Fieldstone Village at Keizer Ridge

According to the documentation, the Alleged Perpetrator 2 (AP2) failed to provide a safe medication administration system for the Alleged Victim (AV) by giving them the wrong medication. On or about December 21, 2024, AP2 was passing medications to the AV. during this medication pass, AP2 failed to check the medication card for the AV’s name, prescription, narcotic log or MAR to ensure the medication card belonged to the AV. AP2 gave the AV another residents medication which made them drowsy to the point where they could not stay awake to eat, stand safely or take a shower. AP2 failed to provide a safe medication administration system for the AV resulting in adverse side effects, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim's (AV) family member reported to facility staff on April 1, 2024, that AV wasn't feeling well. Staff did not check on AV and on or about April 3, 2024, AV took an over-the-counter test for a urinary tract infection, which returned positive. AV was experiencing back pain and frequent urination. On or about April 6, 2024, AV was taken to urgent care by a family member, and it was determined that AV had a urinary tract infection, and medication was prescribed and AV received his/her antibiotics on April 7, 2024. The respondent's failure to ensure timely medical treatment and respond to a change of condition caused pain and unreasonable discomfort to AV. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i)

The Alleged Victim (AV) was a known fall risk and had suffered falls in previous months. On or about March 24, 2024, AV fell while showering and suffered a broken shoulder. AV was placed on frequent checks, however, AV fell again. Documentation shows that frequent checks were being completed for AV even as AV was out of the facility. The facility failed to properly care plan to ensure AV would be safe from falls. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about April 1, 2024, the Alleged Victim (AV) was found to have skin breakdown on his/her sacrum. AV was admitted to the hospital on April 2, 2024, with moisture associated skin damage. AV was care planned for peri care after incontinence and was to have nystatin powder applied four times per day. None of this care was marked completed in AV's record. The facility's failure to mitigate AV’s skin damage caused unreasonable discomfort to AV. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility's failure caused unreasonable discomfort to 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 and has suffered numerous falls at the facility, including one that resulted in a spinal fracture. AV returned to the facility in February 2024 after recovery from the spinal fracture. On or about March 8, 2024, AV suffered another fall where AV suffered a laceration to his/her hand and head, requiring stitches. The facility failed to update AV's care plan to ensure effective fall interventions were in place. The facility's failure 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) fall history. From approximately November 26, 2023, through January 30, 2024, the AV experienced approximately five (5) falls with and without injury. There was interim service plans created with interventions to prevent falls, but the interventions were not effective in preventing the falls. On or about January 03, 2024, an outside provider recommended ambulation assistance to and from the restroom. There is no documented evidence the facility documented this intervention on the AV’s service plan. Since this recommendation, the AV experienced two more non-injury falls, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) had a history of falls. The AV experienced falls in November and December of 2023, some with and without injury. The facility implemented some interventions after AV's November 28, 2023 fall, however, AV suffered 3 more falls, with the fall on December 27, 2023 resulting in AV suffering a skin tear and increased back pain. On or about December 28, 2023, AV was transported to the hospital and diagnosed with a vertebral fracture and had to be sent to a skilled nursing facility for rehabilitation. The facility's failure to properly care plan is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility for their care and has a history of falls. AV is care planned for a two-person transfer and is known not to push call pendant to have staff assist with transfers. According to an investigation, between November 3, 2023, and December 16, 2023, AV experienced multiple falls while attempting to self-transfer, resulting in repeated unreasonable discomfort. The facility failed to provide appropriate services, to include care planning and/or implementation of interventions, which is a violation of resident rights, is considered neglect of care and constitutes abuse., which is a violation of resident rights, is neglect of care which constitutes abuse.

The Alleged Victim (AV) had a recent diagnosis of a neurological condition which impairs balance and mobility. AV was a high risk for falls and had a history of falls. AV suffered a fall on December 12, 2023 which he/she hit his/her head. The facility failed to implement interventions to prevent further falls. On or about December 13, 2023, AV suffered another fall and was sent to the hospital and diagnosed with a fractured hip. The facility's failure to properly care plan is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) receives medication for Leukemia, which needs to be ordered every 18 days. Staff marked the medication as ordered, however, it was not ordered. AV went without his/her medication from October 19, 2023 to October 23, 2023, placing AV at risk for harm. 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) receives medication for Leukemia, which needs to be ordered every 18 days, however, staff are waiting to order when there are 7-10 days left. AV went without his/her medication from September 12, 2023 to September 21, 2023, placing AV at risk for harm. 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) moved into the facility on October 10, 2023. The facility was to dispense AV's medication to him/her. AV's adult child gave the facility all of AV's medications to dispense beginning on October 11, 2023. Facility staff failed to dispense medication to AV for approximately 5 days, placing AV at risk for serious harm. 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) moved into the facility on October 10, 2023. The facility was to dispense AV's medication to him/her. AV's adult child gave the facility all of AV's medications to dispense beginning on October 11, 2023. Facility staff failed to dispense medication to AV for approximately 5 days, placing AV at risk for serious harm. 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) moved into the facility on July 27, 2023. AV had medications that the facility was to administer to AV. On July 28, 29 and 30, AV did not receive his/her medications as ordered, placing AV at risk for harm. 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) was scheduled to receive medication daily for his/her seizure disorder. AV did not receive his/her medication on May 28, 2023 and May 29, 2023, placing AV at risk for harm. 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) has suffered previous falls. On or about March 19, 2023, AV suffered a fall after using the restroom, was transported to the hospital and diagnosed with a broken arm. The facility's failure to properly care plan for AV's safety is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) was prescribed 1-10 mg pain medication. AV was given 1 1/2 tablets of 10 mg pain medication, which led to AV running out of his/her pain medication. AV reported going through withdrawals due to running out of medication early, causing unreasonable discomfort. 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.

On or about January 27, 2023, the Alleged Victim (AV) brought four cups of medication to the office. Staff were leaving AV's medications in his/her room and not watching AV take his/her medications. The medications in question included heart, blood pressure and pain medications. Staff were not following AV's care plan or internal policies of watching AV take his/her medications. The facilities failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about January 27. 2023, the Alleged Victim (AV) asked another resident to request a PRN narcotic medication so they could give it to AV, because he/she was experiencing pain. On three separate occasions, the facility has run out of AV's narcotic pain medication, most recently on January 26 and 27. AV did not receive his/her pain medication for four doses, leaving him/her in pain. The facility's failure to provide medication as ordered is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) was a known fall risk, and was also known to forget to call for assistance. AV was care planned for a two person transfer. On or about December 9, 2022, AV suffered a fall in his/her bathroom and was found on the floor by staff. AV was transferred to the hospital and was diagnosed with a fractured leg. The facility's failure to properly care plan to ensure AV's safety is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about October 24, 2022, the Alleged Victim (AV) was found outside the facility at a neighboring apartment complex. AV was care planned to be on 1 to 1 care, due to his/her wandering. The facility failed to have enough staff to complete 1 to 1 care this day and AV left the facility, placing AV at risk for harm. The facility failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about September 27, 2022, Alleged Perpetrator #2 (AP2) gave old seizure medication to the Alleged Victim (AV). This medication had been discontinued by AV's physician due to the medication not working and AV receiving new seizure medication. AV knew it was the incorrect medication, AV did not take it and AP2 did not stay to witness AV taking the medication. AV's correct medication was in the overstock area, AP2 grabbed the incorrect medication. AV suffered a seizure the next morning. AP2 had made prior medication errors at the facility, however, the facility failed to provide additional training to ensure prevention of future medication errors. AP2's actions are a violation of resident rights, are considered neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system, 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) received his/her medication as ordered. AV was sent to the hospital on September 16, 2022 and returned the same day, however, staff did not know AV had returned. AV went without needed medication for three medication passes, placing AV at risk for harm. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) had an order to be administered an inject-able medication daily. Staff needed to be delegated in order to administer the medication, and staff that were administering medications on July 20 and July 21, 2022. AV missed this medication again on July 26, 2022, as staff was still not delegated to administer the medication. AV was placed at risk for serious harm by not receiving this medication as ordered on multiple occasions. The facility's failure to administer medication as ordered is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about June 25, 2022, the Alleged Victim (AV) was given another resident's medication by Alleged Perpetrator #2 (AP2), placing AV at risk for harm. AP2 was not delegated to dispense medication and had not had his/her verification of skills checklist completed. The facility failed to ensure AP2 was properly trained and delegated prior to letting him/her dispense medication on his/her own. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about June 20, 2022, the Alleged Victim (AV) was not given his/her morning dose of insulin. A staff was not delegated to give insulin and tried to contact other staff to assist, and was unsuccessful. AV did not get his/her morning insulin until noon, resulting in AV having very high blood sugar and having to be sent out to the hospital for observation. AV was placed at risk for serious harm by not receiving his/her medication as ordered. The facilities 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 receive daily medication for memory. The facility failed to re-order AV's medication timely, leaving AV without his/her medication for approximately a week, causing AV to have more confusion and behaviors. The facility failed to provide medication as ordered, 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) pain medication was available to be administered as ordered. He/she went without medication for at least 5 consecutive doses resulting in the inability to sleep. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about February 20, 2022, the Alleged Victim (AV) advised staff that he/she was not feeling well and had vomited. No treatments were offered to AV to help ease his/her discomfort. Staff did not notify the Nurse or place AV on any type of alert charting to monitor his/her symptoms. On or about February 22, 2022, AV requested to be sent to the Emergency Room and was diagnosed with a bowel obstruction. The facility's failure placed AV at risk for serious harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility’s failure to use the results of an ABST to develop and routinely update the facility’s posted staffing plan and complete or update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to develop, maintain, and implement an Acuity Based Staffing Tool in accordance with OAR 411-054-0037(1-7).

The facility failed to develop, maintain, and implement an acuity-based staffing tool in accordance with OAR 411-054-0037(1-7). Per complainant, If I’m doing a med pass and they are helping someone who is a two person assist there is no one on the floor.

The facility failed to develop, maintain, and implement an Acuity Based Staffing Tool. The facility’s failure is a violation of Oregon Administrative Rules.

The facility allegedly failed to develop, maintain, and implement an Acuity Based Staffing Tool. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to develop, maintain, and implement an Acuity Based Staffing Tool. The facility’s failure is a violation of Oregon Administrative Rules.

According to the documentation, the Alleged Perpetrator 2 (AP2) failed to provide a brief change for the Alleged Victim (AV) when they called for assistance. On or about September 03, 2024, the AV used their call button to request services to be changed as they had urinated in their brief. The AP2 answered the call light and said they would be right back to assist the AV. The AP2 did not return to the AV and the oncoming shift changed the AV approximately four hours later. The AP2 failed to provide a brief change for the AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to protect the resident which is a violation of Oregon Administrative Rules.

According to the documentation the facility failed to protect the Alleged Victim (AV) from financial abuse. Witness 2 (W2) found the AV’s ID and insurance cards in the toilet cover dispenser in a community bathroom. The AV was aware their wallet was missing but thought it was misplaced in their room. It is documented the AV does not use the community restroom down stairs. It was determined an Unknown perpetrator (AP2) stole the AV’s wallet and took their debit and credit care. AP2 failed to protect the AV from financial abuse, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to protect the AV from financial abuse, which is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) relies on facility staff to ensure resident’s rights. According to an investigation, on or about August 26, 2024, it was discovered that unknown Alleged Perpetrator 2 (AP2) stole a diamond from AV's ring. AP2's actions are considered financial exploitation and constitutes abuse. The facility did not keep AV free from financial exploitation, which is a violation of Oregon Administrative rules.

The Alleged Victim (AV) is to receive his/her blood pressure medication once a day in the morning. On or about June 19, 2024, AV was given his/her last pill of this medication. The facility failed to re-order AV's medication, causing AV to not receive his/her medication for three days. Staff are to re-order medication 5 days prior to the last dose is given. 6 different staff administered the last 7 doses of AV's medication and did not re-order the medication. The facility's failure is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) had money taken from his/her room. AV had approximately $200.00 in a money clip. AV noticed the cash was missing and only $14.00 remained. AV's money was taken by an unknown Alleged Perpetrator #2 (AP2). AP2's actions are a violation of resident rights, are considered neglect of care and constitutes financial abuse. The facility's failure to protect AV from financial abuse is a violation of Oregon Administrative Rules.

The facility failed to fully implement and update an acuity-based staffing tool. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

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 this is a violation of Oregon Administrative Rules.

The facility failed to have all equipment necessary for the health, safety, and comfort of the resident must be kept clean and in good repair. An investigation determined this 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 occurred.

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

The facility failed to carry out medication orders as prescribed, multiple residents medications were discontinued without orders. An investigation determined this is a violation of Oregon Administrative Rules.

On or about February 19, 2024, the Alleged Victim (AV) reviewed video footage in his/her room and found that the Alleged Perpetrator #2 (AP2) took his/her phone charger from his/her room. AP2's actions are a violation of resident rights, are considered neglect of care and constitute financial abuse. The facility's failure to protect AV from financial abuse is a violation of Oregon Administrative Rules.

The facility failed to have a staff person who administers the medication visually observe the resident take the medication unless the prescriber's order for that specific medication states otherwise, which is a violation of Oregon Administrative Rules.

The facility failed to carry out medication and treatment orders as prescribed per complaint that on 09/22/23 at 1400 hours a resident had been given another residents levothyroxine, which is a violation of Oregon Administrative Rules.

On or about August 31, 2023, the Alleged Victim (AV) gave Alleged Perpetrator #2 (AP2) his/her debit card to take AP2's child to the fair. AP2 removed $200.00 from an ATM with AV's debit card. AP2's actions are a violation of resident rights, are considered neglect of care and constitute financial abuse. The facility failed to protect AV from financial abuse, which is a violation of Oregon Administrative Rules.

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

The facility failed to implement a service plan that reflects the resident's needs as identified in the evaluation, which is a violation of Oregon Administrative Rules.

On or about May 28, 2023, the Alleged Victim (AV) called for assistance. Alleged Perpetrator #2 (AP2) answered the call to transfer AV to use the restroom. AP2 failed to follow the care plan to transfer AV with a gait belt and two people AP2 picked AV up, in effort to transfer AV when AV slipped from AP2's grasp, falling to the ground and suffering a fracture to his/her femur. AP2's actions are a violation of Resident rights, are considered neglect of care and constitute abuse. The facility's failure is a violation of Oregon Administrative Rules.

On or about February 15, 2023, it was discovered through documentation review that the Alleged Victim (AV) had not received his/her mood altering medication for 30 days or more. Alleged Perpetrator #2 (AP2) was a newer employee and did not understand that he/she needed to check that particular time frame for medication pass. AV did not have any adverse reaction noted, however, missing medication could place AV at risk for harm. The facility failure to provide a safe medication administration system is a violation of Oregon Administrative Rules.

On or about January 18, 2023, Alleged Perpetrator #2 (AP2) was passing medications to Witness #2 (W2). AP2 did not watch W2 take the medication and walked away prior to W2 taking the medication. W2 set his/her medication down on the table between W2 and the Alleged Victim (AV). AV took the medication that was in the cup. There was no negative outcome to AV. The facility's failure to provide a safe medication administration system is a violation of Oregon Administrative Rules.

On or about November 7, 2022, Alleged Perpetrator #2 (AP2) accepted $300.00 from the Alleged Victim (AV) via an inter-bank transfer. AP2 removed the money from his/her account via automated teller machine. AP2 may have given the money back to AV, however, taking money from residents for any reason, in any form is not allowed, and considered financial abuse. AP2's failure 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 Oregon Administrative Rules.

On or about October 16, 2022, it was discovered by facility staff that the Alleged Victim's (AV) had missing pain medication. It is unknown when the medication went missing or who took the medication. Alleged Perpetrator #2 (AP2, Unknown) took the missing medication, which is a violation of resident rights, is considered neglect of care and constitutes financial abuse. The facility failed to protect AV from financial abuse, which is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) receives inject-able blood sugar medication when his/her blood sugar count is above 110. On or about October 3, 2022, Alleged Perpetrator #2 (AP2) gave AV his/her medication even though his/her blood sugar was below 110. AP2's failure to provide a safe medication administration system is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failure is a violation of Oregon Administrative Rules.

The facility failed to ensure proper storage of medications and ensure the medication administration record (MAR) was clear regarding insulin given to residents. The Alleged Victim (AV) and another resident were scheduled to receive the same dosage at the same time of insulin. A loose insulin pen was found in the med room drawer, and only one injection was in the sharps container, however, the MAR indicated both residents received their medication. The failure is a violation of Oregon Administrative Rules.

The facility failed to ensure proper storage of medications and ensure the medication administration record (MAR) was clear regarding insulin given to residents. The Alleged Victim (AV) and another resident were scheduled to receive the same dosage at the same time of insulin. A loose insulin pen was found in the med room drawer, and only one injection was in the sharps container, however, the MAR indicated both residents received their medication. The failure is a violation of Oregon Administrative Rules.

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

The facility failed to carry out medication and treatment orders which is a violation of Oregon Administrative Rules.

On or about June 1, 2022, it was discovered that the Alleged Victim (AV) had 4 cups of medications in his/her room that weren't taken by AV. Medication Technician staff are to watch residents take medication and not leave medication in AV's room. The facility failed to provide a safe medication administration system, which is a violation of Oregon Administrative Rules.