Table Rock Memory Care Community

The Alleged Victim (AV) relies on the facility for care and is a high fall risk. AV is care planned for falls to be monitored, to ensure AV is wearing proper footwear, to encourage AV to use a walker and wheelchair, and is also care planned as independent with transfers and ambulation. On or about March 25, 2025, AV reported they had a leg wound and needed assistance, claiming they bumped their leg on something. Then on April 12, 2025, AV had two separate falls, when ambulating in common areas independently without any assistive devices. According to an investigation, AV had been declining recently and was a higher fall risk, possibly due to new medications, and despite AV's service plan indicating to encourage AV to use their walker or wheelchair, AV did not have a walker or wheelchair to use. The facility failed to provide services, to include properly care planning and/or implementing interventions to mitigate AV’s declining health and to ensure resident safety, resulting in physical injury, 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 is a high fall risk. AV is care planned for falls to be monitored, to ensure AV is wearing proper footwear, to encourage AV to use a walker and wheelchair, and is also care planned as independent with transfers and ambulation. AV had a fall on April 20, 2025, and again on April 27, 2025, both when AV ambulating in common areas independently without any assistive devices. According to an investigation, despite AV's service plan still indicating to encourage AV to use their walker or wheelchair, AV did not have a walker or wheelchair to use. The facility failed to provide services, to include properly care planning and/or implementing interventions to mitigate AV's fall risk and to ensure resident safety, placing AV at risk for harm, 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 care planned to have line of sight supervision from facility care staff. On or about March 23, 2025, AV had an unwitnessed fall, resulting in right foot toe fracture and unreasonable discomfort. According to an investigation, facility staff were helping other residents and did not have AV in line of sight. The facility failed to follow the care plan which is a violation of resident’s rights is neglect of care and constitutes abuse.

Both the Alleged Victim (AV) and Witness 1 (W1) rely on the facility for care, and W1 has a history of behaviors that affect other residents. According to an investigation, on or about March 18, 2025, W1 touched AV in an inappropriate sexual manner while both the Alleged Perpetrator 2 (AP2) and the Alleged Perpetrator 3 (AP3) were present, but on their cell phones. The facility failed to provide services, to include implementing interventions and/or appropriately care planning for Witness #1’s (W1) known behaviors, and providing a safe environment for AV, resulting in significant emotional harm, unreasonable discomfort, and serious loss of personal dignity for AV. The facility failure is a violation of resident rights, is considered neglect of care and constitutes abuse. Both AP2 and AP3’s actions are a violation of resident rights, are considered neglect of care and constitute abuse.

The Alleged Victim (AV) relies on the facility for his/her care and is a known fall risk. Between March 31, 2024 and January 3, 2025 AV has had numerous falls, some resulting in injury, to include hitting his/her head, skin tears, bruising, and scrapes. At least seven (7) of the falls include AV's wheelchair and it was noted the wheelchair brakes did not work, however the wheelchair was not replaced for multiple months. The facility failed to appropriately care plan and implement reasonable interventions to address AV’s falls, resulting in repeated unnecessary 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 care, is a fall risk, and is care planned for staff to monitor AV when in common areas and to remind AV to use their walker. According to an investigation, on or about December 31, 2024, AV was wandering around the facility without their walker. There were no staff monitoring AV, and AV ultimately fell, resulting in blunt head injury, contusion of right knee, skin tear right upper arm. The facility failed to provide services, to include following AV's care plan and monitoring AV for safety, 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/her care. According to an investigation, AV experienced approximately five falls between November 5, 2024, and December 20, 2024, resulting in injuries and unreasonable discomfort. The facility failed to provide appropriate services according to AV’s needs, relating to care plans and lack of appropriate interventions and instructions, to mitigate the risk of injury due to AV's increase in falls, which is a violation of resident rights, is neglect of care, and constitutes abuse.

The Alleged Victim (AV) was a known fall risk with a history of falls. The facility failed to provide appropriate services according to the AV's needs, relating to their number of falls with lack of appropriate interventions. According to an investigation, the AV experienced multiple unwitnessed falls between approximately November 5, 2024, and December 18, 2024, resulting in pain and injuries. The failure is a violation of resident rights, is considered neglect of care, and constitutes abuse.

The Alleged Victim (AV) relies on the facility for care, has a history of falls, and uses a walker to ambulate. On or about December 11, 2024, the AV was ambulating with their walker very quickly, when the Alleged Perpetrator 2 (AP2) grabbed the walker to slow AV down. AV lost their balance and started to fall, so AP2 quickly and forcefully guided AV into a chair, which resulted in bruising on AV's ribcage. According to an investigation, AP2 was the only one in the facility providing care to residents, due to the other scheduled staff being on their break or lunch, and AP2 was also in the process of passing medications to other residents. The allegation that AP2 neglected AV was investigated and inconclusive for abuse and neglect. The facility failed to provide services, to include sufficient staff to meet resident's scheduled and unscheduled needs, and provide a safe environment for AV, 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 safety. The Alleged Perpetrator 2 (AP2) has a history of flirty and inappropriate behavior with both residents and staff. AP2's actions made staff and residents uncomfortable but nothing was done about it as it was implied it was just a culture difference. On or about December 9, 2024, AV reported that AP2 was kissing and touching them inappropriately over the past few months. According to an investigation, AP2 came in to AV's room often and would kiss AV on the mouth, sometimes with their tongue and it had recently progressed to AP2 rubbing their body on AV where AV could feel that AP2 was sexually aroused. AV felt violated and began self-isolating and put the covers over their head, faking being asleep, in an attempt to avoid AP2's advances. AP2 actions are a violation of resident rights, are considered neglect of care and constitute sexual abuse. The facility failed to protect AV from inappropriate sexual contact, 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/her care and is a known fall risk, partially due to an increase in medications prescribed to manage AVs behaviors. According to an investigation, between October 12, 2024, and December 10, 2024, AV had approximately 6 falls, some resulting in injury including but not limited to a head injury, skin tears, abrasions and bruising. The facility failed to provide services, to include implementing effective interventions to mitigate AV’s falls and monitoring AV for safety, resulting in repeated unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Both the Alleged Victim (AV) and Witness 1 (W1) rely on the facility for care and have a history of aggressive behaviors resulting in physical altercations with each other. On or about November 29, 2024, AV and W1 got into a physical altercation in the hallway of the facility where AV and W1 choked each other. The facility failed to implement effective interventions to address both AVs and W1s aggressive behaviors, and provide a safe environment for AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Both the Alleged Victim (AV) and Witness 1 (W1) rely on the facility for care and have a history of aggressive behaviors resulting in physical altercations with each other. On or about November 29, 2024, AV and W1 got into a physical altercation in the hallway of the facility where AV and W1 choked each other. The facility failed to implement effective interventions to address both AVs and W1s aggressive behaviors, and provide a safe environment for AV, 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, has a history of falls, and is care planned for staff to remind AV to use their walker. According to an investigation, on or about November 24, 2024, AV was seen by facility staff to be up in AVs room without using AVs walker. Facility staff were on their way to do another task and did not stop to remind AV to use their walker per the care plan. Approximately 5 minutes later AV was found on the floor after falling. AV was sent to the hospital where AV was diagnosed with a urinary tract infection and ultimately a fractured hip that required surgery. The facility failed to follow AV's care plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Both the Alleged Victim (AV) and Witness 1 (W1) rely on the facility for care. W1 has a history of aggressive behaviors resulting in resident-to-resident altercations and is care planned for staff to keep an eye on W1 when around other residents. On or about November 4, 2024, W1 came out of their room and pushed AV down, resulting in AV hurting their back and knees. The facility failed to implement interventions to address W1 aggressive behaviors and provide a safe environment for AV, 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. AV has a history of aggressive behaviors resulting in resident-to-resident altercations and is care planned for staff to keep an eye on AV when around other residents. On or about November 4, 2024, AV came out of their room and got into a resident-to-resident altercation. The facility failed to implement interventions to address AV aggressive behaviors, placing them at risk for harm, 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 and the facility is in charge of AV's medications. According to an investigation, AV is on a medication for a clotting disorder and was given no medication, or an incorrect dose for multiple days resulting in AV's platelet count to be low. It was stated that if AVs platelet count got very much lower, it could be very dangerous to AV and result in spontaneous bleeding in the GI system or the brain. The facility failed to ensure AV received their medications as prescribed and provide a safe medication system, resulting in low platelets, which is violation of resident’s rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility to provide a safe environment and requires staff to remind and ensure the AV used an assistive device for ambulation. According to an investigation, on or about October 2, 2024, the AV's cottage was left unattended with no staff present. The AV ambulated independently without their assistive device and fell, resulting in an injury to the head. The allegation that the Alleged Perpetrator 2 (AP2) neglected the AV was investigated and determined to be inconclusive. The facility failed to ensure adequate staff in numbers to meet scheduled and unscheduled needs of residents' at all times, placing the AV at risk of harm, which is a violation of resident rights, is considered neglect of care, and constitutes abuse.

The Alleged Victim (AV) has a complex diabetic medication regimen and relies on the facility to manage their medications. According to an investigation, on or around September 20, 2024, the AV was admitted to the facility without medications. The AV was not provided their prescribed medications for approximately three days, creating a risk of serious harm. The AV experienced a fall on or about September 23, 2024, resulting in pain. The AV was not provided medication to relieve their pain. The facility failed to provide a safe medication administration system to ensure AV’s medication was available to be administered as ordered, which is a violation of resident’s rights, is neglect of care, and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. AV uses a wheelchair or walker for ambulation, requires staff assistance with transfers, and has history of falls. AVs care plan directs AV to use his/her call button for help, but also indicates AV cannot remember to use the call button and AV's behavior plan states that AV should be kept within line of sight to reduce falls. According to an investigation, on or about September 17, 2024, AV was found on the floor in AV's room by care staff, resulting in a skin tear and bruising to AV's right forearm. The facility failed to appropriately care plan and implement reasonable interventions to address AV’s ongoing falls, which is 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 inappropriate sexual behaviors and is care planned to be redirected when trying to enter opposite gender rooms. According to an investigation, on or about August 29, 2024, W1 went into AV's room and inappropriately touched AV while she/he was sleeping. The facility failed to provide a safe environment for AV, causing unreasonable discomfort, which 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 care. W1 has a history of hypersexual behavior resulting in inappropriate interactions with facility residents and staff. According to an investigation, on or about August 28, 2024, W1 followed AV to the courtyard where W1 touched AV’s chest, pulled AV’s head back and then forcefully kissed AV on the mouth. The facility failed to implement interventions and/or appropriately care plan for W1's behaviors and provide a safe environment for AV, 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/her care and has a history of falls. According to an investigation, between May 2, 2024 and August 18, 2024, AV had multiple falls, some resulting in hospitalization, and injuries to include bruising, a bump on the head, a head laceration requiring sutures, and a fractured hip. The facility failed to implement interventions and/or appropriately care plan related to AV’s safety and history of falls, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Both the Alleged Victim (AV) and Witness 1 (W1) rely on the facility for care. On or about August 7, 2024 W1 pushed AV while AV was standing in the common area of the facility, causing AV to have an injury fall. Then on or about November 4, 2024, W1 ran their walker into AVs wheelchair in the common area, resulting in pain to an open wound on AV’s leg. The facility failed to implement effective interventions to address W1 repeated aggressive behaviors and provide a safe environment for AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) has a dementia diagnoses, a prosthetic limb, and relies on the facility to provide a safe environment. According to an investigation, on or about July 8, 2024, the AV was transported to the emergency department via ambulance without their prosthetic and left unattended in the waiting room for approximately five hours, causing the AV discomfort and emotional distress. The facility failed to provide appropriate services and provide a safe environment for AV, 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/her care and has a history of falls. According to an investigation, between February 28, 2024 and July 4, 2024, AV had approximately four (4) falls resulting in injury to include skin tears and bruising. The facility failed to implement interventions and/or appropriately care plan related to AV’s safety and history of falls, causing repeated unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) has had multiple falls since he/she began living in the facility. On or about February 26, 2024, AV suffered a fall from his/her bed and was sent to the hospital for evaluation. The facility had not placed any interventions to reduce the risk of falls prior to AV's fall on February 26, 2024. AV fell again on March 7, 2024. The facility's failure to properly care plan placed AV at risk for serious harm. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about February 6, 2024, staff found the Alleged Victim (AV) stumbling out of his/her room with blood and a cut on his/her head. AV has a condition where he/she passes out while having bowel movements, and is to have his/her bowel movements monitored and take medication when no bowel movement has occurred for two days. On the day in question, AV hadn't had a bowel movement for approximately 3 days and was not given any medication. AV was sent to the hospital where he/she received stitches in his/her head. The facility's failure to provide a safe medication administration system and ensure there are enough staff to check on residents consistently is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about December 31, 2023, at approximately 3:49 AM, the Alleged Victim (AV) had rolled out of bed and complained that his/her wrist hurt worse, as AV had previously complained that his/her wrist hurt. At approximately 11:35 AM, staff discovered that the Alleged Victim's (AV) left arm and wrist was very swollen and looked as if it were broken. Later that day at 3:45 PM, AV was placed on alert for increased pain in the wrist. AV's family member showed up the next day and determined to take AV to the hospital where he/she was diagnosed with a fractured wrist. The facility's failure to ensure timely medical treatment placed AV in unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) was a known fall risk. AV suffered 6 falls between November 14, 2023 and December 4, 2023. No interim service plans were put into place during that time to reduce AV's number of falls. On or about December 18, 2023, AV was heard yelling from his/her room. AV was found on the floor in the middle of his/her room laying on his/her side, AV stated he/she was trying to get out of bed. AV suffered a bump on his/her cheek, a cut on his/her eyebrow and a cut on his/her left hand. 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 November 8, 2023, Witness #1 (W1) went into the Alleged Victim's (AV) apartment and woke AV up. AV yelled at W1 to get out of his/her apartment. W1 jumped on top of AV in his/her bed and began hitting AV in the face. Staff intervened and removed W1 from AV and W1 began hitting staff. W1 has a history of altercations with staff and other residents. AV received a laceration to his/her face and was sent to the hospital for evaluation. The facility's failure to properly care plan for W1, including interventions for behaviors led to the incident with AV. 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 have aggressive behaviors to both staff and residents. On or about November 8, 2023, AV punched Witness #1 (W1) while he/she was sleeping. AV and W1 were transferred to the hospital for evaluation, where W1 was determined to have an injury to his/her cheek. The facility's failure to properly care plan for AV's behaviors placed W1 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) has a history of behaviors and takes medication to help alleviate these behaviors. On or about September 5, 2023, AV's physician faxed the facility and pharmacy new orders for two different types of medication for AV. On that same day, Alleged Perpetrator #2 (AP2) approved the changes without checking the original order. The pharmacy had accidentally discontinued one of AV's medications, which was not caught by AP2. Another staff should have completed the triple check of the medication, however, this was not completed. AV did not receive his/her medication for 3 days, which could cause AV to have behaviors that would place AV and others at risk for serious harm. AP2's failure is a violation of resident rights, is considered neglect of care and constitutes abuse. The facilities failure to ensure proper oversight is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about July 4, 2023, the Alleged Victim (AV) was outside in the facility courtyard. AV appeared to be dressed too warm for the day, Alleged Perpetrator #2 (AP2) and Alleged Perpetrator #3 (AP3) determined to bring AV into the facility so AV could change into clothes that were better suited for the warm day. AP2 and AP3 pulled AV into the facility, using force. AP2 and AP3's actions placed AV at risk for harm, which is a violation of resident rights, is considered neglect of care and constitutes physical abuse. The facility's failure to properly train staff to work with residents in this situation is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #1 (W1) has a history of being verbally aggressive to the Alleged Victim (AV) and staff. On or about June 15, 2023, W1 was sitting in the dining area when AV walked by. While AV was walking by, W1 pushed his/her wheelchair in front of AV, causing AV to stop walking. W1 then pushed AV to the ground, causing AV to hit his/her head on the ground. Emergency services were called and took AV to the hospital where he/she was diagnosed with a subdural hematoma to the head. The facility's failure to properly care plan to ensure AV's safety is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) has a history of stroke, seizure and hypertension and is prescribed medications for these ailments. AV did not receive many of these medications during the month of May 2023 and June 2023, due to the facility not ordering medication timely and ordering medication from the incorrect pharmacy and through the incorrect physician, leading to AV's medications not being refilled. The facility's failure to provide AV's medication as ordered placed AV at risk for harm. 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.

Witness #1 (W1) is known to have behaviors and is care planned to be redirected from other residents at the facility. On or about April 16, 2023, W1 had an angry and aggressive outburst and punched a facility staff member. A few minutes later, W1 and the Alleged Victim (AV) engaged in an altercation where AV suffered a bruise to his/her hand. The facility's failure to follow the care plan is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) was noted to have a change of condition on February 4, 2023 and again on February 23, 2023. AV was noticed to be declining by many staff in the facility. AV's physician was not informed of the change of condition until March 13 2023 when the facility requested a hospice evaluation. AV was care planned for safety checks. On or about March 15, 2023, Alleged Perpetrator #2 (AP2) checked on AV at 8:00 PM, 10:00 PM, 11:00 PM and 11:50 PM. At 10:00 PM, AP2 stated that AV was on the floor, however, AP2 did not make contact with AV to see if AV needed assistance. At 11:00 PM, AP2 notes that AV was still on the floor, and still made no contact with AV for assistance. At the 11:50 PM check, AV was still on the floor and AP2 advises staff that AV is on the floor and has been for some time. Staff check on AV at approximately midnight and determine AV is not breathing. Staff called 911 and management, but did not attempt CPR, as AV is noted to have a DNR in place. When EMS arrived, it was discovered that AV did not have a valid DNR on file. AP2's failure to ensure resident safety is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility's failure to assess and intervene is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about February 15, 2023, the Alleged Victim (AV) was walking to the bathroom and tripped over his/her roommates fall mat. AV had previously complained about the fall mat, stating it was a tripping hazard. AV suffered a bruise and abrasion over his/her left eye and a broken arm. The facility failed to provide a safe environment, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is diagnosed with Diabetes and needs to have regular nail care performed by a professional. AV's nails were not clipped for multiple months, causing unreasonable discomfort for AV. The facility's failure to provide or assist with hygienic needs of the resident is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) was found multiple times in his/her bed with wet briefs soaked through to the bed sheets, and at times, AV was in bed without sheets. AV's fingernails were overgrown and were dirty and had suffered a pressure ulcer. AV was unshaven and wished to be. The facility failed to provide proper hygiene for AV, causing unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to protect the Alleged Victim (AV) from mental and emotional abuse. Witness #1 (W1) and Witness #2 (W2) engaged in multiple altercations, making AV fearful for W2, causing AV to try to protect W2 from W1. AV was alarmed by W1 harming W2 to the extent that AV wants to move from the facility. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about May 28, 2022, there was a verbal and physical altercation between Witness #1 (W1) and the Alleged Victim (AV). W1 was hitting, yelling and taunting AV. The facility failed to provide a safe environment, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) has a history of behaviors and physical aggression with staff and residents. On or about March 15, 2022, AV took items from a table that Witness #1 (W1) was sitting at. W1 is protective of his/her space. AV and W1 engaged in an altercation where AV and W1 punched each other in the face and torso. Neither resident was hurt, however, both residents were 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) suffered a fall on March 30, 2022 and again on April 3, 2022. The facility failed to update AV's care plan regarding falls until May 16, 2022, placing AV at risk for further harm from falls. The facilities failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) had a recent fall on February 15, 2022. AV had 4 falls after his/her fall on February 15, 2022, 3 resulting in injury to AV. The facility failed to properly care plan to decrease AV's falls. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about February 16, 2022, Witness #8 (W8) struck the Alleged Victim (AV) on the left eye. W8 has a history of being agitated and aggressive. On or about February 17, 2022, W8 was trying to take AV's walker and wheelchair, W8 had been redirected, however, that intervention was not working. W8 went over to AV again, and hit AV 3 times on the right side of his/her face. 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 February 2, 2022, the Alleged Victim (AV) was found to have a bruise and dried blood on AV's arm. Later that morning while doing cares, staff found bump on AV's head with dried blood. AV's family took AV to the emergency room, where it was discovered that AV had three (3) broken ribs. AV is care planned to have a night light on in his/her bathroom. It was discovered that AV's night light was not on. The facility failed to follow the care plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about January 12, 2022, facility staff notified the Alleged Perpetrator #2 (AP2) regarding the Alleged Victim's (AV) status of wounds on his/her legs. AV had open, weeping wounds on his/her legs, under tubi-grip socks. AP2 looked at AV's legs and ordered staff to cut the tubi-socks off. Staff did not feel comfortable cutting off the socks and told AP2 as much. AP2 did not remove the tubi-socks and did not check back in with staff to ensure the task was completed before leaving for facility for the day. AP2's actions caused AV undue pain and suffering and placed AV at risk for serious harm. AV was sent to the hospital on January 13, 2022 at 6:30 am and diagnosed with deep tissue pressure injury with superimposed cellulitis and trauma half way up his/her legs. AP2's failure to intervene when AV's condition changed is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility's failure to intervene when the residents condition changed is a violation of resident rights, is considered neglect of care an constitutes abuse.

The Alleged Victim (AV) has a history of constipation and the facility was to monitor his/her bowel movements and report to hospice. On or about December 25, 2021, AV was having trouble with a bowel movement and was sent to the hospital for treatment. AV was on hospice and was not to be sent to the hospital but was supposed to advise hospice. The facility staff and administrator did not realize AV was on hospice. AV's bowel movements were not consistently logged in the bowel health log or the shift report, which placed AV at risk for serious harm. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) and Witness #1 (W1) were known to have behaviors and interact negatively with other residents. AV and W1 had previous encounters with each other and with other residents and were to be kept separated to avoid altercations. On or about December 25, 2021, AV was having behaviors and talking to him/herself. W1 pushed AV down. There were no injuries to either resident, however, both residents were 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.

On or about November 14, 2021, the Alleged Victim (AV) was found on the floor of his/her room with Witness #1 (W1) standing over him/her. AV stated that W1 attacked him/her and pulled him/her out of the bed. AV stated he/she had back pain after the incident. W1 is known to have behaviors and aggressive actions towards staff and residents. The facility failed to properly care plan for W1, leaving other residents 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) has had multiple falls while trying to self-transfer. Interventions were put into place to reduce and protect when AV has falls, including a fall mat to be placed bedside, however, AV fell on November 14, 2021, there was no fall mat in place and AV's walker was placed several feet away, out of AV's reach. The facility failed to follow the care plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about November 10, 2021, it was discovered that the Alleged Victim (AV) had a wound on his/her side which was bleeding. AV stated that the wound was bothering him/her, but was not sure how long the wound had been there. Staff are to shower AV on Wednesdays and Saturdays, clip his/her nails, turn or reposition AV every two hours, assist with toileting every two hours and change AV's incontinence brief as needed. Facility documentation does not indicate that staff were completing any of these tasks for AV. The facility's failure to follow the care plan caused risk of harm and unreasonable discomfort to AV. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about October 20, 2021, the Alleged Victim (AV) was found in his/her room with a black eye and a swollen cheek, AV stated that someone knocked him/her down. Staff advised Alleged Perpetrator #2 (AP2) and Management of AV's condition. AP2 determined the bruise was from a marker, and not from anyone knocking AV down. No investigation was completed of the incident and AV was not properly assessed to ensure that he/she did not have a serious injury. AP2's failure 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 resident rights, is considered neglect of care and constitutes abuse.

According to documentation, the Alleged Perpetrator 2 caused emotional harm and a loss of personal dignity to the Alleged Victim by using humiliating and profane language in the presence of AV and others. AP2's actions are considered emotional/verbal abuse. The facility is responsible for the services provided and conduct of staff and this failure is a violation of Oregon Administrative Rules.

On or about December 8, 2023, a facility staff saw the Alleged Perpetrator #2 (AP2) yelling at the Alleged Victim (AV) and grabbing his/her arms. When AP2 let go of AV, staff observed blood on AV's arms. AV suffered skin tears and bruising from this interaction with AP2. 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.

On or about 02/16/2023, the Alleged Perpetrator (AP2) failed to follow the Alleged Victim’s (AV) care plan regarding ambulation. AP2’s failure resulted in AV suffering a fall and sustaining an injury to their head requiring stitches. AP2’s actions are a violation of resident rights, is considered neglect of care and constitutes abuse. The facility’s failure is a violation of Oregon Administrative Rules

The Alleged Victim (AV) is care planned to have his/her briefs changed regularly each shift. Alleged Perpetrator #2 (AP2) was working on the evening of 1/03/2023. AV was found the morning of 1/4/2023 in a soaked brief and his/her bed was soaked. It was discovered that AV's brief had not been changed since 4:30 pm the previous day. AP2 failed to follow AV's care plan, causing unreasonable discomfort. AP2's actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility's failure is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) requires assistance from facility staff with toileting and brief changes. On or about January 2, 2023, AV was moved from the common area to the dining room for dinner when it was discovered by staff that AV's brief was soaked and hadn't been changed. Alleged Perpetrator #2 (AP2) had documented a change of brief at 4:00 pm, however, AV's brief was not changed. AP2's actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility failure is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) has a history of wounds on his/her bottom. AV was noticed to have an open wound above AV's right buttock. The facility tried to complete wound care, however, the ulcer worsened and the facility did not have any orders to be completing wound care for AV. AV was ultimately sent out to the Emergency Department, where it was determined AV would receive wound care from an outside agency. The facility's failure to ensure proper wound care 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 ensure a resident had access to all of their records. An investigation determined this 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.

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 make available records to the Department upon request. 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.

Facility failure to have awake qualified direct care staff sufficient in number to meet the scheduled and unscheduled needs of residents, which is a violation of Oregon Administrative Rules. .

The facility failed to fully implement and update an acuity-based staffing tool. The facility failure is a violation of Oregon Administrative Rules.

The facility failed to keep all equipment in good repair in accordance with OAR 411-054-0200(4)(i) per complaint that the facility washer is broken.

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. 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.

The facility failed to have written policies and procedures and accounting records for handling resident's personal incidental funds (P.I.F.). An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to keep an accurate Medication Administration Record (MAR) of all medications that are administered by the facility. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to develop and implement policies and procedures that address the safekeeping of residents' possessions. An investigation determined this is a violation of Oregon Administrative Rules.

On or about March 4, 2022, morning staff arrived to find the Alleged Victim (AV) in his/her recliner, where he/she had been left the evening before. AV had a soaked brief and had not been changed during night shift. Alleged Perpetrator #2 (AP2) worked night shift, and according to video documentation, AP2 never approached AV to provide care, and in fact, AP2 was seen on video with his/her head down on the table sleeping. AP2's actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility's failure is a violation of Oregon Administrative Rules.

On or about March 2, 2022, the Alleged Victim (AV) was feeling ill and had a bout with diarrhea, which ended up all over AV's bed, self and blankets. Av's room smelled of feces. AV called for help but no one came to help AV. Alleged Perpetrator #2 (AP2) was on shit that night and responsible for the care of AV. AV's care plan states that AV was to have safety checks every two hours. AP2 could not verify that he/she actually checked on AV that often. It is unknown how long AV was laying in his/her own feces that evening, however, this action placed AV at risk for harm and in unreasonable discomfort. AP2's actions are a violation of resident rights, are considered neglect of care and constitutes abuse. The facility failure is a violation of Oregon Administrative Rules.

The facility failed to have a policy for safekeeping of residents possessions

The facility failed to have a policy in place regarding residents belongings for safe keeping, which is a violation of Oregon Administrative Rules.