The Arbor at Avamere Court

On January 27, 2026, ODHS Adult Protective Services (APS) completed investigation #00438350 and issued a written investigation report, which is incorporated here by reference. Alleged Victim (AV) lived at Respondent’s facility. Facility staff is responsible to administer AV"s medications as prescribed. On or about November 7, 2025, the Alleged Victim (AV), received an incorrect dose of prescribed medication. Facility staff were responsible for administering AV’s medications as ordered. AV was prescribed 1 mg of an anxiety/agitation medication but was instead administered 2 mg. As a result of the medication error, AV experienced three falls on the same day in which one of these falls caused AV to sustain a hematoma to the forehead. The facility's failure to provide a safe medication administration system to mitigate risks resulted in AV experiencing unreasonable and unnecessary discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On January 27, 2026, ODHS Adult Protective Services (APS) completed investigation #00434112 and issued a written investigation report, which is incorporated here by reference. The Alleged Victim (AV) resided at the Respondent’s facility. The facility failed to implement and consistently follow progressive, appropriate, and effective fall-prevention interventions to mitigate AV’s known fall risk. On or about October 20, 2025, AV sustained abrasions to both knees after falling in the bathroom. Based on facility documentation and interviews, AV had a significant fall history prior to incident, experiencing more than 20 falls since May 2025, several of which resulted in injuries. These repeated failures to provide adequate supervision and interventions caused multiple unwitnessed falls, unreasonable discomfort, which is a violation of resident rights., is considered neglect of care and constitutes abuse.

On September 5, 2025, ODHS Adult Protective Services (APS) initiated investigation #00424646 and issued a written investigation report, which is incorporated here by reference. Alleged Victim (AV) lived at Respondent’s facility and required assistance with toileting due to physical and/or cognitive limitations. According to facility documentation and staff interviews, AV was left in soiled briefs on multiple occasions throughout September 2025. These incidents were not isolated and reflect a pattern of inadequate care. The failure to respond to AV’s toileting needs in a timely and consistent manner caused AV to experience continued unreasonable discomfort, which is a violation of resident rights, is considered neglect of care which constitutes abuse.

On September 5, 2025, ODHS Adult Protective Services (APS) initiated investigation #00424646 and issued a written investigation report, which is incorporated here by reference. Alleged Victim (AV) lived at Respondent’s facility. On September 4, 2025, the Alleged Victim (AV), who has a documented history of falls, experienced an unwitnessed fall while seated in his/her recliner. AV's fall resulted in physical injuries including a hematoma on the forehead, and skin tears to the left elbow and left knee. AV’s care plan included specific fall prevention interventions, notably the placement of a chair sensor in AV’s recliner to alert staff when AV attempted to stand or move. The facility failed to ensure that this intervention was properly implemented. The absence or malfunction of the chair sensor contributed to the lack of timely supervision and response, resulting in AV’s fall and subsequent injuries. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about September 1, 2025, Witness 1 (W1) punched Alleged Victim (AV) in the shoulder when AV did not move as W1 had asked. Based on facility documentation and interviews, W1 has a known history of having altercations with other residents and will have violent outbursts towards other residents without warning. W1 is care planned to be within staff's eyesight when W1 is in common area and if staff are to leave common area, W1 is to be redirected back to his/her room. At time of incident, there were no staff present when W1 was in the hallway when the altercation took place with W1 and AV. The facility failed to appropriately monitor Witness 1 (W1) according to his/her known behavior and prior altercations at time of incident. The failure resulted in a physical altercation and causing unreasonable discomfort to the AV, which 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’s (AV) care needs and wound care. On or about January 20, 2025, AV was observed with extensive encrusted feces in AV's peri area, including to AV's peri wound, that could not be washed off after multiple attempts, so AV's pubic hair was cut for a sterile catheter change. On February 27, 2025, AV was observed with dried feces on his/her bottom, thighs, and some in the catheter area. Based on facility documentation and interviews, AV is care planned for assistance with catheter/peri care once every shift and after every bowel movement. By failing to ensure that AV was properly cleansed after toileting, resulted in AV suffered a serious loss of personal dignity and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care, which constitutes abuse.

The Alleged Victim (AV) is a known fall risk. On or about January 22, 2025, AV suffered a fall in his/her restroom, causing an abrasion to his/her knee and arm, and a bruise to his/her back. AV requires standby assistance, and on this day was left in the restroom by him/herself while staff retrieved items needed. AV was found on the floor about a minute later. The facility's failure to follow the care plan to ensure AV's safety is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to follow Witness 1’s (W1) service plan by not redirecting them away from another resident’s room. W1 has a known behavior of wandering in and around other resident rooms. W1 is service planned to be redirected away from other resident rooms when exhibiting this behavior. On or about February 17, 2025, the AV was seen in the doorway of the Alleged Victim’s (AV) doorway. Staff walked by W1 and did not redirect them. Approximately five minutes later, staff went into AV’s room and found the AV laying on the ground with a skin tear and a bump on their head. The failure to follow the care plan to redirect W1 away from AV lead to a resident to resident altercation causing harm to the AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On January 12, 2026, ODHS Adult Protective Services (APS) completed investigation #00377431 and issued a written investigation report, which is incorporated here by reference. On or about January 9, 2025, the Alleged Victim (AV), who resides at the Respondent’s facility, requested their prescribed opioid pain medication. Facility staff are responsible for administering AV’s medications as ordered by the prescriber. Based on a review of facility documentation and staff interviews, it was determined that the facility had run out of AV’s prescribed opioid pain medication on the date of the request. As a result, the medication was unavailable when AV requested it. Facility records indicate that AV reported a pain level of 8 out of 10 on January 9, 2025. In response, staff administered an over-the-counter pain medication, which was documented as ineffective in relieving AV’s pain. The investigation concluded that the facility failed to maintain a safe and effective medication administration system, resulting in AV not receiving their prescribed opioid PRN medication. This failure caused AV to experience pain and unreasonable discomfort due to the lack of appropriate pain management, which is a violation of resident rights, is considered neglect of care and constitutes abuse

On or about November 20, 2024, Witness #1 (W1) was witnessed rubbing the Alleged Victim's (AV) breast while sitting next to each other at the breakfast table. W1 has a known and documented history of sexual behaviors. W1's care plan failed to have specific interventions regarding W1's history of sexual behaviors. The facility's failure to protect AV from sexual abuse 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’s (AV) care needs and wound care. On May 16, 2024, AV had a skin irritation/tear on his/her buttocks area. Home Health gave instruction to facility on how to care for wound due to Home Health ending. At time of Home Health ending care services for AV, the area of irritation was about the size of a quarter with no open wound. Based on interviews and facility documentation, by June 2, 2024, AV was sent to hospital for lump at rectal area and was admitted for infected ulcer. An investigation determined the facility failed to follow directives on wound care resulting in AV sustaining a stage 4 pressure wound. The facility's failure resulted in AV’s condition worsening causing further unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to follow Alleged Victim's (AV) care plan related to AV's fall history. The failure resulted in AV experiencing two injury falls in a short period of time; one fall was on April 26, 2024, and the second fall occurred on April 27, 2024. After each of these two falls, AV sustained a hematoma to his/her face. The facility's failure caused AV unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about March 27, 2024, Witness 1 (W1) entered Alleged Victim's (AV) room after lunch, W1 twisted AV's arm resulting in AV sustaining a bruise to his/her forearm. Based on facility documentation and interviews, the facility failed to appropriately monitor W1 according to his/her known behavior and prior altercations. The facility's failure resulted in a physical altercation, causing unreasonable discomfort to the Alleged Victim, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement appropriate interventions and failed to provide appropriate supervision related to the Alleged Victim’s (AV) known history of falls. Based on facility documentation and interviews, AV fell 3 times in the span of six weeks. It was determined that after each fall, the facility failed to put new timely fall interventions in place and facility failed to assist AV with mobility resulting in AV suffering a fall that resulted in a head injury. After AV's March 4, 2024, fall AV was sent to the hospital for treatment in which AV was diagnosed with a brain bleed. Facility documentation states that AV suffered falls on February 4, 2024, March 4, 2024, and March 11, 2024. AV's medical documentation states that AV's February 4, 2024, fall caused a bruise to AV's face as well as a brain bleed that was not diagnosed until the March 4, 2024, fall incident that resulted in hospitalization. The facility's failure to properly care, 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 facility failed to implement interventions and appropriately care plan related to the Alleged Victim's (AV) fall history. The failure resulted in AV experiencing an unwitnessed fall on or about December 3, 2023, was transferred to the hospital, and diagnosed with rib fractures. Based on facility documentation and interviews, AV has a history of falls. AV suffered two falls prior to incident. In both of falls prior to incident, AV suffered injuries and the facility failed to appropriately document interventions related to preventing falls when ambulating. The facility failed to appropriately care plan and implement reasonable person-centered fall interventions to address AV's prior falls, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and provide appropriate supervision related to the Alleged Victim’s (AV) known history of falls. On or about October 9, 2023, AV fell and sustained a hip fracture. Based on facility documentation and interviews, AV had previous falls on April 17,2023, July 1, 2023, July 28, 2023, and August 8, 2023; four of these five falls occurred in AV's bathroom. The facility's failure to implement fall preventions/interventions regarding AV's care needs with toileting and mobility assistance to and from the bathroom, caused AV to experience multiple falls, causing unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about August 28, 2023, Alleged Victim (AV) was involved in a resident-to-resident altercation with Witness 1 (W1) in which W1 hit and punched AV while AV was wandering near W1. As a result of W1's aggressive behavior, AV fell against the wall and sustained an injury as a result of the fall. Based on facility documentation and interviews, the facility failed to appropriately monitor W1 according to his/her known behavior and prior altercations. The failure resulted in a physical altercation and causing unreasonable discomfort to the Alleged Victim, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about August 28, 2023, Witness 1 (W1) was involved in a resident-to-resident altercation with Alleged Victim (AV) in which W1 walked up to AV and started hitting AV in the chest. Based on facility documentation, W1 and AV were involved in a prior resident-to-resident altercations. The facility failed to appropriately monitor W1 according to his/her known behavior and prior altercations with AV. The failure resulted in a physical altercation, causing unreasonable discomfort to AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately monitor Witness 1 (W1) according to his/her known behavior and prior altercations. On or about August 22, 2023, W1 and Alleged Victim (AV) had a resident-to-resident altercation in which W1 pushed AV causing AV pain to his/her head and bottom. Based on facility documentation and interviews, AV and W1 had physical altercations with each other on May 18, 2023, June 21, 2023, and August 11, 2023. Facility staff were to ensure that AV and W1 were kept away from other in public areas. The facility's failure resulted in another physical altercation between AV and W1, causing unreasonable discomfort to the AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about July 18, 2023, Witness 1 (W1) spit on Alleged Victim (AV), AV responded by hitting W1 and W1 then responded to AV hitting him/her by hitting AV back. W1 has a history multiple resident-to-resident altercations. Based on facility documentation and interviews, the facility failed to implement appropriate interventions and failed to appropriately monitor W1according to his/her known behavior and prior altercations. The facility's failure resulted in a physical altercation, causing unreasonable discomfort to both AV and W1, 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 on or about June 13, 2023, without staff knowledge. Based on interviews and facility documentation, when residents push on the exit door it can loosen the screws which demagnetizes the door and makes the facility unsecured. The facility was aware that the exit door had been disengaging which resulted in AV also eloping on May 30, 2023, and on June 5, 2023. The facility's failure to provide a safe environment placed the AV at risk of harm. is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and provide appropriate supervision related to the Alleged Victim’s (AV) known history of falls. Based on facility documentation and interviews, AV fell on December 1, 2022, on December 21, 2022, on January 25, 2023, on February 26, 2023, and on March 15, 2023. The facility failed to develop sufficient fall preventions/interventions to AV's care plan following AV's fall on February 26, 2023. AV fell again on March 15, 2023, causing injury to his/her face. The facility's failure to appropriately care plan for AV's fall risk, caused unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and provide appropriate supervision related to the Alleged Victim’s (AV) known history of falls. Based on facility documentation, AV suffered falls on 10/29/22, 11/13/22, 12/12/22, 12/31/22, and 1/25/23. The facility's failure to develop sufficient interventions to mitigate AV's fall risk, caused AV unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and provide appropriate supervision related to the Alleged Victim's (AV) fall history. The failure resulted in AV experiencing an unwitnessed fall on or about January 23, 2023, was transferred to the hospital and was diagnosed with a broken hip. AV suffered pain and 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 monitor Witness 1 (W1) according to his/her known behavior and prior altercations. The failure resulted in a physical altercation and causing unreasonable discomfort to the Alleged Victim (AV), which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately monitor Witness 1 (W1) according to his/her known behavior and prior altercations. The facility's failure resulted in a physical altercation between W1 and Alleged Victim (AV) which caused a skin tear injury to AV's right elbow causing unreasonable discomfort, 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 implement interventions and appropriately monitor Witness 1 according to his/her known behavior and prior altercations. The failure resulted in a physical altercation, causing unreasonable discomfort to the Alleged Victim, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness 1 (W1) had known inappropriate behaviors and the facility failed to care plan according to those behaviors. Between March 12, 2022 and May 28, 2022, W1 had more than one incident in which W1 either made sexual comments to residents or touched a resident including Alleged Victim (AV) in a sexually manner without permission. The facility failed to put sufficient interventions in place for W1 to protect others from W1's inappropriate behavior, which ultimately led to an incident where W1 made inappropriate sexual contact with another resident by touching AV's genitals. The facility’s failure to put sufficient interventions in place for W1 is considered 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 fall, was transferred to the hospital and diagnosed with a fractured hip, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about April 17, 2022, Witness 1 (W1) and Alleged Victim (AV) had a resident-to-resident altercation in which W1 twisted and pinched AV's arm causing a bruise/red mark. Based on interviews and facility documentation, W1 has a history of aggressive behaviors and W1 is care planned to be supervised and redirected when he/she is showing signs of escalating behaviors. The facility failed to follow W1's care plan by failing to ensure W1 was receiving the basic care and supervision needed which resulted in physical harm to AV. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness 1 (W1) has a history of wandering into other residents' room and being physically aggressive with others. On or about April 13, 2022, W1 entered Alleged Victim's (AV) room which resulted in a resident to resident altercation that caused injury to AV. Based on witness statements and facility documentation, the facility failed to follow W1's care plan and failed to respond to W1's increasing behaviors which caused harm to AV. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about December 28, 2021, Alleged Victim (AV) was sent to the hospital for treatment after being found with a wound on his/her buttocks that was bleeding, oozing, and skin was black. Based on interviews and facility documentation, it was determined that facility failed to properly care plan, and initiate interventions to respond to AV's behaviors when he/she resists assistance with his/her Activities of Daily Living. The facility's failure caused AV unreasonable discomfort, leaving AV at risk for harm which is a violation of resident rights, is considered neglect of care, and constitutes abuse.

On or about December 18, 2025, 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 was not 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.

On or about December 12, 2025, the facility failed to have an Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population, their needs, and all required Activities of Daily Living (ADL). Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. Facility was not 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.

Based on interview and record review, conducted during an investigation on 02/27/26, the facility’s failure to provide records to the Department upon request was substantiated. Findings include but are not limited to: A review of electronic communication, dated 11/07/25, indicated the Department requested documents related to the facility’s Acuity-Based Staffing Tool (ABST) alleged event date 11/01/25. The facility had not provided all requested documentation by the due date of 11/08/25. The facility's failure to provide records to the Department upon request 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.

On or about September 1, 2025, 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.

On or about August 30, 2025, 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.

On or about August 29, 2025, 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.

On or about August 20, 2025, 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 Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population, their needs, and all required Activities of Daily Living (ADL). Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. Facility was not 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. Corrective Action taken on related allegation.

The facility failed to have an Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population, their needs, and all required Activities of Daily Living (ADL). Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. Facility was not 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. Corrective Action taken on related allegation.

On or about August 6, 2025, 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.

On or about July 27, 2025, 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.

On or about April 20, 2025, 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.

On or about April 1, 2025, 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.

Based on interview and record review, conducted during an investigation on 02/27/26, the facility’s failure to provide records to the Department upon request was substantiated. Findings include but are not limited to: A review of electronic communication, dated 03/18/25, indicated the Department requested documents related to the facility’s Acuity-Based Staffing Tool (ABST) alleged event date 02/17/25. The facility had not provided all requested documentation by the due date of 03/19/25. The facility's failure to provide records to the Department upon request is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during an investigation on 02/27/26, the facility’s failure to provide records to the Department upon request was substantiated. Findings include, but are not limited to: A review of electronic communication, dated 11/08/24, indicated the Department requested documents related to the facility’s Acuity-Based Staffing Tool (ABST) alleged event date 11/01/24. The facility had not provided all requested documentation by the due date of 11/12/24. The facility's failure to provide records to the Department upon request is a violation of Oregon Administrative Rules.

On or about October 31, 2024, Alleged Perpetrator 2 (AP2) was observed yelling at Alleged Victim (AV) to stop eating from another resident's plate. Based on interviews and facility documentation, AP2 yelled in an abrasive tone in an intimidating manner when AV told AP2 it was okay to eat off the other resident's plate. AP2 stated that he/she was struggling to control his/her emotions prior to the incident. AP2's actions caused AV to feel frighten which is considered verbal and emotional abuse. The facility failed to provide a safe environment for AV 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 per complaint it takes an average of 20 mins to respond to call lights, which is a violation of Oregon Administrative Rules.

The facility failed to keep all equipment necessary for the health, safety, and comfort of the resident in clean and good repair, which is a violation of Oregon Administrative Rules.

On or about March 12, 2024, a Licensing Complaint Unit (LCU) Investigation determined the facility failed to have enough staff to meet the scheduled and unscheduled needs of the resident. Based on facility documentation and interviews, it was confirmed that facility is staffing, 1 staff for every 12 residents. As a result, the facility is not meeting that scheduled and unscheduled toileting needs of the residents. The facility's failure is a violation of Oregon Administrative Rules.

On or about May 1, 2023, 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 for a total of 30 days

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. The facility's failure to provide a safe environment is a violation of Oregon Administrative Rules.

On or about December 24, 2021, Alleged Perpetrator 2 (AP2) used physical force on Alleged Victim (AV) when AP2 was working in the role as AV's caregiver. An investigation determined that AP2's actions caused AV to get a skin tear about 3.5cm X 1.5cm with some bloody drainage which constitutes physical abuse. The facility failed to provide a safe environment for AV which is a violation of Oregon Administrator Rules.

The facility failed to provide a safe medication administration system which resulted in Alleged Victim (AV) not receiving his/her blood thinner as ordered from November 2, 2021 through November 10, 2021. Based on facility documentation and interviews, AV failed to receive his/her correct medication according to the dosage, route, frequency and time as described in the medical order. The facility's failure is a violation of Oregon Administrative Rules.