Windsong at Eola Hills

Alleged Victim (AV) and Witness 1 (W1) reside in the Respondent’s facility and depend on facility staff for their daily needs and for maintaining a safe environment. W1 has a documented history of behavioral issues involving other residents, including resident-to-resident altercations. These behaviors have resulted in multiple prior incidents in the dining room, including one in April 2025 and three in July 2025. On or about October 31, 2025, facility staff discovered the aftermath of resident-to-resident altercation involving AV and W1. W1 was found lying on the floor next to a dining room chair with a skin tear on the right forearm and the left jaw/cheek. W1 also reported head pain consistent with hitting their head. AV sustained a skin tear on the left hand. The Respondent failed to provide adequate oversight and to ensure a safe environment for residents. This constitutes abuse by neglect as defined in OAR 411-020-0002(1)(b)(A)(i).

Alleged Victim (AV) and Witness 1 (W1) reside in the Respondent’s facility and rely on facility staff for their safety and assistance with daily care needs. AV has a documented history of visual hallucinations, anxiety, and episodes of frustration. W1 has a history of irritability and becoming overwhelmed by loud noises and crowded environments, as well as a documented history of resident-to-resident altercations. This includes an incident on or about October 10, 2025, in which W1 threw a coffee cup at another resident in the dining room. The facility failed to implement and follow the interventions in place to mitigate risk to AV, which contributed to a resident-to-resident altercation between AV and W1. On October 13, 2025, AV was yelling in the dining room. In response, W1 threw W1’s dinner plate on AV and then held the plate upside down over AV’s head, smearing food onto AV. The Respondent failed to follow implemented interventions. This constitutes abuse.

Alleged Victim (AV) resides in the Respondent’s facility and relies on facility staff for AV’s safety and assistance with daily care needs. AV has a history of falls and is identified as a high fall risk, including seven (7) falls prior to the incident on October 11, 2025. Despite this known risk, the facility failed to develop and implement sufficient interventions to mitigate risk to AV. On or about October 11, 2025, facility staff found AV lying on AV's back in the middle of AV's room. AV experienced a fall, striking AV’s head on the floor. AV was transported to the hospital and diagnosed with multiple left rib fractures, a fracture of the left 5th metatarsal, and a fracture of the left radius. AV remained hospitalized from October 11 through October 13, 2025. Respondent failed to develop and implement appropriate interventions to address AV’s known fall risk. This constitutes abuse by neglect.

Alleged Victim (AV) resides in the Respondent’s facility and relies on facility staff for AV’s safety and assistance with daily care needs. AV has a history of falls and is identified as a high fall risk, including a fall on October 11, 2025, that hospitalized AV from October 11 through October 13, 2025, with multiple fractures. Av's service plan reflects keeping AV's cellphone on nightstand next to bed so AV does not to get up for it, and place walker next to AV's bed. Despite AV's known fall risk, the facility staff failed to follow AV service plan and interventions to mitigate risk to AV. On or about October 15, 2025, AV was trying to get out of bed to look for AV's phone & purse. Facility staff found AV lying on the floor next to AV's bed, AV’s wheelchair and walker were in front of h/h dresser not by AV’s bed. Respondent failed to follow AV's service plan and interventions. This constitutes abuse by neglect

Alleged Victim (AV) lives at Respondent’s facility. AV has history of falls, including an incident that occurred in August 2025, resulting in injury and requiring a two-week hospital stay. AV's service plan reflects that AV is a fall risk, and interventions in place, facility staff to perform safety checks on AV 2 times per shift (every 4 hours), AV uses fronted wheeled walker, and requires one-person assistance with ambulating, transfers, bathing, dressing, personal hygiene and toileting. On or about September 17, 2025, facility staff found AV lying on h/h back on the floor in the bathroom, with shower on. AV has a lump on back of head, and left shoulder pain. AV transported to emergency room for evaluation. Respondent failed to provide a safe environment, and follow AVs service plan, which constitutes abuse by neglect.

The Alleged Victim (AV) relies on AP1 for safety. AV has declining memory, lack of orientation to place, time and situation. AV is known to follow staff and other residents around the facility. On or about September 9, 2025, Alleged Perpetrator 2 (AP2) went on break, AP2 did not notice AV following closely behind prior to opening the door, and AV came out right after AP2. AP1 had not provided elopement training to AP2 prior to AV eloping from AP1. The allegation that AP2 failed to provide a safe environment was investigated and the determination was not substantiated. The facility failed to provide a safe environment, and an appropriate training to AP2 around resident elopements, which is a violation of resident’s rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. On or about June 12, 2025, AV pushed call light for assistance, at approximately 2:16pm and again at 2:25pm. At approximately 3:16pm, no care staff entered AV's room during that time. The facility failed to answer call light in a timely manner, which is a violation of resident rights, is neglect of care and constitutes abuse

Alleged Victim (AV) and Witness (W1) are residents of a memory care facility, and rely on AP1 for safety, oversight and daily needs. W1 has a history of resident-to-resident altercations; mostly taking place in the dining room. W1 has a habit of holding onto things. W1 and AV both use walkers and have history walking without their walkers. On or about June 10, 2025, AV was walking in the dining room with h/h walker, when W1 grabbed AV walker and would not let go. AV hit W1 hand, and W1 hit AV in the back. W1 was without W1 walker. Staff intervened only after the incident took place. AP1 failed to provide a safe environment and provide oversight to W1 resulting in W1 grabbing AV walker which led into a physical altercation, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility to administer his/her medications. Facility policy is that medications should be reordered when residents have 5 days’ worth of medication left. On or about June 04,2025, at approximately 6:00am while administering medication, staff discovered that AV was out of AV’s anxiety medication, leading to AV missing morning dose. AV’s medication was not reordered in compliance with the facility's policy. This led to AV experiencing heightened levels of anxiety, increased behavioral issues, rapid breathing and a high heart rate. medication. The facility failed to administer medication as ordered, which is a violation of resident rights is considered neglect of care and constitutes abuse.

Alleged Victim (AV ) is identified as a high fall risk. Prior to moving into the facility on or about April 16, 2025, AV had a history of falls. Between April 16, 2025, and May 24, 2025, there were 16 documented falls involving AV. The service plan dated approximately April 15, 2025, reflects AV’s history of falls. AV does not have a history of agitation or anxiety and is not experiencing behavioral concerns and AV does not have a history of pacing and wandering. AV does have non-pharmaceutical interventions in place that include offering black coffee, engaging in conversations about family, providing a change of face, and offering outdoor walks. AV’s has ISP interventions to address frequent falls; NOC-shift, safety checks increased to every 3 hours, staff to offer toileting assistance at the beginning of the shift, staff to offer toileting assistance prior to dinner, during safety checks staff to ask AV if assistance with toileting is needed. On or about May 24, 2025, Witness 4 (W4) observed AV circling the hallways. AV was seen coming around a corner at a high rate of speed with pants falling below the waist. As AV transitioned from carpet to wood flooring, Av’s pants fell, and AV tripped and landed onto h/h left side. Witness 4 (W4) reported that AV had not been taken to the restroom. AV typically seeks out staff for assistance, as AV cannot remember the restroom location. The service plan indicates that staff are to offer and assist with toileting at the beginning of the NOC shift. The facility failed to provide adequate supervision and oversight and follow the Individualized Service Plan (ISP), resulting in AV’ falling and fracturing h/h hip.

Alleged Victim (AV) is unable to manage AV's own medications and is dependent upon AP1 to properly administer all medications. AV has a physician’s order for anti-anxiety medication daily; two (2) pills in the am, one (1) pill in the afternoon and one (1) pill at night. Alleged Perpetrator 2 (AP2) and Alleged Perpetrator 3 (AP3) missed AV's second am pill for three-days in a row on starting on May 23, 2025, through May 25, 2025. AP2 and AP3 do not have a completed Medication Technician training. The allegation that AP2 and AP3 failed to provide a safe medication administration system by failing to administer AV the correct medication was investigated and determined, not substantiated. The facility failed to provide a safe medication administration system which is a violation of resident rights, is considered neglect of care and constitutes abuse.

AV resides at AP1 and has a responsibility to provide AV assistance with managing medications and including ordering, storing and administration. AV is prescribed narcotic medications per physician orders. On or about April 21, 2025, it was discovered that 16.75mL of AV's narcotic pain medication was unaccounted for. According to the Narcotic log there should have been 21.5 mL remaining. Only 4mL remained in the bottle. AP1 failed to ensure a safe, adequate medication administration system, which resulted in AV's prescribed narcotics being diverted by an unknown Alleged Perpetrator (AP2). AP2s actions were investigated and determined to be inconclusive. The facility failed to provide a safe medication administration system, which is violation of resident’s rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) and Witness 1 (W1) rely on the facility for care. W1 has a history of aggressive behaviors resulting in resident-to-resident altercations, and is care planned for staff to intervene if other residents try to redirect W1. According to an investigation, on or about April 25, 2025, AV tried to redirect W1 from the dining area, resulting in W1 slapping AV on the left cheek and experiencing unreasonable discomfort. The facility failed to follow the care plan and interventions for W1 and provide a safe environment for AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility for care and services, including meal preparation. The AV is intolerant of mushrooms and has been care planned to not be served mushrooms. According to an investigation, the AV was served mushrooms by the facility on or about June 4, 2024, October 9, 2024, and November 11, 2024, causing the AV to have stomach pain and diarrhea on multiple occasions. The facility failed to follow the AV’s care plan, which is a violation of resident rights, neglect of care, and constitutes abuse.

Description of Incident Under the prior ownership: Modified diets including specialized diets ordered by a health professional have to be provide by the facility. Kitchen staff have been trained on specialized diets and have references to help them understand each diet. There is a whiteboard in the kitchen where all the residents’ names, room numbers and dietary needs are listed. Residents on specialized diets have blue plates, and only these residents get the colored plates. Kitchen staff refused to get thickening powder for a resident who had an order for thickened liquids. The kitchen staff have had issues with the minced and moist and other specialized diets on multiple occasions. Residents have been served food that is incorrect for their specialized diet. Care staff have to frequently check meals to ensure that residents are getting the correct texture diet. Kitchen staff do not follow the dietary guidelines or service plans. The kitchen staff do not have any methods for quality control. The facility failed to provide a safe environment, have oversight over kitchen staff, and failed to follow the service plans of Alleged Victim (AV) and other residents, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) and Witness 1 (W1) both rely on the facility for their care. W1 has a history of aggressive behaviors and physical altercations, and is care planned to be redirected if attempting to make physical contact with others. According to an investigation, on or about January 5, 2025, AV was walking into their room, when W1 saw AV and attempted to follow him/her. AV told W1 to not enter the room, and W1 shoved AV into a table and onto the floor, breaking the table and causing AV to obtain a skin tear to his/her right elbow. The facility failed to follow W1 care plan and provide a safe environment for AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) and Witness 1 (W1) both rely on the facility for their care. W1 has a history of aggressive behaviors and physical altercations, and is care planned to be removed from the area by care staff when W1 appears to be agitated. According to an investigation, on or about January 4, 2025, W1 was attempting to take bingo cards to their room after an activity and multiple residents were telling W1 to leave the cards there. W1 was getting agitated and when AV told W1 that the cards belonged to the facility W1 grabbed AV's neck and face while yelling at AV. It took facility staff approximately three (3) minutes to get W1 to let go of AV, resulting in unreasonable discomfort to AV. The facility failed to follow W1 care plan and provide a safe environment for AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) and Witness 1 (W1) both rely on the facility for their care. W1 has a history of aggressive behaviors and physical altercations. According to an investigation, on or about December 21, 2024, W1 hit and pushed AV against the table when AV wouldn’t give W1 their coat. The facility failed to provide a safe environment for AV, causing unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) and Witness 1 (W1) both rely on the facility for their care and have a history of physical altercations. According to an investigation, on or about December 11, 2024, W1 struck AV with a closed fist and palm. AV experienced emotional distress and was fearful of W1. The facility failed to provide a safe environment for AV, causing unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility for his/her care. Witness 1 (W1) has a history of behaviors and physical altercations and is care planned for frequent supervision, and redirection. According to an investigation, on or about November 14, 2024, W1 grabbed AV's head and pulled AV backwards in their chair while AV was eating dinner, placing AV at risk for harm. The facility failed to provide services to keep AV safe, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) and Witness 1 (W1) both rely on the facility for their care. W1 has a history of aggressive behaviors and physical altercations, and has previously assaulted AV. According to an investigation, on or about September 1, 2024, W1 grabbed AV's arm when AV told W1 to stop trying to take another residents keys. AV experienced emotion distress and was fearful of W1. The facility failed to provide a safe environment for AV, causing unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) and Witness 1 (W1) both rely on the facility for care. Witness 1 (W1) has a history of behaviors resulting in physical altercations with other residents. According to an investigation, on or about August 13, 2024, AV was slapped by W1 in the dining room, resulting in AV’s emotional distress and right eye pain that required use of prn pain medication. The facility failed to implement interventions and/or appropriately care plan forW1's behaviors and 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 provide a safe medication administration system to the Alleged Victim (AV) by receiving a double dose of medications. On or about August 28 and 29, 2024, the AV received double the dose of a medication which can cause high blood pressure, headaches, cold like symptoms and G.I. issues. On or about August 31, 2024, the AV was sent to the hospital for high blood pressure, shakiness, lethargy and tenderness to the stomach, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) and Witness 4 (W4) both have a history of behaviors and physical altercations with each other. According to an investigation, on or about August 7, 2024, W1 grabbed AV’s wrists/arms in the dining room, resulting in AV’s emotional distress, bruising to AV's left hand and arm, and a cut to the top of AV's left hand. The facility failed to implement interventions and/or appropriately care plan forW1's behaviors and 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 provide a safe environment for the Alleged Victim (AV) by not implementing appropriate interventions for Witness 1’s (W1) known behaviors that affect other residents. Between June 27, 2024, through July 17, 2024, W1 was engaged in approximately six resident to resident altercations with numerous residents within the facility. There is no documented evidence indicating the facility implemented interventions for W1’s known aggressive behavior towards others, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to implement appropriate interventions for Witness 1’s (W1) known history of resident-to-resident altercations. On or about July 12, 2024, W1 and the Alleged Victim (AV) were involved in an altercation with eachother. On or about July 14, 2024, W1 and the AV were involved in another altercation resulting in W1 slapping the AV in the face, 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) known fall history. On or about June 30, 2024, the AV was found outside of another resident’s room on the floor. The AV was complaining of shoulder and neck pain and was sent to the hospital for evaluation. At the hospital, the AV was diagnosed with a fracture in their cervical spine. Upon further investigation, the facility did not ensure the AV had their mobility device with them at the time of the fall, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to provide a safe environment to ensure the facility was secured and prevented the Alleged Victim (AV) from eloping. On or about June 10, 2024, the AV managed to exit the secured facility without the staff knowing. At approximately 8:15 pm, local law enforcement found the AV in a neighboring apartment complex and notified the facility of the elopement. The facility failed to provide a safe secure environment 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) who is a known fall risk. On or about March 29, 2024, at approximately 6:30 am, the AV was found on the floor, and it appeared the AV was left in their wheelchair all night and not placed in bed with proper fall interventions in place. The bed was observed to be undisturbed and noted the resident did not sleep in their bed the night previous and was left in their wheelchair all night. The failure resulted in the AV to slide out of their wheelchair suffering a fractured hip which required surgery, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility to provide a safe medication administration system for the Alleged Victim. After review of training documentation, it was determined the facility failed to train the Alleged Perpetrator 2 (AP2) to safely pass medication before passing medication. The failure resulted in the AP2 to administer the wrong dose of behavioral medication causing risk of increased behaviors. AP2’s failure to provide a safe medication administration system is a violation of resident rights, is considered neglect of care and constitutes abuse. The facilities failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to care plan appropriate interventions for the Alleged Victim’s (AV) history of self-transferring and not requesting assistance resulting in falls. On or about February 29, 2024, the AV attempted to self-transfer resulting in a fall and hit their head. The AV was sent to the hospital for assessment and was diagnosed with a wrist fracture due to the fall, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility for his/her care. AV had a physician’s order for daily weight checks and to notify the RN and/or Doctor if weight gain is plus/or minus three pounds. According to an investigation, AV had an increase of approximately six pounds and the RN and/or Doctor was not notified for approximately two or three days, resulting in AV experiencing shortness of breath, labored breathing, and a bloody nose and being sent to the hospital for treatment. The facility failed to provide medical treatment as ordered, which is a violation of resident rights, is neglect of care which constitutes abuse.

According to the documentation, the facility failed to provide a safe medication administration system for the Alleged Victim’s (AV) behavioral medication. The failure resulted in the AV to receive the wrong dose of their behavioral medication which caused increased agitation and potential harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to ensure medications were available for the Alleged Victim (AV). On or about January 25, 2024, through January 28, 2024, the AV did not receive their medication for depression resulting in increased agitation, 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) continued falls. The failure resulted in the AV falling numerous times causing pain and unreasonable discomfort, 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 to prevent skin injuries for the Alleged Victim (AV). The failure resulted in the AV suffering numerous skin tears, 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 Witness 1 (W1) for their history of behaviors. The failure resulted in W1 pinching the Alleged Victim (AV) on their chest causing pain and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) had recently returned from the hospital after being disoriented and vomiting. AV was placed on alert for a couple hours after his/her return. On September 16, 2022, AV refused medications and was not placed on alert, and suffered a non injury fall. The facility failed to implement interventions after this fall and the AV fell again on September 18, 2022, suffering a broken ankle. The facility failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about August 22, 2022, AV ran out of his/her inhaler medication for 3 scheduled doses, placing AV at risk for harm. AV suffered shortness of breath during this time. The facility failed to follow their own protocol to ensure that AV did not run out of his/her inhaler medication. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) has suffered 11 falls between July 18, 2022 and October 2, 2022, suffering lacerations, bumps, bruises and skin tears. AV was to be wearing shoes, and during a few of the falls, was found without shoes. AV was also to be supervised and staff were to anticipate AV's needs when he/she is in the common area, however, AV had 3 unwitnessed falls in the common areas. The facility's failure to follow AV's care plan is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about July 3, 2022, Witness #1 (W1) and the Alleged Victim (AV) engaged in an altercation where W1 hit AV on the arms several times. AV and W1 had been in previous altercations and interventions were in place to keep them from having altercations. The facility failed to provide a safe environment, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Between July 1, 2022 and September 7, 2022, the Alleged Victim (AV) suffered approximately 14 falls, with and without injury. Some interventions were put into place, however, AV continued to fall before some interventions could be put into place. AV suffered pain and unreasonable discomfort. The facility failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) returned from the hospital with redness on his/her coccyx. Staff were instructed to check AV every two hours to reposition and ensure his/her brief was dry. Staff did not check AV's brief, leaving his/her in a soiled brief multiple times. AV's redness continued to worsen until he/she had sores. Hospice began treating the sores with medicated cream. The facility's failure to follow the care plan lead to undue pain and suffering for AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is care planned to have staff escort him/her to the dining room in his/her wheelchair. On or about February 24, 2022, the AV was walking back to his/her room with another resident and fell. AV's fall resulted in a broken hip. The facility failed to follow the care plan, as they did not bring AV to the dining room in his/her wheelchair or return AV to his/her room in a wheelchair. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is a known wanderer and is care planned for staff to be redirected when going into other residents rooms and to be monitored while wandering. On or about February 11, 2022, AV entered Witness #1's (W1) room. W1 asked AV to leave, however, AV did not and W1 grabbed AV by the arm and escorted AV from his/her room, in the process, W1 scratched AV's arm. The facility failed to follow AV's care plan, which placed AV at risk for harm. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to appropriately care plan related to the Alleged Victim's (AV) fall history. On or about January 18, 2022, AV was found on the floor after falling out of his/her bed. AV suffered bruises to his/her arms and legs. The facility's failures are a violation of resident rights, are considered neglect of care and constitute abuse.

On or about January 5, 2022, the Alleged Victim (AV) was prescribed medication to prevent strokes. AV's medication was placed in the MAR, however, the medication was not administered by Alleged Perpetrator #2 (AP2) from January 5, 2022 to January 12, 2022. AV had received his/her AM doses of this medication, it was only the PM doses that were missed. AV did not have any adverse reactions, however, AV was placed at risk for harm by missing prescribed medications. AP2 was not properly trained in medication administration until after this incident. The allegation of abuse against AP2 is not substantiated. The facility failure to provide proper training and a safe medication administration system is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) has a history of falls. AV had 11 falls between August 2021 and December 2021, mostly which resulted in injury to AV. On October 7, 2021, AV fractured his/her left shoulder. No change of condition was completed by the facility at that time. AV suffered 4 falls in December 2021, the facility failed to implement new fall interventions after those falls. On or about December 28, 2021, AV fell again, re-fracturing his/her left shoulder. The faciilty failed to properly care plan to ensure the safety of AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is known to fall and had 16 falls in 4 months. AV is care planned to have staff assistance when ambulating. On or about December 13. 2021, AV was found lodged between two chairs. AV suffered bruising to his/her shoulder, eye and hip. The facility failed to follow the care plan, 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 W1 known aggressive behaviors. The failure resulted in numerous resident to resident altercations including aggressive altercations and inappropriate touching of other resident’s private areas, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to ensure supervision and staff support regarding known aggressive behaviors related to Witness #1 (W1) and the Alleged Victim (AV). An incident occurred between W1 and the AV where W1 caused AV to have redness to his/her wrist and chest. The facility's failure 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 Witness 1’s (W1) known aggressive behaviors towards residents. On or about October 26, 2021, W1 got into a physical altercation with the Alleged Victim (AV) in the dining room. W1 punched the AV multiple times in the arm causing pain and emotional harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about October 20, 2021, the Alleged Victim (AV) suffered a fall in the dining room. AV is care planned to be escorted to meals and activities, be reminded to use handrails, offer AV to sit and rest or encourage AV to go to his/her room, due to his/her fall history. On this day, AV was not escorted to the dining room, he/she was wandering the halls alone. AV was sent to the emergency room after the fall and diagnosed with bruising on his/her buttock, back and left knee. The facility's failure to follow the care plan is a violation of resident rights, is considered neglect of care and constitutes abuse.

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

The facility failed to consistently staff to the levels, intensity and qualifications indicated by the Acuity-Based Staffing Tool (ABST). 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.

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, staffing plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to 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.

The facility allegedly failed to administer medication as ordered for the Alleged Victim. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to consistently staff to the levels, intensity and qualifications indicated by the Acuity-Based Staffing Tool (ABST). 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.

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.

Alleged Perpetrator 2 (AP2) failed to provide a safe medication administration system to ensure the Alleged Victim's (AV) medications were administered as ordered. On or about November 11, 2025, two of AV’s medications were found on the floor of the activity room where AV was attending activities. AV requires AV’s medication to be crushed, not given whole. Staff are instructed to observe residents taking their medication during administration. AV did not receive medications as order, AP2's actions placed AV at risk of serious harm, are considered neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.

The facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to have an 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 provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. 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.

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

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

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

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

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

Description of Incident Under the prior ownership: Modified diets including specialized diet orders by a health professional have to be provided. There is a whiteboard in the kitchen where all the residents’ names, room numbers and dietary needs are listed. Alleged Perpetrator #2 (AP2) was trained on specialized diets and has references to help understand them. Residents on specialized diets have blue plates, and only these residents get the colored plates. On or about March 2, 2025, AP2 cut the carrots for lunch an inch wide which is too large and too hard for minced and moist specialized diet. W1 address this with AP2 before lunch was served. On or about March 3, 2025, Alleged Victim (AV) choked on two pieces of pork from AV's lunch that were too fatty, dry, and large for AV to eat. AV is service planned for a minced and moist diet. On March 8, 2025, AP2 was disciplined for not providing food of the correct texture to AV resulting in a choking episode. AP2 failed to follow the care plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to ensure the care plan was being followed, which is a violation of Oregon Administrative Rules.

Alleged Victim (AV) relies on the facility for his/her care. According to an investigation, on or about February 7, 2025, Alleged Perpetrator 2 (AP2) was assisting AV with a transfer when AP2 became frustrated and yelled and cursed at the AV, causing AV to become scared and fearful, grabbing onto the bathroom grab bar in distress. The facility failed to protect AV from verbal/emotional abuse which is a violation of Oregon Administrative Rules.

Alleged Victim (AV) relies on the facility for care and for a safe environment. On or about October 19, 2024, the Alleged Perpetrator 2 (AP2) pinched the AV while providing care. AV noticeably presented with pain following AP2's pinch. AP2’s actions are a violation of resident rights, are considered neglect of care and constitute physical abuse. The facility failed to ensure AV was in a safe environment and protected from physical abuse which is a violation or Oregon Administrative Rules.

Alleged Victim (AV) relies on the facility for his/her care. AV is a fall risk and is care planned to have a fall mat placed next to their bed when they are in it. On or about October 10, 2024, Alleged Perpetrator #2 (AP2) helped AV into bed for a nap, and did not place the fall mat beside AV's bed. A few hours later AV was found on the floor bleeding from a laceration on top of their head, and abrasions on their right forearm, leg and side. AV was transported to the hospital and needed multiple staples to close the head laceration. AP2 failed to follow the care plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to ensure the care plan was being followed, which is a violation of Oregon Administrative Rules.

Alleged Victim (AV) relies on the facility for his/her care. On or about September 9, 2024, Alleged Perpetrator 2 (AP2) was assisting AV with toileting after a bowel movement, when AP2 told AV that they were "nasty". AV became upset and asked AP2 to leave. AP2’s actions are a violation of resident rights, are considered neglect of care and constitute verbal abuse. The facility failed to protect AV from verbal/emotional abuse which is a violation of Oregon Administrative Rules.

Alleged Victim (AV) relies on the facility for h/h care. According to an investigation, AV was given their last dose of medication for restlessness on August 18, 2024 at approximately 2 pm and the Alleged Perpetrator 2 (AP2) was told to call to get more medication delivered to the facility immediately. AV’s medication did not arrive by the next scheduled dose that evening, and when someone else called for a follow-up, it was indicated the medication was never ordered, and it could not be delivered until the next day. AV missed their 7 pm dose on August 18, 2024, resulting in AV being more easily awakened and restless, then overly drowsy the next day. AP2’s actions are a violation of resident rights, are considered neglect of care and constitutes abuse. The facility failed to administer medication as ordered which is a violation of Oregon Administrative Rules.

Alleged Victim (AV) relies on the facility for h/h care. According to an investigation, AV's psychotropic and anti-anxiety medication dosages had recently been changed. On or about August 17, 2024, and again on August 18, 2024, the Alleged Perpetrator 2 (AP2) gave AV the incorrect dose of these medications, resulting in AV having increased anxiety/agitation. AP2 failed to administer medications as ordered, causing increased anxiety/agitation, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to provide a safe medication system which is a violation of Oregon Administrative Rules.

According to the documentation, the Alleged Perpetrator (AP2) failed to follow the service plan for the Alleged Victim (AV) when they display signs of irritation or aggression. The failure resulted in the AV punching AP2 and AP2 punching the AV back in the chest, which is a violation of resident rights and is considered physical abuse. The facility failed to provide a safe environment which is a violation of Oregon Administrative Rules.

On or about September 11, 2022, Alleged Perpetrator #2 (AP2) measured the Alleged Victim's (AV) blood glucose levels and they were at 53. AP2 failed to follow facility protocol for hypoglycemic incident and instead administered diabetic medication, which placed AV at risk for serious harm. AV was sent to the hospital and diagnosed with hypoglycemia. AP2's actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility's failure is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) failed to receive his/her ordered medication from August 18, 2022 to August 22, 2022. The facility's failure to administer AV's prescribed medication is a violation of Oregon Administrative Rules

The Alleged Victim (AV) is a known fall risk and is care planned to be checked multiple times per night for safety. On or about April 6, 2022, AV was found on the floor in his/her apartment, had blood around his/her head, which was partially dried and was covered in urine. AV was sent to the hospital and was diagnosed with a laceration on the back of his/her head, requiring 5 staples and a fractured clavicle. Alleged Perpetrator #2 (AP2) was on shift that night and failed to follow AV's care plan to check on AV during his/her shift. AP2's actions are a violation of resident rights, are considered neglect of care and constitutes abuse. The facility's failure is a violation of Oregon Administrative Rules.

In December 2021, the facility failed to administer ordered medication for the Alleged Victim (AV). AV did not have any adverse reactions to missing the medication, however, the facility was responsible to ensure AV's medication was available. The facility's failure to provide medication as ordered is a violation of Oregon Administrative Rules.