Azalea Gardens Senior Living

The Alleged Victim (AV) relies on the facility to maintain a safe environment and ensure resident rights. Witness 1 (W1) is identified to have inappropriate sexual behaviors, and staff are to be aware of W1's whereabouts at all times. According to an investigation, on or about July 17, 2024, the AV was left alone with W1 and touched in a sexual and inappropriate way by W1, causing unreasonable discomfort and a loss of dignity. The facility failed to appropriately staff for adequate supervision of W1, resulting in a violation of resident’s rights and neglect of care, which constitutes abuse.

The Alleged Victim (AV) relies on the facility to maintain safe environment and ensure resident rights. Witness 1 (W1) is identified to have inappropriate sexual behaviors. The facility failed to develop care plan interventions for W1's inappropriate sexual behaviors. According to an investigation, on or about July 17, 2024, the AV was touched in a sexual and inappropriate way by W1, causing unreasonable discomfort and a loss of dignity for the AV. The facility failed to appropriately care plan, which is a violation of resident’s rights, is neglect of care, and constitutes abuse.

Alleged Victim (AV) relies on the facility to administer his/her medications. On or about June 24, 2024, the facility became aware that AV’s medications were not being authorized by the pharmacy. As a result of AV not being administer his/her medication, AV was notably experiencing increased agitation and shakiness. There is no indication the facility made any attempts to assist AV in getting his/her medications. The facility failed to have medication available for AV, which is a violation of resident rights is neglect of care and constitutes abuse.

The Alleged Victim (AV) is a fall risk and has a history of falls. The AV was noted to have multiple falls between January 14, 2024, and January 21, 2024, placing the AV at risk for harm. There was no evidence to indicate the facility had developed a fall reduction plan or implemented interventions to address the AV's falls. The facility's failure to properly care plan to reduce AV's risk of falls is a violation of resident rights, is considered neglect of care, and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. AV’s Care Plan stated he/she is to have a 1-person assist with all transfer. On or about September 3, 2023, AV was found lying on his/her right side with his/her side of his/her face on the floor with a towel wrapped around. There was a Care Partner present with AV which was applying pressure to AV’s head until EMTs arrived. On or about August 20, 2023, AV was attempting to self-transfer from his/her recliner to their wheelchair. AV’s feet went out from under them, and the power had flickered from the wheelchair causing AV to fall. AV then used the pendant for help but staff were not notified. He/she was yelling from his/her room for help. On or about August 17, 2023, AV rang his/her pendant, and a staff called another staff member to come to AV’s room. AV was found on the floor in front of the dresser. AV stated his/her leg collapsed under him/her when he/she attempted to stand and transfer from the wheelchair to the recliner. The facility failed to follow the care plan around AV’s transfers, putting AV in risk of harm, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) is a high fall risk with a history of prior falls, AV requires full assistance by two staff members with all transfers. On or about March 19, 2023, AV sustained a fall in their room. AV was found on the floor near their recliner. AV stated they had come back from the bathroom and their wheelchair folded up on them. Staff heard a loud bang and responded, finding AV siting on the floor near their recliner. It appears there was no staff present to have help AV transfer from the wheelchair into their recliner. The facility failed to follow AV’s care plan, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) is a high fall risk with a history of prior falls, AV requires full assistance by two staff members with all transfers. On or about March 31, 2023, AV was found sitting on the floor next to their bed. AV had slid out of their bed while getting up to go to the bathroom. Staff had come into AV’s room and had found AV in the floor. It appears there was no staff present to have help AV transfer from the wheelchair into their recliner. The facility failed to follow AV’s care plan, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. On or about March 2, 2023, AV was being helped to the bathroom and on to the toilet, while at the AV lost consciousness and slipped down the toilet. As a result, AV sustained a fall and hit their head and also sustained a cut in their mouth causing AV to bleed from their mouth. The facility failed to provide a safe environment for AV while being in the bathroom resulting in injury to AV, which is a violation of resident rights, is neglect of care and constates abuse.

Alleged Victim (AV) relies on the facility for his/her care. On or about September 26, 2022, Witness 1 (W1) went into AV’s room after hearing noises from the room. Staff opened the locked door and W1 was in AV’s room. W1’s pants were down, and he/she walked into the bathroom after being startled by the staff member. AV was on his/her bed with no pants on and his/her legs spread open. W1 had other incidents prior in which he/she was exhibiting sexual behaviors on or about June 7th, 12th and 22nd, July 12th and 17th, 2022. During each incident, the facility did not include any interventions to prevent W1 from exhibiting sexual behaviors. The facility failed to properly care plan, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. Witness 2 (W2) has a history of ongoing behaviors that include complaining, arguing, making derogatory comments including cussing and resident-to-resident altercations. On or about May 28, 2022, AV heard W2 making a comment about his/her wight, which made W2 feel “fat shammed”. AV retaliated by throwing water on W2. A second verbal altercation between AV and W2 took place a short while later the same day. The facility failed to care plan around W2’s known behaviors, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) has a history of behaviors including resident-to-resident altercation. On or about April 10, 2022, AV was involved in a confrontation with another resident’s family member. On or about April 28, 2022, AV was being verbally aggressive with caregivers. On or about May 19, 2022, AV was being verbally aggressive towards other residents. On or about May 28, 2022, AV was being verbally aggressive towards Witness 2 (W2) causing W2 to throw a cup of water at AV. AV’s last Care Plan was updated on April 13, 2022, since then, there does not appear to be any new interventions put in place regarding AV’s known behaviors. The facility failed to care plan around AV’s known behaviors, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for h/h care. AV was not administered his/her pain medication for approximately 5 doses. The facility failed to follow policy regarding reordering-controlled substances, resulting in AV running out AV’s prescribed pain medication. 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.

Alleged victim (AV) relies on the facility for his/her care. On several occasions AV was not administered his/her medications in a timely manner. The facility failed to administer medication as ordered, which is violation of resident’s rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. AVs provider ordered Capillary blood glucose (CBG) checks four times a day. The facility failed to ensure physician orders were followed. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility for his/her care. AV was not administered his/her medication for approximately thirteen (13) days. Facility attempted to get the medication, but not in sufficient time to receive medication and administer as prescribed. AV was transferred to the hospital for treatment. Facility failed to have medications available which is a violation of resident rights is considered neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. On or about June 21, 2023, AV had returned from the hospital due to a five-day stay and discovered that his/her wallet with $6,000.00 in it had gone missing. The facility cameras were reviewed but they do not show the entire hallway. It is believed that an unknown Alleged Perpetrator 3 (AP3) may have taken AV’s property. AP3 failed to protect AV from financial exploitation, which is neglect of care and constitutes abuse. The facility failed to protect AV from financial exploitation, which is a violation of Oregon Administrative Rules.

Alleged Victim (AV) relies on the facility for his/her care. On or about April 15, 2023, a verbal altercation became physical between Alleged Perpetrator 2 (AP2) and AV. AP2 was witnessed by staff grabbing AV’s hat and turning it to the side. AV yelled at AP2 not to touch their hat. AP2 grabbed the bill of AV’s hat one more time before walking back to the activities room. AP2 failed to protect AV from mental and or emotional abuse, which is neglect of care and constitutes abuse. The facility failed to protect AV from mental and or emotional abuse, which is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during a site visit on or about October 23, 2023, it was confirmed that the facility failed to carry out medication and treatment orders as prescribed for resident, 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 facility failed to provide a safe environment for the Alleged Victim(AV) by not protecting them from financial exploitation by the Alleged Perpetrator 2(AP2). AP2 is responsible for financially exploiting the AV. An investigation determined this is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) had medication stolen by The Alleged Perpetrator 2 and is responsible for theft of medications, which is considered financial exploitation and constitutes abuse. The facility failed to protect AV from theft which is a violation of Oregon Administrative Rules.

Alleged Victim (AV) relies on the facility for h/h care. Alleged Perpetrator 2 (AP2) failed to administer AV’s medications on several days in the month of February 2022. 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.

The facility allegedly failed to administer medication as ordered for Alleged Victim (AV). An investigation determined no facility wrongdoing or abuse occurred. On or about January 30, 2022, Alleged Perpetrator 2 (AP2) yelled and used derogatory language towards Alleged Victim (AV). AP2’s actions are considered verbal/emotional abuse, which is a violation of residents rights, is considered neglect of care and constitutes abuse. The facility failed to protect AV from verbal/emotional abuse which is a violation of Oregon Administrative Rules.

The facility failed to treat residents with dignity and respect, which is a violation of Oregon Administrative Rules.

Alleged Victim (AV) relies on the facility to administer his/her medications. On or about December 20, 2021, Alleged Perpetrator 2 (AP2) did not give AV his/her 8:00 pm medication. AP2 failed to provide medication that he/she pre-poured and that was supposed to be given within a two-hour window per company policy. AV was in pain due to the missed medications. AP2 failed to provide a safe medication administration system, which is neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system for AV, which is a violation of Oregon Administrative Rules.

Alleged Victim (AV) relies on the facility to administer his/her medications. On or about December 20, 2021, Alleged Perpetrator 2 (AP2) did not give AV his/her 8:00 pm medication. AP2 failed to provide medication that he/she pre-poured and that was supposed to be given within a two-hour window per company policy. AV did not receive his/her beta blocker medication that treat high blood pressure, high eye pressure medication and sedative medication that treats anxiety and panic disorders. AP2 failed to provide a safe medication administration system, which is neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system for AV, which is a violation of Oregon Administrative Rules.

The Facility failed to comply with safe medication administration or treatment practices, which is a violation of Oregon Administrative Rules.