Capital Manor Retirement Community

Witness 1 (W1) has a history of previous resident-to-resident altercations. W1 has interventions in place, if W1 has signs of escalating behavior, staff to offer W1 coffee, offer 1;1 conversation, staff will move W1 away from others, staff to monitor W1's reactions to the behavioral expressions around W1 and redirect accordingly. On or about May 4, 2025, W1 and Alleged Victim (AV) were in the dining room. W1 was yelling and staff did not intervene, W1 was walking towards caregiver when W1 bumped into AV's wheelchair. W1 thought AV hit W1 and yelled at AV to "get out of the way!'. W1 got ready to punch AV then SV tapped W1's tummy, so W1 smacked AV's forehead. The facility failed to provide AV a safe environment and follow W1's interventions resulting in a resident-to-resident altercation, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) has history of wondering around and entering other resident rooms, has aggressive behaviors and altercations with other residents including W1. W1 does not like when other residents enter W1 room. AV and W1 have history of resident-to-resident altercations with interventions in place, W1 to participate in activities away from AV, and staff to ensure AV is not near W1 while in common areas. On December 26, 2024, AV went into W1's room. W1 pushed AV out of W1's room resulting in W1 having a skin tear 2-3 cm long on W1's upper left arm. W1 was given pain medication and skin tear was bandaged. AV complained of lower back pain, and crying after the incident and required OTC pain medications. The facility failed to provide a safe environment and properly plan care for AV's known wondering into other residents rooms, resulting in a resident-to-resident altercation with injury to AV and W1, which is a violation of resident’s rights, is neglect of care and constitutes abuse.

Witness 1 (W1) has history of wondering around and entering other resident rooms, has aggressive behaviors and altercations with other residents including Alleged Victim (AV) . AV does not like when other residents enter AV's room. W1 and AV have history of resident-to-resident altercations with interventions in place, AV to participate in activities away from W1, and staff to ensure W1 is not near AV while in common areas. On December 26, 2024, W1 went into AV's room. AV pushed W1 out of AV's room resulting in AV having a skin tear 2-3 cm long on AV's upper left arm. AV was given pain medication and skin tear was bandaged. W1 complained of lower back pain, and crying after the incident and required OTC pain medications. The facility failed to provide a safe environment and properly plan care for W1's known wondering into other residents rooms, and properly care plan for other residents to not enter AV room, resulting in a resident-to-resident altercation with injury to AV and W1, which is a violation of resident’s rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) moved into the facility approximately February 2022. When AV first moved into the facility, staff followed AV without AV's knowledge, to see if AV could go on walks and get back to the facility. AV service plan dated on or about August 29, 2024, indicates AV has dementia, AV's short-term memory is not good and needs redirection often to find AV's apartment and find AV's way from activities. AV is independent with ambulation. AV wore a wander guard when AV first came to the facility due to leaving the facility and not finding AV's way back. AV no longer wears wander guard, staff to let the nurse know if AV leaves facility and cannot find AV's way back. On or about September 22, 2024, at approximately 7:00 am AV was in AV's apartment and dressed, at approximately 10:06 am AV was seen in common area and given mask to wear, at approximately 10:20 am kitchen staff reported seeing AV walk down the driveway, at approximately 12:00 pm two staff made inquiries about if AV had been seen, and staff replied. "No, I haven't. I just got here." No further report given to any other staff or floor nurse until approximately after 2:00 pm. Administrator notified via phone of AV not seen at approximately 2:57 pm and LEA notified at approximately 3:37pm. On or about September 23, 2024, K9 team found AV at approximately 12:00 pm on the side of the highway in thick blackberry bushes. AV was transported to the hospital and admitted. AV was diagnosed with extensive abrasion to AV's face. arms and legs; acute kidney injury with rhabdomyolysis, secondary to dehydration; and acute metabolic encephalopathy representing delirium that resolved during hospitalization. AV was discharged from the hospital on October 3, 2024. The facility failed to provide a safe environment, failed to plan and implement safety checks on AV when AV level of care required an increase in reminders to find AV's apartment dining room and activity location as noted in AV's service plan dated Aust 29, 2024. The facility failure is a violation of resident rights, is neglect of care and constitutes abuse.

The Alleged Victim (AV) is a known wanderer and had poor cognition. On or about September 12, 2024, AV wandered from the facility and was found approximately a half mile away at a coffee shop. Facility staff were not aware that AV was missing. On September 13 and September 15, 2024, AV had went to see a friend, staff were unaware AV was gone until the friend called the facility to let them know. AV had a wander guard in place, but it did not notify staff leaving. AV also was on one to one supervision, however, staff were not providing the supervision, allowing AV to leave on September 13 and 15. The facility's failure placed AV at risk for harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness 1 (W1) and Alleged Victim (AV) have a history of resident-to-resident altercations. W1 service plan indicates the noise from TV room near W1's room will create expressions of frustration and confusion. W1 will at times go into the room and ask the group to keep the noise down. AV is known to be territorial over the living room. Interventions for W1 at the time of the altercation included redirecting W1 with a drink, snack book, walk, or item, and keeping W1 in areas with staff. On September 2, 2024, in the TV Room W1 pushed a side table in AV's right side and W1 hit AV. Resulting in bruising and pain on AV's right side. The facility failed to provide a safe environment, adequate supervision and appropriately care plan and implement reasonable interventions to address W1's frustration of the noise from TV room, resulting in a resident-to resident altercation between W1 and AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) is a high fall risk with a history of unwitnessed falls. AV's service plan dated approximately August 4, 2024, indicates AV is a 1-person assist for transfers into wheelchair, uses a wheelchair for all ambulation, and is a 1-person assist with pushing AV's wheelchair. AV's fall precautions/interventions indicate, keep all walkways & hallways free of clutter, wear non-slip shoes, slippers or socks, motion sensor to notify staff when AV is ambulating in apartment, care staff to check in with AV and ensure safety. Motion sensor placed in bathroom, staff to check on AV and offer assistance with toileting when bathroom sensor goes off. Ensure there are no items in front of the motion sensor at the head of the bed. Breaks to be locked and wheelchair placed at bedside. As needed treatments indicate, Fall Mat per Hospice okay to use while in bed, monitor for safety. On or about August 7, 2024, AV was found on the floor next to AV's bed. AV sustained an abrasion on AV's left cheek and AV's left eye was swollen. Alleged Perpetrator 2 (AP2) failed to follow AV service plan, the facility failed to provide adequate supervision, and training over AP2 to ensure AV service plan was being followed. AV was found on the floor, fall mat was not in place, AV's wheelchair was not within reach of AV and the breaks were not locked. AV's motion sensor had not activated when AV fell. AP2 reported, AV refused to allow AP2 to place the fall mat, AP2 did not document the refusal or notify proper staff. AP2 was trained on service plans, and dementia. AP2 was not trained on abuse, or documentation, per AP2's training file, 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) but not connecting the tab alarm and checking on them every hour. On or about June 17, 2024, the AV was found on tipped over on the left side still in their wheelchair. Upon inspection of the AV, the facility noted the tab alarm was not hooked up correctly and staff admitted to not checking them hourly as their care plan directed 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 the Alleged Victim (AV) regarding fall interventions. The failure resulted in the AV suffering two falls causing lacerations to their head requiring medical intervention and staples to close the laceration, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, on or about April 13, 2023, the facility received physician’s orders for a seat belt for the Alleged Victim’s (AV) wheelchair. The facility failed to implement the seat belt which resulted in the AV suffering from multiple falls with injury, 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 Witness 1’s increased agitation and resident to resident altercations. The failure resulted in a physical altercation with the Alleged Victim causing 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 care plan for Witness 1’s (W1) known behaviors towards other residents. The failure resulted in W1 getting into an altercation with the Alleged Victim (AV) causing the AV to fall, hit their head and received a laceration, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness 1 (W1) and Alleged Victim (AV) have a history of resident altercations. On or about April 26, 2022, AV grabbed W1 hand, and W1 began hitting AV. AV sustained a laceration to left middle finger. AV’s interventions at time of incident were not effective. The facility failed to appropriately care plan and implement effective interventions to address AV’s increasing and ongoing aggressive behaviors, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness 1 (W1) and Alleged Victim (AV) have a history of resident altercations. On or about April 26, 2022, W1 grabbed AV hand, and AV began hitting W1, as a result AV was upset and agitated for the rest of the evening. W1’s interventions at time of incident were not effective. The facility failed to appropriately care plan and implement effective interventions to address W1’s increasing and ongoing aggressive behaviors, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness 1 (W1) has a history of agitated, combative behaviors and resident-to-resident altercations. On or about April 19, 2022, W1 started hitting and pulling Alleged Victims (AVs) hair. W1’s interventions at time of incident were not effective. The facility failed to appropriately care plan and implement effective interventions to address W1’s increasing and ongoing aggressive behaviors, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) and Witness 1 (W1) have history of altercations with staff and other residents which has resulted in injuries. On or about March 24, 2022, AV and W1 were heard screaming, staff investigated and found AV and W1 fighting, and hitting each other. AV had fingernail marks on left forearm and bruising, W1 had abrasions to right upper arm. The facility failed to appropriately care plan and implement reasonable interventions to address AV and W1 ongoing behaviors, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) and Witness 1 (W1) have history of altercations with staff and other residents which has resulted in injuries. On or about March 24, 2022, AV and W1 were heard screaming, staff investigated and found AV and W1 fighting, and hitting each other, resulting in injury to both. The facility failed to appropriately care plan and implement reasonable interventions to address AV and W1 ongoing behaviors, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness 1 (W1) relies on the facility for his/her care. W1 has a history of agitation and aggressive behaviors towards other residents. On or about January 20, 2022, W1 had aggressive behavior towards Alleged Victim (AV), which lead to a resident-to-resident altercation. W1 grabbed AV by the hand leaving a bruise on top of AVs right hand. The facility has interventions in place that have not been effective. The facility failed to properly plan care and implement new interventions which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to follow Witness 1's care plan for monitoring and behaviors. The failure resulted in W1 having an unwitnessed physical altercation with the Alleged Victim causing injury, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to follow Alleged Victim's (AV) care plan for monitoring and behaviors. The failure resulted in an unwitnessed physical altercation causing injury to AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) and Witness #1 (W1) have history of being in verbal altercations, and both have history of resident-to-resident altercations. AV has interventions in place when AV is agitated and anxious. On or about November 21, 2021, AV was agitated after being woken from a nap. W1 struck AV in the face, as a result of AV behaviors. The facility failed to redirect and offer AV interventions. The facility failed to follow care plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse.