Carlty Gardens

According to the documentation, the Alleged Perpetrator 2 (AP2) failed to follow protocols for medication pass, leading to the Alleged Victim (AV) to not receive their medications as prescribed. On or about November 26, 2024, AP2 was passing medications and failed to follow training protocols regarding AV’s medications. As a result, the AV did not receive their medications, which assist with breathing and pain management. The AP2 placed the AV at risk of harm for pain and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to notify the AV’s primary care provider of the missed medications which placed the AV at risk of harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility for his/her care. According to an investigation, on or about, November 26, 2024, Alleged Perpetrator 2 (AP2) took AV’s call light by grabbing AV’s wrist in a forceful manner and making inappropriate comments, resulting in AV experiencing unreasonable emotional and physical discomfort. AP2’s actions are a violation of resident rights, are considered neglect of care and constitutes physical abuse. It was also discovered that the facility has been aware of AP2s concerning behavior since August 2024 and did not do any follow-up investigation or monitoring of AP2’s conduct. The facility failed to ensure a safe environment, which is a violation of resident rights, is neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility for their care, including medication management. From approximately November 3, 2024, to November 25, 2024, AV was not given several doses of his/her scheduled medications, as it was unavailable, which caused AV to experience pain and was unable to sleep. The facility failed to provide a safe medication administration system to ensure AV’s medication was available to be administered as ordered. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. The allegation that Alleged Perpetrator 2 (AP2) neglected AV was investigated and determined to be inconclusive.

According to the documentation, the facility failed to ensure medication was available for the Alleged Victim (AV) to ensure they could have proper respiratory function. The AV is prescribed an inhaler for daily use and for PRN use when experiencing shortness of breath. On or about October 13, 2024, the AV was experiencing shortness of breath and requested their PRN inhaler. There was no documented evidence the facility had both scheduled and PRN inhalers available for the AV to use causing 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) failed to provide incontinence care and food and beverages to the Alleged Victim (AV) causing unreasonable discomfort. Witness statements indicated having found the AV soiled or heavily soiled in urine and feces shortly after AP2’s shift ended. During the investigation of the AV being left in soiled clothes, it was also discovered the AP2 refused to provide food and beverages to the AV. The AP2 not providing incontinence care to the AV and refusing to provide them with food and beverages is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to properly train the AP2 on all required trainings before working the floor is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to properly care plan appropriate interventions for the Alleged Victim’s (AV) known fall history. The AV experienced approximately three injury falls between September 12, 2024, through November 03, 2024. On or about November 03, 2024, the AV experienced a ground level injury fall causing severe pain to their leg. On November 04, 2024, the AV was unable to bear weight on their leg and was sent to the hospital. The AV returned from the hospital later on the same day with no diagnosis of injury. On November 05, 2024, the AV was still complaining of severe pain and was subsequently sent back to the hospital. The AV was then diagnosed with a fractured fibula. The AV experienced a significant change of condition and was admitted to hospice care. the AV was not able to return to their baseline level of care after this fall with injury. After each of the three injury falls, there was no documented evidence the AV’s service plan was updated with progressive, appropriate interventions to mitigate their falls, which resulted in a fall 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 follow the Alleged Victim’s (AV) service plan by ensuring the chair alarm was on and functioning. The failure resulted in the AV falling out of their chair and fracturing their neck requiring evaluation at the hospital and causing continuous pain, 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 Witness 1 (W1) behaviors to prevent resident to resident altercations. The failure resulted in a physical altercation between W1 and the Alleged Victim (AV) who suffered a fractured pelvis, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about December 14, 2022, the Alleged Victim (AV) was given another residents medication during medication pass. The facility was continuing to check AV's vitals through out the day. AV's blood pressure and pulse dramatically decreased and emergency services were called. AV was transported to the hospital where he/she was treated and remained in the hospital for a few days to recover. The facility's failure to provide a safe medication administration system is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is care planned for full assist with showering, toileting and housekeeping services. At times, AV was only being set up for showers and not assisted with them. AV was found by family with bowel material on him/her. AV experienced unreasonable discomfort from not being clean, assisted with showers and from not having his/her sheets changed when requested. The facility's failure to follow the care plan is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) had previously had family and friends to assist him/her with medical appointments. AV's family and friends are no longer able to assist AV. AV missed multiple medical appointments, which has placed AV at risk for harm. The facility's failure to assist AV with medical appointments and transportation is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about June 7, 2022, the Alleged Victim (AV) was found on the floor of his/her apartment. AV suffered two falls that morning, at 6:05 am and again at 6:50 am. AV is care planned to have an alarm on his/her bed and chair. That morning, AV's alarm did not go off for either fall. AV went to bed after the second fall, and when he/she awoke, AV was unable to move his/her right leg. AV was sent out to the hospital, where he/she was diagnosed with a broken right hip. The facility's failure to ensure AV's bed and/or chair alarm was working is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to ensure supervision and staff support regarding known behaviors related to Witness #1 (W1). An incident occurred between W1 and the Alleged Victim (AV) where they were each gripping and squeezing each others arms. The facility failed to provide a safe environment, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is care planned for staff to know his/her whereabouts at all times and to not be left with other residents of the opposite sex. On or about January 29, 2022, AV was left in the common area with Witness #1 (W1) who is the opposite sex of AV. AV was touching W1, which made W1 visibly upset. The facility failed to follow the care plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #1 (W1) is known to have sexualized behaviors directed at other residents. On or about November 12, 2021, the Alleged Victim (AV) was in his/her room watching TV when W1 came into his/her room and started to massage his/her shoulders and touched AV's chest. AV asked W1 to stop, however, W1 then rolled AV into his/her room and touched AV with his/her private parts. AV was placed at a risk for harm as staff were not watching W1 in order to stop his/her behaviors. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about October 31, 2021, Witness #2 (W2) was observed hugging the Alleged Victim (AV) from behind, and AV was struggling to get away from W2. W2 has had prior instances of sexualized behaviors and the facility has many interventions in place, however, W2 continues to interact inappropriately with opposite gender residents. The facility failed to provide a safe environment and adequate supervision, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

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 facility failed to have a training program that includes methods to determine competency of direct care staff through evaluation, observation, or written testing. The facility’s failure 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 a licensing violation or abuse occurred.

The facility failed to fully implement and update an Acuity Based Staffing Tool (ABST). An investigation determined a licensing violation or abuse occurred.

Facility failure to provide a commercial dishwasher. An investigation determined a licensing violation or abuse occurred.

The facility failed to carry out medication and treatment orders as prescribed. An investigation determined a licensing violation or abuse occurred.

The facility failed to fully implement and update an acuity-based staffing tool. An investigation determined a licensing violation or abuse occurred.

An investigation determined a licensing violation or abuse occurred. An investigation determined a licensing violation or abuse occurred.

Facility failure to ensure the resident's right to the freedom and support to access food at any time. An investigation determined a licensing violation or abuse occurred.

The facility failed to have safe medication and treatment administration systems in place that are approved by a pharmacist consultant, registered nurse, or physician. An investigation determined a licensing violation or abuse occurred.

The facility failed to carry out medication orders as prescribed. An investigation determined a licensing violation occurred.

The facility failed to fully implement and update an acuity-based staffing tool. An investigation determined a licensing violation occurred.

Facility failed to have a training program that includes methods to determine competency of direct care staff through evaluation, observation, or written testing. Facility must also maintain written documentation of all trainings completed by each employee. An investigation determined a licensing violation or abuse occurred.

The facility failed to immediately investigate and report abuse or suspected abuse to the Department. An investigation determined a licensing violation or abuse occurred.

The facility failed to carry out medication and treatment orders as prescribed. An investigation determined a licensing violation or abuse occurred.

The facility failed to carry out medication orders as prescribed. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to develop and implement a written policy that prohibits the falsification of records. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to ensure a health services system include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation. An investigation determined a licensing violation occurred.

The facility failed to carry out medication and treatment orders as prescribed. An investigation determined a licensing violation or abuse occurred.

The facility failed to ensure the preparation, completeness, accuracy, and preservation of resident records. An investigation determined a licensing violation or abuse occurred.

The facility failed to comply with safe medication administration or treatment practices. An investigation determined a licensing violation or abuse occurred.

The facility failed to immediately notify the local Department office, or the local AAA, of any incident of abuse or suspected abuse. An investigation determined a licensing violation or abuse occurred

The facility failed to carry out medication orders as prescribed. An investigation determined a licensing violation or abuse occurred

The facility failed to carry out medication and treatment orders as prescribed. An investigation determined a licensing violation or abuse occurred.

The facility failed to keep all equipment in good repair, which is a violation of Oregon Administrative Rules.