Rn Villa Senior Care

The Alleged Victim (AV) relies on the facility for assistance with care including catheter care and bathing assistance. The AV was identified as having a history of wounds. According to an investigation, the AV was not assisted with bathing, appropriate catheter care, and was left in the same brief for approximately eight days, from June 5, 2025, to June 13, 2025. There was no documented evidence the facility was monitoring the AV's skin. The AV was discovered with open wounds to the groin, buttocks, and thighs on June 16, 2025, and required hospitalization. The facility failed to monitor the AV's condition and provide needed care and service, which is a violation of resident’s rights, is neglect of care, and constitutes abuse.

The Alleged Victim (AV) receives assistance from the facility staff with wound care. AV has a large wound on his/her head, which requires staff to clean and re-dress the wound daily. On or about May 9, 2025, AV stated that staff were not performing daily wound care for him/her. AV does not have feeling on his/her head, therefore, doesn't know if the wound is ok or not. Records indicate that there were at least 4 nonconsecutive days where AV's wound care was not completed. AV's wound is complex and requires daily cleaning to ensure that AV's chances of infection are reduced. The facility's failure to follow the care plan places AV at risk for harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) receives his/her medication from facility staff. On or about December 17, 2024, the facility had not received the refill of AV's medication. Staff faxed the provider for the medication refill, however, they did not receive a response nor did they receive AV's medication. Additional requests were sent to the provider without response on December 20 and December 22, 2024. On or about December 23, 2024, AV suffered from a seizure due to not receiving his/her medication as ordered. From December 19, 2024 until December 23, 2024, AV missed 9 doses of his/her scheduled medication. Prior to this incident, the facility did not have safe guards in place to ensure timely availability of medication, including ensuring that staff understand to notify the Nurse or the Administrator of medications not being available. The facility's failure to ensure a safe medication administration system is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility for administration of medication. On or about November 26, 2024, AV's physician increased AV's pain medication dosage due to AV's chronic pain. The updated order was sent to the pharmacy on November 27 2024, however, due to the holiday, AV's medication was not filled and delivered to the facility until December 4, 2024. AV did not receive the increased medication until December 4, 2024, therefore, AV suffered continued pain and unreasonable discomfort from November 26, 2024 until December 4, 2024. AV's medication didn't change, it only increased. The facility had a process and the medication available that they could have increased AV's medication until the prescription was filled. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility to manage their medications and treatments. The AV had treatment orders for wound cleaning to be done daily. According to an investigation, beginning on or about October 2, 2024, the AV's wound was noted to not be cleaned properly on multiple occasions, placing the AV at risk of developing an infection. There was no documented evidence facility staff had been providing the wound care daily as ordered. The facility failed to provide the AV's wound care as ordered, which is a violation of resident’s rights, is neglect of care, and constitutes abuse.

The facility failed to provide appropriate services according to the Alleged Victim’s (AV) needs and medical care. The failure resulted in AV’s condition worsening, and had to be transferred to the hospital for treatment, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility for mobility and transfer needs. According to an investigation, staff incorrectly re-positioned the AV while in bed, causing injury and pain to their left shoulder. The facility failed to appropriately care plan and instruct staff on the proper procedure to assist the AV with re-positioning, which is a violation of resident’s rights, is neglect of care and constitutes abuse.

On approximately 3 separate occasions, the Alleged Victim (AV) failed to receive his/her medications as ordered. AV's medications were left on his/her bedside and staff did not watch AV take his/her medication. This action placed AV at risk for harm for not receiving medications as ordered. 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 bed bound and relies on staff for assistance with cares. AV made statements that it takes up to an hour sometimes for staff to respond to his/her call light. AV's call logs show at least 36 times when AV waited for at least 30 minutes to have a response from facility staff. Waiting for staff to respond made AV feel neglected by staff and feel that waiting so long for changing of soiled briefs may cause AV to have skin breakdown. The facility's failure to ensure that call lights were answered timely is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is bedbound and requires care from the facility with all activities of daily living, including incontinence care. AV is able to use his/her call light reliably when he/she needs assistance. AV frequently had long call light wait times to be assisted with incontinence. AV has chronic pressure wounds that require facility care. When call lights are not answered timely, due to lack of staffing, AV had not been changed for up to 4 or 5 hours, causing AV unreasonable discomfort. The facility's failure to ensure proper staffing to meet the needs of the residents are a violation of resident rights, are considered neglect of care and constitute abuse.

The Alleged Victim (AV) requires assistance with activities of daily living from facility staff, including incontinence care. AV complained of having to wait for 1-2 hours for assistance from staff when he/she activated his/her call light. Call light log response times show anywhere from 20 minutes to 1 hour and 30 minutes. AV was left in unreasonable discomfort while waiting for staff to respond to the call light. The facility's failure to timely respond to call lights is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility is responsible to provide medication for the Alleged Victim (AV). On or about October 10, 2023, AV did not receive his/her pain medication timely, resulting in AV suffering unnecessary pain and discomfort. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about September 22, 2023, it was noticed by staff that the Alleged Victim (AV) had a sore on his/her backside. Staff noted the information in the progress notes, however, no one notified the facility Nurse of the wound. The facility Nurse found out about the wound on October 9, 2023 and contacted AV's physician and ordered wound care from home health, as well as wound care from facility staff. From September 22, 2023 to October 9, 2023, AV's wound worsened, causing unreasonable discomfort and risk of serious harm. The facility's failure to provide timely wound care and respond to a change of condition is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) was incontinent of bowel and bladder, and as well was bed bound. On or about July 10, 2023, AV was found at the facility double briefed with an elevated temperature, altered mental status, and dry fecal matter. AV was transported to the hospital and the hospital could not rule out infection due to AV not being changed properly and double briefing is not acceptable practice, as it does not allow staff to know if AV needs to be changed or not. The facility's failure to provide proper incontinence care is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about January 1, 2023, the Alleged Victim (AV) received incorrect medication from staff. AV showed signs of low blood pressure and was sent to the hospital for evaluation. AV returned to the facility with instructions to eat and drink something if AV became light headed. 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.

Alleged Victim (AV) has history of high anxiety around facility staff not responding to call light and has a behavior support plan in place. If staff unable to answer the call button immediately set a time for their return. The facility expectation is for staff to respond in fifteen (15) minutes to a resident call light. On or about November 28, 2022, AV pushed h/h call light for assistance with incontinence care and waited approximately one (1) hour and five (5) minutes, causing unreasonable discomfort. The facility failed to answer call light in a timely manner, which is a violation of resident rights, is neglect of care and constitutes abuse.

The facility failed to provide appropriate services according to the Alleged Victim’s (AV) needs for two persons assist which resulted in injury. On or about September 08, 2022, AV was transferred by Hoyer, using inappropriate sling for AVs size. AVs left leg was hit at the Hoyer sling bar, resulting in pain. AV was sent to emergency room and was found to have a fracture in the left knee. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility, and Alleged Perpetrator 2 (AP2) failed to provide a safe medication administration system to ensure the Alleged Victim's (AV) medication was administered as ordered. On or about August 14, 2022, AV did not receive h/h narcotic pain medication as prescribed, resulting in AV being upset and not feeling well. The facility, and AP2’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility to manage his/her medications. According to an investigation, on or about July 25, 2025, it was discovered the AV's narcotic pain medicaitons had been replaced with other over the counter medicaitons by an unknown Alleged Perpetrator 3 (AP3) , resulting in a loss of prescription medication for the AV. The failure is a violation of Oregon Administrative Rules. The allegation that AP2 financially exploited the AV was investigated and determined to be not substantiated.

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

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

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

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

The Alleged Victim (AV) receives his/her medication from facility staff. Between March 2025 and the end of April 2025, Alleged Perpetrator #2 (AP2) administered medication to AV. AV had requested his/her as needed narcotic medication and was told that he/she couldn't have it as he/she had already taken in within the 6 hour time frame. AV knew that he/she had not taken any medication and had asked Management about it. The facility completed an investigation and determined that AV's narcotic medication was being given much more often than what AV had mentioned. AP2 was signing out AV's medication, which was not being given to AV. AP2's actions are a violation of resident rights, is considered neglect of care and constitutes financial abuse. The facility's failure to protect AV from financial abuse is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) receives his/her medication from facility staff. Between March 2025 and the end of April 2025, Alleged Perpetrator #2 (AP2) administered medication to AV. AV had requested his/her as needed narcotic medication and was told that he/she couldn't have it as he/she had already taken in within the 6 hour time frame. AV knew that he/she had not taken any medication and had asked Management about it. The facility completed an investigation and determined that AV's narcotic medication was being given much more often than what AV had mentioned. AP2 was signing out AV's medication, which was not being given to AV. AV had not trusted staff in the past but had made a trustful relationship with AP2. When AV learned of the diversion of his/her medication by AP2, AV became significantly emotionally traumatized. AP2's actions are a violation of resident rights, is considered neglect of care and constitutes emotional abuse. The facility's failure to protect AV from emotional abuse is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) receives his/her medication from facility staff. Between March 2025 and the end of April 2025, Alleged Perpetrator #2 (AP2) administered medication to AV. The facility completed an investigation and determined that AV's narcotic medication was being given much more often than what AV had mentioned that they were taking. AP2 had signed out medication for AV when AV did not request any medication. AP2's actions are a violation of resident rights, is considered neglect of care and constitutes financial abuse. The facility's failure to protect AV from financial abuse is a violation of Oregon Administrative Rules.

The facility failed to keep the interior of the facility free from unpleasant odors and clean and in good repair, which is a violation of Oregon Administrative Rules.

The facility failed to take measures to prevent the entry of rodents, flies and mosquitoes and other insects, which is a violation of Oregon Administrative Rules.

The facility failed to ensure delegation and teaching was provided and documented by a RN in accordance with the Oregon Administrative Rules (OAR) adopted by the Oregon State Board of Nursing (OSBN), which is a violation of Oregon Administrative Rules.

The facility failed to keep an accurate MAR, which is a violation of Oregon Administrative Rules.

On or about December 27, 2023, Alleged Perpetrator #2 (AP2) was assisting the Alleged Victim (AV) with his/her shower. AP2 used AV's toilet while AV was in the shower. AV did not tell AP2 that AP2 could use his/her toilet, and it was upsetting to AV, causing him/her emotional distress. AP2's actions are a violation of resident rights, is considered neglect of care and constitutes abuse. The facility's failure to ensure AV's rights is a violation of Oregon Administrative Rules.

The facility failed to implement a service plan that reflects the resident's needs per complaint that a resident is unable to use their call button to summon help, and the facility has done nothing to assist the resident, which is a violation of Oregon Administrative Rules.

The facility failed to ensure the implementation of services per complaint that a resident is not receiving assistance with putting on their compression stockings, and there is no housekeeping, and laundry is not folded and put away, which is a violation of Oregon Administrative Rules.

The facility failed to provide three daily nutritious, palatable meals with snacks available seven days a week per complaint that meals arrive late and cold, and sometimes they are not served a meal, and they were served a burnt sandwich, 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 per complaint that call light response is long and residents are not getting changed timely, which is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) receives medication which is supposed to be administered at 8:00 am. Alleged Perpetrator #2 (AP2) did not administer AV's medication until 10;00 am, causing AV unreasonable discomfort. AP2's actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility's failure to provide a safe medication administration system 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 per complaint that a resident had to wait up to an hour multiple times for assistance, which is a violation of Oregon Administrative Rules.

The facility failed to ensure service plan was reflective of the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence per complaint that a resident has not had a shower since 10/26/23, which is a violation of Oregon Administrative Rules.

The facility failed to provide three daily nutritious, palatable meals with snacks available seven days a week per complaint that some meals have not been delivered, and the food is usually cold, and no snacks are provided, 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 per complaint that a resident's call light was on for 53 minutes, which is a violation of Oregon Administrative Rules.

The facility failed to carry out medication orders as prescribed per complaint that multiple residents were not administered their medications as ordered, which is a violation of Oregon Administrative Rules.

The facility failed to provide three daily meals, seven days a week per complaint that a bed bound resident had not been provided at least two meals, which is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) is prescribed pain medication as needed. On or about October 23, 2023, AV requested pain medication and it took Alleged Perpetrator #2 (AP2) approximately 3 hours to deliver the medication to AV, leaving AV in unreasonable discomfort. AP2's actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility's failure to provide a safe medication administration system is a violation of Oregon Administrative Rules.

The facility failed to assess for and monitor change in conditions per complaint that the facility was not providing wound care as ordered, which is a violation of Oregon Administrative Rules.

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

On or about August 2023, the Alleged Victim (AV) purchased a burger and soft drink for Alleged Perpetrator #2 (AP2). AP2 accepted this from AV, which is not allowed, as no gifts can be accepted by staff from residents. AP2's actions are a violation of resident rights, are considered neglect of care and constitutes financial abuse. The facility's failure is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) receives his/her ordered medication from facility staff. On or about May 26, 2024, Alleged Perpetrator #2 (AP2) was passing medications. AV was receiving cares so AP2 placed AV's medication back on the cart and went to pass medications to another resident, who was eating. AP2 set the other residents medication back on the cart and continued to pass medications to other residents. When AP2 returned to AV's room to pass his/her medications, another residents medications were given to AV. AP2 told AV the medications given were incorrect, causing AV to become upset, have an upset stomach and worry all night about the medication that was given to him/her. AP2's actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility's failure to provide a safe medication administration system is a violation of Oregon Administrative Rules.

The facility failed to ensure the staff person who administers the medication must visually observe the resident take the medication per complaint that a resident's medication was left at their bed side, which is a violation of Oregon Administrative Rules.

The facility failed to provide three daily nutritious, palatable meals with snacks available seven days a week per complaint that the food is always cold and some residents do not get food or desert, which is a violation of Oregon Administrative Rules.

The facility failed to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned per complaint that staff did not know what the hypoglycemic polices were and they did not know what to do when a resident had low blood sugar, which is a violation of Oregon Administrative Rules.

On or about 12/03/2022, Witness #3 (W3) approached Alleged Victim (AV) room and found Alleged Perpetrator 2 (AP2) being load and verbally aggressive with AV while providing care. W3 attempted to diffuse the situation but AP2 continued to yell at AV, resulting in AV becoming upset, which 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) is care planned for two (2) people assist for personal care, ADL, and ambulation, mobility needs. On or about 12/03/2022, Alleged Perpetrator 2 (AP2) was providing care and repositioning AV without Assistance, resulting in unreasonable discomfort, and placed AV at risk for harm. AP2 failed to provide a safe environment and follow the care plan, which is a violation of resident rights is considered neglect of care and constitutes abuse. The facility failed to provide a safe environment which is a violation of Oregon Administrative Rules.

The facility failed to have sufficient staff to meet the scheduled and unscheduled needs of the residents. It was determined the lack of staff is leading to needs not being met or taking extended periods of time to be met. 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. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

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.

Facility failure to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident per OAR 411-054-0070(1) as stated in complaint that facility had no med techs on duty and facility was having untrained caregivers pass medications.

Facility failure to have a training program that includes methods to determine competency of direct care staff through evaluation, observation, or written testing per OAR 411-054-0070(2)(a) as stated in complaint that caregivers and new staff were passing medications without proper training.

The facility failed to carry out medication orders as prescribed in accordance with OAR 411-054-0055(1)(f) per complaint that the facility is not giving residents their medications.

The facility failed to have sufficient staff to meet the scheduled and unscheduled needs of the residents in accordance with OAR 411-054-0070(1) per complaint that there is not enough staff to administer meds timely.

The facility failed to carry out medication orders as prescribed in accordance with OAR 411-054-0055(1)(f) per complaint that the facility is administering medications 2 hours late.

The facility failed to have sufficient staff to meet the scheduled and unscheduled needs of the residents in accordance with OAR 411-054-0070(1) per complaint that there is not enough staff to assist residents with toileting.

The facility failed to include the resident in the service planning team in accordance with OAR 411-054-0036(5) per complaint that the facility has not gone over the service plan with resident in over 6 months.

The facility failed to establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases in accordance with OAR 411-054-0050(1) per complaint that direct care staff are not wearing proper PPE during a Covid outbreak.

The facility failed to ensure medication and treatment orders were carried out as prescribed in accordance with OAR 411-054-0055(1)(f) per complaint that a resident with skin issues is not receiving wound care assistance as prescribed by h/her physician.

The facility failed to have sufficient staff to meet the scheduled and unscheduled needs of the residents in accordance with OAR 411-054-0070(1) per complaint that there is not enough staff to meet resident needs.