The Grove Memory Care

The Alleged Victim (AV) has cognitive deficits and relies on the facility for his/her care. According to an investigation, on or about April 24, 2025, AV was exhibiting symptoms of a change in condition at around 2:00 PM when staff observed AV slumped over in his/her wheelchair. AV was transported to the hospital more than four hours later at around 7:33 PM with left sided facial droop and left sided extremity weakness, resulting in a risk of serious harm. The facility failed to intervene timely when the resident's condition changed, which is a violation of resident’s rights, is neglect of care and constitutes abuse.

The Alleged Victim (AV) resides at the facility and relies on the facility for his/her care and safety. Witness 2 (W2) is AV's spouse and was AV's primary caregiver before AV moved to AP1. According to an investigation, on or about March 30, 2025, W2 would yell at AV and handle AV roughly, pull on AV's limbs and hit AV during their interactions, resulting in AV grimacing, becoming visibly upset and experiencing uncontrollable tremors. AV's service plan did not provide specific interventions for staff to follow to protect AV from physical abuse. The facility failed to properly plan care and protect AV from physical abuse, 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 resident-to-resident altercations and rely on the facility for their care. W1 is known to become aggressive in social settings and is care planned for staff to intervene and re-direct W1's behaviors. According to an investigation, on or about August 26, 2024, AV was struck in the face during an altercation between W1 and care staff. A care plan was initiated for staff to keep AV and W1 separated. On August 27, 2024, W1 pushed AV in the common area living room, causing AV to fall and hit his/her head. AV was sent to the hospital and diagnosed with a fracture of the back and concussion to the head, resulting in unreasonable discomfort and emotional harm. The facility failed to properly address resident behaviors and provide a safe environment, which is a violation of resident rights, is neglect of care which constitutes abuse.

The Alleged Victim (AV) and Witness 1 (W1) both have a history of behaviors and resident-to-resident altercations. Behavior interventions were for one-to-one staff to be present with W1 at all times while out in the community and a door alarm in place to alert staff when W1 left his/her room. According to an investigation, on or about August 8, 2024, AV was outside W1’s room when W1 came out of the room, placed his/her hand around AV's neck and struck AV on the right side of AV's eye, resulting in redness to his/her right eye and neck areas. The facility failed to provide a safe environment which is a violation of resident rights, is neglect of care which constitutes abuse.

The Alleged Victim (AV) and Witness 1 (W1) rely on the facility for his/her care. W1 has a history of behaviors and resident-to-resident altercations. W1's behavior interventions are for one-to-one staff to be present with W1 at all times while out in the community and a door alarm in place to alert staff when W1 left his/her room. The door alarm was not documented in the service plan and no alarm was heard by staff. According to an investigation, on or about August 8, 2024, AV was outside W1’s room when W1 came out of the room, swung at AV during an altercation, resulting in AV stumbling backwards, creating a risk of serious harm. The facility failed to properly care plan, which is a violation of resident rights, is neglect of care which constitutes abuse.

The Alleged Victim (AV) relies on the facility for his/her care. AV and Witness 1 (W1) have a history of resident-to-resident altercations and are care planned for staff to manage behavioral episodes. According to an investigation, on or about June 06, 2024, W1 charged toward AV, threw AV into a chair, causing AV to fall to the ground. W1 then started hitting AV in the face, resulting in a laceration to AV's scalp. The facility failed to provide a safe environment and address the resident's behaviors, which is a violation of resident’s rights, is neglect of care and constitutes abuse.

The Alleged Victim (AV) is dependent on the facility to meet his/her safety needs and has a history of exit seeking and attempting to elope from the secured unit. According to an investigation, on or about March 19, 2024, AV eloped from the secured unit by following staff through an exit door into the lobby area. The facility failed to address the resident's behaviors and provide a safe environment which is a violation of resident rights, is neglect of care which constitutes abuse.

The facility failed to appropriately monitor Witness 1 (W1) according to his/her known behaviors and prior altercations. On or about May 31, 2024, Alleged Victim (AV) was watching television in the facility common area while W1 was standing near AV, with W1's back to AV. Based on facility documentation and interviews, W1 turned towards AV without provocation, and grabbed and twisted AV's right arm. During the investigation, the investigator observed that facility staff documented W1's behavioral intervention methods as being ineffective in preventing W1's behavior from escalating which placed other residents at risk of physical harm. Prior to incident, W1 had multiple events in which W1 demonstrated aggressive behavior, including physical contact with other residents and caregivers amounting to six incidents over a 3-month period. The facility's failure to properly care plan and implement appropriate behavior interventions for W1, resulted in his/her aggressive behavior escalating, causing a physical altercation with AV which resulted in pain and unreasonable discomfort to the AV, which is a violation of resident rights, is considered 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 verbal aggression, threats towards other residents and acting out. W1's service plan includes behaviors of threatening harm and reacting aggressively to others and did not provide clear direction to staff regarding interventions when behaviors occur. According to an investigation, on or about May 23, 2024, W1 made a threatening statement to hit AV then kicked AV, which resulted in AV falling. The facility failed to provide a safe environment for AV and failed to properly address behaviors, which is a violation of resident rights, is neglect of care which constitutes abuse.

The Alleged Victim (AV) relies on the facility to administer his/her medications. According to an investigation, on or about April 25, 2024, AV did not receive numerous doses of medications to treat agitation, behaviors and elevated blood pressure. AV was agitated and frequently initiated physical altercations with other residents and staff. The facility failed to provide a safe medication system, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to appropriately monitor Witness 1 (W1) according to his/her known behavior and prior altercations. On or about April 20, 2024, W1 attacked Alleged Victim (AV) and caused an injury to AV’s face. The facility’s failure to provide a safe environment resulted in a physical altercation, 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 appropriately monitor Witness 1 (W1) according to his/her known behavior and prior altercations. On or about April 16, 2024, at approximately 9am, W1 grabbed Alleged Victim's (AV) walker and pushed AV down. AV hit his/her head and had a small spot of blood on the back of his/her head. AV was sent to the hospital for treatment and was diagnosed with a concussion as result of physical altercation with W1 in which W1 was the aggressor. The facility's failure to provide a safe environment, caused unreasonable discomfort to AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about April 9, 2024, Witness 1 (W1) and Alleged Victim (AV) had a physical altercation in the hallway of the facility. Based on facility documentation and interviews, W1 has a known history of prior resident-to-resident altercations due to W1's aggressive behaviors and violent outbursts. To prevent/minimize W1's inappropriate behaviors, W1 is care planned to have one-on-one care. At time of incident, the facility failed to have one-one -care for W1 due to facility being short-staffed which resulted in W1 not having a caregiver present to immediately address W1 behaviors as needed. At time of incident, W1's prescribed medication to treat his/her behaviors was not being available. Facility documentation showed W1 was last administered his/her behavior medication on March 30, 2024. The facility's failure to appropriately monitor W1 according to his/her known behavior and prior altercations, resulted in a physical altercation between W1 and AV that caused unreasonable discomfort to 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 resident-to-resident altercations and W1's care plan requires care staff to manage behavior episodes by redirecting W1. According to an investigation, on or about February 25, 2024, W1 put their hands around AV's neck while in the dining room and squeezed AV's neck. AV attempted to move away from W1. The incident resulted in AV being tearful and scared and there were red marks around the back and side of AV's neck. The facility failed to provide a safe environment, which is a violation of resident’s rights, is neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility to ensure a safe environment. Witness 1 (W1) has a history of resident-to-resident altercations. On or about February 17, 2024, AV and W1 had a physical altercation, resulting in AV being hit in h/h face causing pain and unreasonable discomfort. The facility failed to ensure a safe environment for AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide a safe environment. On or about January 23, 2024, according to documentation the Alleged Victim (AV) sustained second degree burns on h/h inner upper thighs, from an unknown origin. AV was taken to the Emergency Department for treatment and experienced pain and unreasonable discomfort. 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 related to the Alleged Victim’s (AV) fall history. On or about October 8, 2023, AV suffered an unwitnessed fall, resulting in a broken rib. The failure resulted in AV experiencing pain and unreasonable discomfort, 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 Alleged Victim (AV) medication for pain was administered as ordered. On or about October 08, 2023, AV received the pain medication more then what was ordered, putting AV at risk of 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 to ensure a safe environment. Witness 1 (W1) has a history of resident-to-resident altercations. On or about August 21, 2023, AV and W1 had a physical altercation, resulting in AV sustaining an injury to h/h arms causing pain and discomfort. The facility failed to ensure a safe environment for AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about July 28, 2023, the facility failed to provide a safe medication administration system to ensure the Alleged Victim’s (AV) blood pressure medication was available to be administered as ordered. H/S went without medication on at least four (4) occasions putting AV at risk and causing unreasonable discomfort. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about July 15, 2023, the Alleged Perpetrator 2 (AP2) spoke inappropriately to Alleged Victim (AV) during care for him/her. AP2's actions caused a loss of dignity to AV, which is considered neglect of care and constitutes abuse. The facility failed to provide a safe environment which is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) relies on the facility to ensure a safe environment. Witness 1 (W1) has a history of resident-to-resident altercations. According to documentation the Alleged Perpetrator (AP2) left W1 unsupervised, On or about July 15, 2023, AV and W1 had a physical altercation, resulting in AV sustaining an injury to h/h mouth causing pain and discomfort. AP2's actions is a violation of resident rights, is considered neglect of care and constitute abuse. The facility failed to ensure a safe environment for AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to documentation, the Alleged Perpetrator (AP2) failed to provide a safe medication administration system to ensure Alleged Victim (AV) medication for anxiety, agitation, and distress was administered. On or about July 15, 2023, AV did not receive the Lorazepam medication as prescribed, resulting in AV and witness 1 (W1) having an altercation. AP2's actions is a violation of resident rights, is considered neglect of care and constitute abuse.

The Alleged Victim (AV) relies on the facility to ensure a safe environment. Witness 1 (W1) has a history of resident-to-resident altercations. On or about July 11, 2023, AV and W1 had a physical altercation, resulting in W1 spitting on AV'S face, after W1 grabbed AV on h/h arm causing pain and discomfort. The facility failed to ensure a safe environment for AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness 1 (W1) had known inappropriate behaviors, the facility failed to care plan according to those behaviors and provide sufficient staff to monitor him/her. On or about July 11, 2023, it was reported that W1 had inappropriate contact with the Alleged Victim (AV). The two Residents were separated. The facility failed to put interventions in place to keep AV safe, which is a violation of resident rights, is considered neglect of care which constitutes abuse.

On or about June 29, 2023, Alleged Perpetrator 2 (AP2) failed to provide a safe environment . AP2 was found putting AV’s soiled gown in AV’s face in front of another staff member, which resulted in AV experiencing a loss of dignity. AP2's actions is a violation of resident rights, is considered neglect of care and constitute abuse. The facility failed to provide a safe environment, which is a violation of Oregon Administrative Rules.

On or about June 01, 2023, the facility failed to follow The Alleged Victim (AV) care plan to provide assistance with toileting and two-hour checks. The failure resulted in AV being found in soiled briefs by another staff member. The failure resulted in AV experiencing a loss of dignity and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The allegation that the Alleged Perpetrator (AP2) failed to follow AV’S care plan was investigated and the determination was Inconclusive.

The facility failed to provide a safe medication administration system to ensure Alleged Victim (AV) Olanzapine medication was administered daily. He/she went without Olanzapine medication for twenty (20) days, resulting in AV at experiencing unreasonable discomfort. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide a safe environment. On or about June 01, 2023, according to documentation the Alleged Victim (AV) sustained bruising on h/h knees, arms and hands from an unknown origin. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility to ensure a safe environment. Witness 1 (W1) has a history of resident-to-resident altercations. On or about May 28, 2023, AV and W1 had a physical altercation, resulting in AV sustaining an injury to h/h face causing pain and discomfort. The facility failed to ensure a safe environment for AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to properly administer the Alleged Victim’s (AV) medications as ordered. According to documentation, on or about May 18, 2023, May 19, 2023, and May 20, 2023, AV was not administered h/h Seroquel. AV experienced agitations and aggressive behaviors causing unreasonable discomfort. The facility failed to Administer Medication as ordered 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 to prevent the Alleged Victim (AV) from frequent falls. The failure resulted in the AV suffering approximately nine falls within an approximate 90-day period, resulting in bruising and pain, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness 1 (W1) had known inappropriate behaviors, the facility failed to care plan according to those behaviors and provide sufficient staff to monitor him/her. On or about April 19, 2023, it was reported that W1 had inappropriate contact with the Alleged Victim (AV). The two Residents were separated. The facility failed to put interventions in place to keep AV safe, 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 for the Alleged Victim (AV). According to documentation the facility was given instructions on or about April 13, 2023, to have AV take only one dose by mouth daily. The failure resulted in AV receiving two doses on or about April 13, 2023- April 20, 2023, putting AV in risk of serious harm. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness 1 (W1) had known inappropriate behaviors, the facility failed to care plan according to those behaviors and provide sufficient staff to monitor him/her. On or about April 10, 2023, it was reported that W1 had inappropriate contact with the Alleged Victim (AV). The two Residents were separated. The facility failed to put interventions in place to keep AV safe, which is a violation of resident rights, is considered neglect of care which constitutes abuse.

Witness 1 (W1) had known inappropriate behaviors, the facility failed to care plan according to those behaviors and provide sufficient staff to monitor him/her. On or about April 10, 2023, it was reported that W1 had inappropriate contact with the Alleged Victim (AV). The two Residents were separated. The facility failed to put interventions in place to keep AV safe, which is a violation of resident rights, is considered neglect of care which constitutes abuse.

Witness 1 (W1) had known inappropriate behaviors, the facility failed to care plan according to those behaviors and provide sufficient staff to monitor him/her. On or about April 10, 2023, it was reported that W1 had inappropriate contact with the Alleged Victim (AV). The two Residents were separated. The facility failed to put interventions in place to keep AV safe, which is a violation of resident rights, is considered neglect of care which constitutes abuse.

Witness 1 (W1) had known inappropriate behaviors, the facility failed to care plan according to those behaviors and provide sufficient staff to monitor him/her. On or about April 10, 2023, it was reported that W1 had inappropriate contact with the Alleged Victim (AV). The two Residents were separated. The facility failed to put interventions in place to keep AV safe, which is a violation of resident rights, is considered neglect of care which constitutes abuse.

Witness 1 (W1) had known inappropriate behaviors, the facility failed to care plan according to those behaviors and provide sufficient staff to monitor him/her. On or about April 07, 2023, it was reported that W1 had inappropriate contact with the Alleged Victim (AV). The two Residents were separated. The facility failed to put interventions in place to keep AV safe, which is a violation of resident rights, is considered neglect of care which constitutes abuse.

Witness 1 (W1) had known inappropriate behaviors, the facility failed to care plan according to those behaviors. On or about April 10, 2023, it was reported that W1 had inappropriate contact with the Alleged Victim (AV). The two Residents were separated. The facility failed to put interventions in place to keep AV safe, which is a violation of resident rights, is considered neglect of care which constitutes abuse.

Witness 1 (W1) had known inappropriate behaviors, the facility failed to care plan according to those behaviors and provide sufficient staff to monitor him/her. On or about April 07, 2023, it was reported that W1 had inappropriate contact with the Alleged Victim (AV). The two Residents were separated. The facility failed to put interventions in place to keep AV safe, which is a violation of resident rights, is considered neglect of care which constitutes abuse.

The Alleged Victim (AV) relies on the facility to ensure a safe environment. Witness 1 (W1) has a history of resident-to-resident altercations. On or about April 07, 2023, AV and W1 had a physical altercation, resulting in AV sustaining a skin tear on h/h left arm causing pain and discomfort. The facility failed to ensure 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 to ensure a safe environment. Witness 1 (W1) has a history of resident-to-resident altercations. On or about April 04, 2023, AV and W1 had a physical altercation, resulting in AV sustaining a skin tear on h/h left arm causing pain and discomfort. The facility failed to ensure a safe environment for 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) needs. On or about March 30, 2023, AV attempted to exit his/her room from the window, which did not have the safety mechanism in place. After throwing his/her belongings out of the window, AV experienced an unwitnessed fall and was transported to the hospital for evaluation. When AV returned to the facility, his/her belongings were still outside of his/her window. 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 to ensure a safe environment. Witness 1 (W1) has a history of resident-to-resident altercations. On or about March 29, 2023, AV and W1 had a physical altercation, resulting in AV being grabbed by W1 causing a skin tear on AV’S arm and causing pain and discomfort. The facility failed to ensure 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 to ensure a safe environment. Witness 1 (W1) has a history of resident-to-resident altercations. On or about March 06, 2023, AV and W1 had a physical altercation, resulting in AV being hit on h/h ribs by W1 causing pain and discomfort. The facility failed to ensure a safe environment for AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness 1 (W1) had known inappropriate behaviors, the facility failed to care plan according to those behaviors and provide sufficient staff to monitor him/her. On or about December 31, 2022, it was reported that W1 had inappropriate contact with the Alleged Victim (AV). The two Residents were separated. The facility failed to put interventions in place to keep AV safe, which is a violation of resident rights, is considered neglect of care which constitutes abuse.

The Alleged Victim (AV) relies on the facility to provide a safe environment. On or about November 12, 2022, the Alleged Perpetrator 2 (AP2) was forceful and rough while changing AV’s brief, leaving h/h feeling embarrassed and suffered emotional distress. AP2’s actions are considered abuse. The facility failed to provide a safe environment which is a violation of Oregon Administrative Rules.

The facility failed to implement interventions and appropriately care plan related to the Alleged Victim’s (AV) fall history. On or about November 06, 2022, AV suffered an unwitnessed fall resulting in an injury to h/h right arm and was transported to the Emergency Department. The failure resulted in AV experiencing pain and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about November 05, 2022, the facility failed to provide a safe environment to the Alleged Victim (AV) according to h/h needs. The failure resulted in AV leaving the secured building, without staff knowledge, placing AV at risk of harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility to ensure a safe environment. Witness 1 (W1) have a history of resident-to-resident altercations. On or about November 05, 2022, AV and W1 had a physical altercation in the living room, resulting in AV being punched in the head by W1 causing pain and discomfort. The facility failed to ensure a safe environment for AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately care plan related to the Alleged Victim’s (AV) wound on h/h lower right calf. On or about October 31, 2022, AV was scheduled for a shower and h/h bandage was not changed. The failure resulted in AV experiencing pain and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to administer medication as ordered for the Alleged Victim’s (AV). AV is to be given Eliquis daily to help prevent blood clots. According to documentation on or about October 28, 2022, AV was not given the Eliquis putting AV at risk of serious harm. 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 related to the Alleged Victim’s (AV) fall history. On or about October 16, 2022, AV suffered an unwitnessed fall, resulting in an injury to h/h elbow. The failure resulted in AV experiencing pain and unreasonable discomfort, 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) needs. On or about October 10, 2022, AV was found upset and crying about being hungry. The failure resulted in AV going hours without food and 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. On or about August 04, 2022, AV suffered an unwitnessed fall resulting in an injury to h/h head and was transported to the Emergency Department. The failure resulted in AV experiencing pain and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to follow the Alleged Victim (AV) care plan for safety checks every two to three hours. According to documentation AV was not checked on the evening of on or about September 22, 2022. The failure resulted in AV being fully dressed in day clothes and left in h/h recliner chair overnight, experiencing unreasonable discomfort and a loss of dignity. The facility failed to ensure care plans were followed, which is a violation of resident’s rights, is considered neglect of care and constitutes abuse.

The facility failed to provide a safe environment for the Alleged Victim. On or about September 20, 2022, AV’s blood pressure was approximately 80/42 and the facility did not sent AV to be evaluated, putting AV in risk of harm which is a violation of resident rights, is considered neglect of care and constitute abuse. The allegation of AP2's substantiation was re-evaluated and the determination was inconclusive.

According to documentation the facility failed to follow the Alleged Victim’s (AV) care plan. AV’s care plan states AV is supposed to have a catheter change every four weeks. The failure resulted in AV not having a catheter change for approximately six weeks. The failure resulted in AV experiencing pain and unreasonable discomfort. The facility failed to ensure care plans were followed, 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 related to the Alleged Victim’s (AV) fall history. On or about August 30, 2022, AV suffered an unwitnessed fall resulting in an injury to h/h right elbow. The failure resulted in AV experiencing pain and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The allegations that the Alleged Perpetrator (AP2) failed to protect AV from Physical abuse was investigated and the determination was inconclusive.

The facility failed to implement interventions and appropriately care plan related to the Alleged Victim’s (AV) fall history. On or about September 05, 2022, AV suffered an unwitnessed fall resulting in an injury to h/h head. The failure resulted in AV experiencing pain and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to documentation the facility failed to follow the Alleged Victim’s (AV) care plan. AV care planned to be checked every two hours. According to documentation AV experienced a fall on or about August 10, 2022, AV waited approximately an hour for help. The failure resulted in AV experiencing 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 care plan related to the Alleged Victim’s (AV) fall history. On or about August 15, 2022, AV suffered an unwitnessed fall resulting in an injury to h/h head and was transported to the Emergency Department. The failure resulted in AV experiencing 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 care plan related to the Alleged Victim’s (AV) fall history. AV suffered from approximately seven different falls from on or about April 07, 2022-October 05,2022 resulting in injuries to h/h back, right upper eye, and scattered bruising on h/h forearm. The failure resulted in AV experiencing pain and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide a safe environment 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 Alleged Victim (AV) is care planed as an elopement risk during a fire drill and staff are to keep AV in sight and escort AV to safety. On or about October 30, 2021, at around 9:00 pm another resident pulled the fire alarm unlocking the facility doors. On or about October 31, 2021, at around 5:57am the facility received a telephone call, AV had been found by law enforcement. Review of cameras show at around 9:11 pm on or about October 30, 2021, AV was walking in the parking lot of the facility. AV came back to the facility with an abrasion to h/h knee. 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 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. The facility’s failure is a violation of Oregon Administrative Rules.

Based on interview and record review conducted during a site visit on 6/09/25, the facility's failure to comply with Change of Conditions and Monitoring requirements was substantiated. The facility’s failure is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) relies on the facility to meet his/her daily needs. According to an investigation, on or about August 27, 2024, the Alleged Perpetrator 2 (AP2) and Alleged Perpetrator 3 (AP3) failed to follow the care plan when they did not stop trying to transfer AV, ensure safety and re-approach AV later when AV was resistive to care, resulting in AV having bruises to hands and wrists. AP2 and AP3's actions are considered neglect and constitutes abuse. The facility failed to protect AV from physical abuse, which violates Oregon Administrative Rules.

The Alleged Victim (AV) relies on the facility to assist with activities of daily living and provide cueing and direction related to cognitive loss. According to an investigation, on or about May 18th, 2024, the Alleged Perpetrator 2 (AP2) failed to provide the assigned one on one supervision of another aggressive resident, resulting in the AV being assaulted, pushed to the ground, and obtaining a head injury. AP2’s actions are a violation of resident rights, considered neglect of care, and constitutes physical abuse. The facility failed to provide a safe environment and keep AV free from physical abuse, which is a violation of Oregon Administrative Rules.

On or about November 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 October 1, 2022 to October 31, 2022, for a total of 30 days.

On or about October 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 September 1, 2022 to September 30, 2022, for a total of 30 days.

The Alleged Victim (AV) has a history of falls and is service planned to be checked every two hours and has a sensor on his/her bed that alerts staff when AV is out of bed. On or about October 27, 2021, the sensor shows AV was out of bed at approximately 9:11pm, and the call system showed eighty-six (86) pages from AVs room. Alleged Perpetrator #2 (AP2) and Alleged Perpetrator #4 (AP4) never responded to any of these pages to check on AV. At approximately 12:23 AM, AV was heard yelling from his/her room, staff checked on AV and found AV on the floor from a fall. AV was not harmed in the fall, however, AV was placed at risk for harm. AP2 and AP4 failed to answer the call light in a timely manner, which is a violation of resident rights, is considered neglect of care and constitutes abuse. Alleged Perpetrator #3 (AP3) was working the assisted living side of the building the night of the incident, therefore abuse against AP3 was found to be inconclusive. The facility failed to ensure AVs needs were met which is a violation of Oregon Administrative rules.