Churchill Retirement Assisted Living

The facility failed to provide appropriate services according to the Alleged Victim’s (AV) care needs which resulted in AV experiencing unreasonable discomfort. On March 14, 2024, and March 25, 2024, AV was served either a partial meal or none at all and any food served to AV was late, causing AV's evening medication scheduled for 4pm to become ineffective at preventing discomfort while also disrupting AV's next scheduled needs. The failure resulted in AV’s condition worsening causing further unreasonable discomfort, 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 Alleged Victim’s (AV) high blood pressure medication was administered as ordered from March 1, 2024, through March 16, 2024. Based on facility documentation and interviews, the facility failed to have AV's blood pressure medication available, causing AV to go without his/her medication for 16 days placing AV at risk for syncope episodes and cognitive changes. The facility's 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 allegedly neglected AV. An investigation inconclusively determined no abuse occurred by AP2.

On February 7, 2024, Alleged Victim (AV) experienced a fall resulting in AV hitting his/her head. AV was admitted to the hospital after the fall and diagnosed with facial injuries, an intracranial hemorrhage, a right periorbital ecchymosis, and bleeding from the lip. Based on facility documentation and interviews, all responsible caregivers were in the laundry room at time of incident. The laundry room is about 30 yards away and is not a part of the locked unit where AV was at time of incident. There was no staff on the floor monitoring residents. There was no staff available to provide supportive services to prevent falls/harm to all residents. Based on AV's care plan, AV needs to be escorted during ambulation to prevent falls and staff are advised to monitor AV closely. Prior to incident, AV was put to bed shortly after being showered but showed signs of agitation, so staff put AV's shoes anticipating movement. However, AV was not monitored closely, allowing AV to get out of bed without staff knowledge which resulted in the fall. The facility failed to provide basic care and adequate supervision to AV which resulted in a fall causing serious physical harm and unreasonable discomfort to AV. When AV was discharged from the hospital, AV was placed on comfort measures. The facility's failure to provide a safe environment for AV is a violation of resident rights, is considered neglect of care, which constitutes abuse.

On January 10, 2024, Alleged Victim (AV) suffered an unwitnessed fall that resulted in a head wound and was transported to the hospital for treatment. Based on facility documentation and interviews, AV has a history of falls, and suffered 4 falls within the month leading up to the incident. The facility's failure to implement interventions and provide appropriate supervision related to the AV's known history of falls, caused AV unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On February 1, 2024, Alleged Victim (AV) suffered an unwitnessed fall that resulted in multiple injuries. Based on facility documentation and interviews, the facility failed to update AV's Service Plan between AV's fall on January 10, 2024, and AV's fall on February 1, 2024. The facility's failure to implement interventions and provide appropriate supervision related to the AV's known history of falls. The facility's failure caused AV continued pain and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide appropriate supervision related to the Alleged Victim’s (AV) known history of falls. On or about December 26, 2023, AV suffered a fall in a common area outside of his/her room. Based on facility documentation, AV was not being actively supervised or escorted by staff and was not in the company of Witness 2 (W2). The facility's failure to provide a safe environment caused unreasonable discomfort to AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide appropriate services according to the Alleged Victim’s (AV) toileting care needs. Based on facility documentation and interviews, AV requires assistance with toileting and is unable to clean himself/herself after a bowel movement. AV utilizes his/her call pendant when he/she is ready for staff assistance. On December 6, 2023, and December 7, 2023, AV pulled the cord in his/her bathroom and also pushed his/her pendant to request help after toileting. Staff took over 30 minutes to respond each time. As a result of waiting for staff for an extended amount of time, AV experienced unreasonable discomfort which could have been reasonably preventable. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide basic toileting care to Alleged Victim (AV). According to facility documentation and interviews, AV was not toileted and cleaned regularly from his/her urine and bowel incontinence. AV was observed sitting in his/her briefs with urine/feces for a long period of time without being changed. AV requires extensive toileting from facility staff. Facility's lack of toileting of AV caused unreasonable discomfort which is a violation of resident rights, is considered neglect of care which constitutes abuse.

The facility failed to provide and/or assist Alleged Victim (AV) with tooth brushing hygiene. AV is unable to manage the task of brushing teeth on his/her own. Per facility documentation and interviews, AV's toothbrush went missing and during this time AV's teeth were not brushed which caused AV unreasonable discomfort and loss of personal hygiene which is a violation of resident rights, is considered neglect of care which constitutes abuse.

Facility failed to assist Alleged Victim (AV) with combing his/her hair according to the resident's preferences and ability. On May 14, 2023, AV was sent to the hospital for treatment. According to investigation, AV appeared disheveled. AV's hair was matted and had a poor odor. The uncleanliness of AV's hair caused unreasonable discomfort and loss of personal dignity to 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 1 (W1) according to his/her known behavior and prior altercations. The failure resulted in a physical altercation between W1 and Alleged Victim (AV) in which W1 pinched, slapped, and pulled AV's hair, causing 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 appropriate interventions and provide appropriate supervision related to the Alleged Victim’s (AV) known history of falls. The failure resulted in AV experiencing several unwitnessed falls with a fall on October 8, 2022, that resulted in a broken hip, causing AV unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to assess and intervene when the Alleged Victim (AV) experienced a change of condition. The failure resulted in AV being transferred to the hospital on or about October 4, 2022, nine days after symptoms appeared, and AV subsequently had surgery. The facility's failure to provide appropriate health assessment, oversight and monitoring when AV's condition changed caused AV unreasonable discomfort which is a violation of resident rights, is considered neglect of care and 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 exposed his/her genitals to the Alleged Victim (AV) without AV's permission, causing AV emotional harm, unreasonable harm, and loss of personal dignity. 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 provide appropriate intervention, assessment, oversight, and monitoring of W1’s increased sexualized behavior. AP2’s actions placed W1, AV, and other residents at risk of harm which 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 placed W1, AV, and other residents at risk of harm which 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, unreasonable harm, and loss of personal dignity. 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 provide appropriate intervention, assessment, oversight, and monitoring of W1’s increased sexualized behavior. AP2’s actions placed W1, AV, and other residents at risk of harm which 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 placed W1, AV, and other residents at risk of harm which is considered neglect of care which constitutes abuse.

Alleged Victim (AV) had known inappropriate sexualized behaviors and the facility failed to implement interventions to appropriately monitor AV according to his/her known behavior and prior altercations. AV had several incidents in which AV 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 AV to protect others from AV’s inappropriate sexualized behavior, which ultimately led to an incident where AV inappropriately exposed and fondled himself/herself in front of another resident(s), causing emotional harm, unreasonable harm, and loss of personal dignity. The facility failed to provide a safe environment for AV and other residents at the facility, which is a violation of resident rights, is considered neglect of care and constitutes abuse. Alleged Perpetrator 2 (AP2) neglected AV by failing to provide appropriate intervention, assessment, oversight, and monitoring of AV’s increased sexualized behavior. AP2’s actions placed AV and other residents at risk of harm which is considered neglect of care which constitutes abuse. Alleged Perpetrator 3 (AP3) neglected AV by failing to intervene and monitor AV's increased sexualized behavior towards other residents. AP3’s actions placed AV and other residents at risk of harm which 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 inappropriately fondled Alleged Victim (AV), causing AV emotional harm, unreasonable harm, and loss of personal dignity. 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 provide appropriate intervention, assessment, oversight, and monitoring of W1’s increased sexualized behavior. AP2’s actions placed W1, AV, and other residents at risk of harm which 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 placed W1, AV, and other residents at risk of harm which is considered neglect of care which constitutes abuse.

The facility failed to ensure the Alleged Victim's (AV) care needs were being met due to a lack of service planning for nail care. AV’s nails were found to be severely over grown and causing skin injuries, resulting in unreasonable discomfort. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to carry out medication and treatment orders as prescribed in accordance with OAR 411-054-0055(1)(f); Per complaint R1 given another residents medication, which is a violation of Oregon administrative Rules.

The facility failed to administer the resident ' s medication as order by their physician as required by 411-054-0055(1)(f). Per complainant resident received another resident's medication, which is a violation of Oregon Administrative Rules.

Alleged Victim (AV) is a known exit seeker and elopement risk. On January 23, 2024, AV exited the secured doors of the facility without assistance. According to documentation, there was no injury to him/her. The facility failed to implement interventions and provide a safe environment, which is a violation of Oregon Administrative Rules.

Alleged Victim (AV) is a known elopement risk. On January 23, 2024, AV exited the secured doors of the facility without assistance. According to documentation, there was no injury to him/her. The facility failed to implement interventions and provide a safe environment, which is a violation of Oregon Administrative Rules.

The facility is responsible for storing and administering all of Alleged Victim's (AV) prescribed medications. In November 2023, one of AV's medications to treat a his/her medical condition was placed on hold by facility staff without a verifiable doctor's order. Based on facility documentation and interviews, the hold erroneously remained in place until audits were done in April 2024. AV did not experience any physical negative effects due to missing significant doses of this medication. The facility failed to provide a safe medication administration system by not having proper protocol in place for following up on medications that have been placed on hold, and this error could have been reasonably preventable. AV had still been taking a secondary medication to treat his/her medical condition until April 2024. The facility failed to provide a safe medication administration system for AV which is a violation of Oregon Administrative Rules. Alleged Perpetrator 2 (AP2) allegedly neglected AV. An investigation determined no abuse occurred by AP2.

The Background Check Unit (BCU) reported to Community Based Care (CBC) Licensing Unit that the facility failed to obtain a background check for a SI (Subject Individual). Based on documentation, the most recent background check for this SI was completed November 12, 2014. Per licensing and background check requirements, facility's employees, volunteers, and contractors must have a background check every two years. The facility failed to provide a safe environment which is a violation of Oregon Administrative Rules.

The facility failed to provide a call system that connects resident units to care staff center or staff pagers. The facility's failure to provide a safe environment is a violation of Oregon Administrative Rules.

The facility failed to complete service plans. The facility's failure to properly care plan is a violation of Oregon Administrative Rules.

On or about May 1, 2023, the facility failed to carry out medication orders as prescribed. The facility's failure to provide a safe medication administration system is a violation of Oregon Administrative Rules.

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

The facility failed to complete service plans quarterly. The facility's failure to properly care plan is a violation of Oregon Administrative Rules.

The facility failed to develop and implement effective methods of responding to and resolving resident complaints. The facility's failure to provide a safe environment is a violation of Oregon Administrative Rules.

The facility failed to carry out medication orders as prescribed. The facility failed to provide a safe medication administration system.

On or about April 1, 2023, the Oregon Health Authority (OHA) reported to the Department that Respondent failed to comply with weekly reporting requirements of vaccinated individuals, residents and staff, to the proper authority as required by law. This failure has been ongoing from February 1, 2023 to February 28, 2023, for a total of 30 days. The Department sent a letter to you in March 22, 2023, which informed you of the failure to report for previous days, and that if you did not report to OHA by March 1, 2023, you would be receiving a penalty in the amount of $7,500.00. The facility has failed to comply with this request for the month of March 2023, resulting in a Civil Penalty.

Alleged Perpetrator 2 (AP2) made inappropriate sexual contact to the Alleged Victim (AV) while AP2 was working as AV's caregiver. On or about April 19, 2023, facility staff found AP2 on all fours on AV's bed with his/her pants down and underwear removed, while AV was lying in bed. AP2 admitted to having regular physical, sexual contact with AV multiple times a week since January 2023. AP2 would hug and kiss AV, lay on top of AV unclothed and rub his/her genitals, and rub his/her genitals against AV. AV is incapable of consent to sexual contact. AP2 is responsible for sexual abuse. The facility failed to provide a safe environment for AV which is a violation of Oregon Administrative Rules.

On or about March 1, 2023, the Oregon Health Authority reported to the Department that Respondent failed to comply with weekly reporting requirements of vaccinated individuals, residents and staff, to the proper authority as required by law. This failure has been ongoing for a total of 30 days.

On or about December 1, 2022, the Oregon Health Authority reported to the Department that Respondent failed to comply with weekly reporting requirements of vaccinated individuals, residents and staff, to the proper authority as required by law. This failure has been ongoing for a total of 30 days.

The Alleged Victim (AV) had money and personal property go missing from his/her room. The property was taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect AV’s property from theft, which is a violation of Oregon Administrative Rules.

The facility failed to immediately notify the local Department office of any incident of abuse or suspected abuse. The facility's failure to provide a safe environment is a violation of Oregon Administrative Rules.

The facility failed to comply with masking requirements. The facility's failure is a violation of Oregon Administrative Rules.

The facility failed to follow to process for issuing an involuntary less than 30-Day Move-Out Notice. The facility's failure is a violation of Oregon Administrative Rules.

Alleged Perpetrator 2 (AP2) failed to administer the Alleged Victim’s (AV) medication as ordered, causing unreasonable discomfort, and placing him/her at risk of serious harm. AP2 is responsible for neglect of care which constitutes abuse. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.

The facility failed to provide a minimum scope of services, daily program of social and recreational activities for residents. The facility's failure to provide a safe environment is a violation of Oregon Administrative Rules.

The facility failed to post the name of the designee in charge by shift or whenever the administrator is out of the facility. The facility's failure to provide a safe environment is a violation of Oregon Administrative Rules.

The facility failed to provide services to assist the resident with bathing. The facility's failure to provide a service is a violation of Oregon Administrative Rules.

The facility failed to provide direct care staff sufficient in numbers to meet the scheduled and unscheduled needs of each resident. The facility's failure to provide a safe environment is a violation of Oregon Administrative Rules.

The facility failed to establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. The facility's failure is a violation of Oregon Administrative Rules.

On or about May 1, 2022, the Oregon Health Authority reported to the Department that Respondent failed to comply with weekly reporting requirements of vaccinated individuals, residents and staff, to the proper authority as required by law. This failure has been ongoing from April 1, 2022 to April 30, 2022, for a total of 30 days.

The Alleged Perpetrator 2 (AP2) gave the Alleged Victim (AV) the wrong medications. AV was then transferred to the hospital for continuing monitoring, due to the risk of serious harm. AP2 failed to protect the AV from the risk of serious harm and his/her actions are considered neglect, and constitutes abuse. The facility failed to provide a safe medication system which violates Oregon Administrative Rules.