Mountain Park Memory Care Community

Witness 1 (W1) is frequently disoriented, even in familiar surroundings and requires supervision. W1 is known to wander and enter other residents’ rooms. Interventions in W1 service plan dated on or about February 28, 2025, include staff to be vigilant in monitoring W1's movements and redirect W1. Alleged Victim (AV) is known to have agitation towards other residents that enter AV's room. AV will become upset when other residents wander into AV's room. Interventions in AV's service plan dated on or about April 23, 2025, include when AV is spending time in AV's room, staff are to encourage AV to leave AV's door closed top prevent others from entering AV's room. On or about May 3, 2025, AV reported to staff, while AV was in h/h room W1 wandered in and hit AV several times in the arm. AV was able to get W1 to leave AV's room. AV sustained bruising to h/h arm. A Temporary Service Plan (TSP) was put into place, instructing staff to monitor W1 trying to enter AV's room. On or about May 4, 2025, AV was in bed sleeping, and W1 was wandering the unit. Staff heard screaming from AV's room, W1 entered AV's room and hit AV, resulting in a skin tear to AV arm, and AV becoming upset. The facility failed to follow W1 service plan interventions to be vigilant of W1 movements, and redirection, and failed to follow the TSP instructing staff to monitor W1 trying to enter AV's room which resulted in an unsafe environment, and injury to AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is known to exhibit wandering behaviors. Witness 1 (W1) has a known history of becoming aggressive when other residents enter W1’s personal space. According to AV’s service plan, dated on or about March 31, 2025, AV has a pattern of entering other residents’ rooms. AV's plan directs staff to redirect AV and offer an activity, it also indicates velcro door guard placed against W1's room to prevent residents from entering W1's room. W1’s service plan, dated on or about April 24, 2025, does not include specific interventions for situations in which other residents enter W1’s personal space. The plan also does not mention the use of signage to discourage entry into W1’s room. On or about May 1, 2025, AV wandered into W1’s room, resulting in a resident-to-resident altercation. W1 yelled at AV and struck AV, causing visible redness to AV’s arm. AP1 failed to follow AV’s service plan by not redirecting AV when AV was observed wandering. Additionally, AP1 did not adequately care plan or implement appropriate interventions to address W1’s known behavioral responses to residents entering into W1's personal space. These failures directly contributed to the altercation and resulted in physical harm to AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) requires services from the facility which include brief changes. AV is know to have skin breakdown in the peri area and has an as needed barrier cream to be applied during brief changes. On or about March 7, 2025, AV suffered a fall where he/she hit his/her head. AV was transported to the hospital, where hospital staff noted that AV had a very heavily soiled brief and an open area of skin breakdown, indicating AV had been in soiled briefs for an extended period of time. Although staff maintain that AV was changed a few hours prior, There is no documentation that AV refused care, was changed, nor is there documentation that AV's barrier cream was applied. The facility's failure to provide incontinence care to AV is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) and Witness #1 (W1) share a room and have had altercations in the past. AV does not like it when others touch his/her things. W1 likes to take items that don't belong to him/her. Staff are to observe W1 for signs of escalating and remove W1 from AV. On or about February 20, 2025, AV and W1 were advised to stay in their rooms. W1 was touching AV's things, AV treid to retrieve their items from W1 when W1 punched AV in the face, causing AV to fall to the floor and have a laceration to his/her lip. AV went to the hospital for observation for high blood pressure. The facility's failure to provide a safe environment is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about February 7, 2025, the Alleged Victim (AV) suffered two unwitnessed falls. AV is a known falls risk with a history of falls. AV has service plan interventions which include to use a walker, have grip socks on, safety checks, room free from clutter and frequent toileting. On this date, AV returned from the hospital sedated. AV was not placed on increased safety checks or monitoring. No interventions were placed between the first and second fall. AV's walker was not present during either fall, and AV did not have grip socks on. The facility's failure to ensure oversight, follow the care plan and ensure interventions were in place is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility for his or her safety. AV wanders around the facility and has a history of exit seeking. AV service plan indicates, in the event of an emergency, staff should prioritize AV's safety due to AV's tendency to exit seek. AV requires consistent guidance and encouragement during evacuation procedures. AV should be escorted to the designated safe area by staff who can provide reassurance and support throughout the process. On or about January 17, 2025 AV eloped from the facility unit during a fire drill, as staff were helping other residents. The facility failed to provide a safe environment, and follow Av’s service plan, with known wandering and exit seeking behaviors, which is a violation of resident’s rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) and Witness 1 (W1) have a history of resident-to-resident altercations, but not with each other. AV Service Plan dated on or about December 20, 2024, AV is services planned for behaviors triggered by other residents walking into AV's room, Interventions: Velcro sign on AV's door to prevent residents from entering AV's room. W1 Service Plan dated on or about December 21, 2024, W1 may become physically aggressive when others enter residents room. Interventions: If staff notice another resident walking into W1's room, staff are to redirect that resident away from W1's room. On or about January 3, 2025, W1 wandered into AV's room. W1 and AV had an unwitnessed resident to resident altercation in doorway of AV's room, staff report hearing resident commotion and when approached saw AV on the ground and W1 standing over AV with W1's hands in a fist. AV complained of head pain, visible scratch/bruising to (L) eye. W1 complained of chest pain and (L) eye blackened. W1 was last seen by staff in W1's room approximately 30 minutes before the altercation. AV was seen by staff walking towards AV's room a few minutes before the altercation. The facility failed to provide a safe environment, and failed to properly plan care around W1 and AV history of resident-to-resident altercations, and the facility has identified AV's behavioral trigger but has not provided adequate person centered interventions to prevent other residents from entering AV's room.

Alleged Victim (AV and Witness 1 (W1) have a history of resident-to-resident altercations, but not with each other. W1 Service Plan dated on or about December 20, 2024. W1 is services planned for behaviors triggered by other residents walking into W1's room, Interventions: Velcro sign on W1's door to prevent residents from entering W1's room. AV Service Plan dated on or about December 21, 2024, AV may become physically aggressive when others enter residents room. Interventions: If staff notice another resident walking into AV's room, staff are to redirect that resident away from AV's room. On or about January 3, 2025, AV wandered into W1's room. AV and W1 had an unwitnessed resident to resident altercation in doorway of W1's room, staff report hearing resident commotion and when approached saw W1 on the ground and AV standing over W1 with AV's hands in a fist. W1 complained of head pain, visible scratch/bruising to (L) eye. AV complained of chest pain and (L) eye blackened. AV was last seen by staff in AV's room approximately 30 minutes before the altercation. W1 was seen by staff walking towards W1's room a few minutes before the altercation. The facility failed to provide a safe environment, and failed to properly plan care around AV and W1 history of resident-to-resident altercations, and the facility has identified W1's behavioral trigger but has not provided adequate person centered interventions to prevent other residents from entering W1's room.

Witness 1 (W1) goes out into the community with W1's support person and has a history of being agitated when returning. W1 has a history of resident-to-resident altercations with other residents and with Alleged Victim (AV). W1 and AV are roommates. W1 service plan dated on or around December 26, 2024, indicates staff to notify med tech and nurse if behaviors or agitation are apparent and interventions aren't working. W1 interventions, medications scheduled and PRN order for agitation; Make sure W1 is provided with W1's own space in W1's room in a low stimulation environment; If staff observe W1 showing signs of escalating behaviors of anxiety, agitation, or aggression towards AV, they are to promptly remove AV from the area for AV's safety. On or about December 29, 2024, W1 was sitting in the dining area getting ready for dinner. W1 went into the living room and sat next to AV. W1 became agitated and started slapping towards AV, resulting in AV and W1 slapping each other. W1 was already upset before the incident with AV, as W1 had been out that day with W1's support person. The facility failed to recognize those sings and implement interventions. The facility failed to follow W1 care plan If staff observe W1 showing signs of escalating behaviors of anxiety, agitation, or aggression towards AV, they are to promptly remove AV from the area for AV's safety, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victims (AV) resides in a locked memory care unit, and depends on the facility for AV needs, and safety. AV's Service plan dated on or about October 8, 2024, indicates AV has glasses, has poor peripheral vision downwards, AV cannot see downwards and will regularly look down at the ground while AV walks to see where AV is going. AV uses assistive device, walker. AV can ambulate and transfer independently with use of four-wheel walker. If staff see AV without AV's walker, staff to assist AV to sit down and encourage the use of AV's Walker. During investigation AV had a prior fall on or about November 30, 2024, and AV's service plan was not updated after this fall. On or about December 23, 2024, Staff observed AV in the dining room. AV stood up from the table with glass in h/h hand, was looking around for something to grab, took a step and fell to the ground landing on AV's right side. AV did not have h/h walker nearby when AV fell. AV was transported to the hospital for evaluation, diagnosed with a proximal right femur fracture, and had surgical intervention. AVs death certificate indicates Date of death December 27, 2024, A. Immediate cause of death acute blood loss anemia. B. Due to or as a consequence of Right intertrochanteric femur fracture. c. Due to severe dementia without behavioral disturbance. The resident's service plan was not reflective and/or lacked resident-specific direction for staff in the following areas: mobility/ambulation; fall risk has conflicting information which contributed to AV's fall in the dining room while staff observed the fall. The facility failed to provide a safe environment and failed to appropriately care plan and implement reasonable interventions, which is violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) and Witness #1 (W1) have a history of altercations. Both residents have interventions in place, AV is to be redirected when wandering and W1 is to be redirected when agitated. On or about December 8, 2024, AV was wandering and W1 was in the common area. AV was taking items, which irritated W1, leading W1 to walk to AV and try to take away the item that AV picked up. W1 then hit AV in the arm. Facility staff failed to redirect either resident. The facility's failure to provide a safe environment is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) is a resident of the Resident Care Facility Memory Care Unit and relies on the facility for his or her safety. AV is known wander within the facility and outside. AV is reported to take walks in the afternoons. On or about October 15, 2024, AV was outside in the courtyard unsupervised and wondered through an open, unlocked courtyard gate. It is believed the back gate was left open by the landscaping company. The facility failed to provide a safe environment, which is a violation of resident’s rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) and Witness 1 (W1) have a history of being involved in resident-to-resident altercations, and have a history of aggressive behaviors. W1 has a history of wandering into other resident rooms. AV does not like other residents entering into AV's room. On or about August 21, 2024, W1 entered into AV's room. AV was found on top of W1, hitting W1. W1 was observed to be hitting AV back. W1 was last seen by staff walking around the memory care unit prior to entering AV's room. W1's service plan does not have listed interventions to address W1 wandering into other resident's room. As a result of the resident-to-resident altercation, AV sustained a cut, approximately 1 inch in length to AV's right ring finger. Additionally, AV presented as very emotional following this altercation with W1, requiring a PRN medication for emotional distress. The Facility failed to provide a safe environment for AV and the facility failed to appropriately adjust W1 care plan and implement reasonable interventions to address W1s continued wandering into other resident rooms, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness 1 (W1) has a history of resident-to-resident altercations with other residents. Alleged Victim (AV) and W1 have a history of resident-to-resident altercations with each other. W1 is known to wander the neighborhood. AV does not want anyone to come into AV’s room nor touch AV's belongings. AV wants AV’s door to remain locked to keep resident’s out of AV’s room. On or August 15, 2024, W1 was able to open AV’s door and walk into AV’s room. AV told W1 to get out. W1 walked over to AV and W1 slapped AV in the face. The lock on AV's door was malfunctioning when you jiggle the handle, the door would come unlocked. AV does not feel safe and feels AV is going to have to use physical force to protect AV's self and room. The facility failed to provide a safe environment and implement appropriate interventions to mitigate the risk of serious harm to AV and protect AV from W1 entering Av's room. The facility failed to keep AV door lock in good working condition, which resulted in the lock not working and allowing W1 to come into AV room and hit AV in the face, which is a violation of resident rights, is neglect of care and constitutes abuse.

Witness #1 (W1) is known to engage in altercations and is care planned that when he/she begins to wander, that staff will redirect, keep an eye on W1 when he/she is not in his/her apartment and to offer one to one or offer coffee or tea. On or about August 4, 2024, W1 wandered into AV's room and hit AV on the face and arm. The facility's failure to follow W1's care plan placed AV at risk for harm. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness 1 (W1) is known to randomly hit residents and staff and may become triggered when other residents attempt to redirect W1. Alleged Victim (AV) has never had a resident-to-resident altercation. If W1 is showing aggressive tone or behavior from other residents, W1 may retaliate with physical aggression. If W1 is walking around anxious, agitated, or aggressively staff are to redirect other residents away from W1. Staff are to offer beverages and have one-on-one conversation to provide comfort to W1 when W1 is agitated. W1 has behavioral medications, but s known to refuse medications. On or about July 14, 2024, W1 was walking around the unit, walked up to AV and took AV's clothing off the back of AV's wheelchair. AV told W1 to give it back and W1 hit AV on the face, causing AV's earring to come out and cause AV to experience pain. Staff were helping other residents with their back to AV and W1. Staff are not consistent with mitigating W1's behaviors. The facility failed to provide a safe environment, adjust the service plan and properly plan care for W1 leading to continued aggressive behavior., which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #1 (W1) Service Plan dated on or about May 22, 2024, indicates W1 is diagnosed with agitation, dementia without behavioral disturbance. W1 Active Triggers are when someone comes into W1's room and W1's space. Staff are too direct W1 and ensure W1 stays on W1 side of the room, have a labeled sign above W1's bed and W1 needs to be reoriented to W1's apartment and surroundings in the neighborhood. W1 forgets W1 has a roommate . W1 has a history of resident-to-resident altercations. Alleged Victim's (AV's) Service Plan dated on or about June 26, 2024, indicates AV is anxious, has anxiety disorder, and is sometimes assaultive. AV has no active triggers. AV keeps to self for the most part and in between meals, AV likes to rest. On or about June 30, 2024, staff heard W1 yelling from W1 and AV's room. Staff found AV holding W1's arms to stop W1 from punching AV in the face. W1 hit AV by punching AV in the face multiple times. From March 2024-June 2024, there are at least two documented resident-to-resident altercations in which W1 made physical contact with a resident in a room. There is no specialized signage at AV/W1's door nor any specialized signs to assist W1 to locate W1's bed in the room as directed in W1's service plan. The facility failed to provide a safe environment, and follow the W1's care plan, placing AV at risk of harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to follow the care plan and provide appropriate services according to the Alleged Victim (AV)'s needs relating to showers and providing available PRN medications to AV prior to assisting AV with daily cares. AV has PRN medication available to assist with AV refusing to shower. The PRN medication available to AV were not consistently offered to AV. This failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) is service planned as extensive assist with dining/eating and as having a food allergy to peanuts. On or about May 15, 2024, AV was given a peanut butter cookie as an after dinner snack. AV ingested the peanut butter cookie and shortly after experienced high blood pressure. AV reported feeling weird and having slight trouble breathing. The facility failed to follow the care plan which is a violation of resident’s rights is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. AV is a known wander, often forget to use h/h walker, and often wander into other resident rooms. AV's service plan dated on or about April 17, 2024, has interventions in place to ensure AV has on shoes or non-skid socks when ambulating around community. Staff are to leave bathroom or night light on during night to help AV find bathroom if AV wakes up. During NOC, staff to check that AV's walker is at bedside while AV is asleep so that walker is within reach is AV wakes up. Staff to redirect AV is seen entering another resident’s apartment. On or about April 25, 2025, AV wandered into another resident’s room and had an unwitnessed fall. AV was diagnosed with a fracture left humerus bone. Staff identify AV as a wanderer but there are no interventions provided in AV's service plan to mitigate risks associated with wandering. The facility failed to appropriately care plan around AV wandering, and failed to follow AV care plan by staff no redirecting AV when AV entered another resident’s room resulting in AV falling and fracturing h/h humerus bone.

Witness 1 (W1) service plan dated March 6, 2024, indicates W1 becomes distressed and will try to get involved if residents become agitated or engage in arguing/disagreements. Staff to provide W1 with reassurance and attempt to redirect W1 if W1 becomes distressed. W1 leaves the door to the apartment opened during the day. On or about March 27, 2024, W1 and Alleged Victim (AV) switched rooms. On or about April 3, 2024, W1 was in h/h room when AV came into W1's room thinking the room was AV's. AV was irritated because AV thought W1 was taking AV's things. W1 is upset and frustrated with AV coming into W1's room. This resulted in a resident-to-resident altercation, AV reports W1 punched AV, AV appeared in distress. The facility failed to appropriately care plan and implement reasonable interventions to address AV wondering into W1 room, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide appropriate services according to the Alleged Victim (AV)'s needs. AV is service planned for incontinence care, peri care and shower care. On or about February 2, 2024 AV's rash on h/h body and peri area was first noticed by the facility staff. Community Medical Partners were notified by the facility of AV's rash on or about March 5, 2024. During investigation, it was determined AV was left in urine-soaked briefs and bedding on several occasions for long periods of time. Resulting in a rash to AV's body and peri area for a prolonged period of time causing AV discomfort, itchiness and pain, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide appropriate services according to the Alleged Victim (AV)'s needs. AV is service planned for assistance with transfers, toileting care, and assistance with showering cares. AV has a history of urinary tract infections, with one occurring on February 23, 202024. AV did not receive AV's showers from February 14, 2024 to March 22, 2024 with minimal interventions, put into place for missed showers. AV's skin was in contact frequently with urine, which contributed to AV's rash and pressure sore. The facilities only interventions were to apply a barrier cream to AV's back and a powder to AV's peri area. AV sustained rashes in AV's peri area, a pressure sore and a rash on AV's back that began to ooze pus that caused AV pain. .AV experienced significant skin injuries, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide appropriate services according to the Alleged Victim (AV)'s needs. AV has a history of skin issues. AV is service planned for assistance with toileting cares. AV sustained a rash to AV's skin near the peri area. AV has been left in urine-soaked briefs, clothes and bedding for long periods of time. AV's service plan did not include information about AV's peri area rash or treatment. AV experienced prolonged rash, skin injuries, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim 's (AV's) service plan states that AV is independent in toileting cares. AV is to receive brief checks, changes and peri care daily for incontinence. AV has been found in urine-soaked briefs, clothing and/or bedding on several different occasions. AV is to receive showers every Wednesday and Saturday PM and PRN. AV has missed showers with no evidence of AV receiving a shower at an alternate day and/or time. AV's skin concerns are to be logged on shower sheets for RSM/LPN and to make a Med Tech aware. Starting on or about February of 2024, AV was found to have a rash on AV's lower back tailbone area that progressively worsened throughout February and March and spread onto AV's thighs. AV's rash on AV's tailbone and thighs was first noticed on or about February 7, 2024 and logged on the shower sheet. AP2 did not know about AV's rash until approximately February 23, 2024. AP2 checks the shower logs every Monday. AV has had a prolonged rash that has caused pain to AV for over a two-month period. AV's MAR and doctors' orders are to be followed as written by the Primary Care Physician. On or about March 21, 2024, AP2 applied another resident's barrier cream with menthol in it on AV's rash; the barrier cream is not on AV's MAR and is not a part of AV's doctors' orders. AP2 did not follow AV's doctors' orders and MAR. AP2 directed other care staff to apply a barrier cream belonging to another resident to AV's rash. AP2’s actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility failed to provide services, and safe medication administration system, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness 1 (W1) has a history of being agitated with other residents and staff, and being involved in resident-to-resident altercations . W1 will yell at staff and other residents. W1 and Alleged Victim (AV) have only been in verbal altercations in the past. W1's service plan requires interventions if W1 becomes agitated or angry, staff are to redirect W1 by attempts to do an activity or task, offer a snack or drink, attempt to provide care 3 times, and then wait 10 minutes and try a different caregiver. On or about March 20, 2024, AV was leaving the dining area after breakfast and AV entered the shared room of AV and W1, W1 became agitated with AV, yelling at AV, and W1 grabbed AV's walker and pushed AV to the floor in a shared room. As a result of the resident-to-resident altercation, AV had a bruise and skin tear on AV's left upper wrist. The facility failed to provide a safe environment for AV and follow W1' s care plan interventions, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim's (AV’s) service plan indicates AV is a one person assist with toileting. AV has history of refusing to be changed in the AM consistently. AV has been observed laying in urine-soaked linen and clothing. Shower log shows last shower documented for AV was on or about January 9, 2024. On or about March 8, 2024 AV was found to have a rash on AV’s left hip and buttock. AV is not service planned for refusal of care. The facility failed to properly plan care and provided appropriate services according to AV needs. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide appropriate services according to the Alleged Victim (AV)'s needs. AV has a history of rashes. AV is service planned for full assistance with incontinence care, and showering. AV's service plan states that AV is independent in skin care; but the service plan only provides a generic intervention of reporting all new skin issues to a med tech with no further instructions on how to prevent future skin issues from occurring. Investigation determined AV did not receive showers on several occasions, and left in urine-soaked briefs on several occasions. AV sustained a skin rash to AV's thigh, buttocks and lower back and rash worsened over the course of exposure to urine. AV rash, skin injuries, and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide appropriate services according to the Alleged Victim (AV)'s needs. AV has a history of rashes. AV is service planned for incontinence and peri care. AV sustained a rash to the back of AV's thighs. During investigation, it was determined AV being left in urine-soaked briefs contributed to AV sustaining a rash to the back of AV's thighs and genital area. The facility's only interventions were to apply creams and bandages to AV's rash with no other interventions set in place. AV's rash caused AV unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) suffered a significant change of condition on or about September 14, 2023, due to a weight loss and decline in activities of daily living. On or about September 21, 2023, AV returned from the hospital after an injury fall. On or about September 23, 2023, ti's noted that AV is continuing to use the restroom by him/herself, placing him/her at risk for harm. The facility's failure to properly care plan for AV's safety from falls is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about September 21, 2023, the Alleged Victim (AV) was found in his/her room with a laceration to his/her forehead, due to a fall in his/her bathroom. AV was sent out to the hospital for treatment. The facility's failure to provide a safe environment for AV is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim Admit into the facility on or about February 21, 2023. AV has a history of six falls from February 21, 2023, to August 25, 2023. AV has a diagnosis of dementia and vertigo, uses a walker/wheelchair to ambulate and is a one person assist with transfers to and from wheelchair. AV fell out of bed on or about August 1, 2023, was found on the floor, sent to the hospital, and diagnosed with a hip fracture. Between August 1, 2023, and August 25, 2023, AV repeatedly attempts to get out of bed experiences hallucinations and increased confusion. Per AVs service plan the only intervention the facility had in place were safety checks with no specific instruction for the intent of the safety checks. No other instructions were provided to staff. On August 25, 2023, AV was found on the floor of their apartment with h/h left arm and knuckles bleeding. AV stated they hit their head on the floor. Staff reported, it looks like AV had been trying to get out of bed. AV was sent to the ED. As a result of the fall on August 25, 2023, AV suffered a blow to their head complained of head pain and required seven (7) stiches in h/h left arm. The facility failed to intervene when the Alleged Victim ‘s (AV) condition changed, failed to appropriately care plan, and implement reasonable resident specific interventions to address AV’s ongoing falls, repeated attempts to get out of bed which led to falls and address the hallucinations and increased confusion and communicate interventions to staff, which is violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. Witness #1’s (W1) has a history of resident-to-resident altercations because W1 does not like people of the opposite sex in h/h room. A stop sign was placed on W1's door and an ISP initiated for staff to redirect other residents from going into W1's room. On or about July 21, 2023, staff escorted and left AV into W1's room to watch TV with W1's roommate. W1 found AV in h/h room, became upset, and as a result W1 dragged AV across the floor into the hallway causing AV to have rug burns. The facility failed to provide a safe environment and follow W1 care plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility, and Unknown Alleged Perpetrator 3 (AP3) failed to provide a safe medication administration system. On or about June 12, 2023, through June 22, 2023, AV was observed by family to be experiencing a change of mood, being withdrawn, constipated, and complained of pain. During a doctor’s appoint on or about June 22, 2023, it was discovered AV had another resident’s medication patch on h/h back. It is unknown for exactly how long AV had the patch on since it was not dated. The allegation that AP2 failed to provide a safe medication administration system, was investigated and the determination was not substantiated. The facility, and AP3’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for care and supervision. AV service plan date on or about December 27, 2023, interventions staff to reposition, transfer from a wheelchair to a bed or another chair. If AV exhibits anxiety by restlessness, trying to get up and down from wheelchair and chair, staff will report and document behaviors that may arise. AV requires a full escort to meals and activities; staff will encourage AV to come into the community areas for increased supervision while awake. AV is not able to use the community call system while in AV's room to alert staff to AV's needs. AV’s primary language Japanese and does not have the ability to understand and be understood. AV speaks Japanese, and AV at times will respond in English with yes and no questions or simple responses. AV can still understand English. AV has poor ambulation gait, decreased ROM, decreased mobility AV uses Assistive Devices (AD), Wheelchair, and hospital bed. AV primarily uses AV's wheelchair and cannot self-propel; AV will need one staff member to assist AV with transfers in and out of the wheelchair. AV has history of falls, balance problems, physical weakness. AV has decreased awareness, medications affecting balance, and a diagnosis that would contribute to falls. Fall preventions include staff will encourage AV to be out in the common area while awake for increased supervision, staff will ensure AV is assisted to a common area or has a tabletop activity to keep AV engaged while the staff is assisting other residents. Staff to set AV up with activity while AV waits for dinner. Staff to keep pathways clear, and clutter picked up in room and common areas. Staff to ensure AV has non-skid footwear for transfers. On or about March 8, 2024 , AV was escorted by staff to the common area to watch TV. AV tried to stand up, AV sat back down, and then got up again and attempted to walk, and AV was found on the floor. AV was diagnosed with Fracture to L3 Vertebrae. AV’s Service Plan has contradicting statements on AV ability to communicate needs, AV "doesn’t have the ability to understand and be understood"; contradictory to, "AV speaks Japanese, and AV at times will respond in English with yes and no questions or simple responses. AV can still understand English". In interviews staff report contradicting statements on how AV communicates h/h needs, when AV wants assistance, AV will let the staff know with head nods and hand gestures; AV speaks mainly in AV's native language, AV understands English. AV's Service Plan describes AV's mobility and Assistive Devices as, "Wheelchair, and hospital bed. AV primarily uses AV's wheelchair and cannot self-propel; AV will need one staff member to assist AV with transfers in and out of the wheelchair." contradictory to interview from staff AV using a walker, AV is encouraged to use a walker and wheelchair, AV ambulates with a walker, AV uses a wheelchair for mobility and identified by observation noted by APPS in video of incident on or about March 8, 2024, AV's walker was beside AV, AV reaching for AV's walker, AV grabbing AV's walker losing AV's balance and falling to the floor. AV service plan indicates AV has poor ambulation, gait, decreased ROM, decreased mobility. AV has history of falls, balance problems, physical weakness. AV has decreased awareness, medications affecting balance, and a diagnosis that would contribute to falls. Fall preventions include staff will encourage AV to be out in the common area while awake for increased supervision. The facility failed to provide a safe environment for AV known gait disturbance and fall history by not providing the proper supervision when in the common area. The facility failed to properly plan care around AV's ability to communicate and make AV needs known, when AV is known to use hand gestures and head nods to get staff attention and only speak in native tongue and failed to care plan around AV using a walker with known mobility issues. The facility failed to follow the care plan by not assisting with transfers and providing supervision in the common area.

Alleged Victim's (AV's) service plan for Dietary/Eating dated on or about February 6, 2023, notes instructions: Regular, Physical assistance, Hand under hand. AV is on Regular diet and regular texture foods, s/he is also on thin liquids. AV requires staff assistance with eating, staff to offer physical eating assist at all meals. AV is often using staff assist for eating. Interim service plan for Weight loss and assistance with eating dated on or about June 24, 2021, use hand under hand technique, Encourage fluids between every few bites. On or about February 18, 2023, around 12:30 PM, Alleged Perpetrator 2 (AP2) was feeding AV when AV choked on food. As a result of the choking the food was not successfully dislodged and AV was pronounced deceased by EMS. Per Facility Protocol: Conscious Choking (Cannot Cough, Speak, Cry or Breathe) instructions; 1) Give 5 back blows. 2) Give abdominal thrusts. 3) Repeat 1 and 2 until: object is forced out; person can cough forcefully or breathe, or person becomes unconsciousness. If person becomes unconscious, carefully lower person to ground and give care of unconscious choking, beginning, and looking for an object. Per the training staff are supposed to complete the Heimlich Maneuver if a resident chokes. The facility video recording shows the first three staff not completing the Heimlich maneuver. The facility failed to provide a safe environment, the licensee is responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of his or her employment duties. Which is violation of resident’s rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) has history of following Witness 1 (W1) and wandering into W1 other residents’ rooms. AV interim service plan has behavioral interventions in place when AV is feeling anxious and/or wandering. Staff are to encourage AV to fold baby clothes, and when AV is finished, staff to unfold them and bring them back form more folding if needed. On or about January 13, 2023, AV was wandering into other resident’s rooms, AV was stopped by giving AV some food. AV later continued to wander and went into W1 room where a resident-to-resident altercation took place and W1 pushed AV in the hall. The facility failed to follow the care plan which is a violation of resident rights is neglect of care and constitutes abuse.

The facility failed to provide a safe medication administration system to ensure the Alleged Victims (AV) medication orders were administered as prescribed. It was discovered that AV was administered the incorrect dose of a blood thinning medication resulting in blood work coming back high and placing AV at significant risk of harm. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) service plan indicates AV has a history of wandering and getting lost causing anxiety. AV takes medication at night for increased anxiety at bedtime. Staff will add non-pharm interventions and document if successful or not if onset of behavior occur. Interventions for AV's behavior for feeling overwhelmed, anxious, fearful, angry, sullen, crying include; Staff to offer AV job around the community to complete, Staff offer to take AV on a walk, Staff to offer a snack/drink with 1:1 conversation and Engage AV in activities. From approximately September 16, 2022-November 17, 20222, AV showed increased agitation and anxiety by exit seeking and yelling. On or about October 20, 2022, AV started antibiotics for an UTI. Even after AV finished antibiotics, AV continued to be agitated and exit seek. On or about November 17, 2022, AV woke up agitated and violent towards staff. AV started to throw items resulting in skin tear/cuts on the left leg. The facility failed to adjust the service plan and implement reasonable interventions for AV leading to continued aggressive behavior, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) is a resident and under the care of the locked facility for the safety of the resident. AV has a history of eloping and getting lost. From approximately October 09, 2022 to October 31, 2022, AV attempted to the exit through the window twice. On or about October 31, 2022, AV was awake and agitated, and staff decided to give AV space. AV was able to slide opened the window, push out the screen and crawled through the window. A resident notified staff about AV missing. The facility called police who found AV at least .40 miles away in a grocery store parking lot. It was dark and the weather was 53 degrees with fog and rain. AV reports receiving an injury to the knee when AV crawled out of the window, but documents state AV hurt AV's hand/arm. The facility failed to ensure the screws that held the window lock in pace were tight and secure. The facility failed to provide a safe environment, and an appropriate safety plan around Av’s elopement behaviors, which is a violation of resident’s rights, is considered neglect of care and constitutes abuse.

Witness #1 (W1) is known to hallucinate, pace constantly throughout the day, and invade other residents’ personal space. W1 service plan, staff to check with W1 if seen pacing and encourage W1 to sit down. Alleged Victim (AV) has history of hallucinations and resident-to-resident altercations. AV ISP staff to immediately redirect AV when seen hallucinating and begins to bat at the air. On or about October 08, 2022, W1 was wandering around facility, and AV seen hallucinating in common area. Camera review shows AV seen speaking to W1, leading to a resident-to-resident physical altercation, resulting in W1 choking AV and both falling to the ground. AV sent to emergency room due to pain. The facility failed to follow resident care plan which is a violation of resident’s rights is neglect of care and constitutes abuse.

The facility failed to follow the Alleged Victim (AV) care plan. AV has history of wandering into other residents’ rooms. AV care plan indicates if AV begins to wander to close to Witness 1 (W1) room, staff to promptly redirect AV away from W1. On or about, September 22, 2022, AV wandered into W1 room, and was slapped in the face by W1. This failure 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 care plan indicates “do not seat other residents at the same table with the resident” “during mealtimes W1 is to have the table to themselves so they don’t get agitated and be verbally aggressive to others”. On or about September 22, 2022, Alleged Victim (AV) and W1 were seated at the same table. W1 became agitated was verbally aggressive with staff. W1 threw a napkin, and food at AV. W1 also kicked AV under the table. The facility’s failure to follow the care plan is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) has a history of choking and is care planned to have his/her food cut into small pieces and have moisture on the food, such as gravy or sauce. On or about August 15, 2022, AV was fed tater tots that were not cut up and also did not have any sauce. Staff noticed that AV sounded different and had AV drink some water, avoiding AV choking, however, AV was placed at risk for harm by not having his/her food prepared properly. The facility failure to follow the care plan 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 Witness #1 (W1). An incident occurred where W1 punches the Alleged Victim (AV) in the face. 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) was known to have a history of altercations and wandering into other residents rooms. AV's service plan did not have any interventions in place regarding wandering. On or about July 18, 2022, AV wandered into Witness #2's (W2) room and got into an altercation with Witness #1 (W1) and W2 where the two residents slapped AV. The facility failed to properly care plan, 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 April 26, 2022, the Alleged Victim's (AV) medication was inadvertently discontinued in error. On or about June 21,2022, it was discovered that the medication had been discontinued, as there was a computer glitch while making an update to the medication on AV's record. AV did not receive needed medication for approximately two months, placing AV at risk for serious harm. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide a safe medication administration system to ensure the Alleged Victims (AV) medication was administered as prescribed. It was discovered that AV did not receive h/h medication from approximately April 08, 2022, to June 22, 2022. The facility’s failure 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 walker within his/her reach in the dining room. On or about May 26, 2022, AV's walker was not within his/her reach. AV got up from the dining room table to walk to his/her walker, tripped on the wheel and fell backwards. AV was taken to the emergency room and diagnosed with a broken hip. The facility failed to follow the care plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness 1 (W1) relies on the facility for his/her care. W1 has a history of agitation, behavioral disturbance, and resident to resident altercations. On or about December 26, 2021, W1 behavior escalated from verbal incident to physical incident towards Alleged Victim (AV). W1 slapped AV on the right cheek. The facility failed to properly plan care and implement interventions for W1 behaviors which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #1 (W1) has history of wandering around the facility and into Victim (AV) room. On or about November 26, 2021, W1 wandered into AVs room and hit AV in the face. On or about November 30, 2021, W1 wandered into AVs room and a physical altercation occurred, W1 hit AV in the face leaving a red area to the right of AV lower lip and a bruise to AV right arm. The facility failed to properly plan care and provided interventions appropriate to mitigate W1 wandering and aggressive behaviors towards AV, which is a violation of resident rights is considered neglect of care and constitutes abuse.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

Based on interview and record review conducted during the investigation on April 22, 2026, the allegation that the facility failed to provide records to the Department upon request was substantiated. Findings include, but are not limited to, the following: A review of electronic communication dated September 3, 2025, showed that the Department requested documents related to the facility’s Acuity-Based Staffing Tool (ABST) for the alleged event dated August 25, 2025. The facility did not provide all requested documentation by the due date of September 4, 2025. The facility's failure to provide records to the Department upon request is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

Based on observation and interview, conducted during a site visit on 06/25/25 and 06/26/25, the facility's failure to have exit door alarms was substantiated. That placed residents at risk and constituted an immediate threat to residents' health and safety. On 06/24/25, the Department received a Report of a Serious Event in which Resident 1 had eloped from the facility through an exterior courtyard door. The facility was a memory care and had the following five distinct and separate neighborhoods: Mount Scott; Happy Valley; Milwaukie; West Linn; and Oregon City. In an observation of the Mount Scott neighborhood on 06/25/25, the alarm of the interior exit door to the courtyard was inaudible. In an interview, Staff 2 (Assistant Executive Director) stated s/he didn't know why it would be turned off, but was able to turn the alarm back on. In an observation of the West Linn neighborhood on 06/25/25, the alarm of the interior exit door to the courtyard was inaudible. In an interview, Staff 4 (Med Tech) stated "the battery is dead." In an interview, Staff 3 (Maintenance) stated s/he fixed the alarm in the West Linn neighborhood. In an observation of the Oregon City neighborhood on 06/25/25, the alarm of the interior exit door to the courtyard was found to have a very faint and fast "chirp" sound when the door was opened. The chirp was faintly audible standing in the doorway and could not be heard in other areas of the neighborhood. In an interview, Staff 3 stated s/he fixed the alarm in the Oregon City neighborhood. The facility's failure to have exit door alarms was substantiated.

Based on observation and interview, conducted during a site visit on 06/25/25 and 06/26/25, the facility's failure to exercise reasonable precautions against any conditions that may threaten the health, safety, or welfare of residents was substantiated. That placed residents at risk and constituted an immediate threat to residents' health and safety. Findings include, but are not limited to: On 06/24/25, the Department received a Report of a Serious Event in which Resident 1 had eloped from the facility through an exterior courtyard door. The facility was a memory care and had the following five distinct and separate neighborhoods: Mount Scott; Happy Valley; Milwaukie; West Linn; and Oregon City. In an interview, Staff 2 (Assistant Executive Director) stated the following: Resident 1 resided in the Mount Scott neighborhood; Resident 1 recently eloped from the facility through an exterior courtyard door; and Staff 2 believed landscapers did not secure the door prior to leaving on the day of the incident. The following observations of the Mount Scott neighborhood exterior courtyard doors were made on 06/25/25 at approximately 9:49 am: The south exterior courtyard door was unlocked and opened by Staff 2; The Compliance Specialist attempted to close the door, but the magnet lock did not engage; and Staff 2 was able to secure the door only after grabbing the top of the door and slamming it shut with immense force. Observations at approximately 3:45 pm: The north exterior courtyard door was unlocked and opened by Staff 3 (Maintenance); The door caught on the pavement below, preventing it from swinging shut; The south exterior courtyard door was unlocked and opened by Staff 3; The Compliance Specialist attempted to close the door, but the magnet lock did not engage; and Repeated attempts by Staff 3 and the Compliance Specialist to secure the door were unsuccessful until the door was slammed shut with immense force, and the magnet lock finally engaged. In an observation on 06/26/25, at approximately 7:28 pm, the following occurred: The south exterior door was ajar; The Compliance Specialist attempted to close the door, but the door and gate magnets were not aligned and could not connect; and The door required lifting by the Compliance Specialist to connect and engage the magnets to lock and secure the door. In an interview on 06/26/25, Staff 4 (Caregiver) s/he did not know the exterior courtyard door was not secured or having problems. In an interview on 06/26/25, Staff 2 stated s/he was unaware the exterior courtyard door was opened, but that they were onsite with Staff 3 to repair the courtyard door to prevent further incident. In an observation on 06/26/25, Staff 3 and the Compliance Specialist tested the exterior courtyard door after repairs and the magnet lock engaged successfully. The facility's failure to exercise reasonable precautions against any conditions that may threaten the health, safety, or welfare of residents was substantiated.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during an investigation on 06/30/26, the facility’s failure to provide records to the Department upon request was substantiated. Findings include but are not limited to: A review of electronic communication, dated 04/23/25, indicated the Department requested documents related to the facility’s Acuity-Based Staffing Tool (ABST) alleged event date 04/20/25. The facility had not provided all requested documentation by the due date of 04/24/25. The facility’s failure to provide records to the Department upon request is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during an investigation on 06/30/26, the facility’s failure to provide records to the Department upon request was substantiated. Findings include but are not limited to: A review of electronic communication, dated 06/05/25, indicated the Department requested documents related to the facility’s Acuity-Based Staffing Tool (ABST) alleged event date 03/21/25. The facility had not provided all requested documentation by the due date of 06/06/25. The facility’s failure to provide records to the Department upon request is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

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 documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

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 records to the Department upon request. The facility’s failure is a violation of Oregon Administrative Rules.

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 documentation upon request. An investigation determined this 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.

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 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.

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 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.

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 records to the Department upon request. The facility’s failure is a violation of Oregon Administrative Rules.

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 records to the Department upon request. The facility’s failure is a violation of Oregon Administrative Rules.

During an investigation on 08/06/25 and 08/07/25, the facility’s failure to provide records to the Department upon request was substantiated. A review of electronic communication, dated 12/08/24, indicated the Department requested documents related to the facility’s Acuity-Based staffing Tool (ABST) alleged event date 11/25/24. The facility had not provided all the requested documentation by the due date of 12/09/24. The facility’s failure to provide records to the Department upon request was substantiated.

The facility’s failure to provide records to the Department upon request was substantiated.

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 records to the Department upon request. The facility’s failure is a violation of Oregon Administrative Rules.

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 records to the Department upon request. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

Alleged Victim (AV) is Service Planned for wandering and is known to take objects from shared facility community spaces and AV interventions include; bringing another object to AV, asking AV to complete another task and or redirecting AV. On or about November 05, 2024, Per Investigators Video Footage of Incident Observations; AV was walking around the facility with the facility vacuum and AV walked past the staff desk and grabbed a jacket that didn’t belong to AV. Alleged Perpetrator 2 (AP2) walked up to AV and snatched the vacuum and jacket away from AV. AP2 then bends down to get the vacuum cord and in this process AP2 seems to bump into AV with AP2’s bottom. AV with an open hand slaps AP2 on AP2’s lower back. AP2 stands up and pushes AV back by placing AP2’s left hand on AV’s stomach and AP2 pushes AV against the wall. AV stretches AV’s right hand with a closed fist and hits AP2 in the throat or just below AP2’s throat. AP2 uses AP2’s left hand and grabs AV’s right wrist and then AV walks away. The facility failed to provide a safe environment, oversight for the health and safety of AV. According to an investigation, AV experienced Unreasonable discomfort. The failure is a violation of Oregon Administrative Rules. The allegation that AP2 Physically Abused AV was investigated and determined AP2’s actions are a violation of resident rights, are considered neglect of care and constitutes physical abuse.

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 records to the Department upon request. The facility’s failure is a violation of Oregon Administrative Rules.

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 records to the Department upon request. The facility’s failure is a violation of Oregon Administrative Rules.

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 records to the Department upon request. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide records to the Department upon request. The facility’s failure is a violation of Oregon Administrative Rules.

A review of Resident 1’s signed physician orders, dated 08/16/24, revealed an order for “MORPHINE (MSIR) 15 MG TABLET take 0.5 tablets by mouth 3 times daily as needed for pain (Additional ½ tab may be offered for pain 8/16-8/18).“ A review of Resident 1’s 08/01/24 – 08/31/24 MAR revealed the above order was not entered into the MAR. A review of “Suspected Abuse or Unexplained injury reporting form,” dated 08/30/24, revealed “on 8/27/2024 at 4pm MT gave [Resident 1] a PRN of Morphine because [s/he] said [s/he] was in pain. [S/He] has a PRN card for it. End date on the card was 8/18/24. The end date was unnoticed by the MT on shift.” During an interview, Staff 1 (Resident Services Manager) stated Resident 1’s PRN medication should have been added to the MAR, but was not and Resident 1 did not have an order for a PRN pain medication to be given on 08/27/24.

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 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.

Based on interview and record review, conducted during a site visit on November 18, 2024, the facility's failure to carry out medication orders as prescribed was substantiated for 1 of 1 sampled resident (# 1). Findings include, but are not limited to: A review of Resident 1's physician orders, dated March 01, 2024, showed an order for the following: Rifaximin 550 mg tablet, one tablet by mouth two times daily, for alcohol cirrhosis. A review of Resident 1's Medication Administration Record (MAR), dated May 01, 2024-May 31, 2024, indicated the following: Between May 02, 2024 andMay 06, 2024, Rifaximin was unavailable; and the facility had reordered the medication and was awaiting its delivery. In an interview, Staff 1 (Assistant Executive Director) and Staff 2 (Resident Services Manager) acknowledged the medication was not available. The facility's failure to carry out medication orders as prescribed was substantiated.

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 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 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 allegation that the Alleged Perpetrator 2 (AP2) neglected the Alleged Victim (AV) was investigated and determined to be not substantiated.

It was determined the facility’s failure to ensure the implementation of services was substantiated. An investigation determined that a licensing violation had occurred.

Alleged Victim (AV) relies on the facility for his/her care. AV has cognitive impairments, has difficulty understanding English, and h/h primary language is Mandarin. AV's Service Plan directs staff to use a soothing voice and be patient while trying to communicate with AV. On or about October 13, 2023, AP2 uses derogatory language such as, "Cracked in the head," "You're covered in poop, I'm not touching you." "Gross." and "AV should be in an insane asylum," . AP2 spoke in a harsh tone and yells at AV to "Get up, get up," and orders AV to "Sit down!" multiple times. AP2 was properly trained to work with residents. AP2 did not follow the Service Plan or their training protocol. As a result of the incident, AV experienced unreasonable discomfort and loss of personal dignity. AP2's actions is considered verbal/emotional abuse. The facility failed to protect AV from verbal/emotional abuse which is a violation of Oregon Administrative Rules.

Alleged Victim (AV) Service Plan indicates AV's primary language is Mandarin. AV does not have the ability to understand and to be understood. Staff to be patient when trying to communicate with AV. Try to guide AV and give visual cues and modeling as much as possible. AV is able to make simple decisions but also needs safety awareness assistance. AV has history of falls, physical weakness, poor gait, poor balance, and decreased mobility. Staff will need to provide assistance with ambulation. AV will need assistance with transferring. AV has incontinence issues. Staff will need to offer AV assistance with toileting upon waking, before and after meals, as well as before bedtime. Staff to check on AV during NOC shift and offer to provide toileting assistance. Staff to assist with accidents when they are observed and ensure that Peri care is provided. AV should be cleaned and dry after toileting assistance is provided. On or about October 13, 2023, per camera review AV is seen walking down the hall with h/h walker, AP2 is sitting across the room. AV walked into the dining area and started handling the feces in their pants. AP2 stepped in front of AV and as a result, AV lost their balance, fell to the floor, and laid in a soil brief. AV laid on the floor for approximately 6 minutes groaning, asking for help and in discomfort. AP2 did not call for additional staff for assistance to help AV off of the floor. Once AV got h/h-self up off the floor, AP2 refused to help AV with peri care, AP2 instructed AV to sit down and wait approximately 5 min until the next staff member could help clean them up. AP2 was trained by the facility to work with residents, facility staff are supposed to call for another staff to help when a resident falls. As a result of AP2's actions, AV experienced unreasonable discomfort and loss of personal dignity, which is neglect and abuse. The facility failed to ensure the residents rights/treatment was being followed, which is a violation of Oregon Administrative rules.

Alleged Victim (AV) Service Plan indicates AV's primary language is Mandarin. AV does not have the ability to understand and to be understood. Staff to be patient when trying to communicate with AV. Try to guide AV and give visual cues and modeling as much as possible. AV is able to make simple decisions but also needs safety awareness assistance. AV has history of falls, physical weakness, poor gait, poor balance, and decreased mobility. Staff will need to provide assistance with ambulation. AV will need assistance with transferring. AV has incontinence issues. Staff will need to offer AV assistance with toileting upon waking, before and after meals, as well as before bedtime. Staff to check on AV during NOC shift and offer to provide toileting assistance. Staff to assist with accidents when they are observed and ensure that Peri care is provided. AV should be cleaned and dry after toileting assistance is provided. On or about October 13, 2023, per camera review AV is seen walking down the hall with h/h walker, AP2 is sitting across the room. AV walked into the dining area and started handling the feces in their pants. AP2 stepped in front of AV, and AP2 kicked AV's walker, as a result, AV lost their balance, fell to the floor. AV laid on the floor for approximately 6 minutes groaning, asking for help and in discomfort. AP2 did not call for additional staff for assistance to help AV off of the floor. AP2 attempted to yank AV up by one arm/hand while AV was unable to assist. Once AV got h/h-self up off the floor and sat in a chair, AV attempted to get up from the chair and AP2 pushed AV back into the chair. AP2 instructed AV to sit down and wait approximately 5 min until the next staff member could help clean them up. AP2 was trained by the facility to work with residents, facility staff are supposed to call for another staff to help when a resident falls. As a result of AP2's actions, AV experienced unreasonable discomfort and loss of personal dignity, which is neglect and abuse. The facility failed to ensure the residents rights/treatment was being followed, which is a violation of Oregon Administrative rules.

The Alleged Victim (AV) has exit seeking behaviors. On or about October 12, 2023, AV eloped from the facility when Alleged Perpetrator 2 (AP2) did not ensure the gate was locked, after exiting. The AV was outside the facility for about twenty minutes before being located, resulting in AV experiencing unreasonable discomfort and placing AV at risk of serious harm. AP2’s actions are considered neglect and constitutes abuse. The facility failed to provide a safe environment for AV which is a violation of resident rights, is neglect of care which constitutes abuse.

On or about September 29, 2023, Alleged Perpetrator 2 (AP2) used physical force against Alleged Victim (AV) while assisting AV with his/her Activities of Daily Living as a facility staff member, which resulted in a physical injury to AV. AP2 was arrested as a result of this incident. AP2 is responsible for physical abuse. The facility is responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of his/her employment duties. The facility's failure to protect AV is a violation of Oregon Administrative Rules.

On or about June 25, 2023 – June 27, 2023, Alleged Perpetrator 2 (AP2) signed they had administered Oxycodone to Alleged Victim (AV) on MAR however no medication was logged on AV's Oxycodone administration sheet. AV had a shortage of Oxycodone at the end of June. AP2’s actions are a violation of resident rights, are considered neglect of care and constitute financial abuse. The facility failed provide a safe medication administration system, which 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.

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

The facility allegedly failed to provide a safe medication administration system for the Alleged Victim. An investigation determined this 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. An investigation determined this is a violation of Oregon Administrative Rules.

ABST Condition RCFCD23-00692, imposed 5/26/2023, no further action required.

On or about February 01, the Oregon Health Authority reported to the Department that Respondent failed to comply with weekly reporting requirements of vaccinated individuals, residents and staff, to the proper authority as required by law. This failure has been ongoing for a total of 30 days.

On or about December 24, 2022, Alleged Victim was discharged from the hospital back to the facility with directions to discontinue (DC) medications. AV was administered the DC medications for approximately two (2) days. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules. This is the facility's second violation of this kind within a six month time frame. Further rule violation(s) may result if civil penalties or further corrective action.

The facility failed to carry out medication and treatment orders as prescribed, resulting in the resident being administered oxycodone when it wasn't schedule at the correct time, which is a violation of Oregon Administrative Rules.

The facility failed to ensure a resident may not be locked out of or inside of their rooms at any time. It was discovered resident's door was locked, and they had to find staff to unlock the door, which is a violation of Oregon Administrative Rules.

On or about October 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 September 1, 2022 to September 30, 2022, for a total of 30 days.

On or about August 31, 2022 at approximately 8:55 am, Alleged Perpetrator 2 (AP2) gave Alleged Victim (AV) another resident's medications. AV was anxious and vomited later in the day. AP2 was provided training by the facility. The facility notified AVs PCP of the medication error on August 31, 2022. The allegation that AP2 failed to provide a safe medication administration system and administer medications to AV as ordered resulting in a serious risk of harm was investigated and the determination was not substantiated. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.

The facility failed to carry out medication orders as prescribed, resulting in a resident being given a medication at a time it was not scheduled, medication not documented as given, and a resident has not being given medication for several months, which is a violation of Oregon Administrative Rules.

On or about July 19, 2022, Alleged Perpetrator 2 (AP2) did not follow proper procedure and gave the Alleged Victim (AV) the incorrect dosage of medication, which caused AV to experience unreasonable discomfort. AP2's actions are considered neglect and constitutes abuse. The facility failed to provide a safe medication administration system to ensure AV's medications were administered as ordered which violates Oregon Administrative Rules.

Alleged Victim (AV) is care planned to have h/h bed lowered to the lowest possible position. On or about July 08, 2022, Alleged Perpetrator #2(AP2) was assisting AV with daily care. AP2 left AV room and did not lower AVs bed to the lowest position which resulted in AV falling and sustaining two (2) lacerations to h/h head. AP2 failed to follow the care plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to ensure the care plan was being followed, which is a violation of Oregon Administrative Rules.

Alleged Perpetrator 2 (AP2) failed to provide a safe medication administration system. On or about June 30, 2022, AP2 administered another resident a cup of coffee mixed with medication. AP2 failed to watch the other resident completely drink the coffee mixed with medication and walked away. The other resident gave Alleged Victim (AV) the coffee cup and AV is seen on video footage drinking from the cup. AV was transported to the hospital as a result of not feeling good after drinking the coffee mixed with mediation. AP2's actions are considered neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.

On or about, June 29, 2022, Alleged Perpetrator 2 (AP2) did not follow proper procedure when showering the Alleged Victim (AV), which caused unreasonable discomfort and resulted in bruises on AV's hands/arms. AP2s actions are considered physical abuse. The facility failed to protect a resident from physical abuse which violates Oregon Administrative Rules.

The facility failed to administer the resident's medication as order by their physician, resulting in resident being given medication at a time it was not scheduled, which is a violation of Oregon Administrative Rules.

The facility failed to respond to the residents change of condition when residents are falling, no interventions are being put in place, which is a violation of Oregon Administrative Rules.