Bridgecreek Memory Care

The Alleged Victim (AV) relies on the facility to provide a safe environment. Witness 1 (W1) and AV had previous resident altercations which the facility did not implement adequate interventions for future altercations. W1 struck AV in the dining room, which caused AV to suffer physical and emotional distress. The facility failed to provide a safe environment for AV, which is a violation of resident rights and is neglect which constitutes abuse.

Witness #1 (W1) had been on alert charting for having an infection, is known to be physically aggressive and has a history of being involved in resident to resident altercations. On or about November 30, 2024, the Alleged Victim (AV) and W1 were in the common area of the facility when AV attempted to get coffee, W1 grabbed AV's wheelchair handle. AV attempted to remove W1's hand and W1 grabbed AV's arm and twisted it, causing AV unreasonable discomfort. Staff are to monitor W1 to keep W1 a safe distance from AV, to avoid altercations. The facility's failure to provide a safe environment is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is a two person transfer. On or about November 21, 2024, AV's pressure alarm went off. Staff went to AV and found AV on the floor in the bathroom with Witness #1 (W1). W1 was attempting to assist AV to the bathroom leading to the fall, which resulted in AV having red marks on his/her knees W1 is known to try to assist other residents with care, and the facility failed to have interventions in place to stop this behavior. The facility's failure to provide a safe environment is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #1 (W1) has the potential to be physically aggressive and has a history of being involved in resident to resident altercations. On or about November 14, 2024, the Alleged Victim (AV) and W1 were in the common area of the facility when W1 instigated a conversation with AV and then pushed and hit AV. This altercation lasted approximately 4 minutes. Staff are to monitor W1 to address aggressive behaviors, however, no staff were present at the time of this altercation. The facility's failure to provide a safe environment is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility for medication management and administration. According to an investigation, AV's medication was depleted on or about November 13, 2024. The AV experienced an increased in behaviors and experienced emotional harm. The facility failed to ensure that the necessary steps were taken timely to get AV's medication on hand before the medication was depleted. This is a violation of resident rights and neglect of care, which constitutes abuse.

The Alleged Victim (AV) and Witness #1 (W1) are known to engage in altercations. The facility had a behavior intervention for W1 to have staff monitor W1 while in the common area, and to separate AV and W1. On or about October 26, 2024, AV and W1 engaged in an altercation where W1 grabbed AV's hand and twisted it, causing AV unreasonable discomfort. The facility failed to provide a safe environment by not having staff present to monitor W1, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) has a history of falls, AV has interventions in place with a transfer pole next to bed, lap buddy while in wheelchair, and pressure alarm in place under AV at all times while in wheelchair and in bed. On or about August 3, 2024, AV was found lying on the floor in the common area, initial assessment AV had no injuries, on August 4, 2024, AV complained of pain and transported to Emergency room. AV returned from the hospital with a diagnosis of fracture pelvic and sacrum and bruising to the right hand. Interventions in place at time of August 3, 2024, fall, focused on the use of a chair alarm and a lap tray, but the chair alarm did not sound, and the lap tray was reported to be broken. These interventions appeared to be ineffective, the facility failed to appropriately care plan and implement reasonable interventions to address AV’s falls, which is violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) has a history of falls. AV interventions in place, encourage AV to be in public spaces while out of bed, frequent safety checks, transfer pole next to AV’s bed, lap buddy while AV is in wheelchair, and pressure alarm in place under AV at all times while in wheelchair and in bed. On or about September 26, 2024, AV was found sitting on the floor on the fall mat next to AV's bed. Initial assessment AV denied pain. AV was transferred to wheelchair and complained of back pain and an abrasion on AV's left rear hip, with redness and swelling to lower left back side was seen. EMT's were called. Interventions in place at time of fall, focused on the use of a chair alarm and a lap tray, but the chair alarm did not sound, and the lap tray was reported to be broken. These interventions appeared to be ineffective, the facility failed to appropriately care plan and implement reasonable interventions to address AV’s falls, which is violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is a known fall risk and was care planned to have a lap buddy on his/her wheelchair to prevent falls. AV is known to remove the lap buddy themselves, and staff are to ensure the lap buddy is in place while AV is in his/her wheelchair. AV had taken the lap buddy off earlier in the day, and staff had replaced it. On or about September 25, 2024, AV experienced a fall from his/her wheelchair. AV was not harmed, however, AV was placed at risk for serious harm. According to video footage, AV removed the lap buddy again, approximately an hour and a half prior to the fall. The facility's failure to ensure AV's care plan was followed to have the lap buddy in place is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) and Witness #1 (W1) are known to engage in altercations with each other. AV has an intervention in place to redirect AV from overcrowded areas to avoid others to grab his/her wheelchair, and especially important to keep W1 from grabbing AV's wheelchair. On or about September 18, 2024, W1 went by AV in their wheelchair and their wheels got stuck as W1 was attempting to get past AV. AV swatted W1 and W1 hit AV on the arm, then slapped AV in the face. The facility's failure to provide a safe environment is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) and Witness 1 (W1) are dependent on the facility to meet his/her safety needs. According to an investigation, on or about September 9, 2024, W1 was involved in a resident-to-resident altercation. Then on September 12, 2024, W1 and AV were involved in an altercation when W1 hit AV on the arm, which resulted in AV receiving a bruise. There were no behavior interventions implemented by the facility following W1's September 9, 2024, altercation. The facility failed to timely address resident behaviors and implement behavior interventions, which is a violation of resident rights, is neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility to provide a safe environment. According to an investigation, the facility was aware that when AV moved in, AV was a smoker, and the facility is a non-smoking facility. AV attempted to elope from the facility multiple times between August 16 and August 28, 2024, and successfully eloped twice. The facility failed to provide AV with a safe environment, which is a violation of resident rights, is neglect of care which constitutes abuse.

Witness 1 (W1) service plan dated on or about May 2, 2024, contains the following information, W1 has a mood problem and has the potential to be physically aggressive. W1 has a history of resident-to-resident altercations. Alleged Victim (AV) does not have a history of resident-to-resident altercations. W1 is known to pinch and grab others. Interventions in place to address W1’s known behaviors include observe and report to the nurse any of the following; risks of harming others such as increased anger, labile mood, or agitation. If W1 shows signs of agitation, intervene before it escalates, remain calm, take a deep centering breath, stand out of reach, listen, and respond with empathy, guide away from source of distress, calmy engage in conversation. If AV's response is aggressive, calmly walk away, ask others to leave the area, ensure everyone is safe, immediately report to nurse, discuss other approaches and re-approach later. Anticipate and remove triggers that cause W1 to show signs of agitation, anger or aggression. Known triggers for W1 are overcrowded areas and excessive noise. On or about July 29, 2024, staff had noticed W1 becoming anxious, and offered W1 a PRN but W1 refused. At approximately 7:35am AV was seated at a table in the dining room when W1 approached AV and pinched AV hard on the arm. W1 was not sufficiently supervised to prevent the altercation, despite W1’s anxious behavior prior to the incident and known behaviors of pinching other residents. The facility neglected AV by failing to provide adequate supervision to address W1’s known behaviors, resulting in unreasonable discomfort when W1 pinched AV on the arm, resulting in redness to AV’s arm and causing AV to cry. The facility failed to provide a safe environment for AV, and appropriately care plan and implement reasonable interventions to address W1’s behaviors, which is violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) Service Plan dated on or about July 2, 2024 indicates AV is to receive safety checks twice per night, AV is able to get in and out of bed, chair, car, without assistance, AV may require occasional assistance with transfers and will ask staff when needed. AV is independent with ambulation and, uses a walker. As a fall prevention intervention AV requires a pressure alarm be under h/h anytime AV is seated or in bed. On or about July 27, 2024, AV experienced a fall while s/he was ambulating without an assistive device and fell prior to reaching the intended chair. On or about July 29, 2024, AV had an unwitnessed fall in h/h room and sustained an abrasion to h/h head; AV was transported to the Emergency Department for evaluation. After returning from the ED on July 30, 2024, staff found AV on the floor of h/h room and AV was transported back to the ED. AV returned back on July 30, 2024 to have AV's bed alarm sound and AV found on the floor in h/h room. Temporary Service Plans provided by the facility did not provide updated transfer, ambulation, or fall prevention intervention instructions for staff until after AV's fourth fall in several days; the TSPs provide information on monitoring AV for latent injury and not fall interventions. Following AV's fourth fall, a TSP was implemented instructing staff to provide AV with frequent safety checks, monitor AV for attempts to self-transfer, and use a fall mat next to AV's bed. The facility failed to appropriately care plan and implement reasonable interventions to address AV’s increasing and ongoing falls, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) relies on facility staff to ensure h/h basic care, safety, and supervision requirements are met. AV service plan dated on or about May 21, 2024, indicates AV is independent with ambulation and transfers, independent using a walker, and requires staff to provide assistance each shift with toileting and as needed or requested by AV. AV often wakes in the night to use the restroom. AV is able to use h/h call light independently. Fall interventions in place, ensure AV is using h/h walker, safety checks three times per shift, sign placed in AV’s room reminding AV to sit before putting h/h shoes on, remind AV to call for assistance, and a bed cane will be placed near AV's bed, check at routine intervals at night without waking. AV experienced an unwitnessed fall on or about May 29, 2024, two unwitnessed falls on or about June 6, 2024, resulting in AV hitting h/h head and being transported to the emergency room (ER) and diagnosed with a contusion to h/h forehead . AV experienced an unwitnessed fall on or about June 19, 2024, when AV was found on the flour attempting to ask for help. AV experienced two more falls on or about June 20, 2024, sustaining bruising to h/h upper back in the first fall and a lump to h/h head in the second fall. AV was transported to the ER and diagnosed with a scalp hematoma. AV experienced unwitnessed falls on or about June 23 & 24, 2024, both noted to be non-injury falls. The fall interventions implemented following these falls were to request a referral for physical and occupational therapy, request a medication review, add a high protein snack before bed, and decrease AV's sleep medication; these interventions were not documented until June 25, 2024. On June 25, 2024, approximately less than four hours after AV's fall on June 24, 2024, AV experienced an unwitnessed fall in h/h room and complained of pain to h/h head, shoulders, leg, and arm. AV was transported to the ER where s/he was diagnosed with a head contusion and found to have bruising and scrapes. AV experienced nine documented unwitnessed falls in under a month; the fall prevention interventions implemented by the facility prior to AV's fall on June 25, 2024, were already in AV's May 21, 2024, service plan or failed to be reasonably be person centered interventions to address Av's increased and ongoing falls, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) and Witness 1 (W1) both have histories of behaviors and resident-to-resident altercations. AV is known to become upset and physically aggressive with roommates and others who enter his/her side of the room. W1 is known to become loud and aggressive with poor impulse control. W1’s service planned behavior interventions instructs staff to escort W1 to his/her room for de-escalation and keep W1 away from others. According to an investigation, on or about June 20, 2024, AV approached W1 in their room to tell W1 to shut up and W1 struck AV in the face with a closed fist, causing pain and injury to AV, which resulted in unreasonable discomfort. The facility failed to provide a safe environment and failed to properly plan care for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on facility staff to ensure h/h basic care, safety, and supervision requirements are met. AV service plan dated on or about May 21, 2024, indicates AV is independent with ambulation and transfers, independent using a walker, and requires staff to provide assistance each shift with toileting and as needed or requested by AV. AV often wakes in the night to use the restroom. AV is able to use h/h call light independently. Fall interventions in place, ensure AV is using h/h walker, safety checks three times per shift, sign placed in AV’s room reminding AV to sit before putting h/h shoes on, remind AV to call for assistance, and a bed cane will be placed near AV's bed. AV experienced an unwitnessed fall on or about May 29, 2024, two unwitnessed falls on or about June 6, 2024, resulting in AV hitting h/h head and being transported to the emergency room (ER) and diagnosed with a contusion to h/h forehead . AV experienced an unwitnessed fall on or about June 19, 2024, when AV was found on the flour attempting to ask for help. Fall intervention put in place, check at routine intervals at night without waking. AV experienced two more falls on or about June 20, 2024, sustaining bruising to h/h upper back in the first fall and a lump to h/h head in the second fall. AV was transported to the ER and diagnosed with a scalp hematoma. The fall prevention intervention listed after AV's fall on June 19, 2024 was not a new intervention as safety checks multiple times per shift was already listed in AV's Service Plan, dated May 21, 2024. The facility failed to appropriately care plan and implement reasonable person-centered interventions to address AV’s falls, which is violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) relies on facility staff to ensure h/h basic care, safety, and supervision requirements are met. AV service plan dated on or about May 21, 2024, indicates AV is independent with ambulation and transfers, independent using a walker, and requires staff to provide assistance each shift with toileting and as needed or requested by AV. AV often wakes in the night to use the restroom. AV is able to use h/h call light independently. Fall interventions in place, ensure AV is using h/h walker, safety checks three times per shift, sign placed in AV’s room reminding AV to sit before putting h/h shoes on, and reminding AV to call for assistance. AV experienced an unwitnessed fall on or about May 29, 2024, in h/h room; the fall prevention interventions implemented after the fall was for a sign in AV's room reminding AV to sit before putting on h/h shoes to be "replaced" and AV safety check times were clarified to be at the beginning and end of each shift, mealtimes, and medication passes. AV experienced two unwitnessed falls on or about June 6, 2024, resulting in AV hitting h/h head and being transported to the emergency room (ER) due to being more confused than normal and being on anticoagulant medication. At the ER, AV was diagnosed with a contusion to h/h forehead and a urinary tract infection. The fall prevention interventions implemented after AV's fall on May 29, 2024, were not new and were interventions already in place in AV's service plan dated May 21, 2024, and the intervention noted after AV's first fall on the morning of June 6, 2024, had not yet been implemented when AV fell the second time resulting in a contusion to h/h forehead. The facility failed to appropriately care plan and implement reasonable person-centered interventions to address AV’s falls, which is violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) and Witness 1 (W1) are both residents of the facility and rely on facility staff to ensure their basic care, safety, and supervision requirements are met. On or about April 18, 2024, W1 displayed aggressive physical behavior towards another resident and no new interventions were put in place to prevent W1's aggression. On or about April 21, 2024 W1 and AV had an altercation where W1 punched AV full force with a closed fist on AV's jaw. After the resident-to-resident altercation, the facility failed to implement new interventions to address W1's behaviors. On or about April 27, 2024, AV was touching another resident's wheelchair , W1 told AV to stop touching the wheelchair, and when AV did not stop, W1 hit AV in the face. AP1 neglected AV by failing to put in place effective person-centered interventions for both AV and W1 leading to a resident-on-resident altercation on April 27, 2024 resulting in AV being hit in the face by W1 having unreasonable discomfort.

Alleged Victim (AV) has a history of falls, approximately 10 falls between February 10, 2024, to April 22, 2024. AV Service Plan dated on or about February 06, 2024, states AV is independent with transfers from bed, chairs, couch, toilet, but may require some assistance during the time AV was healing from fractures , AV is able to ambulate safely with a four-wheeled walker and staff are to encourage AV to use the walker if AV is seen without the walker. A temporary service plan dated on or about February 13, 2024, indicates staff to make sure AV has fall alarm attached at all times. Temporary service plan date on or about April 3, 2024, indicates staff to complete checks on AV every twenty minutes while AV is seated in main TV room to ensure AV's needs are met. AV had a fall on or about April 19, 2024, resulting in a large hematoma a concussion. On April 22, 2024, AV was found in the TV room sitting on h/h bottom. AV's pressure alarm was on but did not make a sound. The facility failed to put effective interventions in place to mitigate AV's continued falls, and did not update AV's service plan to reflect AV's change in condition relating to AV's fall risk and ambulation needs, and facility failed to provide or maintain resident care equipment, which is a violation of resident’s rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) has a history of falls, approximately 11 falls between February 10, 2024, to April 23, 2024. AV Service Plan dated on or about February 06, 2024, states AV is independent with transfers from bed, chairs, couch, toilet, but may require some assistance during the time AV was healing from fractures , AV is able to ambulate safely with a four-wheeled walker and staff are to encourage AV to use the walker if AV is seen without the walker. A temporary service plan dated on or about February 13, 2024, indicates staff to make sure AV has fall alarm attached at all times. Temporary service plan date on or about April 3, 2024, indicates staff to complete checks on AV every twenty minutes while AV is seated in main TV room to ensure AV's needs are met. AV had a fall on or about April 19, 2024, resulting in a large hematoma a concussion. On April 22, 2024, AV was found in the TV room sitting on h/h bottom. AV's pressure alarm was on but did not make a sound. On April 23, 2024, AV call light went off and AV was found lying on h/h right side. AV did not have socks on, and AV stated s/he was heading to the bathroom when s/he slid onto the floor. At the time of the fall AV care needs related to ambulation and transferring had increased. AV was no longer able to ambulate with a walker and required a wheelchair. The facility failed to put effective interventions in place to mitigate AV's continued falls, and did not update AV's service plan to reflect AV's change in condition relating to AV's fall risk and ambulation needs, which is a violation of resident’s rights, is neglect of care and constitutes abuse.

Witness 1 (W1) was on alert for a previous resident-to-resident altercation not involving Alleged Victim (AV) on or about April 18, 2024. On or about April 20, 2024, staff noted W1 was appearing very angry and W1 stated intention to strike other residents in the face, and they had to relocate W1. AV and W1 were involved in a resident-to-resident altercation on or about April 21, 2024, AV wandered into W1’s room; W1 told AV to leave; W1 then struck AV in the right jaw with a closed fist, causing AV to fall back into wall resulting in AV’s face being red and swollen for several days. Alleged Perpetrator 1 (AP1) was aware of WI’s history of aggression and previous altercations including W1 stating the day prior that “h/h had the intention to strike other residents in the face”. Although AP1 put a temporary service plan in place on April 18, 2024, there were no interventions listed other than to report behaviors. AP1 was also aware of AV’s history of entering other resident’s rooms and failed to provide interventions related to this behavior. AP1 neglected AV by failing to put in place effective interventions for both AV and W1 leading to a resident-on-resident altercation resulting in AV being struck and pushed against the wall experiencing pain, redness and swelling to face, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is a known fall risk with a history of falls. According to an investigation, on or about April 19, 2024, AV had an unwitnessed fall, resulting in injury to the right side of AV’s and diagnosis of a concussion. The facility failed to provide appropriate services according to Alleged Victim’s needs, relating to care planning and lack of appropriate interventions and instruction, to mitigate the risk of injury due to AV's increase in falls. This failure is a violation of resident rights, is neglect of care which constitutes abuse.

The Alleged Victim (AV) is dependent on facility staff to meet his/her care needs and has a history of multiple falls with injuries. According to an investigation, on or about January 19, 2024, AV fell in his/her bathroom, resulting in discomfort. The facility failed to properly plan care and maintain a comprehensive care plan with effective fall interventions, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is dependent on facility staff to meet his/her care needs and has a history of multiple falls with injuries. According to an investigation, on or about February 25, 2024, AV fell and was found lying on the floor, resulting in a mark on his/her forehead and discomfort. The facility failed to properly plan care and maintain a comprehensive care plan with effective fall interventions, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is dependent on facility staff to meet his/her care needs and has a history of multiple falls with injuries. According to an investigation, on or about March 8, 2024, AV was found on their knees in a hallway, resulting in an abrasion to his/her nose. The facility failed to properly plan care and maintain a comprehensive care plan with effective fall interventions, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is dependent on facility staff to meet his/her care needs and has a history of multiple falls with injuries. According to an investigation, on or about March 30, 2024, AV fell and was found with a bruise. The facility failed to properly plan care and maintain a comprehensive care plan with effective fall interventions, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is dependent on facility staff to meet his/her care needs and has a history of multiple falls with injuries. According to an investigation, on or about January 7, 2024, AV fell in the dining room resulting in two skin abrasions. The facility failed to properly plan care and maintain a comprehensive care plan with effective fall interventions, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is a known fall risk with a history of falls. According to an investigation, on or about November 9, 2023, AV experienced a fall and was found on the floor resulting in a large lump near AV's spine between shoulder blades. The facility failed to appropriately care plan and effectively implement interventions to address AV's ongoing falls, which is a violation of resident's rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is a known fall risk with a history of falls. According to an investigation, on or about November 14, 2023, AV experienced a fall and hit his/her head, resulting in a laceration to the scalp and hospitalization. The facility failed to appropriately care plan and effectively implement interventions to address AV's ongoing falls, which is a violation of resident's rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is a known fall risk with a history of previous falls at night. According to an investigation, on or about November 27, 2023, AV was found on the floor of his/her room during the night. AV experienced a fall, resulting in a skin tear to his/her elbow. The facility failed to appropriately care plan and effectively implement interventions to address AV's ongoing falls, which is a violation of resident's rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) and Witness 1 (W1) have history of behaviors and resident-to-resident altercations. AV is known to grab other resident’s belongings/walkers/wheelchairs. According to an investigation, on or about September 27, 2023, AV attempted to grab W1’s walker, which resulted in W1 hitting AV and putting his/her hands around AV’s neck. AV experienced unreasonable discomfort and a loss of personal dignity. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care which constitutes abuse.

The Alleged Victim (AV) has a history of falls while residing at the facility. AV suffered 9 falls between November 22, 2022 and April 17, 2023, with and without injury. Interventions that were put into place did not appear to be effective, as AV continued to suffer falls. On or about July 25, 2023, AV was found on the floor of his/her room, with blood coming from a laceration to his/her head and nose. AV was sent to the hospital and diagnosed with a brain bleed. AV returned to the facility on hospice services and on August 18, 2023, AV passed away. The facility's failure to properly care plan to ensure AV was safe from falls is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) and Witness 1 (W1) have history of behaviors and resident-to-resident altercations. W1 is known to become aggressive when other people are too close to him/her or are in his/her space. According to an investigation, on or about July 11, 2023, staff were alerted to a resident-to-resident between incident between AV and W1 when they heard a loud slap and observed AV holding his/her left check, which resulted in unreasonable discomfort and a loss of personal dignity. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care which constitutes abuse.

The facility failed to provide appropriate services according to Alleged Victim (AV)'s needs, relating to toileting. According to an investigation, over a period of a few months, AV was not receiving proper peri care or timely incontinence care, which resulted in infections, rashes, and a loss of personal dignity. These failures are a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is known to wander into other residents’ rooms. Witness 1 (W1) has a history of aggressive behaviors and resident-to-resident altercations. The facility failed to provide appropriate services, relating to care planning, and following the care plan. According to an investigation, on or about January 20, 2023, W1 was placed on one-on-one staffing for his/her behaviors. On or about February 16, 2023, AV and W1 were in W1’s room together when staff found them and observed W1 punch AV in the head and side of the face, which resulted in AV experiencing unreasonable discomfort and loss of personal dignity. This failure is a violation of resident rights, is neglect of care which constitutes abuse.

The Alleged Victim (AV) is known to wander into other residents’ rooms. Witness 1 (W1) has a history of aggressive behaviors and resident-to-resident altercations. The facility failed to provide appropriate services, relating to care planning, and following the care plan. According to an investigation, on or about January 20, 2023, W1 was placed on one-on-one staffing for his/her behaviors. On or about February 16, 2023, AV, W1, and another resident were in W1’s room together when staff found them and observed AV with redness on his/her face and W1 punching the other resident. AV experienced unreasonable discomfort and loss of personal dignity. This failure is a violation of resident rights, is neglect of care which constitutes abuse.

Witness 1 (W1) had recently been care planned for one-on-one staffing due to sexually inappropriate behaviors. According to the investigation, on or about February 6, 2023, W1 did not have one-on-one staffing and was found pushing the Alleged Victim (AV) out of W1’s room, both not fully clothed. The facility failed to provide a safe environment for AV by failing to protect AV from W1's behaviors, placing AV at risk for harm. The facility’s failure is a violation of resident rights, is neglect of care and constitutes abuse. The allegation that AP2 did not provide adequate direct oversight was investigated and determined to be Inconclusive.

Witness 1 (W1) had a known history of sexually inappropriate behaviors. According to an investigation, on or about February 2, 2023, W1 was found in the Alleged Victim’s (AV) room rubbing AV while he/she was sleeping, placing AV at risk for harm and loss of personal dignity. The facility failed to provide a safe environment for AV by failing to protect AV from W1's sexualized behavior, which is a violation of resident rights, is neglect of care and constitutes abuse.

Witness 1 (W1) had a known history of sexualized behaviors. According to an investigation, on or about February 1, 2023, W1 was found kissing the Alleged Victim (AV) while he/she was asleep, which resulted in a loss of dignity. The facility failed to provide a safe environment for AV by failing to protect AV from W1's sexualized behaviors, which is a violation of resident rights, is neglect of care and constitutes abuse.

The Alleged Victim (AV) was care planned for reminders to go to meals and be escorted to and from the dining room. The facility failed to provide appropriate services. According to an investigation, AV was noted as not eating well, three plates of food were found in AV’s room and AV’s dentures were missing, which resulted in AV experiencing weight loss. AV was found in the hallway/TV room area with only a sweatshirt and brief on, resulting in a loss of personal dignity. The facility’s failures are a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is care planned for occasional assistance transferring in and out of bed, chair, and car. According to an investigation, AV experienced approximately two falls while returning to bed on his/her own, one or about December 17, 2022, and another on or about December 18, 2022. The facility failed to appropriately care plan or implement proper interventions to mitigate AV's fall risk and on or about December 27, 2022, AV experienced an additional fall while returning to bed, which resulted in a bruise on AV’s hip. This failure is a violation of resident rights, is neglect of care which constitutes abuse.

The Alleged Victim (AV) is known to have exit seeking behavior and there was a known mechanical issue with the door that was not fixed in a timely manner. On or about May 11, 2022, AV was found outside the facility, which exposed AV to potential harm. The facility failed to provide a safe environment for AV which is a violation of resident rights, is neglect of care which constitutes abuse.

On or about February 28, 2022, AV was independent when he/she experienced a fall that resulted in a fracture. The facility failed to appropriate care plan and provide services according to the Alleged Victim (AV)'s needs when AV returned to the facility. On or about March 30, 2022, and March 31, 2022, AV experienced two unwitnessed falls, resulting in unreasonable discomfort and loss of personal dignity. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to develop, maintain, and implement an Acuity Based Staffing Tool, which is a violation of Oregon Administrative Rule.

The facility failed to develop, maintain, and implement an Acuity Based Staffing Tool, which is a violation of Oregon Administrative Rule.

The facility failed to develop, maintain, and implement an Acuity Based Staffing Tool, which is a violation of Oregon Administrative Rule.

The facility failed to develop, maintain, and implement an Acuity Based Staffing Tool which is a violation of Oregon Administrative Rule.

The Alleged Victim (AV) relies on the facility for care and services. According to an investigation, Alleged Perpetrator 2 (AP2) became verbally aggressive with AV when trying to get AV to sit down in a chair, while AP2 was talking on their phone. AV forcefully sat AP2 down with one arm while holding their phone in the other hand. The facility failed to protect AV from unreasonable discomfort and loss of personal dignity, which is a violation of Oregon Administrative Rule. The allegation that AP2 neglected AV was investigated and determined to be substantiated.

The Alleged Victim (AV) relies on the facility to provide a safe environment. According to an investigation, Alleged Perpetrator 2 (AP2) failed to provide AV with necessary supervision which resulted in AV having an altercation with Witness 1 (W1) in the dining room. As a result of this altercation, AV was struck and received a skin tear. AP2 failed to provide AV with necessary care and services which is a violation of resident rights, is considered neglect which constitutes abuse. The facility failure is a violation of Oregon Administrative Rules.

The facility failed to develop, maintain, and implement an Acuity Based Staffing Tool which is a violation of Oregon Administrative Rules.

On or about July 29, 2025, Alleged Perpetrator 2 (AP2) was handing out snacks to residents when the Alleged Victim (AV) approached the resident that AP2 was assisting. AV is known to take other residents’ food and should be redirected in a calm manner. AP2 grabbed ahold of AV’s clothing and moved AV away from the other resident. AP2’s actions are considered wrongful restraint, which is a violation of OAR 411-020-0002(1)(h)(A)(iii), and is a violation of resident rights and is considered neglect of care. The facility failed to protect AV from wrongful restraint, which is a violation of Oregon Administrative rules.

Alleged Victim (AV) is a resident of a memory care facility and relies on facility staff to ensure basic care, safety and supervision needs are met. AV has a history of falls and has fall intervention to place a fall mat at AV's bedside whenever AV is in bed. On or about March 11, 2025 AV fell,sustained a head injury, and was transported to the emergency room. AV was treated for a head injury and facial lacerations. Alleged Perpetrator 2 (AP2) reported the faciity was short staffed that night and did not place the fall mat at AV's bedside when AV was put into bed. The fall mat was found under AV's bed when AV was found on the floor. AP2’s actions are a violation of resident rights, are considered neglect of care and constitutes abuse. The facility failed to provide a safe environment, and oversight which resulted in the Alleged Victim (AV) sustaining injury from a fall. The failure is a violation of Oregon Administrative Rules.

The facility failed to fully implement and update an acuity-based staffing tool. The facility's failure is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) has history of frequent falls. AV's care plan indicates staff to ensure that bed alarm is working while AV is in bed. The facility failed to follow the Alleged Victim’s (AV) care plan. According to an investigation, AV experienced a fall with no negative outcome. The failure is a violation of Oregon Administrative Rules.

The facility failed to ensure the implementation of services which is a violation of Oregon Administrative Rules.

The facility failed to carry out medication and treatment orders as prescribed which is a violation of Oregon Administrative Rules.

Based on an interview and record review, conducted during a site visit on 06/12/25, the facility's failure to ensure the implementation of services was substantiated. Fall interventions had not been in place on 10/25/24, Service plan dated 10/08/24 listed 13 fall interventions; Progress notes from 10/25/24 revealed staff had not attempted all 13 fall interventions. The incident report dated 10/25/24 confirmed that the fall happened due to fall interventions not being used. It was determined the facility failed to ensure the implementation of services. An investigation determined a licensing violation had occurred.

The facility allegedly failed to assure a qualified caregiver was present due to staff taking breaks at the same time. An investigation determined this is a violation of Oregon Administrative Rules.

Based on interview and record review, during a site visit conducted on November 06, 2024, the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident was substantiated. Findings include, but are not limited to: In separate interviews Staff 1 (ED), Staff 2 (Business Office Manager) indicated staff reported night shift staff had been taking breaks together. Staff 1 reviewed camera system and confirmed this. A review staff communication log revealed on October 01, 2024, general message to all staff “It is against regulations to have staff out of the building together on NOC. 1 at a time only!!!!” The facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident was substantiated.

Based on observation and interview, conducted during a site visit on or about November 06, 2024, the facility failed to ensure fences surrounding the perimeter of the outdoor recreation area must be maintained in functional condition was substantiated. Findings include, but are not limited to: During an interview, Staff 1 (ED) stated the fence had been in the process of being repaired and replaced. Observed at 09:25 am back courtyard area fence was not secure with missing spaces. Two construction persons had been working on the fence. The facility failed to ensure fences surrounding the perimeter of the outdoor recreation area must be maintained in functional condition was substantiated.

Staff 1 (Executive Director) indicated there had been staff that had verbally abused and yelled at residents. Disciplinary action had been taken and the staff member had been terminated. A review of Staff 3 (Former Staff) Employee Disciplinary Record indicated staff had been written up on 07/23/24 for verbal abuse towards a resident on 07/22/24. On 07/30/24 Staff 3 had been terminated for additional verbal abuse and threatening behavior towards a resident. A review of the facility’s policy and procedure for Resident Rights stated, “The resident has the right to be treated with respect and dignity." It was determined the facility had failed to treat residents with dignity and respect. Findings were reviewed and acknowledged by Staff 1. An investigation determined a licensing violation had occurred.

A review of 30-day competency training checklist for Staff 7 (Med Tech) hired on 08/19/24, Staff 8 (Caregiver) hired on 09/15/24, and Staff 9 (Caregiver) hired 09/10/24 indicated Staff 8 and Staff 9 had incomplete training records. Staff 1 (Executive Director), Staff 2 (Registered Nurse), Staff 3 (Resident Care Coordinator), Staff 4 (RDO), and Staff 5 (Resident Care Coordinator), all acknowledged the staff training records had not been properly completed. Staff 1 indicated all staff had undergone training, however, had not completed the paperwork properly. It was determined the facility had failed to have a training program that includes methods to determine competency of direct care staff and maintain documentation regarding each direct care staff's competency. Findings were reviewed and acknowledged by Staff 1. An investigation determined a licensing violation had occurred. Verbal plan of correction: The Executive Director, both Resident Care Coordinators and Registered Nurse will do a full staff training audit to ensure the staff training records are all completed correctly. Executive Director will have this completed by the end of next week.

Based on interview and record review, conducted during a site visit on November 06, 2024, the facility failed to immediately notify the local APD office, or the local AAA, of any incident of abuse or suspected abuse was substantiated for 2 of 2 sampled residents (#s 1 and 3). Findings include but are not limited to: In an interview on November 06, 2024, Staff 1 (Executive Director) confirmed the incidents should have immediately been reported to APS. Review of incident reports for Resident 1 and Resident 2 revealed on September 08, 2024, falls had not immediately been reported to the department. Forms had not been reported to Adult Protective Service (APS). It was determined the facility failed to immediately notify the local APD office, or the local AAA, of any incident of abuse or suspected abuse.

Alleged Victim (AV) requires maximum assistance with all personal care and activities of daily living. AV has an extensive fall history and requires an intervention of a fall buddy on AV's wheelchair to mitigate the risk of falls. Lap buddy intervention was put into effect on April 2, 2024. On or about April 25, 2024, AV was found on the floor in front of AV’s wheelchair, on AV’s right side leaning on AV’s right elbow. AV was singing and not in distress. AV’s alarm was on and working. AV’s lap buddy was not in use. AV’s fall was unwitnessed. AP2 was assigned to AV and forgot to place lap buddy with AV. AV was assessed for injuries with findings of a small skin abrasion on the right elbow with no other injuries noted. AP2 admits the wrongdoing of forgetting to put the lap buddy on AV's wheelchair leading to AV having a fall on AP2 admits the wrongdoing of forgetting to put the lap buddy on AV's wheelchair leading to AV having a fall on 04/25/2024. 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) is administered OTC CBD Cannabis Edibles to help with anxiety and behaviors. On or about April 23, 2024 Witness 3 (W3) and Witness 4 (W4) alerted Alleged Perpetrator 2 (AP2) that AV was seated in the large TV room and appeared to be lethargic, drooling, and less responsive. Vital signs were taken, and AV was hypotensive. AV was cold and clammy to the touch but sweating profusely AV was unable to give a description of what was wrong. AP2 assessed and called 911. AV was taken to the hospital. The emergency room provider notified W1, AV tested positive for THC. It was determined by the facility AP2 unintentionally gave AV another residents' OTC CBD Cannabis Edibles on accident and it did contain THC. AP2 completed all training by the facility to safely pass medications . The failed failed to foresee or prevent the actions or inactions of AP2 intentionally or unintentionally giving AV the wrong medication. . 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 failed to document that they have observed and evaluated the individual's ability to perform safe medication and treatment administration unsupervised. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. An investigation determined this is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) relies on the facility for assistance with mobility, which includes two-person transfers. On or about June 9, 2023, the Alleged Perpetrator 2 (AP2) did not follow AV's care plan and transferred AV by themselves resulting in AV experiencing unreasonable discomfort. AP2's actions are considered neglect and constitutes abuse. The facility failed to ensure care plans were followed which is a violation of Oregon Administrative Rules.

According to an investigation, on or about September 26, 2022, Alleged Perpetrator 2 (AP2) got frustrated and made an inappropriate verbal comment toward the Alleged Victim (AV) when AV was continually knocking on a door, which resulted in the Alleged Victim (AV) experiencing a loss of personal dignity. AP2’s actions are a violation of resident rights, are considered neglect of care and constitutes verbal abuse. The facility failed to protect AV from inappropriate verbal comments made by staff and the failure is a violation of Oregon Administrative Rules.

The allegation that the facility failed to provide a daily meal program for nutrition and hydration in accordance with OAR 411-057-0160(2)(c) per complaint that the facility is only giving residents water during their meals was verified.

The allegation that the facility failed to establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment to include protocols to prevent the development and transmission of communicable diseases in accordance with OAR 411-054-0050(1) per complaint that staff are not following infection control mandates during a covid outbreak. Masks and eye protection are not being worn correctly was verified.

Alleged Perpetrator 2 (AP2) failed to administer ordered medication. On or about January 17, 2022, AP2 administered another resident’s medication to AV. AP2's actions 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.