Prestige Senior Living West Hills

The Alleged Victim (AV) relies on the facility to manage his/her medications and is care planned for standby assistance with all transfers. According to an investigation, facility staff provided AV three days’ worth of his/her medication and allowed AV to leave the facility on his/her own, posing a serious risk of harm. The facility failed to provide appropriate services, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to an investigation, on or about January 9, 2023, AV’s denture plate broke, and AV was unable to chew his/her food. The facility failed to implement interventions and appropriately care plan relating to the Alleged Victim’s (AV) change of condition, which resulted in AV being hungry and losing approximately ten percent of his/her body weight. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to adequately monitor, assess, and document the Alleged Victim's (AV) skin condition, which resulted in AV not receiving timely medical treatment. AV experienced pain and discomfort for an extended period and had to be sent to the hospital for treatment. AP2's actions were determined to be Not Substantiated. The facility failed to assure timely medical treatment, 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, relating to his/her change of condition, increased falls with lack of appropriate interventions, and AV's known inability to use the call system. On or about August 31, 2022, AV experienced a fall while he/she was attempting to self-transfer from his/her wheelchair to the toilet. AV was transported to the hospital and diagnosed with a hip fracture, requiring surgical intervention. The facility failed to care plan to implement appropriate interventions to mitigate the risk of injury relating to falls, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) did not receive medication as ordered, which caused AV unreasonable discomfort. The facility failed to provide a safe medication administration system to ensure AV's medications were available and administered as ordered. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to an investigation, on or about July 12, 2022, the Alleged Perpetrator 2 (AP2) verbally and physically harassed the Alleged Victim (AV) in a sexual nature, which resulted in the AV experiencing unreasonable discomfort and loss of personal dignity. AP2's actions are considered sexual abuse. The failed to protect the AV from sexual abuse, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to an investigation, the Alleged Perpetrator 3 (AP3) was notified of a sexual abuse concern involving the Alleged Perpetrator 2 (AP2), and failed to take appropriate protective actions. Approximately two days later, AV experienced an incident with AP2, resulting in sexual abuse. AP3's failure to take appropriate action and provide a safe environment, is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to provide appropriate oversight of the services and conduct of staff, resulting in sexual abuse of a resident, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility and Alleged Perpetrator 3 (AP3) failed to provide a safe environment. According to the investigation, AP3 was notified about a staff member making inappropriate sexual comments to the Alleged Victim (AV) and did not take appropriate protective actions, which resulted in AV experiencing emotional discomfort and loss of personal dignity. The facility and AP3's actions are considered neglect of care and constitutes abuse.

On or about May 18, 2022, it was discovered during a medication count that approximately nineteen of the Alleged Victim's (AV) narcotic pills were missing. The facility failed to provide a safe medication administration system and did not keep AV free from financial exploitation, which is a violation of resident rights, is neglect of care and constitutes abuse. The allegation that Alleged Perpetrator 2 (AP2) financially exploited AV was investigated, and the allegation of abuse was unable to be determined.

On or about May 18, 2022, it was discovered during a medication count that approximately seven of AV's narcotic pills were missing. The facility failed to provide a safe medication administration system and did not keep AV free from financial exploitation, which is a violation of resident rights, is neglect of care and constitutes abuse. The allegation that AP2 financially exploited AV was investigated, and the allegation of abuse was unable to be determined.

On or about March 8, 2022, the Alleged Victim (AV) fell while trying to self transfer. Staff responded to AV's call, however, one staff could not assist AV and needed more staff to assist. The call system that would allow staff to communicate with each other was not working. Staff had to leave AV on the floor with his/her ankle caught under his/her chair while going to get other staff to assist. AV was on the floor approximately 20 minutes with his/her ankle caught under the chair, causing unreasonable discomfort and was later diagnosed with a sprained ankle. The facility's failure to provide timely assistance is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about December 20, 2021, the Alleged Victim (AV) did not receive his/her pain medication as ordered, as the facility medication system showed AV's medications as discontinued, therefore they could not be given. Alleged Perpetrator #2 (AP2) was not trained how to work with "pending" medications in the system, therefore did not know he/she could give the medication. AP2 was further trained to avoid this instance in the future. The facility failed to provide a safe medication administration system, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility to manage his/her medications. Between November 12, 2021, and November 15, 2021, AV did not receive six doses of his/her anxiety medication and there was no evidence that the facility placed AV on alert charting or monitoring. AV suffered increased anxiety and had trouble sleeping as a result. The facility failed to provide a safe medication administration system to ensure AV’s medication was available to be administered as ordered. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

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

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

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

The facility failed to complete or update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly. The facility’s failure is a violation of Oregon Administrative Rules.

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

The Alleged Victim (AV) relies on the facility for his/her care. According to an investigation, Alleged Perpetrator 2 (AP2) made inappropriate verbal comments to AV, resulting in unreasonable discomfort. AP2’s actions are a violation of resident rights, are considered neglect of care and constitutes verbal abuse. The facility failed to provide a safe environment, which violates Oregon Administrative Rules.

The Alleged Victim (AV) relies on the facility for his/her care. According to an investigation, Alleged Perpetrator 2 (AP2) handled the Alleged Victim (AV) in a rough manner, resulting in unreasonable discomfort. AP2’s actions are a violation of resident rights, are considered neglect of care and constitutes physical abuse. The facility failed to provide a safe environment which violates 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 have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) relies on facility staff to ensure resident’s rights. According to an investigation, sometime in October 2024 the Alleged Perpetrator 2 (AP2) entered into an agreement with the AV to purchase the AV's car. AP2 took possession of the car and failed to make the agreed-on payment to the AV. AP2’s actions are considered financial exploitation and constitutes abuse. The facility did not keep AV free from financial exploitation, which is a violation of Oregon Administrative rules.

The 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 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 a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to ensure a system for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility. An investigation determined this is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) relies on the facility to manage his/her medications. AV was care planned to receive scheduled pain medication three times per day. According to an investigation, on or about, January 1, 2024, Alleged Perpetrator 2 (AP2) did not administer AV’s medication as ordered, causing AV to experience unreasonable discomfort. The facility and AP2 failed to provide a safe medication administration system, which is a violation of resident rights Oregon Administrative Rules.

The facility failed to develop and implement effective methods of responding to and resolving resident complaints. An investigation determined this is a violation of Oregon Administrative Rules.

According to an investigation, it was determined that Alleged Perpetrator 2 (AP2) stole money from the Alleged Victim (AV), totaling approximately $439.00. AP2's actions are considered financial exploitation and constitutes abuse. The facility did not keep AV free from financial exploitation, which is a violation of Oregon Administrative rules.

On or about February 1, 2023, 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”.

Based on interview and observation it was confirmed the facility failed to take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. Findings include: During separate interviews on 10/20/2022 with Resident #1 and #4 (R1 and R4) stated that before the dining room was closed there were flies in the dining room. Staff #1 (S1) stated that the facility does not pick up meal trays until right before the next meal is delivered. S1 stated that the dining room is closed at the moment and all meals are delivered to rooms. During an unannounced site visit on 10/20/2022, The Compliance Specialist (CS) observed gnats flying around in Resident #7 ' s (R7) room and dirty meal trays to be scattered around the community.

Based on interview and observation it was confirmed the facility failed to clean and in good repair. Findings include: During separate interviews on 10/20/2022 with Resident #4 (R4) stated that the facility does not pick up meal trays timely. Staff #1 (S1) stated that the facility does not pick up meal trays until right before the next meal is delivered. S1 stated that the dining room is closed at the moment and all meals are delivered to rooms. During an unannounced site visit on 10/20/2022, The Compliance Specialist (CS) observed: Stains on the carpet in the hallways, All doors in the facility to have extensive black stains on them with multiple doors that were chipped, Light fixture had plastic cover taken off and a light bulb out, and Multiple dirty dishes left out throughout the community.

The facility allegedly failed to provide direct care staff sufficient in number to meet the scheduled and unscheduled needs of the residents. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to have an Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. Facility is not currently staffing to the levels as indicated by the ABST. An investigation determined this is a violation of Oregon Administrative Rules.

The facility allegedly failed to provide household services essential for the health and comfort of the resident. An investigation determined this is a violation of Oregon Administrative Rules.

On or about July 10, 2022, Alleged Perpetrator 2 (AP2) made an inappropriate sexual comment to the Alleged Victim (AV), which resulted in the AV experiencing unreasonable emotional discomfort and loss of personal dignity. AP2’s actions are a violation of resident rights, are considered neglect of care and constitutes sexual abuse. The facility failed to protect AV from inappropriate sexual comments made by staff and the failure is a violation of Oregon Administrative Rules.