Regent Court

The Alleged Victim (AV) relies on the facility to provide a safe environment. According to an investigation, on or about November 7th, 2024, the AV was punched in the back five or six times by Witness 1 (W1). W1 was identified to have behaviors and a history of altercations. The facility failed to put into place person-centered interventions to address W1’s known aggressive behaviors, resulting in unreasonable discomfort when W1 punched AV in the back multiple times. The facility failed to provide a safe environment, which is a violation of resident’s rights, is neglect of care, and constitutes abuse.

The Alleged Victim (AV) is a known fall risk and has suffered multiple falls. AV had a fall on or about October 28, 2024, and then two additional falls on October 30, 2024, putting AV at risk for harm. According to an investigation, the intervention listed after the October 24, 2024, fall is to ensure AV’s wheelchair is locked. This intervention had already been put in place after a prior fall on September 20, 2024. After the fall on October 28, 2024, and the first fall on October 30, 2024, there were no additional interventions put in place. The facility's failure to properly care plan for falls is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is a known fall risk and has suffered multiple falls. On or about October 8, 2024, AV had a fall resulting in skin discoloration to the back of AV's head and a skin tear to AV's left forearm. According to an investigation, interventions put in place after the fall on October 7, 2024, were to do safety checks 4x/shift and to encourage AV to ask for help. Both of these interventions had already been previously put in place after the falls on July 24, 2024, July 29, 2024, and again on September 11, 2024. The facility's failure to properly care plan for falls is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is a known fall risk and has suffered multiple falls. On or about October 7, 2024, AV had a fall resulting in a head injury with skin discoloration. According to an investigation, there were no new interventions documented after AVs fall on September 25, 2024. The facility's failure to properly care plan for falls is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility for care. AV is care planned for assistance with showers two times per week and it is documented that AV prides themselves on their appearance. According to an investigation, AV was described as having a disheveled appearance and sometimes greasy hair. Documentation reveals that during the month of September, 2024, AV was only showered a total of four times, causing a loss of personal dignity. The facility’s failure to provide basic care and services for AV resulted in a loss of personal dignity and is a violation of resident’s rights, are considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is a known fall risk and has suffered multiple falls. On or about October 7, 2024, AV had a fall resulting in a head injury with skin discoloration. According to an investigation, there were no new interventions documented after AVs fall on September 25, 2024. The facility's failure to properly care plan for falls is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) and Witness 1 (W1) both rely on the facility for their care. W1 has a history of aggressive behaviors and physical altercations, and is care planned for staff to provide 1:1 care when W1 is agitated. According to an investigation, on or about July 9, 2024, W1 was agitated and went into AV’s room and hit AV in the shoulder, causing AV distress. The facility failed to follow W1’s care plan and keep AV safe, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The allegation that Alleged Perpetrator 2 (AP2) failed to follow the care plan regarding medication refusals was investigated and determined to be not substantiated.

According to the documentation, the facility failed to care plan appropriate interventions for Witness 1’s (W1) known behavior of resident-to-resident altercations. Between approximately March 06, 2024, through April 07, 2024, W1 had approximately five resident to resident altercations inflicting physical harm to residents. On or about April 20, 2024, W1 entered the Alleged Victim’s (AV) room and hit the AV in the groin causing pain and unreasonable discomfort. There was no documented evidence the facility implemented appropriate interventions to mitigate W1 aggressive behavior, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility for care and has an extensive fall history. During the month of March 2024, AV experienced approximately six (6) falls. According to an investigation, after a few of the falls, the facility failed to implement new, reasonable interventions and on or about March 24, 2024, AV fell and sustained a cut on their nose. The facility failed to put effective, person-centered interventions in place after repeated falls which is a violation of resident rights is neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility for care and has an extensive fall history. During the month of February 2024, AV experienced approximately six (6) falls, some resulting in injury. According to an investigation, following a few of AV’s falls the facility failed to implement new, reasonable interventions and on or about February 22, 2024, AV fell and sustained skin tears above the left eyebrow, on the left hand, and on the right thumb. The facility failed to put effective, person-centered interventions in place after repeated falls which is a violation of resident rights is neglect of care and constitutes abuse.

According to the documentation, the facility failed to properly care plan appropriate interventions to ensure the safety of the Alleged Victim (AV) who has a history of falling. From approximately January 23, 2024, through January 30, 2024, the AV suffered approximately six falls sustaining numerous injuries to the head. There was no evidence the facility implemented progressive interventions to prevent the AV from falling, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to properly care plan appropriate interventions to ensure the safety of the Alleged Victim (AV) who has a history of falling off the couch. On or about January 23, 2024, the AV suffered two falls off the couch while sleeping. The first fall happened at approximately 4:28 sustaining no injuries. Around 7:30 am on the same morning, the AV was found on the floor in front of the couch with a skin tear on their ear, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to properly care plan appropriate fall interventions for the Alleged Victim’s (AV) history of falls. On or about October 14, 2023, the AV was attempting to self-transfer into their recliner and was found lying on the floor by staff. The AV complained of shoulder pain, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to properly care plan appropriate fall interventions for the Alleged Victim’s (AV) continued falls. On or about October 23, 2023, the AV was found in the dining room lying on their back due to an unwitnessed fall which caused unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to train staff appropriately for 1:1 care for the Alleged Victim (AV). On or about November 5, 2023, AV’s 1:1 caregiver left the AV to assist another caregiver with another resident. The AV was found lying on the floor in their room due to an unwitnessed fall, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to properly care plan appropriate fall interventions for the Alleged Victim’s (AV) continued falls. On or about November 6, 2023, the AV suffered a fall and sustained a skin tear above their left eye, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to prevent the Alleged Victim (AV) from leaving the facility unsupervised by facility staff. On or about October 1, 2023, the AV was let out of the locked facility by another resident’s family. The facility noticed the AV was missing and found the AV outside the locked unit, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to implement appropriate fall interventions for the Alleged Victim’s (AV) fall history. From approximately July 30, 2024, through September 26, 2024, the AV experienced approximately 9 falls. There was no documented evidence the facility implemented progressive interventions to prevent future falls, which is a violation of resident rights, is considered neglect of care and constitutes abuse

The Alleged Victim (AV) is a known fall risk and has suffered multiple falls. On or about September 17, 2023, AV was found on the floor of his/her apartment, after trying to use the restroom without assistance. No new interventions were put into place after AV's prior fall on September 14, 2023. The facility's failure to properly care plan for falls is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to properly care plan for the Alleged Victim’s (AV) known history of exit seeking. On or about July 26, 2023, the AV eloped from the facility for an undetermined amount of time. At approximately 6:47 pm, the AV was seen trying to enter the facility through the front door. Upon evaluation, the AV sustained an abrasion to their elbow, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to appropriately care plan for the Alleged Victim (AV) regarding his/her risk of falls and change of condition. AV was found on the floor from a fall, which may have been caused by the fall mat slipping. The facility failed to properly care plan for AV's risk of falls, placing AV at risk for serious harm. The facility failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is a known fall risk and had suffered 5 falls within the last 30 days. On or about July 12, 2023, AV suffered a fall and was found on the floor near his/her recliner with a skin tear to his/her right eyebrow. While the facility care planned for AV's falls, the facility did not have enough staff to allow for one on one care, leaving AV at risk for harm. 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 exit seeker. On or about June 16, 2023, AV exited the facility through a courtyard gate that was unlocked. AV was found approximately 1/8 of a mile from the facility. AV was not harmed, however, AV was placed at risk for harm. The facility's failure to provide a safe environment is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) experienced an unwitnessed fall on or about June 2, 2023, no injuries were documented from this fall, however, it is documented that AV suffered pain from this fall and later had a bruise on his/her forehead. On or about June 3, 2023, AV suffered another unwitnessed fall, where AV was found between his/her bed and the wall. AV complained of neck, back and head pain. Emergency services were called and AV was transported to the hospital where he/she was diagnosed with a brain bleed and admitted to the hospital. The facility's failure to implement appropriate and effective interventions to protect AV from further falls is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about May 31, 2023, two bruises were found on the inner thighs of the Alleged Victim (AV). No staff or AV knew how the bruises happened on AV. It was suggested that the bruises could have happened from staff rolling AV to change him/her, although it could not be determined which staff may have caused this. Alleged Perpetrator #2 (AP2, unknown) caused bruising to AV's thighs, which is a violation of resident rights, is considered neglect of care and constitutes physical abuse. The facility's failure to provide a safe environment is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is a known fall risk and has been found on the floor multiple times. On or about March 8, 2023, AV had two falls in his/her residence. AV was assessed, declined pain and no injuries were observed. On or about March 10, 2022, AV was found to have scrapes on his/her right shin. The facility's failure to properly care plan after numerous falls is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is a known fall risk. AV requires a two person assist with a hoyer lift. AV has experienced 6 falls between February 14, 2023 and March 8, 2023, with and without injury. On or about March 18, 2023, AV was found on the ground after experiencing an unwitnessed fall in his/her residence. AV expressed pain in his/her knee, bruising was observed on his/her knee and back. The facility's failure to ensure proper and effective interventions were in place to assure AV's safety is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is a known fall risk. AV requires a two person assist with a hoyer lift. AV has experienced multiple falls, with and without injury. On or about April 8, 2023, AV was found on the ground after experiencing an unwitnessed fall in his/her residence. AV expressed pain in his/her rib area. The facility's failure to ensure proper and effective interventions were in place to assure AV's safety is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #1 (W1) is known to have behaviors and is care planned to be redirected and isolated from other residents when having behaviors. On or about May 3, 2023, W1 exited his/her room and appeared agitated. Staff then heard the Alleged Victim (AV) calling for help. Staff entered AV's room and found AV on the floor. AV is unable to get out of bed by him/herself. W1 had urinated on the floor and then pulled AV out of bed, onto the floor and into W1's urine. AV was cold to the touch and shivering. The facility's failure to follow the care plan placed AV at risk for harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) was care planned to be re-positioned multiple times per day, due to AV having a pressure sore on his/her knee, which developed from having his/her knee against the wall while in bed. AV's knee was bloody and blood had dried on the wall, sticking AV's knee to the wall. The facility failed to follow AV"s care plan to turn AV multiple times per day, to ensure AV's knee was not against the wall, causing worsening of the pressure sore on his/her knee. The facility's' failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about April 15, 2023, the Alleged Victim (AV) was having behaviors by flooding his/her bathroom and pulling items from the walls. AV was known to have behaviors, but no care plan was put into place to ensure staff knew how to assist when AV was having behaviors. The facility failed to properly care plan and have proper interventions in place to reduce the risk of harm to AV. 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 fall risk. AV suffered multiple falls, with and without injury. On or about March 22, 2023, AV experienced a fall and was not a baseline, AV was sent out to the hospital and returned March 26, 2023. On or about March 28, 2023, AV suffered another fall, resulting in a skin tear to his/her right elbow. The facility's failure to properly care plan 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) is a known fall risk. AV suffered multiple falls, with and without injury. On or about May 6, 2023, AV was found on the floor crawling, trying to open a cabinet door. On or about May 7, 2023, AV was found on the ground after staff hear a loud sound. AV was found to have a bump on his/her head, requiring pain medication. The facility's failure to properly care plan 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) relies on the facility for his/her care. According to an investigation, on or about March 15, 2023, AV tested positive for a virus infection. Over the next five days, AV was noted to be lethargic, often refused both food and liquids, was resistive to care, and was documented to have severe pain and skin breakdown. AV did not have a primary care physician and facility did not contact outside medical assistance until 5 days after change of condition. AV was transferred to the hospital on or about March 20, 2023. AV passed away on or about March 24, 2023, as a result of a combination of infection, dehydration, and acute kidney disease. The facility failed to provide appropriate services to respond to AV’s change of condition, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) was a fall risk and had suffered previous falls, to which no interventions were implemented after these falls. AV was known to lean forward in his/her wheelchair to try to pick up items that weren't there, placing AV at risk for falling. AV was placed on hospice care Nove3mber 2022 with safety measures that required 24 hour supervision and one to one, however, due to staffing shortages, this need was not met. On or about February 24, 2023, AV experienced a fall with injury after AV fell forward while seated in his/her wheelchair. The facility's failure to properly care plan is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about December 2, 2022, the Alleged Victim (AV) was noted to have a temperature of approximately 101, was congested and losing his/her voice. AV was placed on alert due to cold but was not assessed by the facility RN. On or about December 3, 2022, AV stayed in bed all day, which was out of AV's baseline. On or about December 4, 2022, AV was sent to the hospital due to a fire in his/her bathroom, and worries of smoke inhalation. When AV arrived at the hospital, AV was having trouble breathing and was found to have a urinary tract and multiple organ infections. The facility's failure to monitor AV's condition and ensure timely medical treatment is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about December 4, 2022, the Alleged Victim (AV) was sent to the hospital due to possible smoke inhalation. Upon arrival to the hospital, AV presented at 125 lbs and appeared to have an underweight presentation. Per a Nursing assessment at the facility on or about November 22, 2022, AV weighed 178 lbs. AV had an order from his/her physician for weight monitoring monthly, one time a day for 5 days starting on the 1st. There was no documentation from the facility that AV's weight was being monitored, that staff were taking any action or completing any interventions to prevent AV from losing weight or that staff knew AV was losing weight. The amount of weight lost by AV was so significant that it resulted in physical harm and unreasonable discomfort. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately care plan related to the Alleged Victim’s (AV) fall history. On or about October 12, 2022, AV suffered an unwitnessed fall resulting in an injury to h/h feet. The failure resulted in AV experiencing pain and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to administer medication as ordered for the Alleged Victim’s (AV). AV’s physician ordered an antibiotic to treat a possible urinary tract infection. According to documentation H/S did not get the medication for approximately three days after it was ordered. The failure resulted in AV experiencing pain and unreasonable discomfort. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. The allegation that the Alleged Perpetrator 2 (AP2) failed to administer medication as ordered was investigated and the determination was not substantiated.

According to documentation the facility failed to follow the Alleged Victim’s (AV) care plan. AV’s care plan AV needs assistants with toenail care. The failure resulted in AV not getting assistants with toenail care and AV’S toenails were overgrown and curling downwards. The failure resulted in AV experiencing pain and unreasonable discomfort. The facility failed to ensure care plans were followed, which is a violation of resident’s rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately care plan related to the Alleged Victim’s (AV) fall history. The failure resulted in AV experiencing injury and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to documentation the facility failed to follow The Alleged Victim (AV) care plan for safety checks during the night. The failure resulted in AV being found on the floor, and experienced pain and unreasonable discomfort. The facility failed to ensure care plans were followed, which is a violation of resident’s rights, is considered neglect of care and constitutes abuse.

The facility failed to provide a safe medication administration system to ensure the Alleged Victim’s (AV) medications were administered as ordered. AV was not administered medications used to treat depression, fluid retention, and constipation for an extended period of time, placing AV at risk for harm. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately care plan related to the Alleged Victim’s (AV) fall history. On or about September 06, 2022, AV suffered a fall in h/h studio resulting in fracturing h/h pubic bone and femur and was transported to the Emergency Department. The failure resulted in AV experiencing pain and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide appropriate supervision to the Alleged Victim (AV) according to his/her needs. The failure resulted in AV eloping the secured building, without staff knowledge, placing him/her at risk of harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately care plan related to the Alleged Victim’s (AV) fall history. The failure resulted in AV experiencing injury and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately care plan related to the Alleged Victim’s (AV) fall history. The failure resulted in AV experiencing injury and unreasonable discomfort, which 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. On or about July 19, 2022, around 10:40am AV had been found standing outside of the facility at the main entrance doors to the building. According to documentation the courtyard gate was unlatched. The facility failed to provide a safe environment by not ensuring the gate was secured putting AV in risk of harm, which is a violation of resident’s rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately care plan related to the Alleged Victim’s (AV) fall history. The failure resulted in AV experiencing injury and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately care plan related to the Alleged Victim’s (AV) fall history. The failure resulted in AV having a laceration on h/her head, experiencing unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to appropriately care plan and provide care for the Alleged Victim (AV) after his/her change of condition. AV was found to have reddened raised area on his/her buttocks area that required to be turned/repositioned. Staff were not repositioning AV as ordered and the condition worsened causing unreasonable discomfort. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to documentation the facility failed to follow The Alleged Victim (AV) care plan for recording the daily bowel movement. The failure resulted in AV experiencing pain and unreasonable discomfort. The facility failed to ensure care plans were followed, which is a violation of resident’s rights, is considered neglect of care and constitutes abuse.

According to documentation the facility failed to follow The Alleged Victim (AV) care plan for assistants with eating and hydration. The failure resulted in AV pain and experiencing unreasonable discomfort. The facility failed to ensure care plans were followed, which is a violation of resident’s rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) had a history of wandering, getting lost. On or about June 01, 2022, he/she eloped from the facility campus, and was located by a security guard at the hospital AV wandered to. The facility failed to appropriately care plan and failed to provide a safe environment for AV. The failures are a violation of resident rights, are considered neglect of care and constitute abuse.

The facility failed to implement interventions and appropriately care plan related to the Alleged Victim’s (AV) fall history. The failure resulted in AV experiencing injury and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately care plan related to the Alleged Victim’s (AV) fall history. The failure resulted in AV experiencing injury and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately care plan related to the Alleged Victim’s (AV) fall history. The failure resulted in AV experiencing injury and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately care plan related to the Alleged Victim’s (AV) fall history. The failure resulted in AV experiencing injury and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately care plan related to the Alleged Victim’s (AV) fall history. The failure resulted in AV experiencing injury and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately care plan related to the Alleged Victim’s (AV) fall history. The failure resulted in AV experiencing injury and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately care plan related to the Alleged Victim’s (AV) fall history. The failure resulted in AV having a skin tear on h/her forehead, experiencing unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide a safe medication administration system for the Alleged Victim (AV). According to documentation on or about March 24, 2022, AV’S Transdermal patch was not removed. The failure resulted in AV having two patches on or about March 21, 2022- March 24, 2022, putting AV in risk of serious harm. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse

The facility failed to implement interventions and appropriately care plan related to the Alleged Victim’s (AV) fall history. The failure resulted in AV experiencing injury and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide a safe environment. According to documentation, on or about March 16, 2022, the Alleged Victim (AV) sustained an injury on h/her left knee. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse

The Alleged Victim (AV) has a history of falls, some resulting with, and some without injuries. According to documentation on or about March 05, 2022, AV was transferred to the hospital for treatment after a fall s/he had in another resident’s room. As a result AV suffered unreasonable discomfort and pain. The facility failed to care plan or implement new interventions for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility to ensure a safe environment. Witness 1 (W1) and AV have a history of resident-to-resident altercations. The facility failed to ensure a safe environment for AV, resulting in AV and W1 having a physical altercation. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately care plan related to Witness 1’s (W1) known behaviors. On or about February 21, 2022, W1 was found inappropriately touching the Alleged Victim (AV) causing a loss of personal dignity, which is a violation of resident rights, is considered neglect of care which constitutes abuse.

The facility failed to provide a safe environment. On or about February 09, 2022, according to documentation the Alleged Victim (AV) sustained an injury on h/her right elbow from an unknown origin. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide a safe environment. On or about January 12, 2022, according to documentation the Alleged Victim (AV) sustained an injury on h/her head from an unknown origin. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide a safe environment. On or about January 04, 2022, according to documentation the Alleged Victim (AV) sustained a bruise on h/her lip from an unknown origin. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately care plan related to the Alleged Victim’s (AV) fall history. The failure resulted in AV experiencing injury and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. AV is a known fall risk with a history of falls. On or about December 14, 2021, AV had a fall which resulted in bruises. The facility failed to put appropriate interventions in place for AV's fall risk, which is considered neglect of care and constitutes abuse. As the new owner of this facility, you are responsible for correcting any deficiencies which pre-date your ownership. You must correct violations which occurred under previous ownership, as directed by the Department. You will not be responsible for paying civil penalties incurred by previous owner(s). However, if you fail to correct identified deficiencies within the specified time you may be subject to aggravated civil penalties.

Alleged Victim (AV) relies on the facility for his/her care. AV is a known fall risk and has a history of falls. On or about December 15, 2021, AV had two falls within a twenty-four-hour period, with one fall resulting in skin tears. The facility failed to put appropriate interventions in place for AV's fall risk, which is considered neglect of care and constitutes abuse. As the new owner of this facility, you are responsible for correcting any deficiencies which pre-date your ownership. You must correct violations which occurred under previous ownership, as directed by the Department. You will not be responsible for paying civil penalties incurred by previous owner(s). However, if you fail to correct identified deficiencies within the specified time you may be subject to aggravated civil penalties.

The facility failed to Provide a safe environment for The Alleged Victim (AV). On or about December 14, 2021, AV was discovered to have bruises on h/her left temple from an unknown origin. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. AV has a history of falls and was identified as a high fall risk. On or about, December 11, 2021, AV had a fall that resulted in a skin injury. The facility failed to provide adequate staffing and implement appropriate interventions to mitigate the risk of injury due to AV's increase in falls. These failures are a violation of resident rights, is neglect of care which constitutes abuse. As the new owner of this facility, you are responsible for correcting any deficiencies which pre-date your ownership. You must correct violations which occurred under previous ownership, as directed by the Department. You will not be responsible for paying civil penalties incurred by previous owner(s). However, if you fail to correct identified deficiencies within the specified time you may be subject to aggravated civil penalties.

Alleged Victim (AV) relies on the facility for his/her care. AV has a history of falls. On or about December 10, 2021, AV had three falls within a twenty-four-hour period, with one fall resulting in a skin tear and abrasion. The facility failed to appropriately care plan for AV's fall risk. This failure is a violation of resident rights, is neglect of care which constitutes abuse. As the new owner of this facility, you are responsible for correcting any deficiencies which pre-date your ownership. You must correct violations which occurred under previous ownership, as directed by the Department. You will not be responsible for paying civil penalties incurred by previous owner(s). However, if you fail to correct identified deficiencies within the specified time you may be subject to aggravated civil penalties.

The facility failed to implement interventions and appropriately care plan related to the Alleged Victim’s (AV) fall history. The failure resulted in AV experiencing injury and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. AV is a fall risk and is care planned for standby assist while walking. Witness 1 (W1) had a known history of aggressive behavior. On or about November 29, 2021, AV approached W1 and had a resident-to-resident altercation where W1 pushed AV to the floor. AV was diagnosed with a fractured pelvis and required hospitalization and pain management. The facility failed to provide a safe environment by failing to provide adequate staffing, which is a violation of resident rights, is considered neglect of care and constitutes abuse. As the new owner of this facility, you are responsible for correcting any deficiencies which pre-date your ownership. You must correct violations which occurred under previous ownership, as directed by the Department. You will not be responsible for paying civil penalties incurred by previous owner(s). However, if you fail to correct identified deficiencies within the specified time you may be subject to aggravated civil penalties.

The facility failed to implement interventions and appropriately care plan related to the Alleged Victim’s (AV) fall history. The failure resulted in AV experiencing injury and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately care plan related to the Alleged Victim’s (AV) fall history. The failure resulted in AV experiencing injury and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse

The facility failed to implement interventions and appropriately care plan related to the Alleged Victim’s (AV) fall history. The failure resulted in AV experiencing injury and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. On or about November 3, 2021, AV was found to have bruises to AV's forehead, left hand, and left foot from unknown origins. The facility failed to ensure a safe environment, which is a violation of resident’s rights, is neglect of care and constitutes abuse. As the new owner of this facility, you are responsible for correcting any deficiencies which pre-date your ownership. You must correct violations which occurred under previous ownership, as directed by the Department. You will not be responsible for paying civil penalties incurred by previous owner(s). However, if you fail to correct identified deficiencies within the specified time you may be subject to aggravated civil penalties.

Alleged Victim (AV) relies on the facility for his/her care. On or about October 26, 2021, a bruise was discovered on AV’s left side of his/her chin. AV is unable to assist staff in his/her transfer and is to be transferred utilizing the Hoyer lift and two staff members. The origin of the bruise is unknown though believed to have been cause by transferring AV using the Hoyer lift. The facility failed to provide a safe environment for AV, 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 Victim’s (AV) medications were administered as ordered. AV went without h/her Insulin, resulting in AV experiencing unreasonable discomfort. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

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 carry out medication and treatment orders as prescribed. The facility’s failure is a violation of Oregon Administrative Rules.

Alleged Victim (AV) relies on the facility for care and for a safe environment. On or about August 19, 2024, the Alleged Perpetrator 2 (AP2) grabbed AV under their arm and strongly guided AV down the hall against AV's will. AP2’s actions are a violation of resident rights, are considered neglect of care and constitute wrongful restraint/physical abuse. The facility failed to ensure AV was in a safe environment and protected from wrongful restraint/physical abuse which is a violation of Oregon Administrative Rules.

According to an investigation, on or about March 2, 2024, and again on April 13, 2024, the Alleged Victim ingested bar soap. The facility failed to provide a safe environment and exercise reasonable precautions against any condition that may threaten the health, safety, or welfare of residents, which is a violation of Oregon Administrative Rules.

On or about August 13. 2023, Alleged Perpetrator #2 (AP2) was assisting the Alleged Victim (AV) with a brief change. AP2 grabbed AV's arm roughly during the brief change, causing AV to sustain three skin tears on his/her arm. AP2's actions are a violation of resident rights, are considered neglect of care and constitute physical abuse. The facility's failure is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) is care planned to be transferred with a gait belt. On or about June 29, 2023, AV was discovered with a bruise on his/her arm. Alleged Perpetrator #2 (AP2) admitted to not following the care plan by not using the gait belt to transfer AV. A few days later, AV was found with a bruise. AP2's actions are a violation of resident rights, are considered neglect of care and constitute abuse.

The facility failed to have sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident in accordance with OAR 411-054-0070(1): per complaint that the resident's pull cord does not work, and staff aren ' t answering it.

The facility failed to have a service plan include a written description of who shall provide the services and what, when, how, and how often the services shall be provided in accordance with OAR 411-054-0036(2)(B)(c)

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

According to documentation the Alleged Perpetrator 2 (AP2) failed to follow the Alleged Victim’s (AV) care plan, to check AV’S metabolic levels twice a day. On or about January 15, 2023, AP2 failed to notify License staff after finding that the AV’S metabolic markers were below 70. The failure resulted in AV being found on the floor unresponsive and needing to be transported to the hospital for treatment. AP2's actions is a violation of resident rights, is considered neglect of care and constitute abuse.

The facility failed to orient direct care staff to the resident including the resident's service plan in accordance with OAR 411-054-0070(4)(g) per complaint staff gave resident a finger food plate and they later learned the resident needed a pureed diet.

The facility failed to have service plans readily available to staff and provide clear direction regarding the delivery of services in accordance with OAR 411-054-0036(2)(b) per complaint staff were not provided service plans for the residents.

The facility failed provide services to assist the resident with mobility including one-person transfers in accordance with the OAR 411-054-0030(1)(e)(A) Per complaint, a resident asked for help with transfering and staff asked them to wait as the staff was busy with another task, resulting in the resident attempting to self-transfer and the fall.

The facility failed to provide assistance with toileting/incontinence care in accordance with OAR 411-054-0030(1)(e)(). Per complained that residents are being left wet/soiled for long periods of time.

The allegation that the facility failed to administer medications as prescribed in accordance with OAR 411-054-0055(1)(f) per complaint that resident received another resident's medications was verified.