Dallas Retirement Village Assisted Living

According to the documentation, the facility failed to reorder the Alleged Victim’s (AV) pain medication and ran out of the medication on approximately April 8, 2023. The failure resulted in the AV to experience cramps and a burning sensation in their leg 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 the Alleged Victim’s (AV) need for assistance with transfers after returning from the hospital. The failure resulted in AV receiving a skin tear during a transfer, 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) recent falls. The failure resulted in the AV falling, requiring medical assessment at the hospital and was diagnosed with a fractured hip, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to ensure the Alleged Victim’s (AV) blood thinning medication was reordered. The failure resulted in the AV missing one dose of their blood thinning medication on or about January 4, 2023, putting him/her at risk for blood clots, 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) request to be toileted every hour. On or about December 28, 2022, the AV slid out of bed as they were trying to go to the restroom. Alleged Perpetrator 2 (AP2) stated they last checked the AV approximately two and a half hours prior to the incident. The failure to properly care plan resulted in a fall and the AV sustaining multiple skin tears and pain, 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 medication administration system by not reordering the Alleged Victim’s (AV) anxiety medication timely. On or about December 18, 2022, the facility ran out of the AV’s anxiety medication and didn’t have any available. The failure resulted in the AV to experience anxiety, stress, and agitation, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to communicate the Podiatrist recommendation to float the Alleged Victim’s (AV) heels to prevent ulceration. The failure resulted in the AV being diagnosed with a stage two (2) pressure injury on their right heel, 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 (AV) medications were administered as prescribed. Per documentation, approximately between January 2022 to September 2022 AV missed h/h Anxiety medication twenty-six (26) times for a total of fifty-two (52) doses and missed h/h narcotic pain medication eighteen (18) times. The failure resulted in AV experiencing increased anxiety, restlessness, pain, and physical withdrawals, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to answer the Alleged Victim’s (AV) call light for approximately seven (7) hours . The failure resulted in the AV going without their oxygen concentrator, causing their O2 levels to drop, causing prolonged fear and discomfort, which is a violation of resident rights, is neglect of care and constitutes abuse.

The Alleged Victim (AV) has a history of injury and non-injury falls. AV had approximately six (6) falls from June 1, 2022, to September 27, 2022. On or about August 26, 2022, AV pushed h/h pendent for assistance without response. AV was found on the floor shaken and upset. The facility failed to appropriately care plan and implement reasonable interventions to address AV’s increasing and ongoing falls, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about July 6, 2022, the Alleged Victim (AV) suffered a fall, resulting in a broken hip, requiring surgery. AV has had previous falls at the facility, without any interventions in place to prevent AV's falls. The facility failed to properly care plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about July 18, 2022, the Alleged Victim (AV) was found with an old bandage on his/her hip. When it was removed, an open wound was discovered. On or about June 30, 2022, and email was sent to staff regarding the wound on AV's hip. From June 30, 2022 to July 18, 2022, there is no documentation that any staff followed up with wound care for AV. AV is care planned to be toileted and showered by staff and to observe AV's skin for any breakdown. No staff reported any findings regarding the bandage on AV's hip or any skin anomalies from June 30, 2022 to July 18, 2022. The facility failed to follow the care plan and failed to provide care to AV's wound, causing unreasonable discomfort. The facility's failure 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 (AV) medications were administered as prescribed. Per documentation, approximately between June 2022 to September 2022 AV missed h/h eye drop medication several times. The failure resulted in AV experiencing repeated unreasonable pain, and discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

AV has a history of falls. On or about April 23, 2022, AV was found on the floor, AV hit h/h head and sustained should and back pain. The facility failed to appropriately care plan and implement reasonable interventions to address AV’s falls, which is violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) moved into the building on March 9, 2022. AV was assessed by Alleged Perpetrator #2 (AP2) prior to move in and was approved for move in by AP2. AP2 delegated staff to administer AV's diabetic medication. AV's blood glucose levels were very sporadic and unpredictable. AP2 was made aware by staff that AV's blood glucose was very sporadic and at times extremely low, between 38 and 60 and other times in the 300's. AP2 did not address this issue and did not contact AV's physician regarding this issue. AV suffered multiple falls and a blackout due to low blood glucose levels. AP2’s actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility failed to provide a safe medication administration system, which is a violation of Oregon Administrative Rules.

Based on interview and record review, the facility failed to provide records to the Department upon request. The facility’s failure is a violation of Oregon Administrative Rules.

On or about March 31, 2025, Alleged Perpetrator 2 (AP2) entered Alleged Victim (AV's) room to assist Witness 4 (W4) in toileting AV. AV informed AP2 that AV's sibling passed away earlier that day. AP2 replied that AP2 did not care. AP2 used a condescending, rude tone when AP2 told AV to use AV's legs and stand up. AV got upset and yelled at AP2 to leave AV's room. AV could hear AP2 over the walkie telling other staff AV was having behaviors, being rude and demanding. AV was grieving and AP2's behavior added to AV's stress, causing AV distress. AP2’s actions are a violation of resident rights, are considered neglect of care and constitutes verbal abuse. The facility failed to provided oversight and a safe environment, which is a violation of Oregon Administrative rules.

Alleged Victim (AV's) anticoagulant medication changes frequently based on AV's lab results. AV missed AV's anticoagulant medication on November 9, 2024. AV's medication update faxed to the pharmacy by staff. AV's pharmacy reported they did not receive the updated anticoagulant medication order. AV's risk of harm for missing one dose of anticoagulant medication a potential increase in bleeding and/or blood in AV's stool. The facility failed to administer AV's medication as ordered, which is a violation of Oregon Administrative Rules.

Alleged Perpetrator #2 (AP2) failed to provide a safe medication administration system to ensure the Alleged Victim's (AV) medications were administered as ordered. AP2 administered AV’s medication at the non-scheduled time despite updates to AV’s MAR. AP2 did not compare AV’s MAR to the narcotics logs showing amended time change for medication administration. AP2 administered AV’s medication at a previously scheduled time resulting in AV receiving a double dose of AV’s medication making AV feel dizzy. AP2 was notified by W1 of the error, AP2 admits to medication error. AP2's actions are considered neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.

According to the documentation, the Alleged Perpetrator 2 (AP2) did not follow the care plan for the Alleged Victim (AV) by not moving the pressure pad alarm from the recliner to the bed. On or about March 08, 2024, AP2 did not follow the care plan to place the pressure pad alarm in the bed as outlined in the care plan. The AV suffered a fall and hit their head resulting in a brain bleed which required medical intervention at the hospital, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

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

Facility failed to ensure resident's ordered medications were available in the facility for administration as ordered. On or about March 20, 2023 and March 21, 2023 AV missed h/h scheduled narcotic pain medication as the facility failed to reorder AV’s medication in a timely manner. The facility failure is a violation of Oregon Administrative Rules.

On or about March 17 and 18, 2023, AV was not administered h/h daily dose of a cognition enhancing medication as ordered. AV suffered no physical harm or discomfort related to missing the medication. The facility failed to administer medication as ordered which 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 in accordance with OAR 411-054-0050(1) per complaint covid prevention processes are not being followed.

Alleged Victim (AV) relies on the facility for his/her care. AV is care planned to have staff stand behind AV and use a padded gait belt when providing mobility assistance. On or about November 03, 2022, Alleged Perpetrator #2 (AP2) was providing toileting, and transfer care to AV. AP2 did not use a padded gait belt at the time of the transfer. AV fell and sustained a fracture left hip and a laceration to h/h head. AP2 failed to follow the care plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to ensure the care plan was being followed, which is a violation of Oregon Administrative Rules.

Based on interview and record review, it was determined the facility failed to complete an Acuity-Based Staffing Tool (ABST) assessment for each resident and update the ABST information when there was a significant change of condition for 2 of 4 sampled residents. Facility was able to update residents while Survey was still on site. Condition not issued, Survey will re-evaluate at revisit.

On or about July 7, 2022, Alleged Perpetrator 2 (AP2) dispensed morning medications to the Alleged Victim(AV). AP2 gave AV an unknown substance that was sitting next to the kitchen sink with a lid on it to take his/her medications. AP2 did not check to see what was in the cup prior to giving it to AV, the liquid was bleach and laundry detergent mixed together. AP2's actions caused unreasonable discomfort and a risk of serious harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility’s failure is a violation of Oregon Administrative Rules.

Alleged Perpetrator #2 (AP2) forced Alleged Victim’s (AV) to get dressed, and a physical altercation took place. AP2's actions are a violation of resident rights, are considered neglect of care and constitute physical abuse. The facility’s failure is a violation of Oregon Administrative Rules.

Alleged Perpetrator #2 (AP2) pulled on Alleged Victim’s (AV) leg causing pain and discomfort. AP2's actions are a violation of resident rights, are considered neglect of care and constitute physical abuse. The facility failed to provide a safe environment, which is a violation of Oregon Administrative Rules.

Alleged Perpetrator #2 (AP2) caused pain and discomfort while changing Alleged Victim’s (AV) catheter bag and assisting AV with nightly routine. AP2's actions are a violation of resident rights, are considered neglect of care and constitute physical abuse. The facility failed to provide a safe environment, which is a violation of Oregon Administrative Rules.