River Terrace Memory Care

The Alleged Victim (AV) relies on the facility for care, which includes medication management. On or about January 13, 2025, AV was given another residents medication, resulting in AV experiencing diarrhea. According to an investigation, there was not a multistep authentication process to verify medications match the physician order prior approving them in the MAR and administering. The facility failed to provide a safe medication system, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The Allegation that AP2 neglected AV was unsubstantiated.

The Alleged Victim (AV) relies on the facility for care. According to an investigation, on or about December 27, 2024, AV went to the hospital for abdominal pain and inability to bear weight, where it was discovered AV had a broken femur. The facility is unsure when or how the broken femur occurred and although AV did have a fall on December 6, 2024 and multiple staff noted AV was unsteady on their feet, AV’s care plan does not mention they are a fall risk and it was not updated with any additional interventions. The facility failed to provide appropriate services according to Alleged Victim’s needs, regarding care planning, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility for care, redirection for wandering and intrusive behaviors, and has a history of altercations with other residents. Witness 1 (W1) is known to be triggered by intrusive behaviors. The AV and W1 had a history of altercations. According to an investigation, on or about December 20, 2024, The AV wandered into W1 room and W1 pushed the AV to the ground, causing redness to the AV’s back and unreasonable discomfort. The facility failed to provide the safety and oversight necessary to prevent resident to resident altercations, which is a violation of resident’s rights, is neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility for care and is care planned for staff to redirect AV if wandering into other resident rooms. On or about December 7, 2024, AV wandered into W1’s room resulting in W1 throwing coffee on AV and slapping AV on the shoulder. The facility failed to provide appropriate services, to include care planning and/or implementation of effective interventions to address AV's behaviors and provide a safe environment for AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility for care and is a known fall risk. On or about November 2, 2024, AV went to the hospital for abdominal pain and it was discovered AV had a compression fracture of the first lumbar vertebrae, that was new since April 2024, when AV had a fall and imaging that showed no fractures at that time. According to an investigation, AV had approximately seven (7) falls between March 6, 2024 and September 3, 3034, with no change of condition documented with AV's mobility changes and increase in AVs pain. The facility failed to provide services, to include implementing interventions and or care planning to mitigate AV’s increasing fall risk, change of condition and monitoring, and resident safety, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care and has a history of falls. On or about July 15, 2024, AV was found on the floor after apparently attempting to self-transfer out of bed. A bed cane, with no corresponding physician's order, was found incorrectly attached to AV's bed, which may have contributed to the fall. The facility failed to provide services according to AV’s needs, which is a violation of resident rights, is neglect of care which constitutes abuse.

The Alleged Victim (AV) is a known fall risk, and their service plan states to keep AV’s walker next to them when they are in bed, remind them to use the call light when they need help, and to perform safety checks on the resident each shift. On or about March 26, 2024, AV was found on the floor in their room, from an unwitnessed fall, and stated they hit their head. According to the investigation, staff cannot recall the last time AV had a safety check prior to the fall and AV’s walker was not next to AV bed, but found approximately 35 feet from the AV’s room in the doorway to another resident’s room. It was also discovered that AV cannot remember to use their walker, despite daily reminders. The facility failed to ensure resident safety, which is a violation of resident rights is neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility for care and has a history of falls. According to an investigation, between March 2, 2024, and March 5, 2024, AV fell approximately three times, with at least one fall resulting in AV being sent to the hospital. The facility failed to put effective, person-centered interventions in place after repeated falls, 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. On or about January 29, 2024, AV was attempting to walk into a room and was blocked by facility staff. AV threw themselves on the ground and hit their head on the door frame, resulting in being sent out to the hospital. AV's service plan does not mention AV having any behaviors of throwing self to floor, or provide staff with any interventions on how to address AV's behavior of throwing self to the ground. The facility failed to appropriately care plan and implement reasonable interventions to address AV’s behaviors, which is violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility for his/her care. The Alleged Victim (AV) is a known fall risk with a history of falls. AV was care planned to remind AV to use walker and that it is within reach. According to an investigation, on or about January 22, 2024, AV was found on floor by his/her apartment, resulting in a head injury. AV’s walker was approximately three to four feet away from AV. On or about January 26, 2024, staff escorted AV from the common area to AV’s apartment where AV started looking for a personal item and started to fall. Staff stepped in and prevented AV from falling, but when staff went to retrieve AV’s personal item from the common area AV fell and was found on the ground crying in pain. AV’s walker was two to three feet away from AV. The facility failed to follow AV’s care plan, which is a violation of resident rights, is neglect of care which constitutes abuse.

The Alleged Victim (AV) began having falls in December 2023, two which resulted in injury to AV. On or about January 10, 2024, AV suffered two separate falls. AV was found on the floor of his/her room. AV reported that he/she slipped out of bed. AV was diagnosed with a hairline fracture to his/her ankle. The facility's failure to ensure interventions were appropriate and properly care plan regarding AV's risk of falls is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) was a known fall risk. On or about January 1, 2024, at approximately 6:30 am, AV suffered a fall and was found on the floor in his/her room, next to his/her bed with complaints of pain to his/her knee. On the same date, approximately two hours later, AV was found on the floor again, complaining of knee pain. AV was care planned to have his/her walker within reach and to have non skid socks on. On the day of the incident, AV did not have on non skid socks, nor was AV's walker within reach. 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 care, has a fall history, and is care planned to be independent with ambulation. According to an investigation, AV had a recent illness that left AV disoriented and sometimes weak. On or about November 29, 2023, AV had an unwitnessed fall, resulting in skin tears to their arms. The facility failed to provide appropriate services according to AV’s needs, regarding care planning, safety checks and monitoring, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility for care, has a fall history, and is care planned to be independent with ambulation. According to an investigation, AV had a recent illness that left AV disoriented and sometimes weak, and had an unwitnessed fall with injury recently. On or about November 30, 2023, AV was complaining of head pain, and it was discovered AV had a scrape skin injury on their head. The facility failed to provide appropriate services according to AV’s needs, regarding care planning, safety checks and monitoring, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility for his or her safety and has a history of exit seeking. On or about August 21, 2023, the facility received a telephone call informing them that AV was observed outside of the locked memory care unit, walking down the street. Facility staff were unaware AV was missing. AV was located approximately 1 mile away from the facility, within blocks of a major thoroughfare and the Willamette River, and brought back to the facility. The facility failed to provide a safe environment, which is a violation of resident’s rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) and Witness 1 (W1) have a history of verbal and physical altercations. The facility failed to provide a safe environment to the Alleged Victim (AV). According to an investigation, on or about May 11, 2023, AV and W1 had a resident-to-resident physical altercation, which resulted in AV sustaining skin tears on their hand and forearm. The facility’s failure is a violation of resident rights, is neglect of care which constitutes abuse.

The Alleged Victim (AV) has a history of falls and is care planned for staff assistance with ambulation, transferring, toileting assistance and to have a fall mat by his/her bed. On or about March 5, 2024, AV was found on the floor next to his/her bed. The fall mat was not in place and there was a portable table tray next to AV's bed. AV suffered a laceration under his/her eye after connecting with the table tray. The facility's failure to follow AV's care plan is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately care plan regarding Alleged Victim’s (AV) known fall risk. AV had approximately four (4) documented falls between January 2, 2023, and February 21, 2023, some resulting in injury including but not limited to scrapes, abrasions, and a closed fracture of the nasal bone. The facility failed to appropriately care plan and implement reasonable interventions to address AV’s increasing and ongoing falls, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility for his or her safety. On or about September 11, 2022, around12:49 pm, the facility was alerted that AV was outside the facility in the parking lot, placing AV at risk for serious harm. Prior to being found outside AV was observed to be exit seeking and has a history of successfully eloping at least one (1) other time. The facility failed to provide a safe environment, which is a violation of resident’s rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility for his or her safety. On or about September 11, 2022, around11:48 pm, AV successfully pushed the back door to the facility open and eloped, placing AV at risk for serious harm. A facility staff member going to break observed AV out of the locked facility and successfully brought them back inside. Review of facility cameras show AV was attempting to get the back door open for approximately 10-15 minutes prior to getting it open, and the back door locking device was found to be broken. AV has a history of successfully eloping from the facility at least two (2) times prior to this incident. The facility failed to provide a safe environment, which is a violation of resident’s rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility for his or her safety. On or about August 29, 2022, around 10:00 am, the facility was alerted that AV was outside the building walking down the street. AV was found approximately 2 blocks away. Review of cameras reveal the family that alerted the facility the resident was down the street was how AV got out of the facility. Despite facility staff being in the front area and having cameras on the front doors, staff did not observe or know the resident had left the building, placing AV at risk for serious harm. The facility failed to provide a safe environment, which is a violation of resident’s rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) was care planned as a fall risk and has a history of falls, which included approximately three falls between August 4, 2022, and August 18, 2022. The facility failed to care plan or appropriately implement interventions according to the Alleged Victim (AV)'s needs, relating to falls. On or about August 25, 2022, AV was found on the floor in his/her bedroom with a head injury and sent to the hospital for evaluation, where he/she was diagnosed with a spinous process fracture. This failure is a violation of resident rights, is neglect of care which constitutes abuse.

The facility failed to implement interventions and appropriately care plan for Alleged Victim’s (AV) changing dental needs. Documentation indicates AV’s service plan was not updated to include staff reminders or assistance to help AV with his/her oral hygiene. As a result, AV’s teeth have turned brown and one tooth broke off. AV developed severe tooth decay and gum disease. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions or appropriately care plan for Witness #1’s (W1) known behaviors. This failure resulted in W1 pushing the Alleged Victim (AV), on or about April 17, 2022, causing AV to fall. W1 then was observed to be slapping and kicking AV, resulting in abrasions and skin tears on AV’s arms, which caused unreasonable discomfort. 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 implement interventions and appropriately care plan related to AV's needs and ensuring s/he has his/her dentures. The failure resulted in a loss of AV's dentures causing a loss of personal dignity and weight loss, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility for care and is care planned to have medication administration done by the facility. On or about January 8, 2025, the Alleged Perpetrator 2 (AP2) was observed giving AV 0.5 ml dose of an antiseizure medication instead of the prescribed dose of 5.0 ml. According to an investigation, AP2 indicated they had always given that dose and were not sure how many times the lower dose was given. It is estimated that AP2 potentially gave AV the lower dose approximately 16 times between December 4, 2024 and January 8, 2025, placing AV at risk for harm. AP2's actions are considered neglect and constitutes abuse. The facility failed to ensure medications were administered as ordered, which violates Oregon Administrative Rules.

The Alleged Victim (AV) relies on the facility for care and is care planned to have medication administration done by the facility. According to an investigation, on or about January 7, 2025, the Alleged Perpetrator 2 (AP2) and Alleged Perpetrator 3 (AP3) were administering medications. AP2 got distracted and AP3 gave the AV medications that belonged to another resident causing unreasonable discomfort and placing him/her at risk of serious harm. AP2 and AP3's actions are considered neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) relies on the facility to provide care and is care planned for the assistance of two staff. According to an investigation, on or about September 9, 2024, the Alleged Perpetrator 2 (AP2) assisted the AV with toileting independently, placing the AV at a risk of harm and resulting in the AV falling to the floor. AP2’s actions are a violation of resident rights, are considered neglect of care, and constitutes abuse. The facility failed to ensure care plans were followed, which is a violation of Oregon Administrative rules.

Alleged Victim (AV) relies on the facility for his/her care. AV is care planned to have direct supervision by staff when in the dining room, and that the staff member that starts a task with AV needs to stay with AV. On or about August 10, 2024, the Alleged Perpetrator #2(AP2) brought AV to the dining room and then went on break, leaving AV unattended. AV fell out of his/her wheelchair resulting in a five-inch scrape down their back. AP2 failed to follow the care plan, which 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.

The facility failed to promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the re-occurrence of abuse. An investigation determined no licensing violation or abuse occurred.

The facility failed to report any suspected abuse to the local APS office. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to ensure the preparation, completeness, accuracy, and preservation of resident records. 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 facility failed to ensure the implementation of services. An investigation determined this is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) relies on the facility for care and to manage his/her medications. The AV experiences foot and leg pain, and staff are to check pain levels and provide medications as needed. According to an investigation, on or about May 15, 2024, the AV called for assistance and was assisted to the floor by the Alleged Perpetrator 2 (AP2). The AV then reported leg pain, and the Alleged Perpetrator 3 (AP3) applied pressure to the AV’s foot, causing the AV to jolt back, hitting their head, losing consciousness, having a seizure, and being hospitalized. AP2 actions were investigated and determined to be unsubstantiated. AP3’s actions are a violation of resident rights, are considered neglect of care, and constitute abuse. The facility failed to ensure the residents rights/treatment was being followed, which 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 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 facility failed to carry out medication orders as prescribed. An investigation determined this is a violation of Oregon Administrative Rules.

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

The facility failed to ensure a resident monitoring and reporting system is implemented 24-hours a day. The facility’s failure is a violation of Oregon Administrative Rules.

Alleged Victim (AV) relies on the facility for his/her care. On or about August 7, 2023, Alleged Perpetrator 2 (AP2) tapped the Alleged Victim (AV) on the mouth and then put their middle finger toward the AV, resulting in a loss of dignity. AP2's actions are considered verbal/emotional abuse. The facility failed to protect AV from verbal/emotional abuse which is a violation of Oregon Administrative Rules.

On or about May 14, 2023, the Alleged Victim (AV) reported their necklace was missing. An investigation reveals that the necklace appears to have been taken by an unknown Alleged Perpetrator #2 (AP2), which is considered financial exploitation and constitutes abuse. The facility failed to protect AV from financial exploitation which is a violation of Oregon Administrative Rules.

The facility failed to implement the resident's right to be given informed choice and opportunity to select or refuse service. 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 provide a service plan with written description of who shall provide the services and what, when, how, and how often the services shall be provided and date and initial changes and entries made to the service plan. The facility’s failure is a violation of Oregon Administrative Rules.

According to an investigation, it was determined that on or about January 20, 2023, Alleged Perpetrator 2 AP2) handled the Alleged Victim (AV) in a rough manner during a change of brief, which caused a bruise and unreasonable discomfort. AP2’s actions are a violation of resident rights, are considered neglect of care and constitutes physical abuse. The facility failed to protect a resident from physical abuse which violates Oregon Administrative Rules.

On or about December 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 November 1, 2022 to November 30, 2022, for a total of 30 days.

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

According to documentation, the Alleged Perpetrator 2 failed to follow the AV's care plan and was rough when providing care. The failure resulted in unreasonable discomfort for AV and AP2's actions are considered physical abuse. The facility failed to protect AV from physical abuse, which is a violation of Oregon Administrative Rules.