Sweetbriar Villa

The Alleged Victim (AV) had numerous falls between September 27, 2022 and October 27, 2022, with and without injury. The facility failed to properly care plan to ensure the safety of AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about October 7, 2022, the Alleged Victim (AV) was found to have a bruise of unknown origin on his/her head. AV has had previous falls in 2022, and it is suspected that AV fell on this occasion. The facility did not put effective interventions in place after AV's previous falls. The facility's failure to properly care plan is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to ensure supervision and staff support regarding known behaviors related to Witness #1 (W1). On or about October 5, 2022, an incident occurred between W1 and the Alleged Victim (AV) where W1 entered AV's room and slapped AV on the face. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide services to the Alleged Victim (AV). On or about September 1, 2022, staff noticed that AV had a cap on one tooth that was starting to lift, causing pain to AV when he/she ate and in general, as it rubbed on his/her cheek and tongue. This went on for over a month without anyone seeking a dental appointment for AV to correct the situation. AV lost 4 pounds in 30 days. Between the dates of August 31, 2022 and October 1, 2022, AV suffered 6 unwitnessed falls with injury, two falls resulting in AV being transported to the hospital, one for stitches in his/her forehead, the other for staples to the back of the head. The facility's failure to provide services to AV is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about August 29, 2022, it was discovered that the Alleged Victim (AV) had been receiving a medication that had been discontinued approximately two weeks prior. AV suffered unreasonable discomfort from continuing to receive medication that had been discontinued. 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) and Witness #1 (W1) are known to have altercations and W1 specifically targeted AV. Staff did not care plan to protect AV from W1's targeting behaviors, leading to AV receiving multiple injuries, including bruising, scratches and abrasions. 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 June 13, 2022, Witness #1 (W1) hit the Alleged Victim (AV) on the head with a remote, causing a red mark to AV's head. W1 is a known aggressor in altercations, and has interim service plans in place to have resident in place where staff can see him/her and frequent checks, however, there is nothing to state how frequent checks should be. The facility did not have enough staff present to ensure this resident could be in sight of staff. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about June 9, 2022, Witness #1 (W1) entered the Alleged Victim's (AV) room, the two began arguing and W1 slapped AV. W1 is a known aggressor in resident to resident altercations, however, the facility's interventions are not reducing the amount of altercations. The facility's failure to properly care plan is a violation of resident rights, is considered neglect of care and constitute abuse.

On or about May 5, 2022, the Alleged Victim (AV) had a change to his/her medication, changing it from as needed to daily dosage. The facility failed to implement this change until May 25, 2022. AV had intermittent instances of constipation, causing unreasonable discomfort. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is known to wander and has limited vision and hearing, preventing him/her from recognizing doors that he/she should not go into. Witness #1 (W1) is known to have aggressive behaviors when someone enters his/her personal space. On or about April 15, 2022, AV attempted to enter W1's room, causing W1 to yell at AV. AV reported that W1 struck him/her in the face, however, it was unwitnessed by staff. The facility failed to provide a safe environment, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about November 13, 2021, Witness #1 (W1) was very agitated and was known to have violent behaviors towards staff and other residents. W1's care plan is not adequate to address the behaviors or aggression by him/her. W1 was ramming his/her mobility device into the doors of the building. W1 was left alone at the front of the building, at which time, W1 engaged in an altercation with the Alleged Victim (AV) by ramming his/her mobility device into AV's mobility device, then grabbed AV's arm. AV was not harmed, however, AV was placed 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 November 13, 2021, Witness #1 (W1) was very agitated and was known to have violent behaviors towards staff and other residents. W1's care plan is not adequate to address the behaviors or aggression by him/her. W1 was ramming his/her mobility device into the doors of the building. W1 was left alone at the front of the building, at which time, W1 engaged in an altercation with the Alleged Victim (AV) and left AV with a scratch to his/her face from W1's fingernails. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to develop, maintain, and implement an Acuity Based Staffing Tool. An investigation determined this is a violation of Oregon Administrative Rules.

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

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

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

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

The Alleged Victim (AV) relies on the facility for his/her care and is service planned for stand-by-assist for safety and to assist with bathing and total assistance with mobility. On or about May 4, 2024, the Alleged Perpetrator 2 (AP2) did not follow AV's care plan left the AV alone in the shower. AV got out of the shower independently and fell, resulting in AV hitting his/her head. AP2's actions are considered neglect and constitutes abuse. The facility failed to ensure care plans were followed which is a violation of Oregon Administrative Rules.

The facility failed to consistently staff to the levels, intensity and qualifications indicated by the Acuity-Based Staffing Tool (ABST). Inconsistencies were identified between the staffing schedule and the data produced by the ABST. Facility is not currently staffing to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

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

The facility failed to provide a safe medication administration system for the Alleged Victim (AV). According to documentation, AV experienced no negative outcome. The failure is a violation of Oregon Administrative Rules.

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

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

According to an investigation, on or about June 28, 2023, Alleged Perpetrator 2 (AP2) took one of AV's sleep medications and gave it to another resident. AP2's actions are considered financial exploitation and constitutes abuse. The facility did not keep AV free from financial exploitation, which is a violation of Oregon Administrative rules.

According to the documentation, the Unknown Alleged Perpetrator (AP2) failed to follow the Alleged Victim’s (AV) care plan during a transfer. The failure resulted in the AP2 pulling on the AV’s wrist to sit them up causing bruising on their wrist, which is a violation of resident rights and is considered physical abuse. The facility failed to follow the care plan which is a violation of Oregon Administrative Rules.

The facility failed to provide a safe and home-like environment. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to make records available to the department upon request. An investigation determined this is a violation of Oregon Administrative Rules.

On or about February 1, 2023, the Oregon Health Authority reported to the Department that Respondent failed to comply with weekly reporting requirements of vaccinated individuals, residents and staff, to the proper authority as required by law. This failure has been ongoing from January 1, 2023 to January 31, 2023, for a total of 30 days.

The facility failed to immediately notify the local Department office, or the local AAA, of any incident of abuse or suspected abuse, which is a violation of Oregon Administrative Rules.

The facility failed to complete quarterly service plans since 1/11/22, placing residents at risk. The facility's failure is a violation of Oregon Administrative Rules.

The facility failed to carry out medication and treatment orders as prescribed, a resident was administered another resident's medications. The facility failure is a violation of Oregon Administrative Rules.

On or about October 27. 2022, the Alleged Victim (AV) was found on the floor beside his/her wheelchair. AV complained of pain and was sent out to the emergency department for evaluation. AV returned the next day and was found to have fractured ribs. The facility failed to properly care plan to keep AV from slipping off his/her wheelchair, which is a violation of Oregon Administrative Rules.

The facility failed to administer the resident ' s medication as order by their physician

the facility failed to exercise reasonable precautions against any condition that may threaten the health, safety, or welfare of residents which is a violation of Oregon Administrative Rules.