Princeton Village Assisted Living Community

On or about May 4, 2024, Alleged Perpetrator #2 (AP2) failed to administer the Alleged Victim's (AV) eye medication and his/her medication that controls seizures, placing AV at risk for serious harm. AP2 did not receive proper training from the facility prior to this incident. AP2's allegation is not substantiated. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about April 27, 2024, the Alleged Victim (AV) did not receive scheduled medication as ordered. Alleged Perpetrator #2 (AP2) was passing medication that day and was unable to find AV's medications in the medication cart and asked other staff to assist finding the medication. This was AP2's first day of working at the facility passing medications and did not have proper training to pass medications. As a result of missing his/her medications, AV suffered increased anxiety . The facility's failure to provide a safe medication administration system is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is a known fall risk and known to drink alcohol occasionally. On or about March 28, 2024, AV was found on the floor of his/her apartment, apparently AV had slipped and fallen on a puppy pee pad. AV was sent to the hospital for evaluation and was diagnosed with broken ribs. The facility's failure to provide a safe environment to ensure AV's safety from falls is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) receives routine insulin. On or about March 19, 2024 and March 23, 2024, AV missed at least one dose of his/her insulin. AV did not have any negative side effects, however, missing his/her insulin placed AV at risk for harm. The facility failed to provide a safe medication administration system, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is care planned to have assistance with his/her compression socks every morning. AV has had to wait until as late as noon to get assistance with the socks. Not having the socks on exacerbates AV's pain in his/her legs. AV will also occasionally need assistance while using the bathroom and will press his/her call button, however, staff at times will not answer for up to two hours, leaving AV unclean. The facility's failure to assist AV when needed caused emotional distress, unreasonable discomfort and a loss of personal dignity, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about February 4, 2024, the Alleged Victim (AV) pressed his/her call light for assistance while using the bathroom. AV waited for over an hour and no staff arrived to assist AV with his/her needs. AV was so distraught that he/she called his/her adult child to find assistance. AV's adult child could not get a hold of any staff either, and ended up calling emergency services to get assistance for AV. The facility's failure to ensure that call lights were answered in a timely manner caused unreasonable discomfort for AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) had a fall in December 2023 with injury. AV's care plan wasn't updated to reflect AV as a fall risk. AV fell again on January 25, 2024 while he/she was trying to get out of bed. The facility failed to properly care plan to avoid falls. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is a known diabetic resident, requiring medication to manage blood sugar and has a history of numbness of his/her feet. AV is known to refuse cares by staff, however, this had not been documented by facility staff. AV's medical condition dictates that he/she should be on at least weekly skin checks to ensure his/her safety. AV was not care planned for weekly skin checks, leaving him/her at risk for skin injury. On or about December 9, 2024, staff discovered that AV's left toe was black. AV was sent to the emergency department and it was determined that AV's toe needed to be amputated and later his/her entire foot. The facility's failure to ensure AV's skin integrity is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is independent with transfers but needs to call for assistance when weak or unsteady. Between November 2023 and January 2024, AV suffered a fall three times while transferring from his/her wheelchair to the recliner. AV had a rug under his/her recliner that did not lay flat on one corner. On December 6, 2023, staff reported that AV may have suffered a fall due to the rug, however, the facility noted this was a non injury fall. On December 8, 2023, AV had a regularly scheduled doctors appointment, where AV complained on having pain in his/her toe. An x-ray confirmed that AV suffered a fractured toe. The facility's failure to ensure interventions were in place to reduce the risk of falls is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) has suffered multiple falls with and without injury. AV was not care planned as a fall risk, even though AV had suffered multiple falls. AV suffered an injury fall on August 16, 2023 where he/she suffered an abrasion. The facility failed to properly are plan as it relates to falls, placing 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) was identified by staff to have aggressive behaviors and has a history of altercations with staff and residents. On or about September 30, 2023, W1 and the Alleged Victim (AV) engaged in an altercation where W1 hit AV in the face approximately 4 times. The facility failed to properly care plan for known aggressive behaviors by W1, placing AV at risk for harm. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about August 31, 2023, it was reported by the Alleged Victim (AV) that Alleged Perpetrator #2 (AP2) touched AV on the breast and between his/her legs. Staff had previously notified management of AP2's inappropriate actions towards staff. Facility management did not address these actions with AP2. The allegation that AP2 was inappropriate with the AV was found to be inconclusive. The facility's failure to address the inappropriate actions with AP2 placed residents at risk for harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about August 22, 2023, the Alleged Victim (AV) used his/her call light to request assistance from staff while using the restroom. AV called at 4:05 AM and waited at least 37 minutes for the call to be answered. AV used his/her call light again at approximately 4:50 AM and waited about 50 minutes for staff to assist him/her, causing AV unreasonable discomfort. The facility's failure to answer the call light timely, causing unreasonable discomfort, is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about August 15, 2023, the Alleged Victim (AV) approached the Alleged Perpetrator #2 (AP2) and requested a timeline of when AV would receive his/her medication. AP2 told AV that he/she could not help him/her at that time and advised AV to go to his/her room. AV continued to follow AP2 requesting information, to which AP2 became upset and raised his/her voice at AV, causing anxiety and shortness of breath. AP2's actions are a violation of resident rights, is considered neglect of care and constitutes verbal abuse. The facility failed to protect AV from verbal abuse, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is a diabetic and requires his/her blood sugar to be checked and receives insulin. On or about July 25, 2023, AV did not receive his/her insulin and his/her blood sugar level was not checked, leaving AV at risk for harm. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about June 17, 2023, Alleged Perpetrator #2 (AP2) was assisting the Alleged Victim (AV) with a shower. AV had recently returned from the hospital due to a urinary tract infection and was still a little weak and shaky. One staff advised AP2 not to shower AV due to his/her weakness, however, another staff advised AP2 to give the shower, which AP2 did. During AV's shower, while drying off, AV fell to the floor. AV was sent out to the hospital and diagnosed with a fractured leg and hip. The facility's failure to properly train staff is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is care planned to be assisted after toileting with peri care. From January 1, 2023 and February 9, 2023, AV waited multiple times more than 15 minutes, multiple times, for staff to assist him/her after pressing the call light. AV suffered stinging pain and unreasonable discomfort while waiting for staff to assist him/her. The facility's failure to answer the call light in a timely manner is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) was serviced planned to have assistance with showers 4 days per week. AV has gone without showers multiple days, causing him/her to experience body odor, dry skin, itchy scalp and low self esteem, which caused AV unreasonable discomfort. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about January 2, 2023, the Alleged Victim (AV) noticed he/she was missing 3 items from his/her bathroom after he/she saw Alleged Perpetrator #2 (AP2) use his./her bathroom and leave the room. AP's actions are a violation of resident rights, are considered neglect of care and constitute financial abuse. The facility failed to ensure that AP2's background check was approved prior to letting AP2 work in the facility unsupervised, knowing that AP2 had a criminal history. The facility's failure to protect AV from financial abuse is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is care planned to have a safety check during night shift. On or about July 24, 2022, AV was found on the floor in his/her room at 5:00 AM by staff. AV had a soiled brief and looked like he/she had been on the floor for a while. AV tried to call for assistance, but no one came to his/her aid. AV was sent to the hospital and it was determined that AV had suffered a cardiac event. The facility's failure to follow the care plan is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about March 9, 2022, the Alleged Victim (AV) was found on the floor in his/her kitchen. AV complained of a bruised jaw and pain in his/her toe after the fall. Staff who assisted AV up did not complete any assessment of AV after the fall to ensure no injuries. The facility's failure to assess after a fall is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) knows how to use his/her call light. AV slept in his/her recliner, as he/she was able to get out of his/her recliner alone, but not able to get out of his/her bed. AV utilized his/her call light on multiple occasions and had to wait anywhere from 20 minutes to almost 6 hours, leaving AV in unreasonable discomfort. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about February 24, 2025, the Alleged Victim (AV) was given 200 mg of medication when he/she was only to be given 50 mg of medication. Alleged Perpetrator #2 (AP2) administered AV's medication incorrectly, placing AV at risk for harm, as AV's physician indicated that AV is a fall risk, although AV is not care planned as a fall risk. This additional medication could have caused AV to become unsteady and suffer a fall. AP2's actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility's failure to ensure a safe medication administration system was determined to be inconclusive.

The facility failed to document that they have observed and evaluated the individual's ability to perform safe medication and treatment administration unsupervised in accordance with OAR411-054-0070; per complaint facility med techs lack training, which is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during an offsite review on 04/07/25 the facility's failure to implement an Acuity-Based Staffing Tool (ABST). The facility failed to have appropriate staffing based upon their ABST on February 4, 2025, however, there is no consistent information to determine that the facility consistently did not staff appropriately, therefore, no condition placed at this time. The facility's failure to staff to their ABST is a violation of Oregon Administrative Rules.

The facility failed to develop, maintain, and implement an Acuity Based Staffing Tool in accordance with OAR 411-054-0037(1-7), which is a violation of Oregon Administrative Rules.

The facility failed to develop, maintain, and implement an Acuity Based Staffing Tool in accordance with OAR 411-054-0037(1-7), which is a violation of Oregon Administrative Rules.

The facility failed to fully implement and update an acuity-based staffing tool in accordance with OAR 411-054-0037, which is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) has his/her medication administered and ordered by facility staff. On or about August 6, 2024, AV advised staff that he/she had not received his/her twice daily medication to reduce the risk of stroke since August 2, 2024. Facility staff looked at the medication system and determined that AV's medication had been discontinued, therefore no medication was re-ordered for AV. There was no negative effect to AV, however, the facility's failure to provide a safe and accurate medication administration system is a violation of Oregon Administrative Rules.

The facility failed to keep resident records for a minimum of three years which is a violation of Oregon Administrative Rules.

The facility failed to carry out medication orders as prescribed per complaint that the facility failed to administer medication as ordered, which is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) receives his/her medication from facility staff. On or about April 27, 2024, AV was not given his/her medication as ordered. AV's missed medications were not properly recorded on the facility medication administration system. Alleged Perpetrator #2 (AP2) failed to administer or record AV's medication. AP2 was not properly trained prior to providing medication administration. The facility's failure to provide proper training and have a safe medication administration system is a violation of Oregon Administrative Rules.

On or about April 27, 2024, the Alleged Victim (AV) did not receive his/her medications as ordered. Alleged Perpetrator #2 (AP2) failed to pass medications as ordered. AP2 was not trained properly prior to passing medication at the facility, resulting in AP2 not being able to find medication for AV. The facility's failure to properly train agency staff is a violation of Oregon Administrative Rules.

On or about April 28, 2024, the Alleged Victim (AV) did not receive his/her blood pressure medication. AV's medication was not available at the facility and had to be re-ordered by staff. The facility has had multiple medication errors within the six months prior to this allegation, leading to a civil money penalty. The facility's failure to provide a safe medication administration system is a violation of Oregon Administrative Rules.

On or about April 27, 2024 and April 28, 2024, the Alleged Victim (AV) did not receive two medications during the med pass. Alleged Perpetrator #2 (AP2) and Alleged Perpetrator #3 (AP3) were not able to find the medication for AV to be able to pass the medications. AV's medications were available but couldn't be found by AP2 and AP3. The facility's failure to provide a safe medication administration system is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) receives his/her medication from facility staff. On or about April 27,2024, AV did not receive 2 of his/her medications as ordered. Alleged Perpetrator #2 (AP2) failed to pass AV's medication, as AP2 could not find the medication to pass. The facility failed to properly train AP2 on the medication administration system prior to AP2 passing medications. The facility's failure is a violation of Oregon Administrative Rules. AP2's failure was found to be not substantiated for abuse.

The Alleged Victim (AV) receives blood sugar medication twice per day, administered by the facility. On or about March 17, 2024, Alleged Perpetrator #2 (AP2) failed to schedule staff who were properly delegated to administer blood sugar medication, therefore, AV failed to receive his/her medication as required. The facility's failure to provide appropriate staff to administer medication is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) receives blood sugar medication once per day, administered by the facility. On or about March 17, 2024, Alleged Perpetrator #2 (AP2) failed to schedule staff who were properly delegated to administer blood sugar medication, therefore, AV failed to receive his/her medication as required. The facility's failure to provide appropriate staff to administer medication is a violation of Oregon Administrative Rules.

The facility failed to complete service plans quarterly per complaint that "care plans are about 3 months behind", which is a violation of Oregon Administrative Rules.

The facility failed to carry out medication and treatment orders as prescribed in accordance with OAR 411-054-0055(1)(f); per complaint a resident missed numerous doses of his/her antibiotics and per complaint the facility has repeatedly lost a resident’s medication and failed to carry out medication orders as prescribed, which is a violation of oregon administrative rules.

The facility failed to administer medications as prescribed per complaint that a resident did not receive a medication on 01/08/24, which is a violation of Oregon Administrative Rules.

On or about December 20, 2023, the Alleged Victim (AV) was found with his/her bedding and clothing soaked with urine, causing unreasonable discomfort. The facility's failure to ensure AV was changed in a timely manner is a violation of Oregon Administrative Rules.

The facility failed to carry out medication orders as prescribed per complaint that the facility administered the wrong dosage of medication to resident, which is a violation of Oregon Administrative Rules.

On or about June 17, 2023, approximately 30 medication cups were found in the Alleged Victim's (AV) room in a cupboard, with medications in them. Alleged Perpetrator #2 (AP2) and Alleged Perpetrator #3 (AP3) knew they were supposed to watch AV take his/her medication, however, AP2 stated he/she was in a hurry. AV did not have any negative side effects of missing 15 days of medication. The facility's failure to provide a safe medication administration system is a violation of Oregon Administrative Rules.

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

The facility failed to document orders in the resident's facility record for all medications and treatments that the facility is responsible to administer, which is a violation of Oregon Administrative Rules.

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

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

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

The facility failed to implement a system for tracking controlled substances, which is a violation of Oregon Administrative Rules.

The facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident, which is a violation of Oregon Administrative Rules.

On or about January 8, 2023, the Alleged Victim (AV) noticed his/her pill box went missing from his/her room. The pill box was taken by Alleged Perpetrator #2 (AP2, unknown). AP2's actions are a violation of resident rights, are considered neglect of care and constitute financial abuse. The facility's failure to protect AV from financial abuse is a violation of Oregon Administrative Rules.

The facility failed to evaluate residents who choose to self-administer their medications upon move-in and at least quarterly and ensure residents have a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications, which is a violation of Oregon Administrative Rules.

On or about January 6,2023, the Alleged Victim (AV) noticed lipstick missing from his/her room. The lipstick was taken by Alleged Perpetrator #3 (AP3, Unknown). AP3's actions are a violation of resident rights, are considered neglect of care and constitutes financial abuse. The facility failure is a violation of Oregon Administrative Rules.

The facility failed to complete resident service plans quarterly, which is a violation of Oregon Administrative rules.

The facility failed to have resident service plans readily available to staff. All resident service plans are placed in a locked room where caregivers do not have access, which is a violation of Oregon Administrative Rules.

The facility failed to document the investigation of abuse, which is a violation of Oregon Administrative Rules.

The facility failed to provide direct care staff sufficient in numbers to meet the scheduled and unscheduled needs of each resident which is a violation of Oregon Administrative rules.

The facility failed to have a service plan reflective of resident's needs as identified in the evaluation and preferences the facility failed to provide clear direction regarding the delivery of services and facility failed to include a written description of who shall provide the services, what, when, how and how often the services shall be provided, which is a violation of Oregon Administrative Rules.

The facility allegedly failed to provide a safe medication administration system for the Alleged Victim, which is a violation of Oregon Administrative Rules.

The Facility failed to ensure adequate professional oversight of the medication and treatment administration system, which is a violation of Oregon Administrative Rules.

The facility failed to have sufficient staff to meet the scheduled and unscheduled needs of the residents, which is a violation of Oregon Administrative Rules.

On or about March 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 February 1, 2022 to February 28, 2022, for a total of 27 days.

The facility failed to develop a residents' service plan reflective of their needs as identified in the evaluation, which is a violation of Oregon Administrative Rules.

The facility failed to provide clear directions regarding the delivery of services and failed include in the service plan a written description of who shall provide the services, and what, when, how, and how often the services shall be provided, which is a violation of Oregon Administrative Rules.

On or about December 29, 2021 at approximately 11 pm, the Alleged Perpetrator #2 (AP2) entered the facility while not working, appeared to drinking and went to the Alleged Victim's (AV) room. While in AV's room, AP2 requested that AV give him/her some of AV's pain medication. AV gave the medication as he/she felt pressured by AP2. AP2's actions are a violation of resident rights, are considered neglect of care and constitute financial abuse. The facility's failure to protect AV is a violation of Oregon Administrative Rules.