Farmington Square Gresham

Both the Alleged Victim (AV) and Witness 1 (W1) rely on the facility for care and have a history of conflict and physical altercations with each other in their shared room. On or about September 30, 2024 and again on October 2, 2024, AV and W1 were in physical altercations, resulting in AV getting hit in the head with a cane and their fingers squished in the cane. The facility failed to implement effective interventions to address both AVs and W1s interpersonal conflict and behaviors, and provide a safe environment for AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is a known fall risk with a history of falls while trying to self-transfer. AV is care planned for wellness checks every hour and to have a body pillow placed beside AV to reduce the risk of AV falling out of bed. On or about, August 9, 2024, AV had an unwitnessed fall, resulting in a skin tear on his/her left hand and was exhibiting dizziness, stuttering, and shaking. On or about, September 5, 2024, AV rolled to the floor from AV’s bed, resulting in AV being sent to the hospital due to hitting his/her head during the fall. It was discovered prior to AV’s first fall, that staff had not seen AV in approximately two hours and prior to the second fall, staff had not placed a body pillow beside AV prior to the fall. The facility failed to follow AV’s care plans, which is a violation of resident rights, is neglect of care which constitutes abuse.

The Alleged Victim (AV) has a history of falls and requires an escort from his/her room. On or about May 26, 2024, AV left his/her room without an assistive device or any staff assistance, which resulted in AV suffering a fall where he/she suffered a laceration above their eye. Staff saw AV ambulating alone, however, they were busy and couldn't assist AV. The facility's failure to follow the care plan, provide a safe environment and have enough staff to ensure that AV received the care he/she needed 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. AV was care planned for shower assistance one-two times a week and staff is also allowed to offer a bed bath. According to investigation, on or about May 7, 2024, Alleged Perpetrator 2 (AP2) was assisting AV with a shower and when AP2 turned to put up the shower wand, AV fell off the shower chair, resulting in AV bumping his/her head and reporting pain to his/her left hip. It was discovered that AV’s family had previously requested the facility not give AV showers due to safety reasons and history of AV falling in the shower. The facility failed to appropriately care plan, which is a violation of resident rights, is neglect of care which constitutes abuse. The allegation that Alleged Perpetrator 2 (AP2) neglected AV was investigated and determined to be not substantiated.

The Alleged Victim (AV) relies on the facility for care and is a known fall risk. On or about April 28, 2024, AV had unexplained discoloration to AV's left leg. AV had shown a pattern of recent falls, due to trying to self-transfer and propel self in the AV's wheelchair. According to an investigation, the facility failed to implement new interventions after AV's unwitnessed injury falls on April 17, 2024, and April 18, 2024, to mitigate the risk of AV's continued falls. The facility failed to provide services, to include implementing interventions to mitigate AV’s increasing fall risk and ensure resident safety, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is prescribed anti-convulsant medication. On or about March 30, 2024, AV was found in his/her room convulsing by staff. AV was sent to the hospital for treatment. It was discovered by the facility that AV's medication had been erroneously discontinued by the facility pharmacy. AV had missed his/her medication from March 27, 2024 to March 30, 2024. The facility did not have a procedure to ensure changed made on the Medication Administration Record by the Pharmacy were correct. 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) relies on the facility for his/her care and is care planned for toileting assistance. On or about, March 27, 2024, AV used his/her call pendant and was calling out for staff overnight without a response. AV was found soiled in his/her brief/bedding the next morning, resulting in unreasonable discomfort and lack of dignity. It was also discovered that around this time, it was known that the call system was not working properly. The facility failed to provide appropriate services, which is a violation of resident rights, is neglect of care which constitutes abuse. The allegation that Alleged Perpetrator 2 (AP2) and Alleged Perpetrator 3 (AP3) neglected AV was investigated and determined to be not substantiated.

The Alleged Victim (AV) relies on the facility for his/her care. AV is care planned to have footrests on wheelchair removed prior to transfer. According to an investigation, Alleged Perpetrator 2 (AP2) was called over to AV's unit by another staff member and asked to provide AV with transfer assistance. AP2 had not worked in AV's unit nor reviewed AV's care plan and failed to properly transfer AV resulting AV, resulting in AV sustaining a skin tear. The facility failed to follow the care plan and to ensure that AP2 was properly trained, which is violation of resident rights, are considered neglect of care and constitutes abuse. The allegation of neglect of care against AP2 was investigated and determined to be not substantiated.

The Alleged Victim (AV) is a fall risk and has a history of falls. The AV’s fall reduction interventions included a non-slip mat or cushion for their wheelchair seat and to assist the AV to the dining room table when noted to be leaning. According to an investigation, on or about February 17, 2024, the AV was observed leaning in their wheelchair. The AV was not assisted to the table and a non-slip pad was not placed in the wheelchair. The AV was left unattended in a common area, resulting in a fall with an injury to the bridge of the nose. The facility failed to follow the AV’s care plan. The facility's failure is a violation of resident rights, is considered neglect of care, and constitutes abuse.

The Alleged Victim (AV) relies on the facility to manage his/her medications. On or about December 15, 2023, AV was prescribed a narcotic for pain. On or about December 28, 2023, the facility discovered that AV's medication was delivered to the facility. AV did not receive his/her medication for approximately two weeks, resulting in continued pain and unreasonable discomfort. The facility failed to provide a safe medication administration, which is a violation of resident’s rights, is neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately care plan regarding Alleged Victim’s (AV) known fall risk. AV has a history of unsteady gait and shuffling their feet while walking and has multiple documented falls. According to an investigation, on or about November 7, 2023, AV was walking in the courtyard and fell, resulting in a skin tear to his/her right palm, left knee and discoloration on right knee. AV had another fall on or about November 8, 2023, while walking out to the dining area, which resulted in a swollen wrist/hand and a skin tear on left elbow. The facility failed to implement interventions to mitigate AV’s increasing fall risk, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility for care and his or her safety. According to an investigation, on or about July 14, 2023, the facility was made aware of concerns that AV was being verbally mistreated by Witness 6 (W6), and it was causing AV emotional harm. The facility was asked to terminate or, at the least, only allow supervised visits between AV and W6. On or about August 10, 2023, the facility indicated they could not limit visitors and did not provide supervised visits. Then on approximately October 20, 2023, concerns were again brought up about the ongoing verbal abuse and treatment of AV by W6, and facility staff wrote written statements of concern for facility management, prompting the facility to exclude W6 from visiting AV. The facility failed to protect a resident from verbal/emotional abuse, 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 regarding Alleged Victim’s (AV) known fall risk. AV has a history of unsteady gait and shuffling their feet while walking and had multiple documented falls. According to an investigation, on or about October 4, 2023, AV was walking in the courtyard and fell, resulting in a skin tear to their shoulder. The facility failed to implement interventions to mitigate AV’s increasing fall risk, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about September 5, 2023, a friend of the Alleged Victim (AV) noted that AV had not received a shower in approximately two weeks. AV is care planned for two showers per week with assistance from staff. AV was embarrassed to go to church or social activities because he/she felt unclean, which is a loss of personal dignity. The facility's failure to provide hygiene services is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) has a history of falls and was care planned as a high fall risk and one-person assist with all transfers. According to an investigation, on or about September 1, 2023, AV fell while self-transferring out of bed into his/her wheelchair. AV was sent to the emergency department where he/she was diagnosed with a head injury. The facility failed to properly care plan to mitigate risk of falls and self-transferring, 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 Witness 3 (W3) by attempting interventions to prevent resident to resident altercations. The failure resulted in multiple physical resident to resident altercations with the Alleged Victim (AV) resulting in injuries, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is care planned to have assistance with nail trimming. AV's nails were noticed by family to be overgrown by 1/2 to 1 inch and were very dirty. AV received a nail trimming from family, and AV experienced pain during the nail trim due to his/her nails being very long. The facility's failure to ensure AV was provided hygiene services is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is care planned to have assistance with brushing his/her teeth and scheduling appointments. AV and his/her family had requested AV to have a dental appointment, however, the facility failed to make a dental appointment for him/her. AV also was not receiving assistance with brushing his/her teeth, leaving his/her teeth dirty. The facility's failure to assist with hygiene 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 environment to prevent the Alleged Victim (AV) from eloping. The failure resulted in the AV taking a dining room chair and used it to climb over the patio fence, sustaining scrapes and bruises, and was returned to the facility by police, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to follow the care plan by ensuring the Alleged Victim’s (AV) walker was oriented in the appropriate direction before the AV used it. The failure resulted in the AV falling and suffering a fracture which required surgical intervention. The AV is not expected to return to baseline for ambulation and will require a wheelchair for future ambulation, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about January 9, 2023, it was discovered that the Alleged Victim’s (AV) narcotic medication was missing. The medication was never logged into the narcotic log book, therefore was never regularly counted as it should have been. Alleged Perpetrator #2 (AP2, Unknown) has taken AV’s narcotic medication, which is a violation of resident rights, is considered neglect of care and constitutes financial abuse. The facility’s failure to protect AV from financial abuse is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about November 8 and November 9, 2022, Witness #1 (W1) shoved the Alleged Victim (AV). Interventions were put into place for staff to redirect residents away from W1, however, there were not enough staff available to ensure this intervention was effective. The facility failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about October 1, 2022, the Alleged Victim (AV) was found walking down the street by law enforcement. AV left the facility unassisted, placing AV at risk for harm. 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 to have his/her legs covered at all times to avoid AV picking at his/her legs causing sores. On or about August 3, 2022, it was noted by AV's family that AV's legs were not covered and his/her legs were bloody from AV picking at the sores on his/her legs from edema. The facility failed to follow the care plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) was consistently combative and resistant to care. AV was prescribed medication to assist with anxiety and agitation, which may have allowed staff to assist AV with his/her care, however, AV was only given the medication on two occasions. On or about May 4, 2022, staff noticed a large amount of blood in AV's bed and sent AV out to the hospital. Hospital staff noted that AV had multiple stage 2 pressure ulcers, extensive skin breakdown, infection, sepsis, dehydration and pain, which appears to be related to incontinence with prolonged time without cleaning. The facility's failure to provide proper care is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to implement interventions, appropriately care plan, and provide adequate supervision, according to AV and W1's history of sexualized behaviors. The failure resulted in sexual contact between AV and W1, placing both residents at risk of serious harm and loss of personal dignity, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

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.

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.

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.

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.

Based on interview and record review, the facility failed to complete or update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly as required.The facility’s failure 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.

The facility failed to provide a safe medication administration system for the Alleged Victim (AV). According to an investigation, AV experienced no negative outcome. The failure is a violation of Oregon Administrative Rules.

The facility failed to provide a safe medication administration system for the Alleged Victim (AV). According to an investigation, AV experienced no negative outcome. The failure 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.

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 July 12, 2024, Alleged Perpetrator 2 (AP2) was providing incontinence care to the Alleged Victim (AV) in his/her bed and used excessive force while turning AV, causing AV to hit his/her head on the wall, causing a small bump on AV's head. AV responding in pain by crying after the incident. AP2's actions caused physical harm to AV, which is a violation of resident rights, is considered neglect of care and constitutes physical abuse. The facility failure is a violation of Oregon Administrative Rules.

Alleged Perpetrator 2 (AP2) made derogatory and demeaning remarks to a co-worker while providing incontinence care to the Alleged Victim (AV) in AV's presence, causing AV to cry. AP2's actions caused AV emotional distress, which is a violation of resident rights, is considered neglect of care and constitutes emotional and verbal abuse. The facility failure is a violation of Oregon Administrative Rules.

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

The facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) is known to be verbally and physically aggressive with staff. AV's care plan directs staff to remove themselves and request another staff if AV is upset with that staff member. On or about May 4, 2024, Alleged Perpetrator #2 (AP2) had experienced AV demonstrating heightened aggression. AP2 went into another residents room and AV was in the room. AP2 directed AV to leave the room, however, AV's behavior escalated and AP2 pushed AV out of the way to leave the room. AP2's actions are a violation of resident rights, are considered neglect of care and constitute physical abuse. The facility's failure to protect AV from physical abuse is a violation of Oregon Administrative Rules.

The facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules.

Alleged Victim (AV) relies on the facility for assistance with mobility, which includes two-person transfers. On or about April 27, 2024, the Alleged Perpetrator 2 (AP2) did not follow AV's care plan and transferred AV by themselves resulting in AV receiving a skin tear requiring first aid and a hospital visit. AP2's actions are considered neglect and constitutes abuse. The facility failed to ensure care plans were followed which is a violation of Oregon Administrative Rules.

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 April 15, 2024, Alleged Perpetrator #2 (AP2) and Witness #2 (W2) were assisting the Alleged Victim (AV) with a shower. During the shower, AV indicated he/she needed to use the bathroom, and started to urinate and have a bowel movement. AP2 became upset and called AV stupid, causing AV emotional distress. AP2's actions are a violation of resident rights, are considered neglect of care and constitute emotional abuse. The facility's failure to protect AV from emotional abuse is a violation of Oregon Administrative Rules.

On or about April 15, 2024, Alleged Perpetrator #2 (AP2) and Witness #2 (W2) were assisting the Alleged Victim (AV) with a shower. During the shower, AV indicated he/she needed to use the bathroom, and started to urinate and have a bowel movement. AP2 became upset and slapped AV on the hand, which is physical abuse. AP2's actions are a violation of resident rights, are considered neglect of care and constitute physical abuse. The facility's failure to protect AV from physical abuse is a violation of Oregon Administrative Rules.

On or about April 15, 2024, Alleged Perpetrator #2 (AP2) and Witness #2 (W2) were assisting the Alleged Victim (AV) with a shower. During the shower, AV indicated he/she needed to use the bathroom, and started to urinate and have a bowel movement. AP2 became upset and slapped AV on the hand, which is physical abuse. AP2's actions are a violation of resident rights, are considered neglect of care and constitute physical abuse. The facility's failure to protect AV from physical abuse is a violation of Oregon Administrative Rules.

The facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) was a known fall risk with a history of falls. On or about January 5, 2024, the Alleged Perpetrator 2 (AP2) was sleeping during their shift. The AV fell around 1:00 am and was assisted by a new staff in training, posing a serious risk of harm. AP2's actions are considered neglect and constitutes abuse. The facility failed to provide a safe environment, which is a violation of Oregon Administrative Rules.

The facility failed to have a secured janitor closet for storing supplies and equipment and have the capacity for locked storage of chemicals. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to ensure that prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to ensure the implementation of services. An investigation determined this is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) relies on the facility for assistance with mobility, which includes two-person transfer. AV is also not to be left alone while he/she is toileting. On or about July 29, 2023, the Alleged Perpetrator 2 (AP2) did not follow AV's care plan. AP2 transferred AV by themselves and left AV alone on the toilet. AV attempted to get off the toilet by him/herself, which resulted in AV falling and hitting his/her head. AV experienced head pain and dizziness. AP2's actions are considered neglect and constitutes abuse. The facility failed to ensure care plans were followed which is a violation of Oregon Administrative Rules.

On or about April 29, 2023, it was discovered that a bubble pack of the Alleged Victim's (AV) narcotic medication had been tampered with and the narcotic medication had been replaced with allergy medication. An investigation could not determine which staff member was responsible for the diversion of the medication. Alleged Perpetrator #2 (AP2) was determined to be inconclusive in this investigation. Alleged Perpetrator #3 (AP3, Unknown) was determined to have taken the medication, which is a violation of resident rights, is considered neglect of care and constitutes financial abuse. The facility's failure to protect the residents from financial abuse is a violation of Oregon Administrative Rules.

On or about April 29, 2023, it was discovered that a bubble pack of the Alleged Victim's (AV) narcotic medication had been tampered with and the narcotic medication had been replaced with allergy medication. An investigation could not determine which staff member was responsible for the diversion of the medication. Alleged Perpetrator #2 (AP2) was determined to be inconclusive in this investigation. Alleged Perpetrator #3 (AP3, Unknown) was determined to have taken the medication, which is a violation of resident rights, is considered neglect of care and constitutes financial abuse. The facility's failure to protect the residents from financial abuse is a violation of Oregon Administrative Rules.

On or about April 29, 2023, it was discovered that a bubble pack of the Alleged Victim's (AV) narcotic medication had been tampered with and the narcotic medication had been replaced with allergy medication. An investigation could not determine which staff member was responsible for the diversion of the medication. Alleged Perpetrator #2 (AP2) was determined to be inconclusive in this investigation. Alleged Perpetrator #3 (AP3, Unknown) was determined to have taken the medication, which is a violation of resident rights, is considered neglect of care and constitutes financial abuse. The facility's failure to protect the residents from financial abuse is a violation of Oregon Administrative Rules.

The facility failed to ensure the implementation of services. The facility’s failure is a violation of Oregon Administrative Rules.

On or about November 18, 2022, the Alleged Victim (AV) slipped out of his/her recliner and was found on the floor. Alleged Perpetrator #2 (AP2) saw AV, however, did not perform an assessment on AV for injuries. On November 26, 2022, AV was assessed for injury after a fall, and staff found that AV had latent discoloring on his/her lower back and was expressing pain. AV was sent to the hospital and was diagnosed with a hematoma to the abdomen and abnormal lab ranges. AP2's failure to complete an assessment on AV 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) was laughing at the Alleged Victim (AV) on a video that AP2 took of AV smoking from a vape pen, given to AV by AP2. AP2’s actions are a violation of resident rights, are considered neglect of care and constitute emotional abuse. The facility failed to provide a safe environment which violates Oregon Administrative Rules.

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

On or about December 3, 2021, the Alleged Victim (AV) was found by staff in his/her room with a soiled brief and dried vomit on his/her clothing. AV's window was open and it was very cold in his/her room. Alleged Perpetrator #2 (AP2) was working the overnight shift and did not check on AV to ensure his/her needs were met. AP2's actions are a violation of resident rights, are considered neglect of care and constitute abuse.