrator 8 (AP8) failed to ensure adequate oversight of the medication administration system was investigated, and determined no abuse occurred.

The facility failed to protect the Alleged Victim (AV) from theft of property. On or about February 10, 2022, it was discovered that some of AV’s PRN narcotic pills were missing. Based on an investigation, it was determined that Alleged Perpetrator 2 (AP2) signed out medication that was not requested or given to AV, and AP2 took AV’s medication for their own use. AP2 was responsible for financial exploitation, which constitutes abuse. The facility’s failure 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) narcotic medication was properly monitored, which resulted in theft. According to an investigation, Alleged Perpetrator 3 (AP3) was notified about concerns of theft and failed to conduct any audits, which resulted in theft of AV's medication. Alleged Perpetrator 4 (AP4) failed to ensure adequate oversight of the medication system, which resulted in theft of AV's medication. AP3 and AP4’s actions are considered neglect and constitutes abuse. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse. The allegation that Alleged Perpetrator 5 (AP5), Alleged Perpetrator 6 (AP6), Alleged Perpetrator 7 (AP7), and Alleged Perpetrator 8 (AP8) failed to ensure adequate oversight of the medication administration system was investigated, and determined no abuse occurred.

The facility failed to protect the Alleged Victim (AV) from theft of property. On or about February 10, 2022, it was discovered that some of AV’s PRN narcotic pills were missing. Based on an investigation, it was determined that Alleged Perpetrator 2 (AP2) signed out medication that was not requested or given to AV, and AP2 took AV’s medication for their own use. AP2 was responsible for financial exploitation, which constitutes abuse. The facility’s failure 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) narcotic medication was properly monitored, which resulted in theft. According to an investigation, Alleged Perpetrator 3 (AP3) was notified about concerns of theft and failed to conduct any audits, which resulted in theft of AV's medication. Alleged Perpetrator 4 (AP4) failed to ensure adequate oversight of the medication system, which resulted in theft of AV's medication. AP3, and AP4’s actions are considered neglect and constitutes abuse. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse. The allegation that Alleged Perpetrator 5 (AP5), Alleged Perpetrator 6 (AP6), Alleged Perpetrator 7 (AP7), and Alleged Perpetrator 8 (AP8) failed to ensure adequate oversight of the medication administration system was investigated, and determined no abuse occurred.

The facility failed to protect the Alleged Victim (AV) from theft of property. On or about February 10, 2022, it was discovered that some of AV’s PRN narcotic pills were missing. Based on an investigation, it was determined that Alleged Perpetrator 2 (AP2) signed out medication that was not requested or given to AV, and AP2 took AV’s medication for their own use. AP2 was responsible for financial exploitation, which constitutes abuse. The facility’s failure 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) narcotic medication was properly monitored, which resulted in theft. According to an investigation, Alleged Perpetrator 3 (AP3) was notified about concerns of theft and failed to conduct any audits, which resulted in theft of AV's medication. Alleged Perpetrator 4 (AP4) failed to ensure adequate oversight of the medication system, which resulted in theft of AV's medication. AP3, and AP4’s actions are considered neglect and constitutes abuse. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse. The allegation that Alleged Perpetrator 5 (AP5), Alleged Perpetrator 6 (AP6), Alleged Perpetrator 7 (AP7), and Alleged Perpetrator 8 (AP8) failed to ensure adequate oversight of the medication administration system was investigated, and determined no abuse occurred.

The facility failed to protect the Alleged Victim (AV) from theft of property. On or about February 10, 2022, it was discovered that some of AV’s PRN narcotic pills were missing. Based on an investigation, it was determined that Alleged Perpetrator 2 (AP2) signed out medication that was not requested or given to AV, and AP2 took AV’s medication for their own use. AP2 was responsible for financial exploitation, which constitutes abuse. The facility’s failure 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) narcotic medication was properly monitored, which resulted in theft. According to an investigation, Alleged Perpetrator 3 (AP3) was notified about concerns of theft and failed to conduct any audits, which resulted in theft of AV's medication. Alleged Perpetrator 4 (AP4) failed to ensure adequate oversight of the medication system, which resulted in theft of AV's medication. AP3 and AP4’s actions are considered neglect and constitutes abuse. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse. The allegation that Alleged Perpetrator 5 (AP5), Alleged Perpetrator 6 (AP6), Alleged Perpetrator 7 (AP7), and Alleged Perpetrator 8 (AP8) failed to ensure adequate oversight of the medication administration system was investigated, and determined no abuse occurred.

The facility failed to protect the Alleged Victim (AV) from theft of property. On or about February 10, 2022, it was discovered that some of AV’s PRN narcotic pills were missing. Based on an investigation, it was determined that Alleged Perpetrator 2 (AP2) signed out medication that was not requested or given to AV, and AP2 took AV’s medication for their own use. AP2 was responsible for financial exploitation, which constitutes abuse. The facility’s failure 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) narcotic medication was properly monitored, which resulted in theft. According to an investigation, Alleged Perpetrator 3 (AP3) was notified about concerns of theft and failed to conduct any audits, which resulted in theft of AV's medication. Alleged Perpetrator 4 (AP4) failed to ensure adequate oversight of the medication system, which resulted in theft of AV's medication. AP3, and AP4’s actions are considered neglect and constitutes abuse. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse. The allegation that Alleged Perpetrator 5 (AP5), Alleged Perpetrator 6 (AP6) Alleged Perpetrator 7 (AP7), and Alleged Perpetrator 8 (AP8) failed to ensure adequate oversight of the medication administration system was investigated, and determined no abuse occurred.

The facility failed to protect the Alleged Victim (AV) from theft of property. On or about February 10, 2022, it was discovered that some of AV’s PRN narcotic pills were missing. Based on an investigation, it was determined that Alleged Perpetrator 2 (AP2) signed out medication that was not requested or given to AV, and AP2 took AV’s medication for their own use. AP2 was responsible for financial exploitation, which constitutes abuse. The facility’s failure 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) narcotic medication was properly monitored, which resulted in theft. According to an investigation, Alleged Perpetrator 3 (AP3) was notified about concerns of theft and failed to conduct any audits, which resulted in theft of AV's medication. Alleged Perpetrator 4 (AP4) and Alleged Perpetrator 7 (AP7) failed to ensure adequate oversight of the medication system, which resulted in theft of AV's medication. AP3, AP4 and AP7’s actions are considered neglect and constitutes abuse. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse. The allegation that Alleged Perpetrator 5 (AP5), Alleged Perpetrator 6 (AP6), and Alleged Perpetrator 8 (AP8) failed to ensure adequate oversight of the medication administration system was investigated, and determined no abuse occurred.

The facility failed to protect the Alleged Victim (AV) from theft of property. On or about February 10, 2022, it was discovered that some of AV’s PRN narcotic pills were missing. Based on an investigation, it was determined that Alleged Perpetrator 2 (AP2) signed out medication that was not requested or given to AV, and AP2 took AV’s medication for their own use. AP2 was responsible for financial exploitation, which constitutes abuse. The facility’s failure 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) narcotic medication was properly monitored, which resulted in theft. According to an investigation, Alleged Perpetrator 3 (AP3) was notified about concerns of theft and failed to conduct any audits, which resulted in theft of AV's medication. Alleged Perpetrator 4 (AP4) failed to ensure adequate oversight of the medication system, which resulted in theft of AV's medication. AP3, and AP4’s actions are considered neglect and constitutes abuse. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse. The allegation that Alleged Perpetrator 5 (AP5), Alleged Perpetrator 6 (AP6), Alleged Perpetrator 7 (AP7), and Alleged Perpetrator 8 (AP8) failed to ensure adequate oversight of the medication administration system was investigated, and determined no abuse occurred.

The facility failed to protect the Alleged Victim (AV) from theft of property. On or about February 10, 2022, it was discovered that some of AV’s PRN narcotic pills were missing. Based on an investigation, it was determined that Alleged Perpetrator 2 (AP2) signed out medication that was not requested or given to AV, and AP2 took AV’s medication for their own use. AP2 was responsible for financial exploitation, which constitutes abuse. The facility’s failure 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) narcotic medication was properly monitored, which resulted in theft. According to an investigation, Alleged Perpetrator 3 (AP3) was notified about concerns of theft and failed to conduct any audits, which resulted in theft of AV's medication. Alleged Perpetrator 4 (AP4) failed to ensure adequate oversight of the medication system, which resulted in theft of AV's medication. AP3, and AP4’s actions are considered neglect and constitutes abuse. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse. The allegation that Alleged Perpetrator 5 (AP5), Alleged Perpetrator 6 (AP6), Alleged Perpetrator 7 (AP7), and Alleged Perpetrator 8 (AP8) failed to ensure adequate oversight of the medication administration system was investigated, and determined no abuse occurred.

The facility failed to protect the Alleged Victim (AV) from theft of property. On or about February 10, 2022, it was discovered that some of AV’s PRN narcotic pills were missing. Based on an investigation, it was determined that Alleged Perpetrator 2 (AP2) signed out medication that was not requested or given to AV, and AP2 took AV’s medication for their own use. AP2 was responsible for financial exploitation, which constitutes abuse. The facility’s failure 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) narcotic medication was properly monitored, which resulted in theft. According to an investigation, Alleged Perpetrator 3 (AP3) was notified about concerns of theft and failed to conduct any audits, which resulted in theft of AV's medication. Alleged Perpetrator 4 (AP4) failed to ensure adequate oversight of the medication system, which resulted in theft of AV's medication. AP3 and AP4’s actions are considered neglect and constitutes abuse. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse. The allegation that Alleged Perpetrator 5 (AP5), Alleged Perpetrator 6 (AP6), Alleged Perpetrator 7 (AP7), and Alleged Perpetrator 8 (AP8) failed to ensure adequate oversight of the medication administration system was investigated, and determined no abuse occurred.

The facility failed to protect the Alleged Victim (AV) from theft of property. On or about February 10, 2022, it was discovered that some of AV’s PRN narcotic pills were missing. Based on an investigation, it was determined that Alleged Perpetrator 2 (AP2) signed out medication that was not requested or given to AV, and AP2 took AV’s medication for their own use. AP2 was responsible for financial exploitation, which constitutes abuse. The facility’s failure 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 (AV)'s needs, relating to his/her change of condition, number of falls with lack of appropriate interventions. AV has a history of falls without appropriate interventions, indicated in case 00183255. On or about February 10, 2022, AV had another fall which resulted in AV experiencing unreasonable pain and discomfort. The facility's failure 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 (AV)'s needs, relating to his/her change of condition, number of falls with lack of appropriate interventions. AV experienced approximately six falls from approximately December 8, 2021, and February 6, 2022, resulting in skin tears and hip injuries, which caused AV repeated unreasonable pain and discomfort. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide appropriate health assessment, oversight, and monitoring when AV’s medical condition changed which resulted in AV experiencing a decline in his/her condition, resulting in AV not receiving timely medical treatment. AV was admitted to the hospital on or about, January 19, 2022, where he/she spent time in the hospital receiving treatment for a serious infection. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide appropriate services according to Alleged Victim (AV)'s needs, relating to his/her change of condition, number of falls with lack of interventions, keeping his/her room free of clutter, and AV's known hesitation to call staff when needing assistance. AV experienced approximately thirty-one unwitnessed falls from approximately November 9, 2021, and January 24, 2022, which resulted in repeated unreasonable discomfort, as a result of some head injuries and skin tears. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility to provide a safe environment. On or about October 29, 2021, AV knocked on the kitchen door and the door fell off the hinges striking AV. AV experienced headaches and a shoulder pain. The facility failed to provide a safe environment, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. The facility failed to appropriately care plan for AV’s behaviors for refusing care when the facility staff attempted to assist AV with his/her Activities of Daily Living. As a result, AV had poor hygiene which caused AV to suffer multiple bacterial infections which is a violation of resident rights is neglect of care and constitutes abuse.

On or about August 11, 2025, Alleged Victim had been found by a family member at approximately 11:12 AM laying in his/her recliner breathing heavily, 911 had been called, and resident was sent to the hospital. The last time the Alleged Victim had been seen by staff had been 8:12 PM the night prior on 08/10/25. The MARs indicated the Alleged Victim had not received his/her medication on 08/11/25. Facility Staff confirmed the Alleged Victim had not received any medications. The facility allegedly failed to administer medication as ordered for the Alleged Victim. An investigation determined this is a violation of Oregon Administrative Rules.

The facility allegedly failed to follow the care plan for the Alleged Victim. An investigation determined this is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during a site visit on 06/27/25, the facility’s failure to provide records to the Department upon request was substantiated. Findings include, but are not limited to: A review of electronic communication showed the Department requested documents related to the facility's APS ABST alleged event date of 11/28/24 on 12/19/24. The facility did not provide the requested documentation by the requested due date of 12/20/24. An email communication on 06/30/25, with Staff 1 (Executive Director) acknowledged that the request for records was received and had not been provided to the Department. The facility’s failure to provide records to the Department upon request was substantiated.

The facility failed to provide documentation upon request. 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 provide documentation upon request in accordance with OAR 411-054-0105(1)(a); An investigation determined no licensing violation occurred.

The facility failed to provide documentation upon request in accordance with OAR 411-054-0105(1)(a); An investigation determined this is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during a site visit on 06/27/25, the facility’s failure to provide records to the Department upon request was substantiated. Findings include, but are not limited to: A review of electronic communication showed the Department requested documents related to the facility's APS ABST alleged event date of 01/02/25 on 01/22/25. The facility did not provide the requested documentation by the requested due date of 01/23/25. An email communication on 06/30/25, with Staff 1 (Executive Director) acknowledged that the request for records was received and had not been provided to the Department. The facility’s failure to provide records to the Department upon request was substantiated.

Based on interview and record review, conducted during a site visit on 06/27/25, the facility’s failure to ensure the implementation of services was substantiated for 1 of 1 sampled residents (#1). Findings include, but are not limited to: A review of Resident 1’s service plan dated 04/09/25 and the facility's shower schedule indicated Resident 1 received shower assistance from the facility in the mornings on Wednesdays and Saturdays. A review of Resident 1’s shower sheets from 01/01/25 through 01/31/25 indicated the resident missed three of nine showers in January and had gone 13 days without a shower. An interview with Staff 1 (Executive Director) and Resident 1 was conducted. Resident 1 indicated there had been times when s/he had not been provided a shower, even though s/he is scheduled to receive showers twice a week. It was determined that the facility’s failure to ensure the implementation of services was substantiated.

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

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

The facility failed to ensure the implementation of services, a resident is not receiving assistance with housekeeping. 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.

The Alleged Victim (AV) relies on facility staff to ensure resident’s rights. On or about, September 7, 2023, it was discovered that an unknown Alleged Perpetrator 2 (AP2) had taken approximately $20 from AV's bag. AP2's actions are considered financial exploitation and constitutes abuse. The facility did not keep AV free from financial exploitation, which is a violation of Oregon Administrative Rules.

The facility failed to provide three daily nutritious, palatable meals with snacks available seven days a week. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to carry out medication orders as prescribed. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to implement a system for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility. An investigation determined this is a violation of Oregon Administrative Rules.

The Facility failed to comply with safe medication administration or treatment practices. An investigation determined this is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) relies on the facility to manage his/her medications. According to an investigation, on or about May 12, 2023, Alleged Perpetrator 3 (AP3) gave AV the wrong medication. AV experienced emotional discomfort and was sent to have labs drawn and vitals monitored. AP3's actions are considered neglect and constitutes abuse. The facility failed to provide a safe medication administration system which violates Oregon Administrative Rules. The allegation that Alleged Perpetrator 2 (AP2) failed to provide appropriate services was investigated and determined to be not substantiated.

On or about May 1, 2023, the Oregon Health Authority reported to the Department that Respondent failed to comply with weekly reporting requirements of vaccinated individuals, residents and staff, to the proper authority as required by law. This failure has been ongoing for a total of 30 days.

Based on an investigation, it was determined that Alleged Perpetrator 2 (AP2) was verbally aggressive towards Alleged Victim (AV), which caused AV emotional distress and loss of personal dignity. AP2’s actions are a violation of resident rights, are considered neglect of care and constitutes verbal abuse. The facility failed to protect AV from verbal abuse, which is a violation of Oregon Administrative Rules.

According to an investigation, on or about February 20, 2023, Alleged Perpetrator 2 (AP2) administered AV a medication not prescribed to AV. AV experienced side effects due to the medication error, including pain, itching and a full body rash. AP2's actions are considered neglect of care and constitute abuse. The facility failed to provide a safe medication management system which is a violation of Oregon Administrative Rules.

The facility failed to fully implement an Acuity Based Staffing Tool. An investigation determined no licensing violation or abuse occurred.

The facility failed to carry out medication and treatment orders as prescribed. An investigation determined this is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) relies on the facility to manage his/her medications. On or about October 20, 2022, Alleged Perpetrator 2 (AP2) did not follow proper procedure for medications and gave AV an additional dose of narcotic pain medication, leaving AV at risk for serious harm. AP2's actions are considered neglect and constitutes abuse. The facility failed to provide a safe medication administration system which violates Oregon Administrative Rules.

The facility failed to carry out medication and treatment orders as prescribed. An investigation determined this is a violation of Oregon Administrative Rules.

On or about August 1, 2022, the Oregon Health Authority reported to the Department that Respondent failed to comply with weekly reporting requirements of vaccinated individuals, residents and staff, to the proper authority as required by law. This failure has been ongoing from July 1, 2022 to July 31, 2022, for a total of 30 days.

On or about July 1, 2022, the Oregon Health Authority reported to the Department that Respondent failed to comply with weekly reporting requirements of vaccinated individuals, residents and staff, to the proper authority as required by law. This failure has been ongoing from June 1, 2022 to June 30, 2022, for a total of 30 days.

On or about June 1, 2022, the Oregon Health Authority reported to the Department that Respondent failed to comply with weekly reporting requirements of vaccinated individuals, residents and staff, to the proper authority as required by law. This failure has been ongoing from May 1, 2022 to May 31, 2022, for a total of 30 days.

The facility failed to keep all interior materials and surfaces clean. An investigation determined this is a violation of Oregon Administrative Rules.

On or about May 1, 2022, the Oregon Health Authority reported to the Department that Respondent failed to comply with weekly reporting requirements of vaccinated individuals, residents and staff, to the proper authority as required by law. This failure has been ongoing from April 1, 2022 to April 30, 2022, for a total of 30 days.