St Andrews Memory Care Community

The facility failed to provide a safe medication administration system to ensure the Alleged Victim’s (AV) medications were administered as ordered. On or about April 3, 2025, AV's physician ordered a medication to treat depression to be stopped and a lower dose of the same medication was ordered to effectively taper AV off the medication. According to an investigation, the order to stop the medication was processed by the facility, but the lower dose order was not. AVs medication was stopped "cold turkey" and between approximately April 4, 2025, and April 11, 2025, AV did not receive any of the medication, resulting in AV exhibiting aggressive behaviors, repeated unreasonable discomfort and emotional harm. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

• The Alleged Victim (AV) relies on the facility for care, requires assistance with eating and drinking, and is a high risk for aspiration. On or about March 18, 2025, AV was being fed by Witness 4 (W4), while W4 was visiting AV in the facility. At the conclusion of the meal AV vomited and had low oxygen levels and AV was taken to the hospital where it was determined AV had an aspiration event. According to an investigation, AV was previously care planned for staff to intervene if W4 was not following AV's feeding precautions, to prevent AV from aspirating, but that part of the care plan had been removed from the care plan. The facility failed to appropriately care plan and implement reasonable interventions to address AV’s known risk of aspirating during feeding by W4, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care and has a history of skin issues. AV is care planned to wear geri-sleeves during the day and at night they need removed, washed and skin integrity observed. According to an investigation, on or about December 22, 2024, AV’s left thumb was swollen, and blood was noted to be on AV’s geri-sleeve. When staff attempted to remove the geri-sleeve, AV showed signs of pain and cried out. The geri-sleeve was cut off and a deep skin wound was observed. AV was sent to the hospital where AV was diagnosed with a Stage IV wound, likely caused by staff not removing AV’s geri-sleeve. The facility failed to follow the 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) rely on the facility for their care. W1 has a history of sexually inappropriate behaviors and previously was living in the (gender) only part of the facility. On or about March 18, 2024, AV and W1 were observed to have inappropriate sexual contact in a common area of the facility, causing AV loss of personal dignity. A few hours later AV was found in W1's room engaged in inappropriate sexual contact again. 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.

According to the documentation, the facility failed to properly care plan appropriate fall interventions for the Alleged Victim’s (AV) repeated falls. From approximately December 27, 2023, through January 18, 2024, the AV experienced approximately four (4) falls with no new fall interventions. On February 03, 2024, the AV complained of back pain and on February 4, 2024, S/he was witnessed by staff to have difficulty standing up, so they sent them to the hospital for assessment. The AV received a diagnosis of a compression fracture and hospital documentation shows the compression fracture is consistent with the AV’s recent falls, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to properly care plan appropriate interventions for the Alleged Victim’s (AV) known behaviors. The failure resulted in the AV to continue to have increased behaviors, falls, and injuries of unknown cause, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to follow the care plan for the Alleged Victim (AV) by always having the scoop mattress on the bed. The failure to have the scoop mattress on the bed resulted in the AV to roll out of bed placing the resident at risk of harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions, appropriately care plan and monitor the Alleged Victim (AV) according to his/her wandering behavior and prior altercation with Witness 5 (W5). On or about September 20, 2023, AV wandered to W5's room, where AV's hand was shut in W5's door. AV was transported to the hospital and diagnosed with a fractured finger, lacerations, and referred to a hand surgeon. 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 care and supervision. According to an investigation Alleged Perpetrator 2 (AP2) physically restrained AV's movements and engaged in aggressive or forceful physical contact with AV. AP2's conduct caused AV emotional and physical distress. AP2's actions are a violation of resident rights, considered physical abuse and constitutes abuse. The facility failed to keep AV free from physical abuse and is a violation of Oregon Administrative Rules.

The facility failed to follow the Alleged Victim's (AV) care plan to provide one on one supervision. The failure resulted in AV experiencing an unwitnessed altercation with Witness 2 and AV was pushed to the ground, was found bleeding from his/her head and transported to the hospital for evaluation, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility to provide care and services. According to an investigation, the AV was restrained by the facility staff on multiple occasions which caused AV physical and emotional distress. This was witnessed by multiple facility staff and they failed to report the abuse. The facility failed to provide uphold the state's mandate on mandatory reporting of abuse, resulting in physical and emotional harm to AV which is a violation of resident rights and constitutes abuse.

The Alleged Victim (AV) relies on the facility for care and supervision. According to an investigation multiple staff members reported that they witnessed Alleged Perpetrator 2 (AP2) physically restrain and engage in aggressive and forceful behavior with AV. Facility staff did not report as mandated, which indicates a systemic failure by facility management. AP2 's actions are considered wrongful use of restraint and constitutes abuse. The facility failed to provide oversight and monitoring of AP2 and staff inaction in reporting witnessed use of wrongful restraints by AP2 to AV, which is violation of resident rights and constitutes abuse.

The Alleged Victim (AV) relies on the facility for care and has a history of falls, which includes a fall on or about June 8, 2023 that that resulted in a right femur fracture. According to an investigation, on or about July 30, 2023, AV was sleeping in a common area recliner. When the only care staff in the area went to check on other residents, AV tried to get up and fell, fracturing their left hip. 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.

According to the documentation, the facility failed to properly care plan and implement appropriate fall interventions for the Alleged Victim (AV) to prevent further falls. The failure resulted in the AV to fall and sustain a laceration to their head, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to properly care plan appropriate fall interventions for the Alleged Victim’s (AV) repeated falls. The failure resulted in the AV to suffer repeated falls, some with injury requiring to be evaluated at the hospital, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide a safe medication administration system to ensure the AV's medication was administered as ordered. The failure resulted in AV going approximately 5 days prior to hospitalization and approximately 3 days after, without his/her blood sugar medication, placing him/her at risk of serious harm, 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 according to the Alleged Victim's (AV) history of falls. The failure resulted in AV experiencing approximately four unwitnessed falls with and without injury, causing repeated unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to follow the AV's care plan and provide appropriate services according to his/her need for mobility assistance. The failure resulted in AV receiving a pressure sore in December of 2022, and another incident of his/her care plan not being followed to take care of the pressure sore in January 2023, causing physical harm and ongoing discomfort to the AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to properly care plan for the Alleged Victim’s (AV) wound care. the failure resulted in the AV to develop wounds on their feet with no interventions to provide wound care to prevent the worsening of the sores, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately monitor related to The Alleged Victim’s (AV) known history of falls. The failure resulted in AV experiencing several unwitnessed falls, causing unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Oregon Department of Human Services received a complaint of suspected abuse that was not initiated or not initiated timely by Respondent. ODHS opened investigation #00217526-AP-176678 on or about August 25, 2022. This investigation determined that the facility’s failure resulted in abuse.

The facility failed to follow the Alleged Victim's care plan to ensure his/her bed alarm was functioning properly and was placed at the lowest setting as fall interventions. The failure placed AV at risk of harm and potential for serious injury, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

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

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

The facility failed to appropriately care plan and monitor AV according to his/her needs and risk of falls. The failure resulted in AV being found with a facial injury and was transferred to the hospital for evaluation, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide a safe medication administration system to ensure AV's medication was administered as ordered, appropriately documented and monitored for signs of continued pain. The failure resulted in AV experiencing pain on or about April 18, 2022, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to documentation, the facility failed to properly care plan and implement intervention to prevent physical resident to resident altercations. The failure resulted in resident-to-resident physical altercations on 02/19/2022 and 02/22/2022 resulting in injury to both residents which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to follow AV's care plan to redirect him/her away from other resident's rooms; and provide appropriate supervision to AV and W1 according to their known behaviors. The failures resulted in AV wandering into W1's room, causing a physical altercation and injury to AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Based on interview and record review, the facility failed to complete or update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly as required. The facility’s failure is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) relies on the facility for care and is care planned to have medication administration done by the facility. The AVs Medication Administration Record (MAR) contains an order for a medication patch to be placed on AV every morning and prior to administration to have the old patch removed. According to an investigation, on or about April 17, 2025, the Alleged Perpetrator 2 (AP2) administered AV's medication patch and did not remove the patch that was already in place. AV was found later in the day with two patches on their body, which placed AV at risk for harm. AP2's actions are considered neglect and constitutes abuse. The facility failed to ensure medications were administered as ordered, which violates Oregon Administrative Rules.

Based on interview and record review, the facility failed to complete or update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly as required. The facility’s failure is a violation of Oregon Administrative Rules.

Based on interview and record review, the facility failed to complete or update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly as required. The facility’s failure is a violation of Oregon Administrative Rules.

On or about June 17, 2024, the outside courtyard doors were found to be left unsecured multiple times. Residents were counted and all accounted for. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to provide a service, by not coordinating care with off-site health services. The facility’s failure is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) and Witness 6 (W6) rely on the facility for their care. W6 was care planned to be redirected away from other residents when he/she is agitated. On or about October 2, 2023, W6 became agitated when Alleged Perpetrator 2 (AP2) removed W6’s dinner plate. W6 began chasing AP2, so AP2 went into another room and shut the door. W6 then turned to AV and pulled their hair. AP2 failed to follow the temporary care plan for W6 resulting in unreasonable discomfort for AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to ensure W6’s care plan was followed and provide a safe environment for AV, which is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) relies on the facility for care and supervision. According to an investigation multiple staff members reported that they witnessed Alleged Perpetrator 2 (AP2) physically restrain and engage in aggressive and forceful behavior with AV. Facility staff did not report as mandated, which indicates a systemic failure by facility management. AP2 's actions are considered wrongful use of restraint and constitutes abuse. The facility failed to provide oversight and monitoring of AP2 and staff inaction in reporting witnessed use of wrongful restraints by AP2 to AV, which is violation of resident rights and constitutes abuse.

The Alleged Victim (AV) relies on the facility for care and supervision. According to an investigation, the Alleged Perpetrator 3 (AP3) was completing an internal investigation to rule out an allegation of abuse of residents by the Alleged Perpetrator 2 (AP2). AP3 indicated that their internal investigation was complete and there was no evidence of the abuse. AP3 reinstated AP2 and bought them back to work. AP3 did not complete a thorough investigation and during interviews with staff members that worked with AP2, approximately four (4) staff members indicated they had previously observed AP2 physically restrain and engage in aggressive and forceful behavior with residents. AP3 brought AP2 back to work and on or about September 15, 2023, AP2 placed AV in a "Full Nelson" hold, picked AV up, and forcefully moved AV into a dining room chair. AV yelled, "No," and "Stop," when this occurred. AP3 's actions are considered neglect of care and constitutes abuse. The facility failed to provide a safe environment, and ensure AV was free from abuse, which is a violation of Oregon Administrative Rules.

The facility failed to ensure a safe medication administration system. An investigation determined this is a violation of Oregon Administrative Rules.

The facility allegedly failed to provide safe environment for the Alleged Victim (AV). This is a violation of Oregon Administrative Rules. Alleged Perpetrator 2 (AP2) used restraining and forceful transfer assistance and care to the AV. On multiple occasions AP2 would pick up or transfer AV in a restraining manor or push AV down in their chair in a forceful manor. AP2 failed to provide a safe environment for AV which is a violation of resident rights and constitutes abuse.

The Alleged Victim (AV) relies on the facility for care and supervision. According to an investigation Alleged Perpetrator 2 (AP2) physically restrained AV's movements and engaged in aggressive or forceful physical contact with AV. AP2's conduct caused AV emotional and physical distress. AP2's actions are a violation of resident rights, considered physical abuse and constitutes abuse. The facility failed to keep AV free from physical abuse and is a violation of Oregon Administrative Rules.

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

The facility failed to have a pre-service orientation and training program for all direct care staff in accordance with OAR 411-054-0070(3) & (4), which is a violation of Oregon Administrative Rules.

The facility failed to ensure that all staff and all direct care staff completed required trainings in accordance with OAR 411-057-0155(2) & (3), which is a violation of Oregon Administrative Rules.

The facility failed to have a secured outdoor recreation area with outdoor furniture sufficient in weight, stability, design, and maintained to prevent resident injury or aid in elopement in accordance with OAR 411-057-0170(6)(d), which is a violation of Oregon Administrative Rules.

The facility failed to ensure a copy of the most current inspection report and any conditions placed upon the license is posted with the facility's license in public view near the main entrance to the facility in accordance with OAR 411-054-0105(5), which is a violation of Oregon Administrative Rules.

The administrator failed to be responsible for ensuring adequate professional oversight of the medication and treatment administration system in accordance with OAR 411-054-0055(1)(a), which is a violation of Oregon Administrative Rules.

The facility failed to ensure that resident service plans are made readily available to staff and provide clear direction regarding the delivery of services as well as ensuring changes and entries made to the service plan are dated and initialed in accordance with OAR 411-054-0036(2)(b) & (d), which is a violation of Oregon Administrative Rules.

The facility failed to ensure medications are kept secure between set-up and administration of medications in accordance with OAR 411-054-0055(1)(d), which is a violation of Oregon Administrative Rules.

According to documentation, the Alleged Perpetrator 2 failed to follow the AV's care plan related to transfers in his/her wheelchair. The failure resulted in AV falling from his/her chair causing unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to ensure AV's safety, which is a violation of Oregon Administrative Rules.

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

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

The facility failed to be responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of his or her employment duties in accordance with OAR 411-054-0025(1)(b), which is a violation of Oregon Administrative Rules.

The facility failed to develop and implement a policy on smoking in accordance with OAR 411-054-0025(7)(e), which is a violation of Oregon Administrative Rules.

The facility failed to develop and implement a written policy that prohibits the falsification of records in accordance with OAR 411-054-0025(8)(a), which is a violation of Oregon Administrative Rules.

The facility failed to keep clean all interior and exterior materials and surfaces in accordance with OAR 411-054-0200(4)(i), which is a violation of Oregon Administrative Rules.

The facility failed to implement a resident's rights to have a safe and homelike environment in accordance with OAR 411-054-0027(1)(r), which is a violation of Oregon Administrative Rules.

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

The facility failed to document that they have observed and evaluated the individual's ability to perform safe medication and treatment administration unsupervised in accordance with OAR 411-054-0070(6)(b)(G), which is a violation of Oregon Administrative Rules.

The facility failed to have a reporting protocol with access to designated staff person who can determine if a change in the resident ' s condition requires further action and provide written communication of a resident ' s change of condition and any required interventions, for direct care staff.

The facility failed have a training program that includes methods to determine competency of direct care staff through evaluation, observation, or written testing and maintain documentation regarding each direct care staff ' s demonstrated competency

The facility failed to assist with toileting and bladder management in accordance with OAR 411-054-0030(1)(e)(G), which 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 for all required 22 ADLs with staff time required to complete the care needs. 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 administer medications as ordered by a physician in accordance with OAR 411-054-0055(1)(f), which is a violation of Oregon Administrative Rules.

The facility failed to develop and implement a written policy that prohibits the falsification of records in accordance with OAR 411-054-0025(8)(a), which is a violation of Oregon Administrative Rules.

The facility failed to provide services in a manner that protects privacy and dignity in accordance with OAR 411-054-0027(1)(g), which is a violation of Oregon Administrative Rules.

According to documentation, the AP2 failed to provide a safe medication administration system when s/he gave AV another resident's medication. The failure resulted in AV being transported to the hospital in a sedated state, which is a violation of resident rights, is considered neglect of care which constitutes abuse. The facility failed to provide a safe medication administration system, which is a violation of Oregon Administrative Rules.

On or about May 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 April 1, 2022 to April 30, 2022, for a total of 30 days.

On or about April 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 March 1, 2022 to March 31, 2022, for a total of 30 days.

On or about March 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 February 1, 2022 to February 28, 2022, for a total of 27 days.

The allegation the facility failed to follow the AV's care plan was investigated and the determination was inconclusive for neglect. During the course of the investigation, it was determined the facility failed to to keep AV records for three years after his/her passing, which is a violation of Oregon Administrative Rules.