New Friends of Coos Bay

The Alleged Victim (AV) is dependent on facility staff to meet his/her care needs and has a history of falls. According to an investigation, on or about January 26, 2025, AV fell out of bed, was experiencing pain and was transported to the hospital. AV was then diagnosed with a hip fracture. The facility had received an order for half bed rails on AV's bed for mobility on December 23, 2024. The bed rails were in the lowered position when AV was last seen by staff prior to the fall. The facility failed to follow the care plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is dependent on the facility to meet his/her safety needs and has a history of falls. According to an investigation, on or about December 11, 2024, AV fell in their apartment, resulting in skin tears to both arms. AV had last been seen by staff sitting in a recliner in the community living room. AV's service planned interventions were for use of a pressure pad alarm in recliner and bed and for stand by assistance with transfers. At the time of AV's fall, there was only one care staff in the resident living area and that care staff had gone to the restroom. The facility did not have a plan or policy for care staff to provide coverage if a staff needed to use the restroom, resulting in a lack of staff to provide supervision and assistance. The facility failed to ensure sufficient staffing to meet resident needs, which is a violation of resident rights, is considered neglect of care which constitutes abuse.

The Alleged Victim (AV) is dependent on the facility to meet his/her safety needs and has a history of wandering on the unit. According to an investigation, on or about July 4, 2024, AV complained of pain and had discoloration and swelling in the collarbone area. AV's service planned interventions include for AV to be escorted to/from activities and the dining room. Prior to the injuries observed, AV was walking around the common area and attending an activity. Another resident told staff that AV fell in the bathroom. The facility failed to follow AV's service plan and escort AV to/from the activity in the common area provide supervision, resulting in AV's unwitnessed fall and fractured collarbone. The facility failed to follow the care plan, which is a violation of resident rights, is considered neglect of care which constitutes abuse.

The Alleged Victim (AV) relies on the facility for his/her care. Witness 3 (W3) has a history of aggressive behaviors towards staff and other residents and is care planned to have two staff assist with care. According to an investigation, on or about May 6, 2024, AV and W3 were fighting over possession of a blanket. After being re-directed by a staff, W3 then reapproached AV and were fighting again over the blanket, resulting in AV having a skin tear and large bruise to the forearm. The facility failed to provide interventions in the service plan for staff to follow when aggressive behaviors occurred, which is a violation of resident’s 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) medication was administered as ordered. The failure resulted in AV going without multiple doses of multiple medications creating a higher risk of falls. AV experienced a non-witnessed fall resulting in skin tears and increased pain. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.

The facility failed to implement interventions and provide appropriate supervision of Witness 1 (W1) according to his/her behaviors. On or about April 19, 2024, W1 was found in the Alleged Victim's (AV) room on two occasions, the second time resulted in AV being inappropriately touched by W1, causing emotional distress and a loss of personal dignity. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to have an updated service plan and task schedule for the Alleged Victim (AV) that properly reflects AV's grooming care needs, resulting in a personal loss of dignity to AV for not being groomed on a regular basis. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim's (AV) service plan was not reflective of interventions to address specific behaviors of AV taking food from other residents or staff during dining service. Instructions outlined in AV's service plan to redirect AV were not attempted during the meal observation on 12/12/23. The facility's failure to properly care plan according to AV's needs escalated AV's behaviors and caused 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 to the Alleged Victim (AV) according to his/her need for toileting assistance. Staff admitted to not being able to provide assistance due to a shortage of staff. The failure resulted in AV experiencing 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 follow Witness 1's (W1) care plan to redirect residents away from his/her room as an intervention to mitigate the risk of resident-resident altercations. The failure resulted in the Alleged Victim (AV) wandering near W1's room causing a physical altercation and AV was pushed to the ground causing unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Under prior ownership: The facility failed to follow the AV's care plan for safety checks and to have supervision according to the AV's needs. The failure resulted in AV experiencing an unwitness fall resulting in hospitalization, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide appropriate supervision to the Alleged Victim (AV) according to his/her needs and ensure a safe environment. The failure resulted in AV eloping the secured building, without staff knowledge, placing him/her at risk of harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to address and obtain medical assistance with the Alleged Victim's (AV) toenail condition. The failure resulted in loss of nails, bleeding and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Under prior ownership: The facility failed to properly monitor and ensure that staff were re-positioning AV per their care plan, which resulted in a risk of serious harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Under the prior ownership: The facility failed failed to appropriately care plan related to the Alleged Victim's known behaviors. AP2 failed to provide appropriate supervision according to the AV's care plan. The failures resulted in a physical altercation causing unreasonable discomfort to AV who was slapped in the face, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement effective interventions and provide adequate supervision according to Witness 1's (W1) known behaviors and history of altercations. The failure resulted in W1 pushing the Alleged Victim, causing him/her to lose their balance and experience unreasonable discomfort, which 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 to provide one on one supervision for behaviors. The failure resulted in AV wandering into Witness 1's (W1) room, aggravating W1, causing him/her to hit AV in the chest and kick him/her in the leg, causing unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to follow Witness 1's (W1) care plan according to his/her need for monitoring and redirecting due to ongoing aggression and altercations. W1 wandered into another Pod of the facility without staff knowledge and got into a physical altercation with the Alleged Victim (AV), pushing AV to the ground, and two other residents had to intervene and redirect W1. The facility's failure caused unreasonable discomfort to AV, and placed other residents at risk of harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility and Alleged Perpetrator 2 (AP2) failed to follow Witness 1's care plan and provide appropriate supervision according to his/her known behaviors and altercations with other residents. The failure resulted in W1 engaging in a physical altercation with the Alleged Victim, causing unreasonable discomfort, which is a violation of resident rights is considered neglect of care and constitutes abuse.

Under the prior ownership: The facility failed to effectively monitor and care plan related to Witness 1's behaviors. The failure resulted in a physical altercation with AV causing unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about March 3, 2023, the Alleged Victim (AV) was exhibiting behaviors of yelling out, which was not addressed by staff. Witness 1 (W1) has a history of aggravation and aggressive behaviors, and is to be redirected from other residents to avoid altercations. The facility and staff failed to provide adequate supervision according to the needs of the residents, resulting in a physical altercation between W1 and AV. The Alleged Perpetrator 2 (AP2) failed to follow W1's care plan to redirect him/her from other residents to prevent further injury, and left the residents unattended during a physical altercation. The facility and AP2's actions are a violation of resident rights, considered neglect of care which constitutes abuse.

The facility failed to implement interventions and appropriately care plan related to the Alleged Victim's (AV) fall history. The failure resulted in several unwitnessed falls with skin injury, causing repeated unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement effective interventions and appropriately care plan related to the Alleged Victim's (AV) fall history. The failure resulted in AV experiencing multiple unwitnessed falls causing repeated unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Under the prior ownership: The facility failed to implement interventions and appropriately care plan related to the Alleged Victim's (AV) behaviors. The failure resulted AV's aggressive behaviors causing him/herself unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Under the prior ownership: The facility failed to implement interventions and appropriately care plan related to Witness 1's behaviors. The failure resulted in a physical altercation with AV causing unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Under the prior ownership: The facility failed to effectively monitor and care plan related to Witness 1's behaviors. The failure resulted in a physical altercation with AV causing unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #3 (W3) is care planned for aggressive behaviors. The facility failed to care plan and provide interventions for the Alleged Victim’s (AV) known behaviors. According to an investigation, on or about January 7, 2023, AV and W3 were having a verbal altercation. Alleged Perpetrator 2 (AP2) and Alleged Perpetrator 3 (AP3) failed to intervene or adequately monitor AV and W3, resulting in W3 pushing AV up against a wall and AV pulling W3's hair. AP2 and AP3's actions are considered neglect and constitutes abuse. The facility failed to appropriately care plan and provide a safe environment, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Under the prior ownership: The facility failed to implement interventions and appropriately care plan related to Witness 3's behaviors. The failure resulted in a physical altercation with AV 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 care plan for Witness #1’s (W1) known behaviors. On or about December 24, 2022, the AV attempted to sit in a chair occupied by W1 and was pushed to the ground. The AV was sent to the hospital and diagnosed with broken bones, and later passed away. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to obtain timely medical treatment and follow up to address Alleged Victim’s (AV) known recurrent medical issue. On or about December 19, 2022, the Alleged Perpetrator #2 (AP2) was told that AV was experiencing pain and symptoms of their known recurrent medical issue. On or about December 24, 2022, at the insistence of AV’s family, AV was taken to the hospital and was diagnosed with a urinary tract infection (UTI) and given antibiotics. The facility and AP2 failed to obtain timely treatment for AV’s change of condition, which caused AV unnecessary discomfort, is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Perpetrator 2 (AP2) made inappropriate verbal comments in the facility in front of the residents while yelling, cussing, and hitting/slamming objects. AP2 is responsible for verbal abuse as result of his/her violent outburst. The facility failed to protect Alleged Victim (AV) from AP2's violent outburst, making AV agitated, causing AV emotional harm. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) has a history of falls. AV is care planned to have a pressure alarm in place when in bed, in recliner, and wheelchair. On or about December 10, 2022, AV was found on the floor yelling for help beside h/h bed. A pressure alarm was not in place and was not alarming at the time of the incident. The facility failed to follow the care plan which is a violation of resident’s rights is neglect of care and constitutes abuse.

Alleged Perpetrator 2 (AP2) made inappropriate verbal comments in the facility in front of the residents while yelling, cussing, and hitting/slamming objects. AP2 is responsible for verbal abuse as result of his/her violent outburst. The facility failed to protect Alleged Victim (AV) from AP2's violent outburst, making AV agitated, causing AV emotional harm. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Perpetrator 2 (AP2) made inappropriate verbal comments in the facility in front of the residents while yelling, cussing, and hitting/slamming objects. AP2 is responsible for verbal abuse as result of his/her violent outburst. The facility failed to protect Alleged Victim (AV) from AP2's violent outburst, making AV agitated, causing AV emotional harm. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Perpetrator 2 (AP2) made inappropriate verbal comments in the facility in front of the residents while yelling, cussing, and hitting/slamming objects. AP2 is responsible for verbal abuse as result of his/her violent outburst. The facility failed to protect Alleged Victim (AV) from AP2's violent outburst, making AV agitated, causing AV emotional harm. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to follow Alleged Victim (AV) care plan. AV is care planned for toileting, staff to check/change AV four (4) times per shift, day, evening, and NOC; skin condition, staff to apply barrier cream with every check/change, staff will wash and dry during incontinence check/changes with applying barrier cream. Documentation provided to the department indicates on or about October 08, 2022, AV had redness to perineal area. Documentation indicates there are several days approximately in October and November 2022, in which there are no documented check/changes during AM and or PM shift, and no documentation of the barrier cream being applied, contributing to an ongoing rash. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is to have his/her hygiene care provided by the facility. Staff knew that AV's toenails were long and in need of cutting, however, no staff provided this service. 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 history of behaviors, including taking other resident’s property. The facility failed to implement interventions or appropriately care plan for the Alleged Victim’s known behaviors. According to an investigation, staff has forcefully removed items from AV that doesn’t belong to him/her on multiple occasions, which resulted in AV becoming combative and striking out. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) care plan indicates AV will be provided transportation for outside appointments from the community bus. AV will receive necessary assistance with transportation. Documentation provided to the department indicates AV has had several rescheduled appointments approximately between June 2022 and January 2023. On or about December 05, 2022, the facility canceled AV medical appointment related to behaviors. The facility faxed the provider on or about December 10, 2022, stating AV had an increase in behaviors related to resident-to-resident altercations and hitting staff. On or about January 20, 2023, the facility cancelled approximately 30 minutes before AVs appointment due to not having transportation. AV had not seen the doctor since 06/2022 as the facility had cancelled or rescheduled all appointments. AV has several medical diagnosis and maintenance medications that require ongoing medical oversight and review. The facility failed to follow AVs service plan which is a violation of resident rights is considered neglect of care and constitutes abuse.

Alleged Victim (AV) lived at Respondent’s facility. On or around August 9, 2022, AV’s primary care physician (PCP) noted an early pressure ulcer to AV’s posterior left heel. The PCP sent the facility orders to float AV’s heels and have AV wear protective slippers (aka “moon boots”). AV’s service plan required staff to implement those measures, and required staff to monitor AV’s skin for redness, apply lotion, and assist with showers twice a week. The service plan also indicated that Alleged Perpetrator #2 (AP2) needed to monitor AV’s skin. On or around October 17, 2022, the facility developed a Temporary Service Plan (TSP) with additional related services. However, witness statements and facility documentation demonstrate that showers and skin monitoring were not occurring at the frequency required by the service plan, and that the moon boots may have been misused. On or about December 4, 2022, AV was in pain when staff removed “sopping wet” moon boats and discovered a round black area on AV’s left heel. At that stage, AV’s heel condition had worsened into a Stage III or IV pressure ulcer and caused AV pain. Alleged Perpetrator #2 (AP2) actions and failure to provide supervision and monitoring of AV known pressure ulcer is a violation of resident rights, is considered neglect of care and constitute abuse. The facility failure to ensure adequate supervision, oversight of staff, services, and failure to ensure AV service plan is followed, resulted in pain, unreasonable discomfort, and ulcer progression, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to follow Alleged Victim (AV) care plan. AV is care planned for showers two (2) times weekly, staff to check AV skin with bath/shower and report any reddened open areas. Staff, trim fingernails, and toenails, and AV will be assisted with toenail and fingernail care after each bath/shower. Documentation provided to the Department indicates AV received two (2) showers approximately in the month of November, and one (1) shower approximately in the month of December. Documentation indicates AV left 4th digit toenail coming off on approximately November 21, 2022, and photos from approximately December 2022 show poor condition of AV toenails and skin condition of feet, resulting in AV complaining of pain, and repeated unreasonable discomfort. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about October 27, 2022, the Alleged Victim (AV) was found on the floor from an unwitnessed fall. AV suffered a head laceration requiring staples. AV was wearing improper footwear, which lead to his/her fall. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) had a large scabby wound covering a quarter of his/her scalp. AV had not received any type of medical attention for this condition since he/she moved into the facility on August 21. 2021. On September 2, 2022, AV saw his/her physician and was referred to a dermatologist on September 26, 2022, where he/she was prescribed a steroid medication to assist with the scalp issues. Within 45 days, AV's scalp had marked improvement. The facility's failure to ensure physician services is a violation of resident rights, is considered neglect of care and constitutes abuse.

Initial: According to witnesses and documentation, the Alleged Perpetrator 2 (AP2) failed to adequately monitor, assess, and document AV's skin condition, which resulted in AV not receiving timely medical treatment. AV experienced pain and discomfort and on or about July 22, 2022, the AV was sent to the hospital where AV passed away a few days later. AP2 did not follow proper procedure for wound care. AP2's actions are considered neglect and constitutes abuse. The facility allegedly failed to provide oversight and monitoring of change of condition, which is a violation of resident rights, is considered neglect of care and constitutes abuse. Amended: Removed language is shown as [bracketed]. According to witnesses and documentation, the Alleged Perpetrator 2 (AP2) failed to adequately monitor, assess, and document AV's skin condition, which resulted in AV not receiving timely medical treatment. [AV experienced pain and discomfort and on or about July 22, 2022, the AV was sent to the hospital where AV passed away a few days later] AV was sent for medical treatment on June 22, 2022. AP2 did not follow proper procedure for wound care. AP2's actions are considered neglect and constitutes abuse. The facility allegedly failed to provide oversight and monitoring of change of condition, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) has a history of low blood sugar. On or about June 12, 2022, AV's blood sugar had been low earlier in the day. AV was offered food to raise his/her blood sugar. That same evening, AV's blood sugar was low again, Alleged Perpetrator #2 (AP2) held AV's insulin, however, did not offer AV any type of snack in order to elevate AV's blood sugar. AP2 stated there was nothing noted in AV's care plan to offer anything when his/her blood sugar was low, just to hold insulin. Later that evening, AV suffered a fall resulting in a closed fracture of his/her right femur, requiring surgical intervention. The facility's failure to properly care plan is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) receives as needed medication to ease pain. On or about April 7, 2022, AV requested pain medication and it took staff over two hours to bring pain medication to AV, leaving AV in unreasonable discomfort. The facility's failure to dispense medication in a timely manner is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to obtain a medical order to address Alleged Victim’s (AV) known recurrent medical issue. On or about March 15, 2022, facility staff took AV to a doctor appointment regarding behavioral changes where it was discussed with AV’s physician that an order for a urinalysis (UA) may be needed if there was no standing order already in place for AV. Upon return to the facility, staff did not follow up to see if there was a standing order and no further action was taken. No UA was obtained on AV. AV was admitted to the hospital on or about March 26, 2022, with among other issues, a urinary tract infection (UTI). The facility failed to obtain a medical order to diagnose AV’s recurrent UTIs, which caused AV unnecessary discomfort, is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility for their care needs to include personal hygiene and total assistance with showers. Between January 2022, and February 2022, it was documented that AV received approximately four (4) showers, causing AV to smell “sour” and sweaty, resulting in a loss of AV’s personal dignity as well as skin breakdown that has now been resolved. The facility failed to follow the care plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility for their care needs to include personal hygiene and oral care. Between January 2022, and early March 2022, it was documented that AV was assisted with getting their teeth brushed approximately three (3) times, resulting in a white film over AVs teeth and a loss of AV’s personal dignity. The facility failed to follow the care plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility to meet his/her daily needs. According to an investigation, on or about September 18, 2025, the Alleged Perpetrator 2 (AP2) failed to follow the care plan when he/she did not attach the leg pegs to AV's wheelchair during use, resulting in AV experiencing a fall with head injury. AP2's actions are considered neglect and constitutes abuse. The facility failed to ensure a safe environment, which violates Oregon Administrative Rules.

The facility failed to administer ordered medication for the Alleged Victim (AV). According to an investigation, AV experienced no negative outcome. The failure is a violation of Oregon Administrative Rules. The allegation that Alleged Perpetrator 2 (AP2) neglected AV was investigated and determined to be not substantiated.

The facility failed to administer ordered medication for the Alleged Victim (AV). According to an investigation, AV experienced no negative outcome. The failure is a violation of Oregon Administrative Rules. The allegation that AP2 neglected AV was investigated and determined to be not substantiated.

The facility failed to administer ordered medication for the Alleged Victim (AV). According to an investigation, AV did not receive ordered medication with no risk of serious harm. The failure is a violation of Oregon Administrative Rules. The allegation that AP2 neglected AV was investigated and determined to be not substantiated.

The facility allegedly failed to administer medication as ordered. An investigation determined no abuse occurred. The failure is a violation of Oregon Administrative Rules. The allegation that Alleged Perpetrator 2 (AP2) neglected AV was investigated and determined to be not substantiated.

The facility failed to provide a safe environment for the Alleged Victim. An investigation determined no abuse occurred. The failure is a violation of Oregon Administrative Rules. The allegation that Alleged Perpetrator 2 (AP2) neglected AV by failing to follow the service plan was investigated and substantiated.

The Alleged Victim (AV) relies on the facility to meet his/her daily needs. According to an investigation, on or about May 3, 2025, the Alleged Perpetrator 2 (AP2) failed to follow the care plan when he/she did not ensure care staff seated AV and W1 at least arm's length away from each other, resulting in AV experiencing unreasonable discomfort and being grabbed. AP2's actions are considered neglect and constitutes abuse. The facility failed to ensure the service plan was followed, which violates Oregon Administrative Rules.

The Alleged Victim (AV) relies on the facility to meet his/her daily needs. According to an investigation, on or about May 3, 2025, the Alleged Perpetrator 2 (AP2) failed to follow the care plan when he/she did not ensure a pressure pad alarm was properly working and in place, resulting in AV experiencing a fall with injury to the elbow. AP2's actions are considered neglect and constitutes abuse. The facility failed to ensure the care plan was followed, which violates Oregon Administrative Rules.

The Alleged Victim (AV) resides at the facility and relies on the facility to meet his/her daily needs. According to an investigation, on or about February 24, 2025, the Alleged Perpetrator 2 (AP2) and Alleged Perpetrator 3 (AP3) subjected AV to involuntary seclusion when AP2 pulled AV's wheelchair backwards into AV's room and AP3 held AV's hands to assist AP2 with getting AV into their room and shutting the door. These actions resulted in AV feeling upset and requiring transport to the hospital for verbal and physical aggression. AP2 and AP3's actions are a violation of resident's rights, are considered neglect of care and constitutes involuntary seclusion and abuse. The facility failed to protect AV from abuse, which is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) resides at the facility and relies on the facility to meet his/her daily needs. AV's care plan indicates AV dislikes loud noise levels. According to an investigation, on or about February 24, 2025, the Alleged Perpetrator 2 (AP2) failed to protect AV from verbal abuse when AP2 harassed AV by using profanity and making repeated sexual comments to and about AV in a loud tone, resulting in AV becoming upset and requiring transport to the hospital for aggression. AP2's actions are a violation of resident's 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.

The Alleged Victim (AV) resides at the facility and relies on the facility to meet his/her daily needs. According to an investigation, on or about February 24, 2025, the Alleged Perpetrator 2 (AP2) and AV were involved in a verbal and physical altercation after AP2 forcefully removed AV from the common area. AP2 physically abused AV when AP2 grabbed AV's forearms, resulting in a skin tear to AV's hand and requiring transport to the hospital for aggression. AP2's actions are a violation of resident's rights, are considered neglect of care and constitutes physical abuse. The facility failed to protect AV from physical abuse, which is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) resides at the facility and relies on the facility to meet his/her daily needs. According to an investigation, on or about February 24, 2025, the Alleged Perpetrator 2 (AP2) failed to follow AV's care plan by implementing interventions for behaviors, resulting in AV's behavior escalating and requiring transport to the hospital and sustaining a skin tear. AP2's actions are a violation of resident's rights, are considered neglect of care and constitutes abuse. The facility failed to protect AV from abuse, which is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) relies on the facility to meet his/her daily needs. According to an investigation, on or about December 13, 2024, the Alleged Perpetrator 2 (AP2) failed to follow the care plan when he/she did not correctly place a pad alarm under AV while seated, resulting in AV being placed at risk of serious harm and experiencing a fall with hospitalization. AP2's actions are considered neglect and constitutes abuse. The facility failed to ensure the care plan was followed, which violates Oregon Administrative Rules.

The Alleged Victim (AV) relies on the facility to meet his/her daily needs. According to an investigation, on or about October 26, 2024, the Alleged Perpetrator 2 (AP2) wrongfully physically restrained the AV when AP2 held AV's hands during personal care when AV was refusing care, resulting in AV experiencing anger and unreasonable discomfort. AP2's actions are considered neglect and constitutes abuse. The facility failed to assure resident's rights, which violates Oregon Administrative Rules.

The Alleged Victim (AV) relies on the facility to meet his/her daily needs. According to an investigation, on or about October 12, 2024, the Alleged Perpetrator 2 (AP2) failed to properly monitor AV's change of condition when he/she did not document administering PRN medication for pain and monitoring of AV's condition. AV was covered in feces and screaming in pain for several hours, resulting in AV experiencing repeated pain and unreasonable discomfort. AP2's actions are considered neglect and constitutes abuse. The facility failed to provide oversight and monitoring of a change in condition, which violates 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.

The Alleged Victim (AV) relies on the facility to meet his/her daily needs and is care planned to have three care staff assist with transfers for toileting. According to an investigation, on or about September 22, 2024, the Alleged Perpetrator 2 (AP2) failed to follow the care plan when he/she did not call for assistance with transferring AV to the toilet, provided transfer assistance to AV and fell during the transfer, resulting in AV falling, having skin tears to his/her legs and experiencing unreasonable discomfort. AP2's actions are considered neglect and constitutes abuse. The facility failed to follow the service plan, which violates 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.

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.

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.

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.

The facility failed to provide direct care staff sufficient in numbers to meet the scheduled and unscheduled needs of each resident. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to ensure the implementation of services. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to carry out medication and treatment orders as prescribed. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to administer the resident's medication as order by their physician. The facility’s failure 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.

The Alleged Victim (AV) relies on the facility to meet his/her daily needs. According to an investigation, on or about July 6, 2024, the Alleged Perpetrator 2 (AP2) failed to follow the care plan when instructing another staff to turn off a pressure alarm and left AV unsupervised, resulting in AV having a fall with injury. AP2's actions are considered neglect and constitutes abuse. The facility failed to follow the care plan, which violates Oregon Administrative Rules.

The facility failed to have a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated, or discontinued medications administered by the facility. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to ensure the implementation of services. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to administer the resident ' s medication as order by their physician. The facility’s failure is a violation of Oregon Administrative Rules.

The Alleged Perpetrator 2 failed to follow Witness 1's care plan to provide 1 to 1 supervision. The failure resulted in W1 being left unattended and engaged in a physical altercation with AV causing injury, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to ensure W1's care plan was followed which is a violation of Oregon Administrative Rules.

According to documentation, the AP2 failed to provide AV with assistance according to his/her needs. AP2’s failure to assist AV with dressing resulted in a loss of personal dignity and is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to protect AV from abuse which is a violation of Oregon Administrative Rules.

According to documentation, the AP2 used physical force when s/he pushed AV into the dining room table in a rough manner. AP2’s actions are considered physical abuse through the use of force that may cause injury, pain or impairment. The facility failed to protect AV from abuse which is a violation of Oregon Administrative Rules.

According to documentation, the AP2 threatened AV by stating s/he wanted to punch AV in the face. AP2’s actions are considered verbal abuse through the use of threat. The facility failed to protect AV from abuse which is a violation of Oregon Administrative Rules.

The facility failed to carry out medication orders as prescribed. The facility’s failure is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) is dependent on the facility for his/her medication administration. On or about March 13 and March 14, 2024, AV did not receive his/her needed medication to control his/her blood sugar. Alleged Perpetrator #2 (AP2) was the medication technician on these days and failed to administer AV's medication as ordered, as AP2 did not have time. AP2's inaction placed AV at risk for harm. AP2's actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility's failure to provide a safe medication administration system is a violation of Oregon Administrative Rules.

According to documentation, Alleged Perpetrator 2 (AP2) failed to follow the Alleged Victim’s (AV) care plan to provide assistance with mobility to prevent falls. The failure resulted in AV being left alone and experiencing an injury fall, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to ensure AV's care plan was followed, which is a violation of Oregon Administrative Rules.

The facility care staff failed to follow the AV's care plan to ensure proper incontinence care was provided. AV experienced no pain or skin breakdown, but the failure is a violation of Oregon Administrative Rules.

AV is to be kept in line of sight of staff while in common areas and out of arms reach of other residents however, the facility leaving all pod doors open for AV to wander makes this care planning ineffective as while wandering in the common areas there are no assigned staff to monitor the common areas. The failure places AV at risk of harm due to history of altercations, which is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) relies on the facility for medication administration. AV is scheduled to have a medication patch applied to him/her every three days. When one is applied, the existing one is to be removed. On or about February 6, 2024, Alleged Perpetrator #2 (AP2) was dispensing medication to AV. AP2 placed AV's medication patch as directed. AV had been very lethargic on February 7, 2024, missing medication administrations, and it was thought by staff that AV was just tired. On or about February 8, 2024, it was discovered that AV had two medication patches on him/her, one on his/her back and another on his/her shoulder, which was caused AV to be over medicated. AP2's actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility's failure to provide a safe medication administration system is a violation of Oregon Administrative Rules.

AV had a missing PRN during a medication audit. The medication was potentially taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect AV from medication theft. This failure is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) and Witness 1 (W1) rely on the facility to meet his/her daily needs. According to an investigation, on or about November 27, 2023, the Alleged Perpetrator 2 (AP2) failed to follow the care plan when he/she did not re-direct AV out of another resident's room, resulting in a physical altercation, AV being pushed down and sustaining a bruise. AP2's actions are considered neglect and constitutes abuse. The facility failed to ensure the care plan was followed, which violates Oregon Administrative Rules.

The Alleged Victim (AV) and Witness 1 (W1) rely on the facility to meet his/her daily needs. According to an investigation, on or about November 27, 2023, the Alleged Perpetrator 2 (AP2) failed to follow the care plan when he/she did not re-direct W1 out of AV's room, resulting in a physical altercation, placing AV at risk of harm. AP2's actions are considered neglect and constitutes abuse. The facility failed to ensure the care plan was followed, which violates Oregon Administrative Rules.

The facility failed to ensure the implementation of services. The facility’s failure is a violation of Oregon Administrative Rules.

The Alleged Perpetrator 2 failed to follow the Alleged Victim's care plan to ensure his/her pressure pad alarm was on and working while in bed, for fall safety. The failure resulted in AV attempting to get up on his/her own, causing a fall with injury, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to ensure AV's care plan was followed which is a violation of Oregon Administrative Rules.

The facility failed to have all interior doors and all equipment necessary for the health, safety, and comfort of the resident be kept in good repair in accordance with OAR 411-054-0200 (4)(i).

The Alleged Perpetrator 2 failed to follow the Alleged Victim's (AV) care plan to ensure h/h pressure alarm was in place to alert staff to AV's attempts to transfer. The failure resulted in AV experiencing an unwitnessed fall and AP2's actions are considered neglect of care and constitutes abuse. The facility's failure to ensure the care plan was followed is a violation of Oregon Administrative Rules.

The facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident in accordance with OAR 411-054-0070(1)

The Alleged Victim (AV) relies on the facility for his/her care. On or about May 30, 2023, AV was exhibiting behaviors and started hitting and choking the Alleged Perpetrator #2 (AP2). AP2 bit AV’s hand in an attempt to get AV to let go of their throat causing injury and unreasonable discomfort. AP2’s actions are a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to protect AV from physical abuse which is a violation of Oregon Administrative Rules.

The facility failed to administer a psychotropic medication as prescribed as prescribed in accordance with OAR 411-054-0055(1)(f) which is a violation of Oregon Administrative Rules.

The Alleged Perpetrator 2 failed to follow the Alleged Victim's care plan to provide toileting assistance. The failure resulted in AV being left alone and fell causing injury, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility's failure is a violation of Oregon Administrative Rules.

Alleged Victim (AV) relies on the facility for his/her care. AV is care planned to have skin protectors on his/her arms. On or about March 24, 2023, Alleged Perpetrators #2-4(AP2-4), were assigned to care for the AV, and AV was found without the skin protectors on and a scratch on AVs elbow. An investigation revealed AP3 failed to follow the care plan, and AP2 and AP4 results were inconclusive. AP3s actions/inactions is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to ensure the care plan was being followed, which is a violation of Oregon Administrative Rules.

According to the documentation, the Alleged Perpetrator 2 (AP2) failed to follow the care plan for the Alleged Victim (AV) by remaining in the room when the AV is showering. The failure resulted in the AV falling in the shower, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to follow the service plan which is a violation of Oregon Administrative Rules.

The facility failed to carry out medication and treatment orders as prescribed in accordance with OAR 411-054-0055(1)(f), which is a violation of Oregon Administrative Rules.

According to an investigation, on or about February 13, 2023, it was determined that Alleged Perpetrator 2 (AP2) took a Pepsi from AV’s refrigerator, resulting in financial exploitation, by way of theft. 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.

According to an investigation, on or about February 4, 2023, Alleged Perpetrator 2 (AP2) made an inappropriate verbal comment about the Alleged Victim (AV) in his/her presence, which resulted in the Alleged Victim (AV) experiencing unreasonable discomfort 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 inappropriate verbal comments made by staff and the failure is a violation of Oregon Administrative Rules.

Alleged Victim (AV) relies on the facility for h/h care and is care planned to have pressure pad alarms for resident safety. On or about February 5, 2023, the Alleged Perpetrator #2 (AP2) was observed turning off AV’s pressure pad alarms, putting AV at risk for harm. AP2’s actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility failed to follow the care plan which is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) is care planned for aggressive behaviors. According to an investigation, on or about January 7, 2023, AV and W3 were having a verbal altercation. Alleged Perpetrator 2 (AP2) and Alleged Perpetrator 3 (AP3) failed to intervene or adequately monitor AV and W3, resulting in AV pushing W3 up against a wall and W3 pulling AV's hair. AP2 and AP3's actions are considered neglect and constitutes abuse. The facility failed to provide a safe environment which is a violation of Oregon Administrative Rules.

On or about December 30, 2022, staff heard screaming coming from the Alleged Victim's (AV) room. Staff went to the room and observed Alleged Perpetrator #2 (AP2) standing over AV, yelling at him/her in an unreasonable manner. AP2's actions are a violation of resident rights, are considered neglect of care and constitute verbal abuse. The facility's failure is a violation of Oregon Administrative Rules.

The facility failed to ensure only individuals with a diagnosis of dementia who are in need of support for the progressive symptoms of dementia for physical safety, or physical or cognitive function may reside in a memory care community in accordance with OAR 411-057-0160(1), which is a violation of Oregon Administrative Rules.

The facility failed to identify and respond to changes of condition, which is a violation of Oregon Administrative Rules.

he facility failed to implement services in accordance with OAR 411-054-0036(2)(g), which is a violation of Oregon Administrative Rules.

The facility failed to implement a training program that includes methods to determine competency of direct care staff through evaluation, observation, or written testing, which is a violation of Oregon Administrative Rules.

The facility failed to carry out medication and treatment orders as prescribed in accordance with OAR 411-054-0055(1)(f) which is a violation of Oregon Administrative Rules.

The facility failed to train staff to identify changes in the resident's physical, emotional, and mental functioning and document and report on the resident's change of condition and have a reporting protocol with access to a designated staff, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action in accordance with OAR 411-054-0040(2)(b) and (c), which is a violation of Oregon Administrative Rules.

The facility failed to provide assistance with toileting in accordance with OAR 411-054-0030(1)(e)(G) which is a violation of Oregon Administrative Rules.

The facility failed to implement written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. An investigation determined a licensing violation or abuse occurred.

The facility failed to provide health services and have systems in place to respond to the 24-hour care needs of residents. An investigation determined a licensing violation or abuse occurred.

The Alleged Victim (AV) relies on the facility for his/her care. On or about August 3, 2022, the Alleged Perpetrator #2 (AP2) discovered a bruise on AV's arm. AP2 noted the bruise in AV’s progress notes but failed to report the bruise to anyone else to rule out abuse. AP2 did not follow abuse reporting guidelines which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to ensure the residents rights/treatment was being followed, which is a violation of Oregon Administrative rules.