Churchill Estates Assisted Living

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 a fall in his/her bathroom, on or about October 9, 2023, in which AV tripped over the bathroom rug, resulting in AV falling to the floor, was transferred to the hospital for treatment and was diagnosed with a fractured left wrist, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide a safe medication administration system to ensure The Alleged Victim’s (AV) medications were administered as ordered. Based on facility documentation and interviews, the facility failed to ensure AV had his/her laxative on hand, which caused AV to miss two weeks of doses, which led to AV experiencing bowel irregularity, pain, and discomfort from constipation. The facility failure is which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide a safe medication administration system to ensure The Alleged Victim’s (AV) medications were administered as ordered. Based on facility documentation and interviews, AV's MAR was missing documented administration of 18 doses of his/her pain management medication, beginning on June 9, 2023 until June 15, 2023, and the associated blank spots on the MAR did not have indicators as the reason for the missed doses. The facility mismanaged AV's medication and AV suffered unreasonable discomfort as a result which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately monitor Witness 1 (W1) according to his/her known behavior and prior altercations which resulted in a resident-to-resident altercation between Alleged Victim (AV) and W1 in which W1 hit AV in the back of the head and started pulling at AV's shirt. The facility's failure to provide a safe environment, caused unreasonable discomfort to the AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately monitor Witness 2 (W2) according to his/her known behavior and prior altercations. The failure resulted in a physical altercation between W2 and Alleged Victim (AV) on or about October 27, 2022, causing unreasonable discomfort to AV. Based on facility documentation, this is the third altercation that AV and W2 engaged in during the month of October 2022. The facility's failure to protect AV from W2's aggressive behavior, is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately monitor Witness 5 (W5) according to his/her known behavior and prior altercations. The failure resulted in a physical altercation, causing unreasonable discomfort to the Alleged Victim (AV), which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide appropriate services for Alleged Victim (AV) according to his/her incontinence care needs. Based on interviews and facility documentation, the facility failed multiple times to assess and intervene with AV's incontinence care needs resulting in failure of basic care, unreasonable discomfort, and serious loss of personal dignity to AV. The facility's 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 experiencing a fall on or about August 30, 2022, in which AV was transferred to the hospital and diagnosed with a fracture of the pelvis and a fracture of the T11 vertebrae. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and provide appropriate supervision related to the Alleged Victim’s (AV) known history of falls. The failure resulted in AV experiencing several documented falls from April 30, 2022 through July 18, 2022, causing unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The allegation that Alleged Perpetrator 2 (AP2) physically abused AV was investigated and findings determined no wrongdoing/abuse occurred.

Witness 1 (W1) had known inappropriate sexualized behaviors and the facility failed to implement interventions to appropriately monitor W1 according to his/her known behavior and prior altercations. W1 had several incidents in which W1 either made sexual comments, exposed/touched self in front of others, and/or touched another person. The facility failed to put sufficient interventions in place for W1 to protect others from W1’s inappropriate sexualized behavior, which ultimately led to an incident where W1 engaged in inappropriate sexual contact with the Alleged Victim (AV), causing AV emotional harm. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse. Alleged Perpetrator 2 (AP2) neglected AV by failing to intervene and monitor W1’s increased sexualized behavior towards other residents. AP2’s actions is considered neglect of care which constitutes abuse. Alleged Perpetrator 3 (AP3) neglected AV by failing to intervene and monitor W1’s increased sexualized behavior towards other residents. AP3’s actions is considered neglect of care which constitutes abuse.

Witness 1 (W1) had known inappropriate sexualized behaviors and the facility failed to implement interventions to appropriately monitor W1 according to his/her known behavior and prior altercations. W1 had several incidents in which W1 either made sexual comments, exposed/touched self in front of others, and/or touched another person. The facility failed to put sufficient interventions in place for W1 to protect others from W1’s inappropriate sexualized behavior, which ultimately led to an incident where W1 made inappropriate sexual contact with the Alleged Victim (AV), causing AV emotional harm. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse. Alleged Perpetrator 2 (AP2) neglected AV by failing to intervene and monitor W1’s increased sexualized behavior towards other residents. AP2’s actions is considered neglect of care which constitutes abuse. Alleged Perpetrator 3 (AP3) neglected AV by failing to intervene and monitor W1’s increased sexualized behavior towards other residents. AP3’s actions is considered neglect of care which constitutes abuse.

The facility failed to provide basic care to Alleged Victim (AV) by not changing AV's bed sheets after AV became ill on or about February 7, 2022 in which AV vomited on his/her bed sheets. Based on interviews and facility documentation, AV developed a skin rash due to poor hygiene during his/her illness and AV's bed sheets were not changed until February 16, 2022, nine days after AV initially became ill. The facility's failure to provide a service for AV is a violation of residents rights, is considered neglect and constitutes abuse.

The facility neglected Alleged Victim (AV) by failing to provide basic care to AV when facility staff failed to respond to AV's call light in a timely manner. AV pressed his/her call light seeking assistance with his/her Activities of Daily Living due to AV feeling dizzy. Due to the facility's failure to respond timely to AV's request for assistance, AV remained seated on the toilet until he/she felt better and was able to return to his/her bed by himself/herself. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

On September 17, 2023, Alleged Victim (AV) did not receive eleven of his/her scheduled morning medications. The facility's failure to provide a safe medication administration system is a violation of Oregon Administrative Rules. Alleged Perpetrator 2 (AP2) allegedly neglected AV. An investigation determined no abuse occurred by AP2.

On or about June 23, 2023, the facility failed to have a safe medication administration system which resulted in Alleged Victim (AV) not receiving his/her medication that improves his/her kidney function as ordered. Based on facility documentation and interviews, Alleged Perpetrator 2 (AP2) placed a hold on AV's medication without written orders from AV's medical provider and did not complete the follow-up steps to remove the hold. The facility is responsible for ensuring adequate professional oversight of the medication administration system and to ensure AV's medication is carried out as prescribed. The facility's failure is violation of Oregon Administrative Rules. AP2 allegedly neglected AV. An investigation determined that AV did experience any physical negative effects due to missing significant doses of this medication. Therefore, abuse did not occur by AP2.

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

On or about May 6, 2023, the facility failed to administer medications to Alleged Victim (AV) as ordered. Based on facility documentation and interviews, AV was given Lorazepam which actually belonged to another resident. The facility's failure to provide a safe medication administration system is a violation of Oregon Administrative Rules. Alleged Perpetrator 2 (AP2) allegedly neglected AV. An investigation determined no abuse occurred by AP2.

The facility failed to provide a safe medication administration system to ensure The Alleged Victim’s (AV) medications were administered as ordered. The facility's failure is a violation of Oregon Administrative Rules. Alleged Perpetrator 2 (AP2) allegedly neglected AV. An investigation determined no abuse occurred.

On April 30, 2023, Alleged Victim (AV) did not receive his/her evening medication which resulted in AV experiencing pain and AV was unable to sleep. Based on interviews and facility documentation, Alleged Perpetrator 2 (AP2) was responsible for maintaining appropriate staffing levels and was the on-call staff member at time of incident. AP2 was contacted by facility staff regarding the lack of medication aid to pass medication for the 8pm medication pass on April 30, 2023. AP2 failed to come into the facility to assist with medication pass and failed to ensure AV's evening medication was administered as ordered. AP2's actions is considered neglect of care and constitutes abuse. Alleged Perpetrator 3 (AP3) was at the facility from approximately 8pm until 9:30pm. AP3 was made aware of the lack of staff to pass medication on April 30, 2023 and declined to assist with medication administration. AP3's actions is considered neglect of care and constitutes abuse. The facility failed to ensure a safe medication administration system which is a violation of Oregon Administrative Rules.

On or about April 30, 2023, the facility failed to administer Alleged Victim's (AV) medication as ordered. The facility's failure to provide a safe medication administration system is a violation of Oregon Administrative Rules. Alleged Perpetrator 2 (AP2) allegedly failed to administer AV's medication as ordered. An investigation determined no abuse occurred by AP2.

On April 30, 2023, Alleged Victim (AV) did not receive his/her evening medications as ordered. As a result of not receiving his/her medications, AV experienced pain and was unable to fall asleep. Based on interviews and facility documentation, Alleged Perpetrator 2 (AP2) was responsible for maintaining appropriate staffing levels and was the on-call staff member at time of incident. AP2 was contacted by facility staff regarding the lack of medication aid to pass medication for the 8pm medications pass on April 30, 2023. AP2 failed to come into the facility to assist with medication pass and failed to ensure AV's evening medications were administered as ordered. AP2's actions is considered neglect of care and constitutes abuse. Alleged Perpetrator 3 (AP3) was at the facility from approximately 8pm until 9:30pm. AP3 was made aware of the lack of staff to pass medication on April 30, 2023, and declined to assist with medication administration. AP3's actions is considered neglect of care and constitutes abuse. The facility failed to ensure a safe medication administration system which is a violation of Oregon Administrative Rules.

On or about April 30, 2023, the facility failed to ensure adequate staff were available to administer medications to Alleged Victim (AV) as ordered. As a result of facility's failure to provide a safe medication administration system, AV missed a single administration of his/her medications which is a violation of Oregon Administrative Rules. Alleged Perpetrator 2 (AP2) allegedly neglected AV. An investigation determined no wrongdoing by AP2.

On April 30, 2023, Alleged Victim (AV) did not receive his/her evening medication which caused AV to experience pain and unreasonable discomfort. Based on interviews and facility documentation, Alleged Perpetrator 2 (AP2) was responsible for maintaining appropriate staffing levels and was the on-call staff member at time of incident. AP2 was contacted by facility staff regarding the lack of medication aid to pass medication for the 8pm medication pass on April 30, 2023. AP2 failed to come into the facility to assist with medication pass and failed to ensure AV's evening medication was administered as ordered. AP2's actions is considered neglect of care and constitutes abuse. Alleged Perpetrator 3 (AP3) was at the facility from approximately 8pm until 9:30pm. AP3 was made aware of the lack of staff to pass medication on April 30, 2023 and declined to assist with medication administration. AP3's actions is considered neglect of care and constitutes abuse. The facility failed to ensure a safe medication administration system which is a violation of Oregon Administrative Rules. Alleged Perpetrator 4 (AP4) allegedly neglected AV. An investigation determined no abuse occurred by AP4.

On or about April 30, 2023, the facility failed to ensure adequate staff were available to administer medications to Alleged Victim (AV) as ordered. As a result of facility's failure to provide a safe medication administration system, AV missed a single administration of his/her medications which is a violation of Oregon Administrative Rules. Alleged Perpetrator 2 (AP2) allegedly neglected AV. An investigation determined no wrongdoing by AP2.

On or about April 30, 2023, the facility failed to ensure adequate staff were available to administer medications to Alleged Victim (AV) as ordered. As a result of facility's failure to provide a safe medication administration system, AV missed a single administration of his/her medications which is a violation of Oregon Administrative Rules. Alleged Perpetrator 2 (AP2) allegedly neglected AV. An investigation determined no wrongdoing by AP2.

On April 30, 2023, Alleged Victim (AV) did not receive his/her evening medications which put AV at risk of suffering from a blood clot and poor heart function. Per AV's physician, AV's evening medications are important to AV's heart health and should not be missed. Based on interviews and facility documentation, Alleged Perpetrator 2 (AP2) was responsible for maintaining appropriate staffing levels and was the on-call staff member at time of incident. AP2 was contacted by facility staff regarding the lack of medication aid to pass medication for the 8pm medications pass on April 30, 2023. AP2 failed to come into the facility to assist with medication pass and failed to ensure AV's evening medications were administered as ordered. AP2's actions is considered neglect of care and constitutes abuse. Alleged Perpetrator 3 (AP3) was at the facility from approximately 8pm until 9:30pm. AP3 was made aware of the lack of staff to pass medication on April 30, 2023, and declined to assist with medication administration. AP3's actions is considered neglect of care and constitutes abuse. The facility failed to ensure a safe medication administration system which is a violation of Oregon Administrative Rules.

On April 30, 2023, Alleged Victim (AV) did not receive his/her evening medications as ordered. As a result of not receiving his/her medications, AV was at elevated risk of cardiovascular issues due to AV's health and preexisting conditions. Based on interviews and facility documentation, Alleged Perpetrator 2 (AP2) was responsible for maintaining appropriate staffing levels and was the on-call staff member at time of incident. AP2 was contacted by facility staff regarding the lack of medication aid to pass medication for the 8pm medications pass on April 30, 2023. AP2 failed to come into the facility to assist with medication pass and failed to ensure AV's evening medications were administered as ordered. AP2's actions is considered neglect of care and constitutes abuse. Alleged Perpetrator 3 (AP3) was at the facility from approximately 8pm until 9:30pm. AP3 was made aware of the lack of staff to pass medication on April 30, 2023, and declined to assist with medication administration. AP3's actions is considered neglect of care and constitutes abuse. The facility failed to ensure a safe medication administration system which is a violation of Oregon Administrative Rules.

On or about April 30, 2023, the facility failed to ensure adequate staff were available to administer medications to Alleged Victim (AV) as ordered. As a result of facility's failure to provide a safe medication administration system, AV missed a single administration of his/her medications which is a violation of Oregon Administrative Rules. Alleged Perpetrator 2 (AP2) allegedly neglected AV. An investigation determined no wrongdoing by AP2.

On or about April 30, 2023, the facility failed to ensure adequate staff were available to administer medications to Alleged Victim (AV) as ordered. As a result of facility's failure to provide a safe medication administration system, AV missed a single administration of his/her medications which is a violation of Oregon Administrative Rules. Alleged Perpetrator 2 (AP2) allegedly neglected AV. An investigation determined no wrongdoing by AP2.

On April 30, 2023, Alleged Victim (AV) did not receive his/her evening medications as ordered. As a result of not receiving his/her medications, AV experienced pain related to AV' medication conditions. Based on interviews and facility documentation, Alleged Perpetrator 2 (AP2) was responsible for maintaining appropriate staffing levels and was the on-call staff member at time of incident. AP2 was contacted by facility staff regarding the lack of medication aid to pass medication for the 8pm medications pass on April 30, 2023. AP2 failed to come into the facility to assist with medication pass and failed to ensure AV's evening medications were administered as ordered. AP2's actions is considered neglect of care and constitutes abuse. Alleged Perpetrator 3 (AP3) was at the facility from approximately 8pm until 9:30pm. AP3 was made aware of the lack of staff to pass medication on April 30, 2023, and declined to assist with medication administration. AP3's actions is considered neglect of care and constitutes abuse. The facility failed to ensure a safe medication administration system which is a violation of Oregon Administrative Rules.

On April 30, 2023, Alleged Victim (AV) did not receive his/her evening medication which elevated AV's risk of blindness due to AV's health and preexisting conditions. Based on interviews and facility documentation, Alleged Perpetrator 2 (AP2) was responsible for maintaining appropriate staffing levels and was the on-call staff member at time of incident. AP2 was contacted by facility staff regarding the lack of medication aid to pass medication for the 8pm medication pass on April 30, 2023. AP2 failed to come into the facility to assist with medication pass and failed to ensure AV's evening medication was administered as ordered. AP2's actions is considered neglect of care and constitutes abuse. Alleged Perpetrator 3 (AP3) was at the facility from approximately 8pm until 9:30pm. AP3 was made aware of the lack of staff to pass medication on April 30, 2023 and declined to assist with medication administration. AP3's actions is considered neglect of care and constitutes abuse. The facility failed to ensure a safe medication administration system which is a violation of Oregon Administrative Rules.

On April 30, 2023, Alleged Victim (AV) did not receive his/her evening medication which resulted in AV being at an elevated risk of cardiovascular issues due to AV's health and preexisting condition. Based on interviews and facility documentation, Alleged Perpetrator 2 (AP2) was responsible for maintaining appropriate staffing levels and was the on-call staff member at time of incident. AP2 was contacted by facility staff regarding the lack of medication aid to pass medication for the 8pm medication pass on April 30, 2023. AP2 failed to come into the facility to assist with medication pass and failed to ensure AV's evening medication was administered as ordered. AP2's actions is considered neglect of care and constitutes abuse. Alleged Perpetrator 3 (AP3) was at the facility from approximately 8pm until 9:30pm. AP3 was made aware of the lack of staff to pass medication on April 30, 2023 and declined to assist with medication administration. AP3's actions is considered neglect of care and constitutes abuse. The facility failed to ensure a safe medication administration system which is a violation of Oregon Administrative Rules.

The facility failed to carry out medication and treatment orders as prescribed. The facility's failure to provide a safe medication administration system is a violation of Oregon Administrative Rules.

Alleged Victim (AV) discovered on April 1, 2023, that his/her prescribed diuretic medication was not included in his/her morning medication pass. Based on facility documentation and interviews, AV's diuretic medication was discontinued by facility in error and AV did not receive his/her diuretic medication for five days. The facility failed to administer AV's medication as ordered which is a violation of Oregon Administrative Rules.

On or about March 13, 2023, the facility failed to properly administer Alleged Victim's (AV) medication. According to facility documentation, AV experienced no negative outcome. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules. Alleged Perpetrator 2 (AP2) allegedly neglected AV. An investigation determined no abuse occurred by AP2.

The facility failed to implement services. The facility's failure to properly care plan is a violation of Oregon Administrative Rules.

The facility failed to have safe medication and treatment administration system in place, medication and treatment orders must be carried out as prescribed. The facility's failure to provide a safe medication administration system is a violation of Oregon Administrative Rules.

On or about November 12, 2022, Alleged Perpetrator 2 (AP2) and Alleged Perpetrator 3 (AP3) wrongfully used physical restraint to restrain Alleged Victim (AV) for convenience of AP2 and AP3. Based on interviews and facility documentation, AP2 and AP3 wrongfully restrained AV and forced AV to take his/her medications when AV refused to take his/her medication. AP2's and AP3's actions are considered wrongful restraint which constitutes abuse. The facility failed to provide a safe environment for AV which is a violation of Oregon Administrative Rules.

The facility failed to properly care plan for Alleged Victim's (AV) behaviors during toileting. The facility's failure is a violation of Oregon Administrative Rules.