Brookdale Salem

According to the documentation, the facility failed to follow the care plan for Witness 1 (W1) by escorting them away from resident rooms. On or about February 14, 2025, W1 entered the Alleged Victim’s room and hit them in the stomach. W1 has a history of wandering into resident rooms resulting in resident-to-resident altercations. W1 service plan was updated on or about December 25, 2024, to redirect them when they are wandering near or in another resident room. The failure to follow the care plan for W1 resulted in a physical altercation between W1 and the AV, 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 follow the care plan for Witness 1’s (W1) history of physical altercations with other residents. on or about January 08, 2025, the AV was instigated a physical altercation with another resident. The facility implemented interventions when in the living room to reduce the probability of future altercations. On or about January 14, 2025, W1 was involved in an altercation with the Alleged Victim (AV) in the living room. W1’s interventions were not being followed at the time of the incident, resulting in an altercation between W1 and the AV. The AV sustained a skin tear to their arm, 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) for their known history of physical altercations with Witness 1 (W1). On or about December 23, 2024, AV and W1 were in a common area together when the AV approached a staff member and stated they were attacked by a resident. There were only two residents awake and in the common area at the same time and that was W1 and the AV. The AV had a scratch on their lip and discoloration on their eye. The facility’s failure to provide a safe environment for the AV resulted in an altercation which they received a scratch on their lip and discoloration on their eye 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 and risk of injury. The AV was previously independent with ambulation but recently was identified as needing ambulation assistance due to numerous falls. From approximately July 14, 2024, through September 06, 2024, the AV experienced approximately four (4) falls. There were no documented interventions which would prevent the AV from continued falls. On or about September 06, 2024, the AV experienced an unwitnessed fall in the facility’s town hall room. The AV notified staff of pain on their right side and had trouble moving their leg. Hospice RN assessment determined the AV did not have a fracture. The next day on or about September 07, 2024, the AV experienced a significant change of condition and overall decline in ability to ambulate. The AV needed 2x transfer assistance and expressed extreme pain in their right leg and could not bear any weight on their leg. On or about September 14, 2024, the AV received an X-ray showing there was a fracture in the AV’s Trochanter. The AV experienced extreme pain and a fracture due to the facility not properly care planning appropriate interventions for the AV, 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) by not adequately performing safety checks for the AV’s known fall history. From approximately March 11, 2024, through May 06, 2024, the AV experienced approximately four falls, one causing cuts on the AV’s face. On or about April 27, 2024, the facility implemented an immediate intervention to put the AV on close watch with AV being with the med tech or caregiver, within close distance and within sight and to implement more frequent checks during sleeping hours. On or about May 06, 2024, the AV suffered an unwitnessed fall at approximately 3:30 pm. The service plan interventions for fall prevention were not being followed, which 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) repeated fall history. From approximately March 9, 2024, through March 19, 2024, the AV suffered approximately three falls one resulting in a closed hip fracture which required medical attention. There was no documented evidence the facility implemented progressive interventions to prevent future falls, 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 fall interventions for the Alleged Victim’s (AV) recent fall history. From approximately January 29, 2024, through March 20, 2024, the AV suffered three falls, one resulting in hitting their head and receiving a laceration and a bump. There was no documented evidence appropriate fall interventions were put into place to prevent the AV from falling, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about March 6, 2024, the facility failed to administer medication as ordered for the Alleged Victim (AV). AV is prescribed an anti-psychotic medication. According to documentation AV did not get the medication for approximately four days. The failure resulted in AV being sent to the Emergency Department and experiencing pain and unreasonable discomfort. The failure 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’s (AV) known fall history. From approximately January 01, 2024, through February 26, 2024, the AV suffered approximately 5 falls. The facility implemented numerous interventions to help prevent the AV from experiencing future falls. On or about February 27, 2024, the AV suffered another fall and sustained a skin tear on their left elbow and forearm. It was later discovered the interventions on the care plan was not being followed, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility to ensure a safe environment. Witness 1 (W1) have a history of resident-to-resident altercations. On or about February 14, 2024, AV and W1 had a physical altercation, resulting in AV being hit in the head causing pain and discomfort. The facility failed to ensure a safe environment for AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to documentation the facility failed to follow the Alleged Victim’s (AV) care plan. AV’S care plan is set for AV to have a textured diet. On or about January 29, 2024, AV was given a whole slice of pizza causing AV to choke and have the Heimlich preformed. The failure resulted in AV experiencing pain and unreasonable discomfort. The facility failed to ensure care plans were followed, which is a violation of resident’s rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to ensure staff read and signed off on a temporary service plan for the Alleged Victim (AV) to have a physical relationship with Witness 1 (W1). The failure resulted in the Alleged Perpetrator 2 (AP2) and Alleged Perpetrator 3 (AP3) attempted to remove the AV from W1’s room but AV refused and sat on the floor. AP2 and AP3 grabbed the AV under their arms, picked them up and physically removed the AV from W1’s room causing bruising under the arms. AP2 and AP3’s failure to follow the care plan causing bruising is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to ensure staff read temporary service plans for the AV which led to bruising, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility to ensure a safe environment. Witness 1 (W1) has a history of resident-to-resident altercations. On or about December 8, 2023, AV and W1 had a physical altercation, resulting in AV being hit in h/h face causing pain and unreasonable discomfort. The facility failed to ensure a safe environment for AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to documentation, the facility failed to implement interventions and appropriately care plan related to the Alleged Victim’s (AV) fall history. On or about December 6, 2023, AV suffered a fall in h/h room, resulting in an injury to h/h right wrist. The failure resulted in AV experiencing pain and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately care plan related to the Alleged Victim’s (AV) fall history. On or about November 30, 2023, AV suffered an unwitnessed fall. The failure resulted in AV suffering an injury to h/h face and experiencing 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 follow the care plan for Witness 1 (W1) to keep them away from other residents. W1 had a history of physical altercations with other residents and was care planned to be always separated from other residents. On or about November 23, 2023, W1 and the Alleged Victim (AV) were involved in a resident-to-resident altercation leaving the AV with discoloration to their left eye and bruising on their shoulder, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately care plan related to the Alleged Victim’s (AV) fall history. On or about November 22, 2023, AV suffered an unwitnessed fall, resulting in an injury to h/h head. The failure resulted in AV experiencing pain and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility to ensure a safe environment. Witness 1 (W1) have a history of resident-to-resident altercations. On or about November 11, 2023, AV and W1 had a physical altercation, resulting in AV being hit in the face causing pain and discomfort. The facility failed to ensure a safe environment for AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately care plan related to the Alleged Victim’s (AV) fall history. On or about November 8, 2023, AV suffered an unwitnessed fall, resulting in a skin tear on h/h shin. The failure resulted in AV experiencing pain and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately care plan related to the Alleged Victim’s (AV) fall history. On or about August 31, 2023, AV suffered an unwitnessed fall in h/h bedroom. The failure resulted in AV suffering a broken nose and experiencing pain and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately care plan related to the Alleged Victim’s (AV) fall history. On or about August 24, 2023, AV suffered an unwitnessed fall, resulting in an injury to h/h face. The failure resulted in AV experiencing pain and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about August 19, 2023, the Alleged Victim (AV) was found outside by a passerby who notified staff inside the facility. AV was outside of the facility, staff had no idea AV was gone and AV had no shoes on. AV was not injured during the course of the elopement, however, AV was placed at risk for harm. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to documentation, the facility failed to implement interventions and appropriately care plan related to the Alleged Victim’s (AV) fall history. On or about August 19, 2023, AV suffered an unwitnessed fall, resulting in an injury to h/h back. The failure resulted in AV experiencing pain and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to implement appropriate interventions for the Alleged Victim’s (AV) history of repeated falls. Between approximately August 03, 2023, through August 24, 2023, the AV experienced approximately 5 falls, one leading to a head laceration requiring staples to close. There is no documentation showing the facility attempted progressive interventions to prevent the falls which lead to injury and discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately care plan related to the Alleged Victim’s (AV) fall history. On or about August 17, 2023, AV suffered an unwitnessed fall. The failure resulted in AV suffering an injury to h/h right eyebrow and experiencing pain and 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 to ensure a safe environment. Witness 1 (W1) have a history of resident-to-resident altercations. On or about August 11, 2023, AV and W1 had a physical altercation, resulting in AV being hit in the mouth causing pain and discomfort. The facility failed to ensure a safe environment for AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

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

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

The facility failed to implement interventions and appropriately care plan related to the Alleged Victim’s (AV) fall history. On or about July 25, 2023, AV suffered an unwitnessed fall. The failure resulted in AV suffering an injury to h/h head and experiencing pain and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately care plan related to the Alleged Victim’s (AV) fall history. On or about July 23, 2023, AV suffered an unwitnessed fall. The failure resulted in AV suffering an injury to h/h lower back and experiencing 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 interventions for the Alleged Victim’s (AV) known fall history. On or about June 22, 2023, at around 11:45 am, the AV was discovered to have a laceration on their head and both elbows. The AV was sent to the hospital, and they received stiches for their wounds. The AV has a history of falls and there is no documented evidence the facility attempted interventions to prevent these falls from occurring. The failure resulted in the AV falling and sustaining lacerations which required a hospital visit and stitches, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility to ensure a safe environment. Witness 1 (W1) have a history of resident-to-resident altercations. On or about June 11, 2023, AV and W1 had a physical altercation, resulting in AV being hit in the mouth causing pain and discomfort. The facility failed to ensure a safe environment for AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately care plan related to the Alleged Victim’s (AV) fall history. On or about May 3, 2023, AV suffered an unwitnessed fall. The failure resulted in AV suffering an injury to h/h left knee and experiencing pain and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately care plan related to the Alleged Victim’s (AV) fall history. On or about May 1, 2023, AV suffered an unwitnessed fall. The failure resulted in AV suffering an injury to h/h head and experiencing pain and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately care plan related to the Alleged Victim’s (AV) fall history. On or about April 23, 2023, AV suffered an unwitnessed fall. The failure resulted in AV suffering an injury to h/h face and experiencing pain and 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 to ensure a safe environment. AV has a history of resident-to-resident altercations. On or about April 04, 2023, AV grabbed Witness 1 (W1)’s walker causing W1 to get upset and then slap AV on the arm. The failure resulted in AV experiencing pain and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility to ensure a safe environment. Witness 1 (W1) have a history of resident-to-resident altercations. On or about April 02, 2023, AV and W1 had a physical altercation, resulting in AV being hit in the arm causing pain and discomfort. The facility failed to ensure a safe environment for AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility to ensure a safe environment. Witness 1 (W1) has a history of resident-to-resident altercations. On or about January 01, 2023, AV and W1 had a physical altercation, resulting in AV being punched in the head by W1 causing pain and discomfort. The facility failed to ensure a safe environment for AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility to ensure a safe environment. Witness 1 (W1) and AV have a history of resident-to-resident altercations. The facility failed to ensure a safe environment for AV, resulting in AV and W1 having a physical altercation. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility to ensure a safe environment. Witness 1 (W1) have a history of resident-to-resident altercations. On or about November 13, 2022, AV and W1 had a physical altercation in W1’s bedroom, resulting in AV having bruising on h/h right forearm causing pain and discomfort. The facility failed to ensure a safe environment for AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Perpetrator (AP2) failed to provide a safe environment for the Alleged Victim. On or about November 05, 2022, AV fell with AP2 while being assisted to the restroom, resulting in AV was transported to the hospital for treatment. The facility failed to provide a safe environment, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

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

The facility failed to implement interventions and appropriately care plan related to the Alleged Victim’s (AV) fall history. On or about October 01, 2022, AV suffered an unwitnessed fall resulting in an injury to h/h head. The failure resulted in AV experiencing pain and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately care plan related to the Alleged Victim’s (AV) fall history. The failure resulted in AV experiencing injury and 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 to ensure a safe environment. Witness 1 (W1) has a history of resident-to-resident altercations. On or about September 29, 2022, AV and W1 had a physical altercation, resulting in AV being slapped across h/h face causing pain and discomfort. The facility failed to ensure a safe environment for AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately care plan related to the Alleged Victim’s (AV) fall history. On or about September 27, 2022, AV suffered an unwitnessed fall resulting in an injury to h/h head. The failure resulted in AV experiencing pain and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility to ensure a safe environment. Witness 1 (W1) have a history of resident-to-resident altercations. On or about September 11, 2022, AV and W1 had a physical altercation, resulting in AV being hit in the chest causing pain and discomfort. The facility failed to ensure a safe environment for AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse

Alleged Victim (AV) relies on the facility to ensure a safe environment. Witness 1 (W1) have a history of resident-to-resident altercations. The facility failed to ensure a safe environment for AV. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility to ensure a safe environment. Witness 1 (W1) has a history of resident-to-resident altercations. The facility failed to ensure a safe environment for AV. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility to ensure a safe environment. Witness 1 (W1) and AV have a history of resident-to-resident altercations. The facility failed to ensure a safe environment for AV, resulting in AV and W1 having a physical altercation. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility to ensure a safe environment. Witness 1 (W1) have a history of resident-to-resident altercations. The facility failed to ensure a safe environment for AV. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility to ensure a safe environment. Witness 1 (W1) have a history of resident-to-resident altercations. The facility failed to ensure a safe environment for AV. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility to ensure a safe environment. Witness 1 (W1) has a history of resident-to-resident altercations. On or about May 02, 2022, AV and W1 had a physical altercation, resulting in AV falling and sustaining a fractured hip causing pain and discomfort. The facility failed to ensure a safe environment for AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to properly care plan appropriate fall interventions for the Alleged Victim’s (AV) repeated falls. From approximately December 05, 2021, through April 07, 2022, the AV experienced approximately 16 times and suffered injuries such as skin tears, stitches, abrasions, and bruises, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to Provide a safe environment for The Alleged Victim (AV). On or about April 10, 2021, AV fell, resulting in a possible fractured hip and experiencing unreasonable discomfort. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions, and appropriately care plan related to the Alleged Victim’s (AV) fall history. The failure resulted in AV having a laceration to h/her scalp, and a skin tear on h/her left elbow, experiencing 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 for the Alleged Victim’s (AV) history of falls with injury. From approximately January 08, 2022, through February 04, 2022, the AV suffered approximately 8 falls, several with injury. There was no documented evidence the facility implemented appropriate interventions to prevent future falls for the AV. After the AV’s approximate 6th fall, the facility updated the service plan for the AV to be a full assist with all ADLs. The facility’s failure to properly care plan for the AV resulted in multiple falls with injury, 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 (AV) known history of elopement and falls with injury. On or about February 02, 2022, the AV was able to leave the secured facility and wander into an alley way. In the alley, the AV sustained a fall and sustained scrapes and bruises to their face. The facility’s failure to properly care plan appropriate interventions to redirect the AV when they are showing signs of exit seeking is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately care plan related to the Alleged Victim’s (AV) fall history. The failure resulted in AV experiencing injury and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the Alleged Perpetrator 2 (AP2) applied a wrongful restraint to the Alleged Victim’s (AV) legs in a manner to confine the resident to the bed. On or about April 11, 2024, day shift staff found the AV in bed with their legs wrapped in a sheet. Facility staff noted the legs were wrapped in a manner to confine the resident to their bed. The AP2 restrained the AV to their bed to confine them to their bed, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is a known fall risk, wears oxygen and is to be assisted by staff while ambulating and transferring. On or about March 7, 2024, AV was standing at his/her closet with Alleged Perpetrator #2 (AP2) and fell backwards, hitting his/her head, elbow and hip. AP2 was not holding onto AV, nor was AV wearing his/her oxygen at the time of the incident. AV was sent out to the hospital for evaluation and was noted to have discoloration on his/her left hip. 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 allegation that the facility failed to protect AV from Physical abuse was investigated and the determination was not substantiated. The allegations that AP2 failed to protect AV from Physical abuse was investigated and the determination was substantiated.

According to documentation Alleged Perpetrator 2 (AP2) failed to use appropriate lifting techniques when assisting the Alleged Victim (AV) to a standing position. The failure resulted in AV suffering pain in their arm, AP2's action is considered physical abuse. The facility failed to protect the AV from physical abuse, which is a violation of Oregon Administrative Rules.

On or about September 28, 2022, the facility discovered the Alleged Victim (AV) controlled medication count was incorrect at the end of Alleged Perpetrator 2 (AP2) shift. There had been no administration from this medication during AP2 shift. AP2’s Morphine bottle count was correct at the being of shift and off, at the end. AP2’s actions are a violation of resident rights, are considered neglect of care and constitute financial abuse. 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.