Skylark Memory Care

The Alleged Victim (AV) resides in a secured Memory Care community and relies on the facility to properly care plan to ensure needs are met. According to an investigation, on or about September 27, 2025, the AV was sent out to the emergency department unaccompanied. The transportation service that returned the AV to the facility dropped them on in the unsecured portion of the facility. The AV was at risk of harm, wandering the unsecured area for approximately three hours. The facility failed to ensure the AV's service plan provided clear instruction for supervision needed when out of the facility, which is a violation of resident’s rights, is neglect of care, and constitutes abuse.

The Alleged Victim (AV) relies on the facility to follow physician's orders and provide meals. The AV has a physician's order for pureed foods and was care planned to receive the altered diet. According to an investigation, on or about September 16, 2025, the AV was given solid foods by Alleged Perpetrator 2 (AP2), placing the AV at risk for choking. AP2’s actions are a violation of resident rights, considered neglect, and constitute abuse. The facility failed to follow the AV’s diet orders and care plan, which is a violation of resident’s rights, is neglect of care, and constitutes abuse. The allegation that Alleged Perpetrator 3 (AP3) , Alleged Perpetrator 4 (AP4), and Alleged Perpetrator 5 (AP5) failed to follow the AVs care plan and physician's orders was investigated and determined to be inconclusive.

The Alleged Victim (AV) relies on the facility for his/her care. The AV has a history of multiple altercations with Witness 1 (W1). According to an investigation, on or about August 29th, 2025, the AV tapped a chair W1 was seated in. In response, W1 stood and threw the AV to the ground by their hair. The AV was sent to the emergency department. The facility failed to appropriately care plan for the on-going altercations between the AV and W1, which is a violation of resident’s rights, is neglect of care, and constitutes abuse.

The Alleged Victim (AV) relies on the facility to provide care. Witness 1 (W1) has a history of behaviors and altercations with others, including the AV on August 23, 2025. Additional interventions to keep W1 and AV separated or supervised when in common areas were not put in place until September 2, 2025. According to an investigation, on or about August 29, 2025, the AV took food from the W1, resulting in a resident-to-resident altercation between AV and W1 causing physical harm. The facility failed to appropriately care plan, which is a violation of resident’s rights, is neglect of care, and constitutes abuse.

The Alleged Victim (AV) relies on the facility to provide care. Witness 1 (W1) has a history of aggressive behaviors and altercations with others, including the AV on August 23, 2025. Additional interventions to keep W1 and AV separated or supervised when in common areas were not put in place until September 2, 2025. According to an investigation, on or about August 29, 2025, W1 took food from the AV, resulting in a resident-to-resident altercation between AV and W1 causing physical harm. The facility failed to appropriately care plan, which is a violation of resident’s rights, is neglect of care, and constitutes abuse.

The Alleged Victim (AV) relies on the facility to arrange for transportation to and from medical appointments. According to an investigation, on or August 12, 2025, the AV was transported to a medical appointment that had been cancelled and was left unattended in the medical office, placing the AV at risk of harm. The facility failed to ensure the AV's transportation was cancelled when the appoint was cancelled, which is a violation of resident’s rights, is neglect of care, and constitutes abuse. The allegation that Alleged Perpetrator 2AP2 neglected the AV by not cancelling the transportation was investigated and determined to be not substantiated.

The Alleged Victim (AV) relies on the facility to maintain a safe physical environment. According to an investigation, on or about May 10, 2025, the AV tripped over a pile of books propping open their door, resulting in unreasonable discomfort, a head injury and an emergency department visit. The facility failed to ensure a safe physical environment, which is a violation of resident’s rights, is neglect of care, and constitutes abuse.

The Alleged Victim (AV) receives his/her medication from facility staff. AV was prescribed pain patches at 5%, however, AV could not afford the payment for medication. AV's medication was purchased by a friend and brought to the facility. The medication that AV's friend purchased was a 4% pain patch. No one at the facility caught this difference and administered these patches to AV without a doctors order for this amount for approximately two months. AV ran out of his/her pain patches, AV's friend could not find 5% pain patches over the counter. AV went without any pain patches for approximately 10 days, which caused unreasonable discomfort to AV. 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 implement interventions and appropriately care plan related to the Alleged Victim's (AV) fall history. The failure resulted in AV experiencing a substantial number of unwitnessed falls, causing ongoing unreasonable discomfort and risk of serious harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) was new to the facility. On or about May 4, 2024, AV was missing, and was found out in the courtyard, AV didn't know how he/she got out there. On or about May 6, 2024, staff were advised that the fire safety door and the facility courtyard gate were broken. The batteries for the fire door have been dead since at least April 29, 2024, meaning the safety door has been unlocked 24 hours a day since that time. AV went missing on or about May 6, 2024 and was found approximately a half mile from the facility by police. The freeway is 300 feet from the facility and there is no fencing preventing anyone from walking into freeway traffic. It was approximately 50 degrees outside, and when AV returned, his/her hands were very cold. The facility's failure to provide a safe environment placed 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 Alleged Victim (AV) and Witness #1 (W1) were engaged in a physical altercation where AV entered W1's room and attempted to take W1's clothes. W1 and AV began pushing each other. The facility is aware that AV likes to wander into others rooms and is care planned for staff to keep him/her from entering other rooms. The facility's failure to provide a safe environment and follow the care plan placed AV at risk for harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) and Witness #2 (W2) have a history of aggressive behaviors and altercations with each other. The facility is aware that AV and W2 have history and they are care planned to be kept separated as much as possible. On or about January 28, 2024, AV and W2 were in the dining area and AV grabbed onto W2 and they were squeezing each other. The facility's failure to provide a safe environment and follow the care plan placed AV at risk for harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #1 IW1) is known to have aggressive behaviors towards other residents and a history of wandering into others rooms and altercations. W1 is care planned to be re-directed and staff provide one to one emotional support. On or about January 28, 2024, W1 wandered into the Alleged Victim's (AV) room and was picking up clothing. AV thought that W1 was taking his/her items. Staff heard screaming and found AV and W1 engaging in an altercation. Neither resident was hurt, however, AV was placed at risk of harm. The facility's failure to follow the care plan is a violation of resident rights, is considered neglect of care and constitute abuse.

On or about January 28, 2024, the Alleged Victim (AV) and Witness #1 (W1) engaged in a physical altercation. Facility staff were aware of the history of altercations between AV and W1. On the day in question, AV became verbally aggressive to W1 in the dining room and W1 grabbed onto AV and they began squeezing each other. The two were separated by care staff, however AV suffered a bruise due to the altercation. The facility's failure to provide a safe environment is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is a known fall risk and is care planned for adequate lighting, unobstructed egress and proper footwear. On or about January 11, 2024, AV was outside on the patio unattended and fell. AV was sent to the hospital and was found to have no injuries from the fall, however, AV was placed at risk for harm due to being outside in the dark, unattended by staff. The facility's failure to properly care plan to reduce AV's risk of falls is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is a known fall risk. Between July 2023 and January 2024, AV fell 14 times, 11 of those resulted in injury to AV. On or about January 17, 2024, AV was moved from his/her room to the common area and sat in a recliner. AV tried to get up and fell. AV complained of pain in his/her hip and was sent to the emergency room for evaluation. It was determined AV suffered a hip fracture. The facility's failure to provide a safe environment is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) has a traumatic brain injury and difficulty with judgement. AV has a history of multiple falls between March of 2023 and January 2024 and is supposed to be on 15 minute checks by facility staff. On or about December 4, 2023, staff heard AV yell for help from his/her room and found him/her on the floor. AV suffered skin tears to his/her arm and elbow and a bruise on his/her knee. The facility failed to follow AV's care plan to ensure his/her safety. 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 falls. On or about November 26 and November 27 of 2023, AV was found with bruising of unknown origin. Staff are to observe AV for safe ambulation and provide assistance as needed. The facility failed to provide a safe environment, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #1 (W1) has a history of behaviors and resident altercations, and is care planned with various interventions to ensure resident safety. On or about November 9, 2023, W1 hit the Alleged Victim (AV) with a table. AV was not injured, but did complain of pain in his/her leg later in the day. W1 was exhibiting behaviors prior to the incident, however, no one intervened with W1 to ensure AV's safety. The facility's failure to provide a safe environment for AV is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) has a history of falls, however, the facility had resolved previous fall history and AV began falling again recently. On or about November 3, 2023, AV suffered two falls, resulting in a cut to his/her knee. AV suffered another fall on November 4, 2023, where the facility discovered AV's oxygen levels were low. AV was placed on 15 minute checks, however, there is no documentation supporting that AV was actually being checked every 15 minutes. The facility's failure to provide a safe environment is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) has a history of falls prior to admission to the facility and while residing at the facility. On or about September 13, 2023, AV suffered a fall where he/she suffered a skin tear to his/her right elbow and redness on his/her right ankle and mid-back. AV was sent out to the hospital for evaluation and returned with a urinary tract infection. The facility failed to properly care plan for AV's risk of 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 had fallen 4 times in June, one fall resulting in a head injury. AV suffered another fall in July, and was placed on one hour safety checks and a new wheelchair was ordered for AV at that time. AV's wheel chair was to have the wheels locked when AV was not in it. On or about August 26, 2023, staff found AV on the floor from a fall. AV was sent to the hospital and was diagnosed with a hip fracture. AV's wheelchair was not locked at the time of his/her fall, nor had AV been checked on hourly, according to documentation. 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) resides in a locked unit. On or about August 16, 2023, Alleged Perpetrator #2 (AP2) exited the locked unit and entered the assisted living. When AP2 exited, AP2 thought the door latched, however, AV grabbed the door and exited behind AP2 without his/her knowledge. AV suffered a fall, resulting in a bruise to his/her leg. The facility staff tightened the door so it will close more quickly to ensure residents can't grab the door before it closes. AP2's actions were found to be inconclusive. The facility failed to provide a safe environment, 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 is care planned for one hour checks, assistance with transfers, toileting before and after meals and physical therapy. Staff are to also ensure that AV's wheelchair is locked at all times. On or about June 22, 2023, at 7:10 am, AV slid out of bed while transferring to his/her wheelchair, and hit his/her head and complained of knee pain. AV's wheelchair was not in the locked position, and AV's last check was at 5:40 am, according to documentation. The facility failed to follow AV's care plan, 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 with and without injury. AV suffered an unwitnessed fall on June 7, 2023 where AV was found with a red mark on his/her head. The facility failed to properly care plan for AV's risk of falls, 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 Alleged Victim (AV) was prescribed antibiotics for a urinary tract infection. The facility received the medication on May 24, 2023, however, did not begin administering the medication until May 26, 2023, which left AV in unreasonable discomfort. The facility's failure to provide a safe medication administration system and administer medications as ordered 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. The AV has a history of behavioral issues and resident to resident altercations including altercations with Witness 1 (W1). AV has a cane and will use it to swing at others. The AV service plan has interventions in place for daily walks. AV was also given behavioral support recommendations on or about March 16, 2023. On or about March 28, 2023, staff responded to raised voices and found W1 trying to take AV cane away. AV was found to have scratches and red areas on the left side of h/h face after the incident. The facility failed to provide adequate supervision, failed to follow the service plan and behavioral support recommendations, which is violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) has a history of exit seeking. AV eloped on or about February 28, 2023, following an outside provider through the locked doors and was found near the kitchen. On or about March 01, 2023, AV eloped out the door and was found heading towards the exit to the parking lot. AV eloped on or about March 03, 2023, through a propped open laundry room door, and was discovered when AV was outside the locked door asking to be let in. AV was gone for approximately fifty (50) minutes without staff knowledge. AV TSP on or about March 01 & 02, 2023, instruct staff to make sure laundry room door is secure and do not prop open laundry room door. The facility failed to provide a safe environment, and follow the TSP, which is a violation of resident’s rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) has a known fall history. AV suffered multiple falls, with and without injury. The facility failed to properly care plan around AV's falls. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about January 7, 2023, the Alleged Victim (AV) and Witness #1 (W1) were showing signs of aggression. AV and W1 were watching television in the common area with only one staff supervising multiple residents. AV and W1 both leaned forward, staff went to see why and W1 punched AV in the back three times before staff could respond. AV suffered a large bruise due to the altercation. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) had a condition that required a nurse to assist the AV in cutting his/her toenails. The facility apparently did not have a nurse available to cut AV’s toenails and failed to coordinate care with an outside medical provider, which allowed AV’s toenails to grow over AV’s toe and caused AV pain. The facility failed to provide appropriate service, which caused unreasonable discomfort, is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) had personal items go missing from their room while he/she was out of the facility. On approximately September 12, 2022, AV went to the hospital and then a rehab facility. On November 19, 2022, AV’s family went to the facility to retrieve some of AV’s belongings. There were numerous items missing and it appeared that another person had moved into AV’s room. The items were taken by an unknown Alleged Perpetrator #2 (AP2) and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect the resident’s property from theft, which is a violation of resident rights is considered neglect of care and constitutes abuse.

On or about November 14, 2022, an apparent drug diversion as well as multiple medication administration errors were discovered. The Alleged Victim’s (AV) Medication Administration Record (MAR) reveals a lack of medication oversight and missing narcotic medication. The allegation that Alleged Perpetrator 2 (AP2) financially exploited AV was investigated and was inconclusive. The facility failed to provide a safe medication administration system and did not keep AV free from financial exploitation, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) is care planned as independent with ambulation using an assistive device. AV has a known history of attempting to ambulate without an assistive device resulting in multiples falls, some with injuries. The facility failed to plan care around AV’s needs regarding ambulation, which is a violation of resident rights, is neglect of care and constitutes abuse.

The facility failed to provide appropriate services and care plan according to the Alleged Victim’s (AV) needs. The Alleged Victim (AV) had known behaviors as well as frequent periods of incontinence and there are no behavior plans in place or other guidance to staff other than to leave AV in his/her soiled garments. AV’s care plan indicates he/she is independent with toileting, despite numerous documented reports of AV walking around the facility in soiled clothes, sometimes for multiple days in a row. Documents reveal AV has been left in soiled briefs/clothes numerous times, staff has placed AV in the shower with his/her pants on where feces was running out of the pants, AV has a yeast infection from being left in soiled briefs, and AV has a pressure sore on his/her coccyx that is approximately 1 in in diameter. On or about November 4, 2022, AV was left in clothes soiled in urine and feces for approximately 5 hours, due to AV being combative. The facility failed to provide appropriate services to respond to AV’s change of conditions, which caused repeated unreasonable discomfort and loss of dignity, 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 multiple documented falls, some resulting in injury including but not limited to a head injury, skin tears, abrasions and bruising. The facility failed to implement interventions to mitigate AV’s increasing fall risk, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about October 20, 2022, an apparent drug diversion as well as multiple medication administration errors were discovered in the facility. The Alleged Victim’s (AV) Medication Administration Record (MAR) reveals a lack of medication oversight and missing liquid narcotic pain medication. An investigation determined that an unknown Alleged Perpetrator 2 (AP2) took AV’s medication. 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.

On or about October 20, 2022, an apparent drug diversion as well as multiple medication administration errors were discovered in the facility. Between approximately October 10, 2022, and October 15, 2022, the Alleged Victim’s (AV) Medication Administration Record (MAR) reveals a lack of medication oversight and approximately 5.75 milliliters (mL) of AV’s liquid narcotic pain medication to be missing. An investigation was inconclusive for Alleged Perpetrator’s 2-4 (AP2-4). The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about October 20, 2022, an apparent drug diversion as well as multiple medication administration errors were discovered in the facility. The Alleged Victim’s (AV) Medication Administration Record (MAR) reveals a lack of medication oversight and missing liquid narcotic pain medication. An investigation determined that an unknown Alleged Perpetrator 2 (AP2) took AV’s medication. 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.

On or about October 20, 2022, an apparent drug diversion as well as multiple medication administration errors were discovered in the facility. The Alleged Victim’s (AV) Medication Administration Record (MAR) reveals a lack of medication oversight and missing liquid narcotic pain medication. An investigation was inconclusive for Alleged Perpetrator’s 2-4 (AP2-4). The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about October 20, 2022, an apparent drug diversion as well as multiple medication administration errors were discovered in the facility. The Alleged Victim’s (AV) Medication Administration Record (MAR) reveals a lack of medication oversight and missing liquid narcotic pain medication. An investigation determined that an unknown Alleged Perpetrator 2 (AP2) took AV’s medication. AP2 was responsible for financial exploitation, which constitutes abuse. An investigation was inconclusive for Alleged Perpetrator 3 (AP3). The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about October 20, 2022, an apparent drug diversion as well as multiple medication administration errors were discovered in the facility. The Alleged Victim’s (AV) Medication Administration Record (MAR) reveals a lack of medication oversight and missing liquid narcotic pain medication. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about October 20, 2022, an apparent drug diversion as well as multiple medication administration errors were discovered in the facility. The Alleged Victim’s (AV) Medication Administration Record (MAR) reveals a lack of medication oversight and missing medication. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about October 20, 2022, an apparent drug diversion as well as multiple medication administration errors were discovered in the facility. The Alleged Victim’s (AV) Medication Administration Record (MAR) revealed numerous documentation discrepancies, medications that ran out and there are multiple instances where it is unclear if AV was receiving their medication per physician orders. The facility failed to provide a safe medication system, which placed AV at risk for harm. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about October 20, 2022, an apparent drug diversion as well as multiple medication administration errors were discovered in the facility. The Alleged Victim’s (AV) Medication Administration Record (MAR) reveals a lack of medication oversight and missing medication. An investigation determined that an unknown Alleged Perpetrator 2 (AP2) took AV’s medication. 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) relies on the facility for his/her care. The facility failed to provide appropriate services and care plan according to the AV’s needs and change of condition. On or about October 4, 2022, the AV was hospitalized for a UTI and was discovered to have a pressure ulcer on his/her bottom that resembled the shape of a toilet seat or bed pan. At hospital discharge AV was scheduled multiple wound clinic appointments that the facility failed to take him/her to, therefore AV’s wound was not attended to for approximately 2 weeks. The facility failed to provide appropriate services to respond to AV’s change of conditions, which caused repeated unreasonable discomfort, 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) increasing fall risk. From approximately July 31, 2022, to October 02, 2022, AV had approximately 18 documented falls, some resulting in injury including but not limited to a head injury, skin tears, abrasions and bruising, and causing AV repeated unreasonable discomfort. The facility failed to implement interventions to mitigate AV’s increasing fall risk, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) care plan(s) indicates AV is a high fall risk, is independent in ambulation and transferring, and has a history of falls. Documentation indicates AV had approximately eight (8) unwitnessed falls; with at least five (5) falls resulting in pain and/or bruising from approximately September 03, 2022, to February 03, 2023. The facility failed to appropriately care plan, 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 facility failed to implement interventions and appropriately care plan regarding Alleged Victim’s (AV) known fall risk. AV had multiple documented falls between May 29, 2022, and August 13, 2022, some resulting in injury, including but not limited to skin tears, abrasions and bruising, and ultimately a head injury with multiple facial fractures. The facility failed to implement interventions to mitigate AV’s increasing fall risk, 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 safety. AV has a history of agitation and aggression towards other residents and members of the care team. On or about January 25, 2022, AV was involved in an altercation with care staff and multiple other residents and there were not enough facility staff on duty to effectively prevent, redirect, and/or deescalate the incident. AV sustained a skin tear to their arm because of the 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.

Alleged Victim (AV) relies on the facility for his/her care and safety. On or about January 25, 2022, AV was involved in an altercation with another resident and was hit in the head. There were not enough facility staff on duty to effectively prevent, redirect, and/or deescalate the 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 their care. AV is care planned for full assistance with toileting and incontinence needs. According to an investigation, on or about, August 15, 2025, the AV was observed with visible feces on their clothing and legs. The Alleged Perpetrator 2 (AP2) was directed to assist the AV with incontinence care. AP2 failed to provide failed to provide appropriate services, and following the care plan, posing lack of personal dignity. AP2’s actions are a violation of resident rights, considered neglect, and constitute abuse. The facility did not keep AV free from neglect, which is a violation of Oregon Administrative rules.

On or about April 13, 2025, the Alleged Victim (AV) became upset at dinner time and began throwing plates and call staff derogatory names. Alleged Perpetrator #2 (AP2) grabbed AV's wrists firmly and told AV to say the derogatory name again to AP2, repeating it twice. After the interaction, AV was scared and crying and asked to be let outside to throw up after the incident. AP2's actions are a violation of resident rights, are considered neglect of care and constitute physical abuse. The facility's failure to protect AV from physical abuse is a violation of Oregon Administrative Rules.

On or about April 13, 2025, the Alleged Victim (AV) became upset at dinner time and began throwing plates and call staff derogatory names. Alleged Perpetrator #2 (AP2) grabbed AV's wrists firmly and told AV to say the derogatory name again to AP2, repeating it twice. After the interaction, AV was scared and crying and asked to be let outside to throw up after the incident. AP2's actions are a violation of resident rights, are considered neglect of care and constitute verbal abuse. The facility's failure to protect AV from verbal abuse is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) is care planned to be toileted three to four times per shift. AV will tear up his/her brief if it becomes wet and try to flush it down the toilet. Alleged Perpetrator #2 (AP2) was working swing shift on January 7, 2025 and responsible for resident cares. Oncoming night shift staff found AV in his/her room, without a brief on, and pieces of brief on the floor, along with water and/or urine on the floor, causing a tripping / fall hazard. AP2 failed to follow AV's care plan to ensure he/she was dry, which is a violation of resident rights, is considered neglect of care and constitutes abuse. Alleged Perpetrator #3 (AP3) allegations were found to be inconclusive in this case. The facility's failure to ensure AV's care plan was followed is a violation of Oregon Administrative Rules.

On or about January 7, 2025, the Alleged Victim (AV) was found in his/her room by staff without a brief or his/her nightgown on and covered in dried feces and his/her nightgown, also covered in feces, was laying on a table where AV eats his/her food. Alleged Perpetrator #2 (AP2) had been working and had noted that he/she had toileted AV at approximately 11:00 pm and noted that AV did not have any bowel movement, although AP2 had mentioned to oncoming staff that AV had just been changed and cleaned up after having a bowel movement. AV was left covered in feces, without clothing on and without a brief. AP2's actions placed AV at risk for serious harm. The facility's failure to ensure that staff carried out proper care for the residents is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) relies on the facility to provide assistance with activities of daily living, including toileting and incontinent care. According to an investigation, on or about January 7, 2025, Alleged Perpetrator 2 (AP2) and Alleged Perpetrator 3 (AP3) were responsible for the care of the AV. At the end of AP2 and AP3's shift, the AV was found in bed significantly soiled with urine and feces, causing discomfort. AP2 and AP3’s actions are a violation of resident rights, considered neglect, and constitutes abuse. The facility did not keep AV free from neglect, which is a violation of Oregon Administrative rules.

The Alleged Victim (AV) relies on the facility to provide assistance with activities of daily living, including toileting and incontinent care. According to an investigation, on or about January 7, 2025, Alleged Perpetrator 2 (AP2) and Alleged Perpetrator 3 (AP3) were responsible for the care of the AV. At the end of AP2 and AP3's shift, the AV was found in bed significantly soiled with urine, causing discomfort. AP2 and AP3’s actions are a violation of resident rights, considered neglect, and constitutes abuse. The facility did not keep AV free from neglect, which is a violation of Oregon Administrative rules.

On or about January 23, 2024, Alleged Perpetrator #2 (AP2) and Witness #3 (W3) were counting narcotics. W3 advised AP2 that the count was off. AP2 proceeded to pop the pill causing the miscount and placed the pill into his/her pocket. AP2 then left the facility as it was the end of their shift. The Alleged Victim (AV) complained of not receiving his/her medication, causing pain and discomfort, and an inability to sleep. AP2's actions are a violation of resident rights, are considered neglect of care and constitute abuse and financial abuse. The facility's failure to provide a safe medication system and oversight of staff is a violation of Oregon Administrative Rules.

On or about November 22, 2023, Alleged Perpetrator #2 (AP2) was doing laundry in the laundry room. AP2 had the laundry room door propped open. AP2 left the laundry room to assist another resident, leaving the door open. The Alleged Victim (AV) left the secure facility through the open laundry door. Facility staff found AV in the assisted living side of the building. AV was not injured, however, AV was placed at risk of harm. AP2's actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility's failure to ensure AV's safety is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) is prescribed medication for a heart condition. AV went to his/her physician and his/her INR levels were 1.1 and should have been between 2.0 and 3.0. A review of the facility documentation showed that AV did not receive his/her medication 9 times. Alleged Perpetrator #2 (AP2) signed off that he/she gave the medication, however there were 9 pills left. AP2's actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility's failure 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 in accordance with OAR 411-054-0070(2)(a) per observations during site visit 11/15/2022

The facility failed to ensure an adequate professional oversight of the medication administration system in accordance with OAR 411-054-0055(1)(f) resident's running out of medications.

The facility failed to contact resident's emergency contact. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to fully implement an Acuity-Based Staffing Tool (ABST). Time and frequency were unable to be determined by the facility's current internal assessment tool. The ABST was unable to produce staff time required to building a staffing schedule. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

The facility failed to have sufficient staff to meet the scheduled and unscheduled needs of the residents. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

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

The facility failed to fully implement and update an Acuity Based Staffing Tool (ABST). An investigation determined this is a violation of Oregon Administrative Rules.

he facility failed to ensure all staff completed pre-service training with all required elements. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide personal and other laundry services. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to consistently staff to the levels, intensity and qualifications indicated by the Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their needs. Inconsistencies were identified between the staffing schedule and the data produced by the ABST. Facility is not currently staffing to the levels as indicated by the ABST. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

The facility failed to carry out medication orders as prescribed in accordance with OAR 411-054-0055(1)(f) per complaint that the facility administered resident the wrong medication.