South Beach Manor

The Alleged Victim (AV) and Witness 1 (W1) both relied on the facility for care. W1 had a documented history of inappropriate sexual behavior with other residents and was care planned for regular observation and supervision. According to an investigation, on or about September 5, 2025, AV was found on the floor in W1's room with their pants and briefs pulled down. W1's hand was observed by AV's genitals. AV appeared afraid, had a mark on their shoulder and there was a wet spot on the floor. W1 stated they waved AV into their room. Following the incident AV was observed guarding AV's peri area. The facility failed to provide service, to include following the care plan and/or implementing interventions to mitigate W1 known behaviors and ensure AV's safety, and causing AV emotional and physical harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse as defined by OAR 411-020-0002(1)(b)(A)(i).

The Alleged Victim (AV) relies on the facility for his/her care and has a history of wandering the halls and attempting to get into other resident rooms. Witness #1 (W1) has a history of physical altercations and has a documented intervention for facility staff to have a visual on W1 when they are in common areas and 1:1 when W1 is agitated. According to an investigation, on or about July 13, 2025, W1 was observed with AV in the hallway, with W1 telling AV what AV cannot do. Several minutes later W1 was heard yelling "get out of my room" before pushing AV and then punching AV in the back. The facility failed to provide services, to include implementing effective interventions 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 his/her care. According to an investigation, AV has a history of repeated falls and AV's care plan indicates AV is independent with ambulation and transfers and does not mention falls. On or about June 22, 2025, AV had an unwitnessed fall resulting in a hospital visit where AV was diagnosed with a head injury. The facility failed to implement effective interventions to mitigate AV’s increasing fall risk 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 his/her care, has a history of physical altercations, and has a documented intervention for staff to keep a visual on AV when in common areas. Witness #1 (W1) has a history of physical altercations and has a documented intervention for facility staff to engage W1 in activity when in hallways. AV and W1 have a previous history of a physical altercation with each other. According to an investigation, on or about April 15, 2025, staff heard residents yelling and found W1 and AV in the hallway with W1 on top of AV and punching him/her, resulting in several areas on AV's face that were discolored, one under AV's left eye, one on AV's left cheek and one just above AV's jaw line. The facility failed to provide services, to include implementing effective interventions 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 his/her care. Witness 1 (W1) has a history of aggressive behaviors resulting in physical altercations with other residents and has a documented intervention for staff to keep an eye on W1 when they leave their apartment. According to an investigation, on or about April 6, 2025, staff were not around when W1 got into a physical altercation with the AV in a common area of the facility, resulting in the AV receiving a contusion to their left hand and bruising to their right cheek. The facility failed to implement interventions to address W1 aggressive 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 his/her care, has a history of aggressive behaviors resulting in physical altercations with other residents, and has a documented intervention for staff to keep an eye on them whenever outside of their apartment. According to an investigation, on or about April 6, 2025, AV and Witness #1 (W1) were arguing over a plate in the dining room. W1 let go of the plate, causing AV to hit themselves in the face with the plate edge, resulting in a bruise, approximately 3 inches long, to AV’s face. AV then started punching W1, resulting in bruising of AV’s knuckles. The facility failed to provide services, to include implementing effective interventions 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) has a known risk with a history of falls and identified decline in condition. According to an investigation, the AV experienced multiple unwitnessed falls between approximately September 20, 2024, and October 30, 2024, resulting in pain, injuries, and repeated discomfort. On or about November 15, 2024, the AV was found on the floor with abrasions and bruising to the head and signs of discomfort. The facility failed to implement interventions according to the AV's needs relating to their decline in condition and number of falls. The failure is a violation of resident rights, is considered neglect of care, and constitutes abuse.

The Alleged Victim (AV) is a known fall risk with a history of falls. According to an investigation, on or about September 18, 2024, the AV had another fall where they were sent to the emergency department with a facial contusion, resulting in pain and unreasonable discomfort. The facility failed to provide appropriate services according to the AV’s needs, relating to care planning and interventions, to mitigate the risk of injury due to AV's falls, which is a violation of resident rights, is neglect of care, and constitutes abuse.

The Alleged Victim (AV) relies on the facility for care, had a recent medication change and was on alert with instructions for staff to watch for an increase in drowsiness, dizziness and poor coordination. According to documentation staff observed an increase in drowsiness and poor coordination, AV was found sleeping in common areas of the facility on multiple occasions, and AV needed assistance to walk and transfer on July 19, 2024 and July 20, 2024. On or about July 23, 2024, AV was found on the floor of h/h bathroom, apparently having fallen from h/h toilet, resulting in a bump on AVs 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/her care and has a history of falls. According to an investigation, on or about July 16, 2024, AV was found on the floor with significant bruising to their right side and was in pain. The facility failed to implement effective interventions to mitigate AV’s increasing fall risk 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 his/her care and is documented as a fall risk. According to an investigation, AV had a history of repeated falls, some with injury. On or about July 15, 2024, AV was found on the floor with a skin tear/abrasion on AV’s elbow. The facility failed to implement effective interventions to mitigate AV’s increasing fall risk and 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 or appropriately care plan for the Alleged Victim’s (AV) known behaviors. AV has an extensive history of behaviors and altercations with other residents. On or about June 23, 2024, AV and Witness 1 (W1) had an altercation where AV shoved their walked into W1, who shoved AV back. AV lost their balance and fell. The facility failed to implement interventions and/or appropriately care plan, 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 his/her care. AV has a history of repeated falls, many with injury, and the fall risk interventions noted after the falls to either be in place already and reused, or nonexistent. According to an investigation, on or about June 19, 2024, AV had a fall while attempting to self-transfer, resulting in skin tear. The facility filed to implement effective interventions to mitigate AV's increasing fall risk, provide a safe environment for AV, and caused AV repeated unreasonable discomfort, 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 full assist with teeth brushing and all hygiene needs. According to an investigation, on or about June 10, 2024, it was reported that AV’s top teeth were in shards and AV’s bottom teeth were black, grey and cracking. The lack of dental care assistance by the facility resulted in unreasonable discomfort and a loss of personal dignity to the AV. The facility failed to provide oral hygiene services for the 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. According to an investigation, on or about May 29, 2024, AV was found to have a large, dried, mucous mass in the back of h/h mouth that required staff to dislodge it. The facility failed to provide oral hygiene services for the 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. According to an investigation, AV had just received a treatment which is known to cause AV itching skin, but there were no skin care interventions put in place to monitor AV for itchiness. On or about May 25, 2024, AV was found with multiple scratches on their shoulder and hands. The facility failed to implement interventions and/or appropriately care plan 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 his/her care. According to an investigation, AV had a history of sliding to the floor from a seated position and was care planned to have the wheelchair footrests removed to help prevent injury, if they slide to the ground. On or about May 20, 2024, AV slid out of their wheelchair and was found sitting between the footrests with abrasions and scrapes. The facility failed to follow the care plan and interventions put in place to mitigate AV’s increasing fall risk 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 his/her care and is documented as a fall risk. According to an investigation, AV had a history of repeated falls, some with significant injury. On or about May 1, 2024, AV had an unwitnessed fall resulting in knee skin injuries. The facility failed to implement effective interventions to mitigate AV’s increasing fall risk 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 his/her care and is documented as a fall risk. According to an investigation, between March 8, 2024 and April 23, 2024, AV was documented to have fallen or have been found on the floor approximately 7 times, with 2 of them resulting in injury. On or about April 24, 2024, AV was again found on the ground in the common area of the facility with AV’s head under their wheelchair and their back on the wheelchair footrests, resulting in a bump to the back of AV’s head. The facility failed to implement effective interventions to mitigate AV’s increasing behaviors and fall risk 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 his/her care and is documented as a fall risk. According to an investigation, AV had a history of repeated falls, some with injury. On or about April 23, 2024, AV had a witnessed fall resulting in a bruise to AV’s finger. The facility failed to implement effective interventions to mitigate AV’s increasing fall risk 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 his/her care and had a significant change of condition relating to falls. According to an investigation, AV had multiple documented falls between February 08, 2024, and April 20, 2024, some resulting in injury. There were interventions noted on facility incident reports, but they were never added to AV’s Service Plan. 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) relies on the facility for his/her care, is a fall risk, and is on blood thinning medication. According to an investigation, AV had multiple documented falls between approximately March 8, 2024, and April 17, 2024, some resulting in injury to include skin tears, abrasions, and a head injury. On at least one occasion AV was sent to the hospital for treatment. The facility failed to implement interventions to mitigate AV’s increasing fall risk, causing repeated 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 related to the Alleged Victim’s (AV) change of condition related to weight loss. According to an investigation, on or about February 24, 2024, new diet orders were received for AV. The new orders were not added to AV's Service Plan and an intervention was not implemented until March 31, 2024. AV was weighed on approximately April 1, 2024, and was discovered to have lost approximately ten (10) pounds in the previous month. The AV experienced a weight loss of approximately 10% over a three-month timeframe, and AV was put on hospice services. The facility’s 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 March 20, 2024, AV suffered an unwitnessed fall in the activity room. AV suffered bruising to his/her hip and forehead. The facility failed to ensure interventions for falls were appropriate and provide enough staff to intervene when necessary. The facility's failure to properly care plan to ensure AV's safety from falls 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 March 21, 2024, AV was found on the floor in the hallway without his/her walker or shoes. AV suffered redness to his/her hip and a previous skin tear had opened and was bleeding. AV was sent to the emergency room and diagnosed with a significant hematoma on his/her hip. The facility failed to ensure interventions for falls were appropriate and provide enough staff to intervene when necessary. The facility's failure to properly care plan to ensure AV's safety from falls is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #1 (W1) has a history of resident to resident altercations and is to have eyes on him/her when in the common area of the facility. On or about March 9, 2024, W1 and the Alleged Victim (AV) engaged in an altercation in the common area of the facility where W1 grabbed AV, leaving marks on AV's neck and arms. Staff are to watch and intervene if they observe W1's behaviors change. The facility failed to have enough staff available to provide eyes on care for W1, allowing the altercation to occur. The facility's failure to provide enough staff 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) relies on the facility for his/her care and is documented as a fall risk. According to an investigation, AV had a history of repeated falls, some with significant injury. On or about March 9, 2024, AV had a witnessed fall resulting in bruising and scratches to AV’s arms and leg. The facility failed to implement effective interventions to mitigate AV’s increasing fall risk 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 his/her care and is documented as a fall risk. According to an investigation, AV had a history of repeated falls, some with significant injury. On or about March 15, 2024, AV had a witnessed fall resulting in a skin tear to AV’s left elbow and an abrasion to their left knee. The facility failed to implement effective interventions to mitigate AV’s increasing fall risk 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 his/her care. On or about March 7, 2024, AV was found on the floor after apparently attempting to self-transfer. AV requires staff assistance with transfers and toileting and has a history of falls resulting in repeated unreasonable discomfort. The facility failed to appropriately care plan and implement reasonable interventions to address AV’s ongoing falls, 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 and has a history of removing feces from their incontinent brief and eating it. On or about March 7, 2024, AV was found on the floor of their room with feces on their hands, arms, legs, and face. The facility failed to properly care plan resulting in a loss of personal dignity, 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 and has a history of falls. On or about March 1, 2024, AV was found on the floor from an unwitnessed fall. AV was crying out, complaining of neck and shoulder pain and was sent to the hospital by ambulance. Documentation shows AV suffered a skin tear to their right forearm and an abrasion to the face. The facility failed to appropriately care plan and implement reasonable interventions to address AV’s ongoing falls, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) and Witness 1 (W1) both rely on the facility for care and have a history of physical altercations. AV is care planned with an intervention to always have staff with them when out in the community. According to an investigation, on or about February 10, 2024, AV and W1 got into an altercation in a common area of the facility where W1 grabbed AV’s wrist, resulting in a skin tear. The facility failed to implement interventions and follow AV’s care plan, 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. On or about January 28, 2024, AV was found on the floor after apparently attempting to self-transfer. AV requires staff assistance with transfers and toileting and has a history of falls resulting in repeated unreasonable discomfort. The facility failed to appropriately care plan and implement reasonable interventions to address AV’s ongoing falls, 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 and has a history of removing feces from their incontinent brief and eating it. On or about January 28, 2024, AV was found on the floor of their room with feces on their hands, legs, and lips. The facility failed to properly care plan resulting in a loss of personal dignity, which is violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) has a history of falls. AV suffered multiple falls with and without injury from November 2023 to January 2024. On or about January 21, 2024, AV fell in the hallway suffering a bruise and pain to his/her hip. AV was sent to the emergency room on January 24, 2024 and found with bruising to the hip and edema to his/her knee from the fall. The facility failed to implement interventions to reduce the number of falls, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Both the Alleged Victim (AV) and Witness 1 (W1) rely on the facility for care and share a room within the facility. W1 has a history of aggressive behaviors resulting in resident-to-resident altercations and has had previous altercations with AV. AV has a history of aggressive behaviors resulting in resident-to-resident altercations, including with W1, and also has a history of wandering into other resident rooms and taking items. On or about January 16, 2024, AV wandered into W1’s side of their shared room where W1 began punching AV in the face, resulting in multiple abrasions and bruising of the head and neck. The facility failed to implement interventions to address W1 and AVs aggressive 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 his/her care and has a history of falls. On or about January 7, 2024, AV was found on the floor from an unwitnessed fall with a skin tear on his/her left arm. The facility failed to appropriately care plan and implement reasonable interventions to address AV’s 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/her safety. On or about December 30, 2023, it was documented that AV had a large bruise of unknown origin on his/her right buttock. 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/her care and is a known fall risk. According to an investigation, on or about December 18, 2023, AV had and unwitnessed fall and was on the floor for an undisclosed amount of time. The facility failed to implement fall prevention interventions commensurate with the frequency and severity of AV's known falls and failed to follow interventions already in place resulting in unreasonable discomfort. The facility failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) has a history of falls. AV is known to wander the halls during typical sleeping hours in the facility, and during this time is when AV has his/her falls. One of the fall prevention's put into place was to increase staff to monitor AV while he/she was wandering during the night. On or about December 8, 2023, another resident alerted staff that AV had fallen. AV was found in the dining room, face down with a cut over his/her left eyelid and swelling to his/her face. AV was sent to the emergency room where he/she received laceration repair to his/her eyelid and was diagnosed with a head injury. The facility failed to implement interventions to reduce AV's known fall history and ensure enough staff were working to ensure monitoring and supervision of AV 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) relies on the facility for his/her care, requires staff assistance with transfers and has a history of falls. On or about December 8, 2023, AV was found on the floor after apparently attempting to self-transfer. AV was taken to the hospital where AV was diagnosed with a closed head injury. The facility failed to appropriately care plan and implement reasonable interventions to assure AV’s safety and address AV’s ongoing falls, which is violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement meaningful interventions or appropriately care plan for the Alleged Victim’s known fall risk. On or about December 1, 2023, AV was found on the floor from an unwitnessed fall that caused pain in AV’s back, neck, head, and knee. The facility failure 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. On or about November 25, 2023, AV was found on the floor after apparently attempting to self-transfer. AV requires staff assistance with transfers and toileting and has a history of falls resulting in repeated unreasonable discomfort. The facility failed to appropriately care plan and implement reasonable interventions to address AV’s ongoing falls, 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 and is documented as a fall risk. According to an investigation, between approximately April 15, 2023 and October 22, 2023, AV was documented to have fallen or have been found on the floor 18 times and AV sustained injury or reported significant pain in approximately ten (10) of the incidents. On or about November 24, 2023, AV was again found on the ground in their room, placing AV at risk of harm. The facility failed to implement effective interventions to mitigate AV’s increasing fall risk 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) has a history of multiple falls. The facility failed to provide appropriate services according to Alleged Victim’s needs, relating to care planning around falls and instruction. On or about November 15, 2023 AV had a fall that was unwitnessed by facility staff, and he/she was found face down on the hallway floor bleeding from their nose. AV was transported to the hospital via ambulance and was diagnosed with a subarachnoid hemorrhage, an open nasal fracture, and multiple abrasions. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care and has a known history of falls. Staff were directed to monitor AV anytime they were up walking and to ensure AV has on appropriate footwear. On or about November 17, 2023 AV had an unwitnessed fall in the dining room and when found AV complained of pain. AV was barefoot and had just walked across wet carpets that had just been cleaned. AV was transported to the hospital for evaluation to ensure that the head injury sustained two days prior had not worsened. The facility failed to implement interventions and / or follow AV care plan, which is a violation of resident’s rights is neglect of care and constitutes abuse.

The Alleged Victim (AV) and Witness #1 (W1) have a history of physical altercations. On November 11, 2023, AV and W1 engaged in an altercation where AV sustained a skin tear to his/her left wrist and W1 sustained a bruise to his/her knuckle. Staff monitoring and redirection were the only interventions put into place until after the fourth incident of altercations. 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) and Witness #1 (W1) have a history of physical altercations. On or about November 11, 2023, AV and W1 engaged in an altercation where W1 was holding onto AV's arm and punched AV in the jaw three times. W1 sustained a skin tear to his/her wrist. The facility's failure to implement meaningful interventions regarding these altercations places residents at risk for 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 known to be involved in altercations with each other, and were known to have at least two previous altercations. On or about November 1, 2023, AV and W1 engaged in an altercation where W1 was holding AV's arm and then punched AV in the jaw three times. AV was noted to have redness to his/her jaw after the interaction. The facility's failure to implement meaningful interventions to reduce altercations placed AV at risk for harm. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is a known fall risk with a history of falls. The facility failed to provide appropriate services according to the Alleged Victim (AV)'s needs, number of falls with lack of appropriate interventions. According to an investigation, AV experienced multiple falls, between July 17, 2023, and September 20, 2023. On or about October 21, 2023, AV experienced another fall, which resulted in a skin tear and bruising. The failure 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 April 15, 2023, and October 21, 2023, 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.

The Alleged Victim (AV) is a known fall risk. AV has a history of multiple falls, some resulting in injury including but not limited to a knee. leg, back, arm and head pain. The facility failed to implement interventions and appropriately care plan 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) and Witness 1 (W1) have history of behaviors and resident-to-resident altercations with each other. According to an investigation, on or about September 30, 2023, AV and W1 engaged in a physical altercation, resulting in dark purple bruising to AV’s right-hand. The facility failed to provide a safe environment for AV which is a violation of resident rights, is neglect of care which constitutes abuse.

The facility failed to implement interventions or appropriately care plan for Witness #1’s (W1) and the Alleged Victim's (AV) known behaviors. On or about September 24, 2023, W1 pushed the AV to the ground, resulting in AV having a head injury and going to the hospital. The facility 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 hitting or elbowing the Alleged Victim (AV) on or about September 15, 2023, causing unreasonable discomfort to the AV. 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.

On or about August 27, 2023, the Alleged Victim (AV) and Witness #1 (W1) engaged in an altercation where W1 pushed AV and knocked him/her to the ground. After the incident, AV and W1 were put on alert for staff to monitor behaviors and intervene if necessary. Later that same day, AV and W1 engaged again, where W1 pushed AV to the ground, resulting in AV having a swollen finger. The facility's failure to ensure 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 has fallen from bed previously. AV had been care planned to have his/her call pendant within reach and have a rolled up blanket on the edge of the bed to assist with AV not falling from the bed. On or about August 26, 2023, AV was found on the floor after falling from the bed. AV suffered redness to his/her hip and was on the floor for an unknown amount of time. The blanket was on the opposite side of the bed by the wall and AV's call pendant was at the foot of his/her bed. The facility failed to follow AV's care plan, which is a violation of resident rights, is considered neglect of care and constitute abuse.

Both the Alleged Victim (AV) and Witness 1 (W1) rely on the facility for care. W1 has a history of aggressive behaviors resulting in resident-to-resident altercations. According to an investigation, on or about August 26, 2023, W1 hit AV in the ribcage with a walker, causing unreasonable discomfort. The facility failed to implement effective interventions to address W1 aggressive 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) is care planned as a two person transfer. AV tends to hold onto the wheelchair during transfers and while doing this, it can cause scratches to AV. Alleged Perpetrator #2 (AP2) and Alleged Perpetrator #3 (AP3) were re-positioning AV in his/her wheelchair, and after the action, AV was found to have a skin tear on his/her arm. The facility's failure to outline how AV hangs onto the wheelchair, and how staff should respond to that wasn't properly outlined in the care plan. The facility's failure to ensure clear directions to staff while providing care is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about August 11, 2023, Witness #1 and the Alleged Victim (AV) had a resident-to-resident interaction, causing AV emotional distress. 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 adequate interventions or appropriately care plan for Witness #1’s (W1) and the Alleged Victim’s (AV) known behaviors. AV and W1 have a documented history of physical altercations with each other on or about June 19, 2023, July 14, 2023, and July 21, 2023, and the only intervention added due to these altercations were to keep them separated and redirected away from each other. On or about August 5, 2023, AV and W1 were involved in another resident-to-resident altercation, in which AV was hitting W1 with a metal water bottle and W1 was punching AV with closed fists. 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 Alleged Victim (AV) has a history of falls. AV has vision issues which contribute to AV's falls. Between June 1, 2023 and July 30, 2023, AV suffered six separate falls, two resulting in AV sustaining a head injury. The facility's failure to properly care plan to reduce AV's number of falls 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.

Alleged Victim (AV) is a known fall risk. Between June 11, 2023, and July 28, 2023, AV experienced multiple falls, some resulting in injury, to include skin tears, and two hip fractures. The facility failed to put effective, person-centered 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) has a history of behaviors. On or about July 9, 2023, AV and Witness #1 (W1) got into a physical altercation resulting in injury to the AV. The facility failed to implement interventions and/or appropriately care plan for AV’s increasing 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 relies on the facility for his or her safety. On or about July 9, 2023, it was documented that AV had a bruise of unknown origin on his/her forehead. There is no documented evidence that the facility investigated where the bruise came from, ruled out abuse or neglect, or implemented additional interventions into AV's service plan to keep AV safe. 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 facility failed to implement interventions and appropriately care plan regarding Alleged Victim’s (AV) known fall risk. According to the investigation, AV had approximately 20-30 falls between January 11, 2023, and June 4, 2023, some resulting in injury including but not limited to a head injury and bruising. On or about June 4, 2023, AV fell which resulted in a sacrum fracture. The facility failed to implement effective 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) is a known fall risk, with a documented history of increased falls recently. Multiple interventions the facility put in place were either already on the service plan or contradicted the service plan. On or about May 26, 2023, AV experienced two falls and complained of back and hip pain and was sent to the hospital for treatment. The facility failed to put effective, person-centered interventions in place after repeated falls, leading to multiple falls with injuries, which is a violation of resident rights is neglect of care and constitutes abuse.

Alleged Victim (AV) is a known fall risk, with a documented history of increased falls recently. Multiple interventions the facility put in place were either already on the service plan or contradicted the service plan. On or about May 25, 2023 AV experienced two falls resulting in face contusions and AV was sent to the hospital for treatment. The facility failed to put effective, person-centered interventions in place after repeated falls, leading to multiple falls with injuries, which is a violation of resident rights is neglect of care and constitutes abuse.

Alleged Victim (AV) is a known fall risk, with a documented history of increased falls recently. Multiple interventions the facility put in place were either already on the service plan or contradicted the service plan. On or about May 15, 2023, AV was found on their bathroom floor resulting in a closed head injury, neck sprain and left shoulder contusion. The facility failed to put effective, person-centered interventions in place after repeated falls, leading to multiple falls with injuries, which is a violation of resident rights is neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility for his/her care. AV has a history of falls and is known to have vision impairment that has resulted in AV getting lost/confused. According to an investigation, on or about May 9, 2023, AV was found to have two large bruises from an unknown cause. The facility failed to provide a safe environment, which is a violation of resident’s rights, is neglect of care and constitutes abuse.

The facility failed to provide a safe environment. According to an investigation, the Alleged Victim (AV) and Witness 1 (W1) have history of behaviors and resident-to-resident altercations. On or about August 23, 2023, W1 pushed AV down, resulting in a scratch to AV’s back. The facility's 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 the Alleged Victim’s (AV) and Witness #1’s (W1) known behaviors and previous altercations with each other. This failure resulted in a physical altercation on or about August 3, 2022, between AV and W1, where both AV and W1 sustained injuries. The facility 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 the Alleged Victim’s (AV) and Witness #1’s (W1) known behaviors and previous altercations with each other. This failure resulted in a physical altercation on or about August 3, 2022, between AV and W1, where both AV and W1 sustained injuries. The facility 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. On or about July 31, 2022, W1 inappropriately touched the Alleged Victim (AV), placing AV at risk for emotional harm. 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 or appropriately care plan for Witness #1’s (W1) known behaviors. This failure resulted in W1 punching the Alleged Victim (AV) in the chin on or about June 22, 2022. 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 or appropriately care plan for the Witness #1’s (W1) known behaviors. This failure resulted in an altercation on or about June 29, 2022, between W1 and the Alleged Victim (AV), where AV was pushed into a wall and received a skin tear on their arm. The facility 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 the Alleged Victim’s (AV) known behaviors. This failure resulted in an altercation on or about June 2, 2022, between AV and Witness #1 (W1), where AV received skin tears and bruising to AV’s hands and arm, which caused unreasonable discomfort. The facility failure is a violation of resident rights, is considered neglect of care and constitutes abuse

The facility failed to implement meaningful interventions and appropriately care plan regarding Alleged Victim’s (AV) known fall risk. AV had multiple documented falls with the facility repeating the same interventions that were previously documented as put in place. On or about April 3, 2022, AV experienced a fall resulting in abrasions to both knees. 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 facility failed to implement meaningful interventions and appropriately care plan regarding Alleged Victim’s (AV) known fall risk. AV had multiple documented falls with the facility repeating the same interventions that were previously documented as put in place. On or about March 20, 2022, AV experienced a fall resulting in a head injury. 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 facility failed to implement meaningful interventions and appropriately care plan regarding Alleged Victim’s (AV) known fall risk. AV had multiple documented falls with the facility repeating the same interventions that were previously documented as put in place. On or about March 3, 2022, AV experienced a fall resulting in pain. 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 facility failed to implement meaningful interventions and appropriately care plan regarding Alleged Victim’s (AV) known fall risk. AV had multiple documented falls with the facility repeating the same interventions that were previously documented as put in place. On or about February 9, 2022, AV experienced a fall resulting in an abrasion. 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 facility failed to implement meaningful interventions and appropriately care plan regarding Alleged Victim’s (AV) known fall risk. AV had multiple documented falls with the facility repeating the same interventions that were previously documented as put in place. On or about January 28, 2022, AV experienced a fall resulting in all-over head pain. 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 facility failed to implement meaningful interventions and appropriately care plan regarding Alleged Victim’s (AV) known fall risk. AV had multiple documented falls with the facility repeating the same interventions that were previously documented as put in place. On or about January 19, 2022, AV experienced a fall resulting in an abrasion. 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 facility failed to implement meaningful interventions and appropriately care plan regarding Alleged Victim’s (AV) known fall risk. AV had multiple documented falls with the facility repeating the same interventions that were previously documented as put in place. On or about January 3, 2022, AV experienced a fall and was transported to the hospital and diagnosed with multiple contusions. 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) has a known history of falls. Between October 5, 2022 through November 14, 2021, AV sustained approximately ten (10) falls, all resulting in injury. On or about November 14, 2021, AV suffered a fall, sustaining an injury to his/her knee. AV was taken to the emergency room to be assessed and returned to the facility. The facility failed to care plan appropriately and implement interventions to mitigate AV’s risk of falls, leading to AV's repeated unreasonable discomfort, which is a violation of resident rights, is neglect of care and constitutes abuse.

The Alleged Victim (AV) has a known history of falls. Between October 5, 2022 through November 6, 2021, AV sustained approximately seven (7) falls, all resulting in injury. On or about November 6, 2021, AV suffered a fall, sustaining a bump and bruise to the back of his/her head. AV was taken to the emergency room to be assessed and returned to the facility. The facility failed to care plan appropriately and implement interventions to mitigate AV’s risk of falls, which is a violation of resident rights, is neglect of care and constitutes abuse.

The Alleged Victim (AV) has a known history of falls. Between October 5, 2022 through October 30, 2021, AV sustained approximately four (4) falls, all resulting in injury. On or about October 31, 2021, AV suffered a fall, sustaining a bump and bruise to the back of his/her head. AV was taken to the emergency room to be assessed and returned to the facility. The facility failed to care plan appropriately and implement interventions to mitigate AV’s risk of falls, which is a violation of resident rights, is neglect of care and constitutes abuse.

The facility failed to provide records to the Department upon request in accordance with OAR 411-054-0105(1)(a), which is a violation of Oregon Administrative Rules.

The facility failed to provide records to the Department upon request in accordance with OAR 411-054-0105(1)(a), which is a violation of Oregon Administrative Rules.

Based on interview and record review, the facility failed to provide records to the Department upon request. The facility’s failure is a violation of Oregon Administrative Rules.

Based on interview and record review, the facility failed to provide records to the Department upon request. The facility’s failure is a violation of Oregon Administrative Rules.

Based on interview and record review, the facility failed to provide records to the Department upon request. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to provide records to the Department upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide records to the Department upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to develop, maintain, and implement an Acuity Based Staffing Tool. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to develop, maintain, and implement an Acuity Based Staffing Tool. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to develop, maintain, and implement an Acuity Based Staffing Tool. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to develop, maintain, and implement an Acuity Based Staffing Tool. 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 develop, maintain, and implement an Acuity Based Staffing Tool. An investigation determined this is a violation of Oregon Administrative Rules.

Based on interview and record review, the facility failed to develop, maintain, and implement an Acuity-Based Staffing Tool (ABST). The facility’s failure is a violation of Oregon Administrative Rules.

Based on interview and record review, the facility failed to develop, maintain, and implement an Acuity-Based Staffing Tool (ABST). The facility’s failure is a violation of Oregon Administrative Rules.

Based on interview and record review, the facility failed to develop, maintain, and implement an Acuity-Based Staffing Tool (ABST). The facility’s failure is a violation of Oregon Administrative Rules.

Based on interview and record review, the facility failed to develop, maintain, and implement an Acuity-Based Staffing Tool (ABST). The facility’s failure is a violation of Oregon Administrative Rules.

Based on interview and record review, the facility failed to develop, maintain, and implement an Acuity-Based Staffing Tool (ABST). The facility’s failure 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). 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 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 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 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 ensure the preparation, completeness, accuracy, and preservation of resident records. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to fully implement and update an acuity-based staffing tool. 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 fully implement and update an acuity-based staffing tool. 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 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 provide sufficient staff to provide a safe environment. An investigation determined this is a violation of Oregon Administrative Rules.

The facility licensee failed to be responsible for the supervision training, and overall conduct of staff when staff are acting within the scope. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to ensure that stairways, halls, doorways, passageways, and exits from rooms and the building must be unobstructed. 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 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 medical and other records were kept confidential. An investigation determined no licensing violation or abuse occurred.

The facility failed to immediately notify the Department office, or the local AAA, of any incident of abuse or suspected abuse. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to administer the resident's medication as order by their physician. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to ensure implementation of services by not having an identified intervention in place for a resident's behavior. An investigation determined this is a violation of 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.