Pelican Pointe Assisted Living Community

The Alleged Victim (AV) was care planned for 2 hour checks to check and change his/her brief and to empty AV's catheter. Staff were not regularly providing personal cares or emptying AV's catheter. From approximately May 16, 2025, to May 19, 2025, AV's brief was not changed by staff and on May 19, 2025, AV was found to be soaked as his/her catheter was leaking and AV's skin was very red, causing unreasonable discomfort. Respondent failed to ensure staff followed the service plan to change AV's brief, causing unreasonable discomfort to AV. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

The Alleged Victim (AV) was a known fall risk and suffered 5 falls between June 12, 2024 and June 27, 2024, with and without injury. During these falls, it was discovered that interventions in place were not being followed, were unknown by staff, or were unclear in the facility care planning. AV had falls with injuries including skin tears and pain. The facility's failure to ensure care planning is proper and clear to all staff is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is a known fall risk. Between June 24, 2024 and June 28, 2024, AV suffered 5 unwitnessed falls. The interventions put into place to reduce falls were ineffective as AV continued to have falls. On or about June 26, 2024, AV suffered an unwitnessed fall which appeared to be without injury, however, later in the day, AV reported that his/her left ankle was painful, and staff noticed discoloration. On June 28, 2024, AV suffered another fall, which appeared to be non injury. On or about July 5, 2024, AV complained of foot pain and bruising. On July 7, 2024, AV requested to go to the hospital and AV was diagnosed with multiple fractures to his/her foot. The facility's failure to properly care plan for AV's fall risk is a violation of resident rights, is considered neglect of care and constitutes abuse

The Alleged Victim (AV) had a history of falls. On or about December 6, 2023, AV suffered a fall in his/her room, which resulted in a bruise and pain to his/her head. The facility failed to properly care plan as it relates to AV's history of falls. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) had a history of falls. On or about December 10, 2023, AV was found on the floor of his/her room, complaining of hip pain and was taken to the hospital, where he/she was diagnosed with a fractured hip, which required surgical intervention. The facility failed to properly care plan to AV's history of frequent falls, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is a known fall risk and has suffered multiple falls. On or about September 5, 2023, AV suffered a fall causing a skin tear to his/her right wrist. The facility failed to properly care plan for AV, with appropriate interventions to reduce his/her risk of falls. The facility failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is a known fall risk and has suffered multiple falls. On or about September 12, 2023, AV suffered a fall where he/she hit his/her head on the floor. The facility failed to properly care plan for AV, with appropriate interventions to reduce his/her risk of falls. The facility failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about August 2, 2023, the Alleged Victim (AV) was seen at the emergency department after a fall and exhibiting confusion. AV was found to have multiple injuries from multiple falls prior to August 2, 2023. AV was a high fall risk and an assessment was completed in June and several interventions were suggested, however, none were implemented. The facility's failure to properly care plan as it relates to AV's falls is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is a known fall risk. On or about August 7, 2023, AV suffered 3 separate falls and was sent to the emergency room, where it was determined he/she injured his/her back. AV had a previous fall on August 3, 2023, and no new interventions to prevent falls were put into place. No assessments were completed on AV to determine the best way to prevent AV's falls. 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) is care planned for assistance with toileting. AV was found on more than one occasion soaked in urine. The facility failed to follow AV's care plan to assure AV's incontinence brief was changed in an timely manner. On or about March 26, 2023, AV was diagnosed with a urinary tract infection, causing unreasonable discomfort. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about March 29, 2023, the Alleged Victim (AV) suffered a fall in his/her apartment resulting in a skin tear to his/her elbow. AV had previously suffered falls on March 22, 2023 and March 25, 2023. From the March 22, 2023 fall, AV was sent to the hospital and diagnosed with a UTI. The facility failed to have the facility RN to intervene and perform a change of condition assessment which would have assured AV was being care planned appropriately as it related to his/her falls. 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) had a sore on his/her buttock and a pressure sore on his/her left foot. Staff were to rotate AV often to keep the sores from worsening, and to clean AV's wounds with soap and water and daily bandage change with ointment as directed by the care plan. Some facility staff were not aware of AV's wounds are were not following the care plan. AV was found with wound dressing which appeared to have not been changed for some time, as it was full of drainage and soaked. The facility's failure to follow the care plan is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) receives pain medication from the facility. Alleged Perpetrator #2 (AP2) was a medication technician at the facility, trained to dispense medication. In July 2022, AP2 was removed from passing narcotic medications due to suspicion of taking narcotics from a resident. On or about August 7, 2022, AP2 was allowed again to dispense narcotic medication again. On or about December 18, 2022, three of AV's narcotic medication bottles were discovered missing. AP2 was responsible for the medication caret the narcotic disappeared from, which almost exclusively happened on his/her watch. AP2's actions are a violation of residents rights, are considered neglect of care and constitute financial abuse. The facility's failure to provide a safe medication administration system is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to perform adequate assessments, implement interventions and appropriately care plan related to the Alleged Victim’s (AV) history of falls, several requiring emergency services. On or about October 17, 2022, AV’s service plan noted a change of condition due to increase in falls, though no meaningful interventions were placed to mitigate the risk of falls or injury. On or about November 15, 2022, AV returned from the hospital, after experiencing an unwitnessed fall with injury to his/her head and skin with no changes in instruction. On or about November 16, 2022, AV was found on the floor, following an unwitnessed fall, unresponsive, had sustained a head injury, and passed away. The facility’s failures are a violation of resident rights, are considered neglect of care and constitute abuse.

The Alleged Victim (AV) was a known fall risk, and had suffered multiple falls. On or about November 15, 2022, the AV suffered a fall, which resulted in a head injury and AV was sent to the hospital for evaluation. AV returned the same day from the hospital. No interventions were put into place to ensure AV's safety from further falls, other than frequent checks, which the facility was already doing, due to AV's past falls. 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) was care planned to have oxygen at all time. On or about November 11, 2022, AV was taken to the dining area with his/her portable oxygen tank. The tank was checked for fullness and deemed to be full by staff. After AV's meal, he/she was taken back to his/her room and stood up out of his/her wheelchair and became unresponsive. Emergency services were called and AV's oxygen saturation was at 41%. AV was taken to the hospital and returned later that day once his/her oxygen level had returned to baseline. The facility's failure to ensure proper training regarding AV's oxygen parameters, the length of time that a portable oxygen tank will last or how to properly ensure the portable tank is put together properly to ensure that it is working correctly. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) receives pain medication from the facility. Alleged Perpetrator #2 (AP2) was a medication technician at the facility, trained to dispense medication. In July 2022, AP2 was removed from passing narcotic medications due to suspicion of taking narcotics from a resident. On or about August 7, 2022, AP2 was allowed again to dispense narcotic medication again, and within a few days, AV's narcotic medication was a different color, appearing to have been diluted. AV soon reported increased weakness and dizziness, was shaky and increased pain. On or about August 18, 2022, the facility was made aware of the discrepancy of the diluted medication, however, AP2 was not removed from passing medications and the evaluation of the medication was not completed until two days later, and the narcotic was found to be clear in color. AP2 was then pulled from passing medications and AV started to feel much better. Further testing of the medication declared that the medication was diluted to 25% strength. AP2's actions are a violation of residents rights, are considered neglect of care and constitute abuse. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) receives pain medication from the facility. Alleged Perpetrator #2 (AP2) was a medication technician at the facility, trained to dispense medication. In July 2022, AP2 was removed from passing narcotic medications due to suspicion of taking narcotics from a resident. On or about August 7, 2022, AP2 was allowed again to dispense narcotic medication again, and within a few days, AV's narcotic medication was a different color, appearing to have been diluted. AV soon reported increased weakness and dizziness, was shaky and increased pain. On or about August 18, 2022, the facility was made aware of the discrepancy of the diluted medication, however, AP2 was not removed from passing medications and the evaluation of the medication was not completed until two days later, and the narcotic was found to be clear in color. AP2 was then pulled from passing medications and AV started to feel much better. Further testing of the medication declared that the medication was diluted to 25% strength. AP2's actions are a violation of residents rights, are considered neglect of care and constitute financial abuse. The facility's failure is a violation of Oregon Administrative Rules.

On or about January 1, 2022, the Alleged Victim (AV) suffered a fall from his/her wheelchair resulting in a fractured neck. AV relies on the facility for all mobility, and is known to use his/her call button multiple times per day. AV is impatient, staff are aware of this. At times, AV is known to not use his/her call button, as AV feels that staff are irritated with him/her, therefore, AV will try to complete tasks on his/her own, placing him/herself at risk for harm. AV has had times where the call button was not answered in a reasonable amount of time.. On the day of the incident, AV did not press his/her call button before trying to complete a task, resulting in the fall. The facility failed to provide a safe environment and answer call lights in a timely manner, which is a violation of resident rights, is considered neglect of care and constitutes abuse.