Monarch Gardens Memory Care

Witness 1 (W1) has a known history of behaviors and or aggression. On or about July 29, 2023, Alleged Victim (AV) was seated at a table in his/her wheelchair when W1 approached and grabbed AV by the shoulder and shook and pulled on AV. Between June 19th through July 27, 2023, W1 was involved in approximately 25 behaviors and or altercations with residents and or staff, putting residents in risk of harm. The facility failed to provide a safe environment for AV, putting AV in risk of harm, which is a violation of resident rights, is neglect of care and constitutes abuse.

Witness 1 (W1) has a known history of behaviors and or aggression. On or about July 17, 2023, Alleged Victim (AV) held their arms out to give W1 a hug. W1’s reaction was to punch AV on the arm, shoulder, and face. AV was slumped in the corner of his/her wheelchair with a blanket covering him/her up. When AV was asked if he/she was hurt, he/she said yes, his/her feelings where hurt. This was the second incident in which W1 has been the aggressor towards AV. The facility failed to provide a safe environment for AV, leading to AV sustaining emotional harm, which is a violation of resident rights, is neglect of care and constitutes abuse.

Witness 1 (W1) has a known history of behaviors and or aggression. On or about July 16, 2023, W1 was walking around in the dining room and walked up to Alleged Victim (AV) and accused AV of stealing. As a result, W1 smacked AV on the head. W1 has hit other residents in the head in prior resident-to-resident altercations. Between June 19th through July 9th, 2023, W1 was involved in approximately 19 altercations and or behavior incidents. There are no indications any updates to W1’s care plan was done prior to the incident from July 16, 2023. The facility failed to care plan around W1’s known history of behaviors, which is a violation of resident rights, is neglect of care and constitutes abuse.

Witness 1 (W1) has a known history of behaviors. Between June 19th through 23rd, 2023, W1 yelled and hit staff or attempted to hit staff on eight (8) occasions, between that same timeframe, W1 was involved in three (3) resident-to-resident altercations. On or about June 23, 2023, W1 was wandering the dining room hall agitated and cursing. Alleged Victim (AV) told W1 he/she needed to watch his/her language. W1 then grabbed AV’s hair and started pulling it, which put AV in risk of harm. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. On or about May 31, 2023, AV was heard yelling, when staff entered the room, they found AV laying on his/her roommate’s bed on his/her back. AV’s roommate was standing over AV holding him/her down by the wrists. Between February 15th through May 31st, 2023, it was listed 15 times in the Observation notes that AV had physical or verbal altercations or behaviors. AV’s care plan had no interventions in the Behavioral plan. The facility failed to properly plan care around AV’s known history of behaviors putting AV in risk of harm, which is a violation of resident rights, is neglect of care and constitutes abuse.

Witness 1 (W1) has a known history of behaviors. Between February 15, 2023, through May 11, 2023, W1 had 5 incident reports written regarding physical behaviors with AV. On or about May 11, 2023, W1 was found over Alleged Victim (AV) on W1’s bed. W1 had his/her first raised and was holding AV down against the bed with their other hand. The facility failed to provide a safe environment for AV leading to several confrontations between W1 and AV, putting AV in risk of harm, which is a violation of resident rights, is neglect of care and constitutes abuse.

Witness 1 (W1) has a known history of behaviors. Between February 15, 2023, through May 6, 2023, W1 had four (4) incident reports regarding behaviors with Alleged Victim (AV). Between February 15, 2023, through May 16, 2023, W1 had eight (8) listed physical altercations or behaviors. On or about May 9, 2023, per video recording being reviewed, it was discovered that W1 opened handed pushed AV’s arm and AV open handed pushed W1 back resulting in a resident-to-resident altercation, and putting AV in risk of harm. The facility failed to provide a safe environment, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. On or about May 6, 2023, after reviewing the camera recording, it was discovered that AV open handed pushed Witness 1’s (W1) arms and W1 open handed pushed AV back. Between February 15th through May 6, 2023, AV had eight (8) incident reports written regarding physical behaviors. The facility failed to provide a safe environment for AV putting AV in risk of harm, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/care. On or about May 6, 2023, AV was sitting on the floor in the dining room and began scooting on their behind ending up close to Witness 1 (W1). W1 then punched AV in the head for no apparent reason. W1 stated that he/she did not hit AV and that AV hit him/her first, which was not the case per the video being reviewed. W1 has a history of physical aggression towards other resident resulting in W1 hitting or slapping others, AV and W1 have also been in prior altercations. The facility failed to provide a safe environment for AV, putting AV in risk of serious harm, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) is known to become easily agitated. On or about April 25, 2023, AV went up to Witness 1 (W1) and stated stomping on their feet. W1 then tried stomping back and AV started stomping and also kicking W1’s shins. AV has had prior incident of foot stomping and kicking involving other residents including W1, which puts AV in risk of harm. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) often has behaviors related to their cognitive decline, is constantly confused, and needs cueing/redirecting often. Staff are required to supervise AV as much as possible. On or about May 25, 2023, Witness 1 (W1) went to AV and started stomping on their feet. AV then tried stomping back and W1 started stomping/kicking AV’s shins. It appears that as the altercation had occurred, staff noticed AV and W1 and separated the two, however, AV’s care plan states staff are required to supervise AV as much as possible, it is more likely than not that if AV was being monitored, the altercation may have been avoided. The facility failed to follow AV’s care plan, which is a violation of resident rights, is neglect of care and constitutes abuse.

Witness 1 (W1) is known to have aggressive behaviors. On or about April 21, 2023, W1 was seen in a boxing position during a resident-to-resident altercation with Alleged Victim (AV). AV states W1 had a hold around his/her neck, W1 has stated AV had punched him/her. W1 has previously punched AV and W1 has been in several prior altercations with residents, during one of those altercations, W1 has also had other residents in a choke hold. The facility failed to provide a safe environment for AV, putting AV in risk of harm, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim’s (AV’s) care plan states he/she is a high fall risk and would try to get up and forgets he/she cannot ambulate very well without his/her wheelchair. On or about March 16, 2023, AV was found on the floor of his/her room by a non-staff member. AV was found near his/her bed. This has not been the first occasion in which AV has been found on the floor. AV was previously found on the floor in their apartment on or about December 15, 2022, putting AV in risk of harm. The facility failed to follow the care plan regarding AV’s high fall risk, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) has a combative history with staff to include hitting while receiving care. On or about March 12, 2023, AV was involved in a resident-to-resident altercation with Witness 1 (W1). AV came up to W1 and poked W1 causing W1 to respond by punching AV in the arm and then AV responded by punching W1 in the chest. The facility failed to provide a safe environment for AV, which put AV in risk of harm, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) has a history of combative/aggressive behaviors with other residents and staff members. On or about March 12, 2023, AV was involved in a resident-to-resident altercation with Witness 1 (W1), which was described as W1 poking at AV causing AV to respond by punching W1 in the arm and W1 then responding by punching AV in the chest. The facility failed to provide a safe environment for AV, putting AV in risk of harm, which is a violation of resident rights, is neglect of care and constitutes abuse.

Witness 1 (W1) has a known history of sexualized behaviors. On or about March 12, 2023, W1 approached Alleged Victim (AV) while AV was sitting in their wheelchair in the doorway of their room and reached out and grabbed them by the breast. W1 has prior incidents of sexualized behaviors with other residents. The facility failed to provide a safe environment for AV, which is a violation of resident rights is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care and oversight. On or about January 20, 2023, AV approached Witness 2 (W2) while Witness 1 (W1) was standing next to W2. AV reached out and grabbed W2’s chest which triggered W1 to hit AV with their cane. The facility failed to provide a safe environment for AV by not providing oversight to assure AV’s safety, which is a violation of resident rights, is neglect of care and constitutes abuse.

Witness 1 (W1) has been having an increased aggressive behavior towards other residents. On or about February 23, 2023, W1 slapped Alleged Victim (AV) in the face for no apparent reason. AV then proceeded to pin W1’s arm that W1 used to slapped AV with. W1 have been in prior resident to resident altercations in which W1 has been the aggressor and there were no previous interventions documented. The facility failed to provide a safe environment for AV, putting AV in risk of harm, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) is care planned as moderately challenged in cognition, constantly confused, and needs cuing and to be redirected often, staff is required to have AV supervised as much as possible. On or about February 23, 2023, AV entered Witness 1’s (W1’s) room. W1 saw AV enter their room and followed AV into the room. A slap sound and yelling were heard and AV left W1’s room holding their face. There is no indication that AV was being supervised by staff to have avoided AV from wondering into W1’s room and getting slapped. The facility failed to follow AV’s care plan putting AV in risk of harm, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) has been having an increased aggressive behavior towards other residents. On or about February 23, 2023, AV slapped Witness 1 (W1) in the face for no apparent reason. W1 then proceeded to pin AV’s arm that AV used to slapped W1 with, putting AV in risk of harm. AV has been in prior resident to resident altercations in which AV has been the aggressor and there were no previous interventions documented. The facility failed to properly plan care and put proper interventions in place regarding AV’s aggressive behaviors towards other residents, putting AV in risk of harm, which is a violation of resident rights, is neglect of care and constitutes abuse.

Witness 1 (W1) has a known history of sexual behaviors. On or about January 22, 2023, after camera footage was reviewed, it was determined that W1 slapped Alleged Victim (AV) on their butt as AV was exiting their room. As a result, the slap caused AV to sustain a fall putting AV in risk of harm. The facility failed to provide AV with a safe environment, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) has a known history of wandering into other resident rooms. On or about February 15, 2023, AV tired to enter into Witness 1’s (W1’s) room. W1 yelled at AV and so AV walked away and sat at the table. W1 then came out of their room and went over to AV. Staff heard AV say “ouch!” and when they rushed to see what had happen, they saw W1 with a clinched fists standing over AV. AV was holding the left side of their head. Other residents witnessed the incident and conformed AV got hit in the head by W1 with a closed fist. AV has had about seven (7) incidents of wandering into other residents’ rooms where resident-to-resident altercations have occurred between November 4, 2022, through February 15, 2023. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Witness 1 (W1) has a history of physical and verbal behaviors which had increased. On or about January 31, 2023, W1 was involved in a resident-to-resident altercation with Alleged Victim (AV) in which W1 was the aggressor. AV was sitting at W1’s table when W1 began to tell AV to move. AV did not understand and suddenly W1 punched AV in the face. W1 claimed that AV tired to bite them, but this was not witness by staff. W1 and AV have had two prior altercations on or about November 2022. W1’s care plan has no plan in place for redirecting due to W1’s known behaviors. The facility failed to properly plan care plan around W1’s known behaviors, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. On or about January 29, 2023, AV was found by care staff out in the parking lot outside of the facility at around 6:15pm. Care staff escorted AV back into the facility. When staff inspected the surrounding building and the exits, they found that a back gate to the courtyard was opened. Due to the failure to ensure all exits and or gates where properly secured, AV was able to elope from the facility leading AV not to have a safe environment and putting AV in risk of harm, which is a violation of resident rights, is neglect of care and constitutes abuse.

Witness 1 (W1) has a history of wandering and opening doors. On or about January 16, 2023, W1 was trying to get into Alleged Victim’s (AV’s) room. AV confronted W1, and W1 punched AV on the nose leading AV to sustain an injury. W1 has had prior resident-to-resident altercations. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. On or about January 14, 2023, AV was walking by Witness 1 (W1) while W1 was sitting in a chair. AV placed their hand on W1’s chair and W1 grabbed AV’s hand and pulled them causing AV to fall to the ground, putting AV in risk of harm. AV has been involved in six prior resident-to-resident altercations between November 23, 2022, through January 10, 2023. The facility failed to provide a homelike environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Witness 1 (W1) has a history of getting into physical altercations with other residents. On or about January 9, 2023, W1 was walking through the dining area when he/she grabbed Alleged Victim (AV) by the back of his/her hair. AV then grabbed W1’s arm and pulled him/her down to his/her knees. W1 has been involved in five (5) prior resident-to-resident altercations. The care plan did not mitigate W1’s history of behaviors. The facility failed to care plan around W1’s known behaviors, which is a violation of resident rights, is neglect of care and constates abuse.

Alleged Victim (AV) has a history of getting into physical altercations with other residents. On or about January 9, 2023, AV was walking through the dining area when he/she grabbed Witness 1 (W1) by the back of his/her hair. W1 then grabbed AV’s arm and pulled him/her down to his/her knees. AV has five (5) prior resident-to-resident altercations, putting AV in risk of harm. The care plan did not mitigate AV’s history of behaviors. The facility failed to care plan around AV’s known behaviors, which is a violation of resident rights, is neglect of care and constates abuse.

Alleged Victim (AV) relies on the facility to administer his/her medication. AV has missed four (4) of their scheduled medications between January 12th through 14th, 2023, due to medication being all on order. It was found that medications were not being ordered correctly and that staff were not properly trained on how/when to order. As a result, missed pain management medication can result in increased pain, behaviors and decreased mobility and participation in ADL’s/activities by AV. The facility failed to provide a safe medication administration system, which is a violation of resident rights, is neglect of care and constitutes abuse.

Witness 1 (W1) has a history of aggressive behaviors toward other residents. On or about January 4, 2023, Alleged Victim (AV) wandered into W1’s room and started going through the room and sat in a recliner. W1 then tried to pull AV out of the room which caused AV to sustain injuries such as scratched and bruising to AV’s wrist. W1 had three (3) prior resident-to-resident altercations between October and December 2022. The facility failed to provide a safe environment for AV, putting AV in risk of harm, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. AV has had behaviors since August 2022; however, their care plan had not been updated appropriately to provide staff preventative care for the behavioral needs of AV. Witness 4 (W4) admitted that some of the facility care plans lacked sufficient information regarding behaviors and interventions. On or about December 28, 2022, AV was walking in the dining area towards the back door. Witness 1 (W1) was standing near the back door, AV walked towards W1 and slapped W1 in the right side of their face. AV started to then walk away and W1 grabbed AV by the hair and pulled AV to the ground. The facility failed to care plan around AV’s known behaviors putting AV in risk of harm, which is a violation of resident rights, is neglect of care and constitutes abuse.

Witness 1 (W1) has a known history of hitting residents when confronted. On or about December 28, 2022, W1 walked by and hit Alleged Victim (AV), AV then begun to walk away from W1 at which time W1 grabbed AV and pulled AV to the ground by the hair. W1 has been in prior resident to resident altercations. The facility failed to provide a safe environment for AV, which is a violation of resident rights is neglect of care and constitutes abuse.

Witness 1 (W1) has a known history of physical and verbal behaviors. On or about December 28, 2022, Alleged Victim (AV) walked by and hit W1, as a result, W1 responded by pulling AV to the ground by their hair. The facility failed to provide a safe environment, putting AV in risk of harm, which is a violation of resident rights, is neglect of care and constitutes abuse.

Witness 1 (W1) has a known history of behaviors. On or about December 28, 2022, W1 was walking in the dining area towards the back door. W1 walked towards Alleged Victim (AV) and slapped AV on their right side of their face. As W1 started to walk away, AV grabbed W1 by the hair and pulled them to the ground. W1 was documented in observation charting notes to have ongoing aggressive behavior issues with both staff and other residents since October 2022, however, W1’s care plan does not clearly indicate any interventions to address W1’s known behaviors. The facility failed to care plan for W1’s known behaviors, which is a violation of resident rights, is neglect of care and constitutes abuse.

Witness 1 (W1) has a history of aggressive behaviors toward other residents. On or about December 23, 2022, Alleged Victim (AV) was walking across the dining room area and walked into W1. W1 reacted by hitting AV in the mouth. As a result, AV sustained an injury to his/her mouth and had blood coming out of their mouth. AV also complained of mouth pain. The facility failed to provide a safe environment for AV, putting AV in risk of harm, which is a violation of resident rights is neglect of care and constitutes abuse.

Witness 1 (W1) is care planned to have aggression behaviors. The only direction for staff was that W1 required supervision and monitoring to help manage or redirect aggressive/combative behaviors. On or about November 16, 2022, W1 approached AV who was waiting for his/her meal. W1 punched AV in the face and the chest. As a result, AV suffered bruising to the face and the chest. W1 had a prior altercation with AV on or about November 7, 2022, in which W1 walked up to AV and punched AV once in the chest and once in the face. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Witness 1 (W1) has a known history of behaviors. On or about September 17, 2022, Alleged Victim (AV) walked up to the doorway where W1 was standing. With no indication of aggressive inclination from AV, W1 punched AV once in the chest and once in the face. This has not been the only altercation between AV and W1. The facility failed to provide a safe environment for AV, putting AV in risk of harm, which is a violation of resident rights, is neglect of care and constitutes abuse.

Witness 3 has a history of being aggressive towards staff, Alleged Victim (AV) and other residents. On or about September 20, 2022, AV and W3 were involved in an altercation resulting in W3 being on top of AV in AV’s bed. W3 had his/her hands around AV’s neck and AV was being chocked. As a result, AV was sent to the hospital and was found to have sustained marks and bruising on his/her neck and body. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Witness 3 (W3) has a known history of behaviors and is care planned to wonder and open other resident’s doors. On or about September 17, 2022, Alleged Victim (AV) and W3 were seen in the hallway. Staff then heard yelling or arguing between AV and W3. W3 then punched AV in the chest and stated that AV was packing up his/her things and W3 did not want AV taking his/her stuff. The facility failed to provide a safe environment for AV, putting AV in risk of harm, which is a violation of resident rights, is neglect of care and constates abuse.

Witness 1 (W1) has a known history of behaviors. Between July 24, through September 15, 2022, W1 had 17 entries of behaviors. On or about September 15, 2022, at around 9:30pm, W1 was talking to Alleged Victim (AV) after W1 had just gotten a cup of hot coffee. They had started to have a disagreement and then W1 tipped over his/her cup of hot coffee onto AV. AV then ran off to take their shirt off clearly in pain from the still. On or about September 15, 2022, at around 10pm, AV came out from his/her room to the hydration cart and grabbed his/herself a cup of hot coffee. He/she then started to talk to W1 and at some point, started to have a disagreement. W1 was seen extend their hand, and AV’s coffee spilled onto him/herself. It had spilled on his/her chest and down to the bottom of his/her sternum in a “U” shape. AV stated it only hurts when it was touched. As a result, AV sustained slight redness on his/her chest. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

On or about June 1, 2022, the nurse made a note about Alleged Victim (AV) stating he/she had a significant change of condition relating to falls. AV sustained three falls within a week, on May 26th and 28th and on June 1, 2022. AV’s care plan dated July 9, 2022, had the only intervention listed for fall risk was for staff to assist AV when AV is ready to sit. The care plan also stated AV is independent with ambulation and transfers. Between July 17th, through August 16th, 2022, AV sustained approximately eight (8) falls, some resulting in injury and one resulting in an ER visit. The facility failed to care plan appropriately and implement interventions to mitigate AV’s risk of falls, which is a violation of resident rights, is neglect of care and constitutes abuse.

On or about July 29, 2022, Alleged Perpetrator #2 (AP2) gave the Alleged Victim (AV) two doses of his/her pain medication instead of one. AP2 did not receive proper training or oversight from the facility regarding medication administration. 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.

Witness 1’s (W1’s) care plan states he/she can become angry with other residents, W1 will yell and at times, grab them by the arms and pull or tug at them. On or about July 18, 2022, W1 was in his/her room, and he/she heard yelling outside his/her door and became aggravated. W1 came out of his/her room and started to yell at Alleged Victim (AV). The yelling escalated and swatted started between the two and W1 scratched AV on top of he/she eye. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim’s (AV’s) care plan states he/she is a high fall risk. During the month of July 2022, AV had sustained six (6) falls. On or about July 9, 2022, AV sustained a fall in their room. He/she was found on the floor next to his/her bed. As a result, AV sustained two skin tears to his/her left hand. The facility failed to provide a homelike environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

On or about June 16, 2022, the Alleged Victim (AV) and Witness #1 (W1) engaged in an altercation where W1 struck AV with closed fist. AV was not injured, however, AV was placed at risk for harm. 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 monitor Witness 1 according to his/her known behavior and prior altercations. The failure resulted in a physical altercation and causing unreasonable discomfort to the Alleged Victim and putting them at risk of serious harm, 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 according to his/her known behavior and prior altercations. The failure resulted in a physical altercation and causing unreasonable discomfort to the Alleged Victim, 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 according to his/her known behavior and prior altercations. The failure resulted in a physical altercation and causing unreasonable discomfort to the Alleged Victim, 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 according to his/her known behavior and prior altercations. The failure resulted in a physical altercation and causing unreasonable discomfort to the Alleged Victim, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness 1 (W1) had known inappropriate behaviors and the facility failed to care plan according to those behaviors. On or about March 29, 2022, W1 was found groping the Alleged Victim (AV). The facility failed to put interventions in place to keep AV safe from W1's known behaviors, 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 according to his/her known behavior and prior incidents. The failure resulted in the Alleged Victim(AV) being exposed to inappropriate sexual behaviors, 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 follow the Alleged Victim's (AV) care plan to supervise and redirect according to behaviors. AV was attempting to enter another resident's room, with lead to physical altercation. The lack of supervision put AV at risk of serious harm and unreasonable discomfort. The facility failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to ensure supervision and staff support regarding known behaviors related to the Alleged Victim (AV) and Witness 1 (W1). An incident occurred between the two where W1 attempted to enter AV's room, resulting in a physical altercation, putting the AV at risk of serious harm and unreasonable discomfort. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Perpetrator 2 (AP2) failed to provide a safe environment for the Alleged Victim (AV). AP2 left the AV unsupervised while AP2 left the area without informing other care staff. AV fell from their chair while unattended, placing AV at risk of harm. AP2’s actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility’s failure to properly train AP2 is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to appropriately care plan regarding the Alleged Victim's (AV) falls to ensure safety. AV fell on or about December 15, 2021 and was transported to the hospital for treatment of skin injury and shoulder dislocation causing pain and discomfort. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

As the new owner of this facility, you are responsible for correcting any deficiencies which pre-date your ownership. You must correct violations which occurred under previous ownership, as directed by the Department. You will not be responsible for paying civil penalties incurred by previous owner(s). However, if you fail to correct identified deficiencies within the specified time you may be subject to aggravated civil penalties. The facility failed to appropriately care plan regarding the Alleged Victim's (AV) falls to ensure safety. AV fell on or about 12/4/2021 multiple times sustaining injuries. On or about 12/8/2021 AV was diagnosed with an arm fracture as a result of the falls. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #1 (W1) has history of inappropriate sexual acts and comments towards staff and residents. On or about November 24, 2021, W1 engaged Alleged Victim (AV) in touching W1 in a sexual manner. The facility failed to put interventions in place and care plan according to W1 behaviors to keep AV safe, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #1 (W1) is known to be aggressive and have altercations in the dining area. W1 is care planned to assure his/her preferred seat is available at mealtimes to avoid altercations. On or about November 21, 2021, Alleged Victim (AV) sat in W1’s preferred seat, which caused W1 to be aggressive towards AV, causing a nosebleed and skin injury to AV’s face. The facility’s failure to follow the care plan is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) is known to sit in the hallway and be aggressive towards other residents. AV is care planned for staff to redirect AV from sitting in the hallways. Witness 2 (W2) is known to wander into other residents’ rooms. W2 is care planned for staff to redirect W2 away from other residents’ rooms and away from other residents. On or about November 14, 2021, AV was sitting in the hallway when W2 wandered into AV's room, which caused a physical altercation between AV and W2. The facility’s failure to follow the care plan is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness 2 (W2) is known to sit in the hallway and be aggressive towards other residents. W2 is care planned for staff to redirect AV from sitting in the hallways. Alleged Victim (AV) is known to wander into other residents’ rooms. AV is care planned for staff to redirect AV away from other residents’ rooms and away from other residents. On or about November 14, 2021, W2 was sitting in the hallway when AV wandered into W2's room, which caused a physical altercation between W2 and AV. The facility’s failure to follow the care plan is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) and Witness 1 (W1) have history of prior resident-to-resident altercations. AV has history of wandering into other resident’s rooms, and W1 has history of escalating behaviors. On or about November 12, 2021, AV wandered up to W1s door and tried to open it. W1 was yelling at AV through the door, W1 opened the door and slapped AV’s face. The facility failed to appropriately care plan and implement reasonable interventions to address AV’s wandering and entering other residents’ rooms and the facility failed to appropriately care plan and implement reasonable interventions to address W1 continued escalating behaviors, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #1 (W1) is known to be aggressive and have altercations in the dining area. W1 is care planned to assure his/her preferred seat is available at mealtimes to avoid altercations. When the Alleged Victim (AV) comes to the dining room, Staff are to show AV open seating options to assure that AV does not sit in W1’s preferred seat. On or about November 8, 2021, AV sat in W1’s preferred seat, which caused W1 to be aggressive towards AV, causing scratches to AV’s face. The facility’s failure to follow the care plan is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) is known to be aggressive and have altercations in the dining area. AV is care planned to assure his/her preferred seat is available at mealtimes to avoid altercations. On or about November 08, 2021, Witness 1 (W1) sat in AV’s preferred seat, which caused AV to be aggressive towards W1, resulting in W1 slapping AV and W1 having scratches to W1’s face. The facility’s failure to follow the care plan is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV), Witness 1 (W1), and Witness 3 (W3) have history of prior resident to resident altercations. W1 has history of and is service planned for wandering into other residents’ rooms. AV service plan indicates facility will keep AV at a safe distance from other residents when AV enters common areas. On or about November 11, 2021, AV was watching TV with other residents. Witness 1 (W1) entered Witness 3 (W3) room causing AV to try to protect W3 from W1. W1 and AV had a physical altercation. The facility failed to follow the care plan which is a violation of resident rights is neglect of care and constitutes abuse.

Alleged Victim (AV), Witness 1 (W1), and Witness 3 (W3) have history of prior resident to resident altercations. AV has history of and is service planned for wandering into other residents’ rooms. W1 service plan indicates facility will keep W1 at a safe distance from other residents when W1 enters common areas. On or about November 11, 2021, W1 was watching TV with other residents. AV entered (W3) room causing W1 to try to protect W3 from AV. AV and W1 had a physical altercation. The facility failed to follow the care plan which is a violation of resident rights is neglect of care and constitutes abuse.

Alleged Victim (AV), Witness 1 (W1), and Witness 3 (W3) have history of prior resident to resident altercations. W1 has history of and is service planned for wandering into other residents’ rooms. W3 service plan indicates facility will keep him/her at a safe distance from other residents when he/she enters common areas. On or about November 01, 2021, W3 was watching TV with other residents. W1 entered AV room causing W3 to try to protect AV from W1. W1 and W3 had a physical altercation. The facility failed to follow the care plan which is a violation of resident rights is neglect of care and constitutes abuse.

Alleged Victim (AV) has history of wandering into other resident’s rooms. Witness 1 (W1) has history of escalating behavior towards other residents. AV and (W1) have history of prior physical altercation with each other. On or about October 21, 2021, AV had gone into another resident’s room. Witness 1 (W1) went to get AV out of the room. W1 slapped AV on the face. The facility failed to properly care plan to implement interventions for AV wandering into other resident’s rooms, and address W1 escalating behavior.

Alleged Victim (AV) relies on the facility for his/her care. On or about September 18, 2023, AV was visually agitated. Alleged Perpetrator 2 (AP2) was told to leave AV alone because of AV’s agitation, but AP2 continued to try to hand AV a cup of water, even though it was clear AV did not want a cup of water. AP2 had room to back out and leave the situation, however instead of leaving the scene, AP2 continued to interact with AV. As a result, AV because physical with AP2 leading to AP2 kicking AV. Ap2 was properly training by the facility and completed all required dementia training. AP2 failed to provide a safe environment for AV, which is neglect of care and constitutes abuse. The facility failed to provide a safe environment for AV, which 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 facility failed to implement safe medication and treatment administration systems, 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 written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day, 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.

According to documentation Alleged Perpetrator (AP2) failed to follow facility’s medication pass protocols. The failure resulted in Alleged Victim (AV) not receiving their medication and put the AV at risk of harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to provide a safe environment which is a violation of Oregon Administrative Rules.

The facility failed to provide a safe medication administration system to ensure Alleged Victim’s pain medication was administered as ordered. Alleged Perpetrator #2 failed to give AV his/her pain medication on August 28, 2022. AP2's failure is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failure is a violation of Oregon Administrative Rules.

According to documentation Alleged Perpetrator (AP2) failed to follow facility’s medication pass protocols. The failure resulted in Alleged Victim (AV) not receiving their medication and put the AV at risk of harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to provide a safe environment which is a violation of Oregon Administrative Rules.

On or about July 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 June 1, 2022 to June 30, 2022, for a total of 30 days. Allegation Notes

Alleged Victim (AV) relies on the facility for h/h care. On or about March 11, 2022, Alleged Perpetrator (AP2) gave the AV the wrong medication. AP2 failed to administer medication as order, which is a violation of resident rights is considered neglect of care and constitutes abuse. The facility failed to administer medication as ordered which is a violation of Oregon Administrative Rules.