The Iris Memory Care

Witness 1 (W1) has a known history of resident-to-resident altercations. Previous altercations were on August 21 and September 10, 2024. On or about October 23, 2024, W1 approached a group of residents in the dining room. W1 grabbed Alleged Victim (AV) by the shoulder before punching AV in the back of the head. After the altercations, there was no new interventions placed to prevent further altercations. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility to administer his/her medication. On or about October 2, 2024, Alleged Perpetrator 2 (AP2) checked out narcotic PRNs for AV and six (6) other residents, however, no PRN medication was requested by staff. On or about October 2, 2024. AP2 tested positive for narcotics during a facility provided UA. AP2 failed provide a safe medication administration system, which is neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility to administer his/her medication. On or about October 2, 2024, Alleged Perpetrator 2 (AP2) checked out narcotic PRNs for seven (7) residents, however, no PRN medication was requested by staff on or about October 2, 2024. AP2 tested positive for narcotics during a facility provided UA. The facility ignored staff members testimony regarding narcotics possible theft. AP2 failed provide a safe medication administration system, which is neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility to administer his/her medication. On or about October 2, 2024, Alleged Perpetrator 2 (AP2) checked out narcotic PRNs for seven (7) residents, however, no PRN medication was requested by staff. On or about October 2, 2024. AP2 tested positive for narcotics during a facility provided UA. The facility ignored staff members testimony regarding narcotics possible theft. AP2 failed provide a safe medication administration system, which is neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility to administer his/her medication. On or about October 2, 2024, Alleged Perpetrator 2 (AP2) signed out PRN narcotics for AV and six (6) other residents. Staff did not request any PRN narcotics for AV and the six other resident. On or about October 3, 2024, AP2 tested positive for narcotics during a mandatory UA. The facility was notified by staff of AP2’s behaviors and errors in the narcotic log on multiple occasions. AP2 failed provide a safe medication administration system, which is neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility to administer his/her medication. On or about October 2, 2024, Alleged Perpetrator 2 (AP2) checked out narcotic PRNs for AV and six (6) other residents, however, no PRN medication was requested by staff. On or about October 2, 2024. AP2 tested positive for narcotics during a facility provided UA. The facility ignored staff members testimony regarding narcotics possible theft. AP2 failed provide a safe medication administration system, which is neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility to administer his/her medication. On or about October 2, 2024, Alleged Perpetrator 2 (AP2) checked out narcotic PRNs for AV and six (6) other residents, however, no PRN medication was requested by staff. On or about October 2, 2024. AP2 tested positive for narcotics during a facility provided UA. The facility ignored staff members testimony regarding narcotics possible theft. AP2 failed provide a safe medication administration system, which is neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility to administer his/her medication. On or about October 2, 2024, Alleged Perpetrator 2 (AP2) checked out narcotic PRNs for AV and six (6) other residents, however, no PRN medication was requested by staff on or about October 2, 2024. AP2 tested positive for narcotics during a facility provided UA. The facility ignored staff members testimony regarding narcotics possible theft. AP2 failed provide a safe medication administration system, which is neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility to administer his/her medications. On or about September 22, 2024, AV moved into a new facility. AV’s insulin medication was transferred from AV’s old facility to AV’s new facility. Alleged Perpetrator 2 (AP2) was given AV’s new medication, however, AP2 only placed the medication on a counter, and it was later discarded. AP2 had marked that AV’s insulin, and all of his/her medication had not arrived, however, AP2 did not notify management that AV’s insulin was not present and did not contact hospice to get more insulin. On or about September 24, 2024, it was discovered that AV’s insulin was not present. AV had missed his/her morning dose of medication without any action being taken. On or about the evening of September 24, 2024, AV had a blood sugar of 503. AP2 failed to provide a safe medication administration system for AV, which is neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) has a known history of falls. On or about September 16, 2024, AV had dark purple bruising on the left side of AV’s face and forehead. The facility had no incident report or documentation to explain the injury AV had sustained. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Witness 1 (W1) has a history of being the aggressor in resident-to-resident altercations. At the time of the altercation, W1 interventions were to have eye level supervision. On or about September 6, 2024, while in the living room, W1 punched Alleged Victim (AV) in the face and body multiple times. Staff were not in the living room when the altercation occurred. The facility failed to follow W1’s care plan, by failing to have eye level supervision, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. On or about September 2, 2024, AV was found in Witness 1’s (W1’s) bed, W1 was touching AV’ stomach under AV’s shirt. Staff attempted to separate AV and W1, and W1 became combative with staff. On or about September 5, 2024, once again AV was found in W1’s room. W1 also attempted to get into AV’s room with AV, and when staff attempted to redirect AV, W1 once again became combative with staff and attempted to force AV to hold W1’s hand. On or about September 10, 2024, once again AV was found in W1’s room. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Witness 1 (W1) and Alleged Victim (AV) have a known history of being involved in other resident-to-resident altercations. On or about August 20, 2024, AV bumped into W1 in the dining room when AV was self-propelling AV’s wheelchair. W1 then hit AV in the head three (3) times. As a result, W1 broke AV’s grasses. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim’s (AV’s) care plan notes he/she is not a fall risk and does not have a pattern of falls. On or about May 29, 2023, AV had a fall with injury. AV was sent to the ER with a hematoma on the left side of AV's head. The hematoma was approximately 5cm x 5cm. AV to be monitored for pain, swelling, and head injury. On or about July 12, 2024, AV was sent to the ER for a fall with injury where AV hit AV's head. AV had three (3) quarter sized bumps on AV's head. AV was to be monitored for pain, swelling, and head injury. On or about July 21, 2024, AV had an injury fall where AV hit AV's head. On or about July 22, 2024, AV was found on the ground. AV was to be monitored for pain, swelling, open skin. AV was sent to the ER on July 22, 2024, for a head injury. On or about August 9, 2024, AV had two (2) falls. AV hit AV's head during one fall causing an abrasion on the back of AV's head. AV was sent to the ER. The facility failed to care plan and mitigate AV’s risk of falls, which is a violation of resident rights, is neglect of care and constitutes abuse.

Witness 1 (W1) has a known history of resident-to-resident altercations due to W1 wandering into other residents’ rooms. On or about July 11, 2024, W1 entered AV’s room, AV grabbed W1 by W1’s hair and pulled W1 out of AV’s room. W1 then pushed AV onto the ground. The facility failed to provide a safe environment for AV, which puts AV in risk of harm and is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) has a known history of resident-to-resident altercations due to AV wandering into tother residents’ rooms. On or about July 11, 2024, AV entered Witness 1’s (W1’s) room, W1 grabbed AV by AV’s hair and pulled AV out of W1’s room. AV then pushed W1 onto the ground. The facility failed to provide a safe environment for AV, which puts AV in risk of harm and is a violation of resident rights, is neglect of care and constitutes abuse.

Witness 1 (W1) has a known history of resident-to-resident altercations. On or about June 20, 2024, W1 held Alleged Victim’s (AV’s) hand, AV then attempted to get his/her hand away from W1 and W1 yanked AV’s right hands pinky. As a result of the altercation, AV’s pinky became swollen and slightly discolored. The facility failed to provide a safe environment for AV, putting AV in risk of harm, which is a violation of resident rights, is neglect of care and constitutes abuse.

Witness 1’s (W1's) service plan states that W1 is not easily angered and does not require intervention to prevent harm to others. W1's service plan also says that W1 has a history of agitation or anxiety triggered by other residents not doing what W1 thinks they should be doing. W1 has a history of verbal cruelty to other residents and resident to resident altercations. On or about June 19, 2024, W1 smacked Alleged Victim (AV). AV attempted to retaliate but was unable to. AV said, "that crazy bitch hit me twice." W1 punched AV twice in the stomach. Despite W1 having a documented history of being aggressive the facility did not put interventions in place for W1's behaviors until after this altercation, which is a violation of resident rights, is neglect of care and constitutes abuse.

Witness 1 (W1) is known to wonder into other resident’s rooms. On or about April 2, 2024, staff heard yelling and went down the hall. When they entered Alleged Victim’s (AV’s) room, they saw AV holding W1 by the hair and W1 swinging his/her arms and hitting AV. This has not been the only altercation W1 has been involved in. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Witness 1 (W1) has a known history of resident-to-resident altercations. On or about March 27, 2024, while in the living room, W1 hit Alleged Victim (AV) in the neck. AV then kicked W1 in the leg. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Witness 1 (W1) has a known history of resident-to-resident altercations. On or about March 28, 2024, Alleged Victim (AV) and W1 were in the dining room, W1 touched AV’s chair and AV pulled the chair away from W1, W1 then reached up and scratched AV’s neck. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) is known to be an exit seeking resident. AV has also previously eloped from the facility when movers were bringing furniture for a new resident. On or about March 23, 2024, AV walked out a side emergency exit door while a mover was moving furniture into the facility. There have been no new interventions put in place to stop another elopement from occurring to AV. The facility failed to properly plan care around AV exit seeking behaviors, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) is care planned to have staff monitor AV’s wandering due to AV’s history of walking into walls. On or about March 10, 2024, AV was found with yellow and black discoloration appearing 8cm x 4cm long half circle on his/her forehead and a bruise on the back of AV’s right upper arm. The facility failed to follow the service plan which put AV is risk of harm when he/she obtained the bruising on his/her forehead and back of right upper arm, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) has a history of resident-to-resident altercations. On or about March 10, 2024, AV tried to grab another resident’s walker. This resulted in AV being hit on his/her arm. AV then hit Alleged Witness 1 (W1) in the back. The facility failed to provide a safe environment for AV, which put AV in risk of harm, which is violation of resident rights, is neglect of care and constitutes abuse.

Witness 1 (W1) has a history of resident-to-resident altercations. On or about March 10, 2024, W1 tried to grab another resident’s walker. This resulted in W1 being hit on his/her arm. W1 then hit Alleged Victim (AV) in the back. The facility failed to provide a safe environment for AV, which put AV in risk of harm, which is violation of resident rights, is neglect of care and constitutes abuse.

The facility failed to provide appropriate supervision to the Alleged Victim (AV) according to his/her needs and history of exit seeking. 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.

Witness 1’s (W1’s) interventions are to ensure room level supervision when Alleged Victim (AV) and W1 are in the same area. On or about February 22, 2024, while AV was lying on the floor, W1 struck AV about two to three times on the back of AV’s head. During the altercation staff did not have room-level supervision on AV or W1. AV and W1 have a history of resident altercations with each other. The facility failed to follow the care plan regarding room level supervision, which is a violation of resident rights, is neglect of care and constitutes abuse.

The facility failed to follow the Alleged Victim's (AV) care plan to mitigate the risk of resident to resident altercations. According to AV's service plan, staff are to provide AV a doll or stroller to keep his/her hands busy to avoid touching other residents, assist AV to a smaller environment for meals and keep him/her safe distance from Witness 1 (W1) due to prior altercations. On or about 02/17/2024, AV walked passed W1 and grabbed his/her meal plate, resulting in a physical altercation. The facility's failure to follow AV's care plan and provide a safe environment, is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) is known to be a high fall risk. AV has sustained two falls on or about February 1st and 3rd, 2024. On or about February 6, 2024, AV had an injury fall. AV hit his/her head and was sent to the hospital and was sent back to be monitored. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. On or about February 10, 2024, AV was crying while walking towards staff down the hall and reported that Witness 1 (W1) came into AV’s room and attacked AV by grabbing AV’s breast really hard. The facility failed to provide a safe environment for AV, putting AV in risk of harm, which is a violation of resident rights, is neglect of care and constitutes abuse.

Witness 1 (W1) has a known history of extremely violent behaviors towards staff and residents. On or about February 9, 2024, Alleged Victim (AV) was walking through the dining room with staff. A resident began to yell at AV, which caused W1 to begin to slap AV in the face. W1 has had multiple documented assaults on staff and residents, however, the facility has failed to care plan around W1’s known behaviors of aggression, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) is care planned to be redirected if he/she is seen in someone else’s room and staff will need to make sure AV stays engaged in the activity program to reduce wandering. On or about February 10, 2024, AV entered Witness 1’s (W1’s) room and shortly after AV was seen hitting the floor. W1 then begun to hit AV 2-3 times with his/her purse. The facility failed to follow the care plan, which put AV in risk of harm, which is a violation of resident rights, is neglect of care and constitutes abuse.

Witness 1 (W1) has history of touching other residents’ belongings, leading to resident-to-resident altercations. On or about February 9, 2024, W1 tried to take Alleged Victim’s (AV’s) walker, when AV said no, W1 attacked AV by clawing at him/her. As a result, AV’s right hand was injured. The facility failed to provide a safe environment for AV known of W1’s known behaviors of touching other residents’ belongings, which is a violation of resident rights, is neglect of care and constitute abuse.

Alleged Victim (AV) has a known history of touching other resident’s belongings. On or about February 5, 2024, AV was being escorted into the dining room when he/she reached out and touched Witness 1’s (W1’s) hat. As a result, W1 stood up and punched AV. AV and W1 have had a prior altercation on or about February 3, 2024. The facility failed to provide a safe environment for AV, putting AV in risk of harm, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) has a known history of grabbing other resident’s walkers and personal items, causing resident-to-resident altercations. On or about February 5, 2024, AV approached Witness 1 (W1) while leaving the dining room. W1 pushed AV away from him/her, and AV grabbed W1 causing them both to fall. As a result of this altercation, AV fell and hit his/her head on the fire door, W1 fell and fractured his/her hip. The facility failed to provide a safe environment for AV and W1, which is a violation of resident rights, is neglect of care and constitutes abuse.

Witness 1’s (W1’s) interventions are to ensure room level supervision when Alleged Victim (AV) and W1 are in the same area. On or about February 5, 2024, after dinner, W1 approached AV leaving the dining room. AV pushed W1 away from him/her, and W1 grabbed AV causing them both to fall. W1 has a history of grabbing other residents’ walkers and personal items, causing resident to resident altercation. During the altercation interventions were not being followed. The facility failed to follow the care plan regarding room level supervision, which is a violation of resident rights, is neglect of care and constitutes abuse.

Witness 1 (W1) has an extensive history of resident-to-resident altercations cause by him/her not respecting other resident’s space. On or about February 4, 2024, W1 walked up behind Alleged Victim (AV) and grabbed AV’s chest. The facility failed to provide a safe environment for AV, putting him/her at risk of harm, which is a violation of resident rights, is neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility to ensure a safe environment. Witness 1 (W1) has a history of resident-to-resident altercations. On or about February 3, 2024, AV and W1 had a physical altercation, resulting in AV being pushed causing unreasonable discomfort. The facility failed to ensure a safe environment for AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness 1 (W1) has a known history of touching other residents leading to resident-to-resident altercations in prior community. On or about January 21, 2024, W1 tried to take Alleged Victim’s (AV’s) walker by squeezing AV’s left forearm. As a result, AV sustained bruising to his/her forearm. The facility failed to provide a safe environment for AV, leading to AV sustaining bruising, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) has a known history of falls. Between November 21, 2023, and December 6, 2023, facility care staff failed to review several temporary care plans which included fall interventions. During that same time period, AV suffered several falls and was injured. On or about December 6, 2023, a Home Health Physical Therapist left the following written instructions for staff, “Instructions: Requires constant supervision and assistance for safety due to high fall risk.” The facility disregarded the Physical Therapist’s December 6, 2023, written instructions. The facility failed to provide a safe environment for AV, resulting in falls to AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Witness 1 (W1) has a known history of agitation and aggression including multiple altercations with other residents. On or about December 11, 2023, W1 entered Alleged Victim’s (AV’s) room and begun throwing items around. AV got upset and tried to pull W1 out of his/her room. As a result, W1 begun to hit AV in the hallway outside AV’s room. The facility failed to provide a safe environment for AV, putting AV in risk of harm, which is a violation of resident rights, is neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility to ensure a safe environment. Witness 1 (W1) has a history of resident-to-resident altercations. On or about November 28, 2023, AV and W1 had a physical altercation, resulting in AV being hit in h/h arm causing pain and unreasonable discomfort. The facility failed to ensure a safe environment for AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions, appropriately care plan and monitor Witness 1 (W1) according to his/her aggression and prior resident altercations. The failure resulted in W1 punching the Alleged Victim in the arm, causing unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions, appropriately care plan and monitor Witness 1 (W1) according to his/her aggression and prior resident altercations. The failure resulted a physical altercation with the Alleged Victim, causing unreasonable discomfort and risk of harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim’s (AV’s) service plan states he/she needs stand by assistance for toileting and assistance dressing. AV has a history of falls. On or about October 27, 2023, AV had a fall with injury in his/her bathroom. As a result of the fall, AV sustained a skin tear on his/her left hand and pain on his/her neck. AV was left alone in the bathroom and did not receive stand by assistance. The facility failed to follow AV’s care plan, which is a violation of resident rights, is neglect of care and constitutes abuse.

According to documentation, the facility failed to implement interventions and appropriately care plan related to the Alleged Victim’s (AV) fall history. On or about August 31, 2023, AV suffered a fall in h/h room, resulting in AV an injury to h/h head and was sent 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.

Alleged Victim (AV) relies on the facility to manage his/her pain. Staff are to reposition AV frequently to help with his/her pain. AV will yell out in pain when he/she is being rotated. It was recommended by Infinity Rehab that AV get Baclofen for his/her pain but there was no Baclofen on AVs MAR. There are no other interventions by the facility to help reduce AV’s pain. The facility failed to provide appropriate pain control, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) has a known history of falls. On or about April 12, 2022, AV sustained a fall which resulted in AV getting stuck between his/her bed side rail and mattress and caused AV a fracture L2 vertebrate. AV had sustained a previous fall earlier in the day and a fall on April 9, 2022, and a prior fall in December 2021 which resulted in a broken neck to AV. During all prior falls, the facility had not documented new interventions to prevent future falls. The facility failed to care plan appropriately and implement interventions to mitigate AV’s risk of falls, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) is care planned to have barrier cream to AV’s sores. Staff are not applying barrier cream to AV’s sore as stated in his/her orders. Since AV moved into the facility, his/her sore have gotten worse. The facility failed to follow the care plan, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. AV has multiple small bruises on his/her left shoulder. When turning residents, staff hold onto their shoulders. Staff are not adequately trained on how to turn or transfer a resident. The facility failed to provide a safe environment, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. On or about March 20, 2022, AV had a fall in his/her bedroom and was stuck between his/her nightstand and bed. As a result, AV sustained a 2 cm skin tear on his/her left wrist, a 6 cm laceration to the dorsum on the left foot, a 14 cm laceration on the lower left leg down to the fascial layer, a V-shaped laceration on the lateral posterior aspect of the left lower leg with a 5 cm branch and a 4 cm branch that was down to the subcutaneous fat, a 1.5 cm laceration on the left chin and ecchymosis to his/her check, shoulder, arms, legs, and thigh. AV had two (2) prior falls on February 20th and March 11th, 2022, which resulted in injury to AV. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. On or about January 7, 2022, AV was discharged from the hospital with a Foley catheter and Home Health orders which the facility was aware of. The facility made note that AV needed Home Health but did not send a fax to Home Health until February 10, 2022. On March 1, 2022, there was sediment in the catheter and staff had brought up concerns about the catheter. On or about March 15, 2022, AV was admitted to the hospital and diagnosed with a catheter associated urinary tract infection. The facility failed to provide medical treatment as ordered, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. On or about January 7, 2022, AV was discharged from the hospital with orders including wound management every two (2) days with instructions with a referral to Home Health. Staff assessed wounds on January 13, 2022, but nothing else was documented related to Home Health until February 10, 2022, when staff faxed them requesting service. On or about March 15, 2022, AV was admitted to the hospital with multiple concerns regarding lack of care. The facility failed to provide service, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) is care planned to received catheter checks 3x per shift. AV has been found with a full catheter bag on multiple occasions. AV’s catheter bags are not being cleaned properly. AV’s catheter bags have been found on the floor, in the shower and in the sink. Staff are not appropriately trained on how to provide catheter care. The facility failed to follow the care plan, which is a violation of resident rights, is neglect of care and constitutes abuse.

On or about April 26, 2022, a medication audit was completed at the facility. Between January 27, 2022 and April 27, 2022, the Alleged Victim had missed multiple medications, including 58 doses of stroke medication, 122 doses of pain medication, 65 doses of mood enhancer medication and 58 doses of blood pressure medication that should have been administered by Alleged Perpetrator #2 (AP2). AV expressed being in pain on multiple occasions during this time. On March 27, 2022, AV suffered a stroke. During the month of April, AV was sent to the emergency room two times for seizures, which AV has not had a history of seizures in the past. AP2's actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility's failure to ensure proper training of AP2 is a violation of resident rights, is considered neglect of care and constitutes abuse.

Based on interview and record review, the facility failed to provide records to the Department upon request. The facility’s failure is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during a site visit on 07/01/26, the facility’s failure to provide records to the Department upon request was substantiated, which is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during a site visit on 07/01/26, the facility’s failure to provide records to the Department upon request was substantiated, which is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during a site visit on 07/01/26, the facility's failure to have policies and procedures in place to assure the prevention and appropriate response to any incident was substantiated, which is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during an investigation on 02/26/26, the facility’s failure to provide records to the Department upon request was substantiated, which is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during an investigation on 02/26/26, the facility’s failure to provide records to the Department upon request was substantiated, which is a violation of Oregon Administration Rules.

Based on interview and record review, conducted during an investigation on 02/26/26, the facility’s failure to provide records to the Department upon request was substantiated, which is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during an investigation on 02/26/26, the facility’s failure to provide records to the Department upon request was substantiated, which is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during an investigation on 02/26/26, the facility’s failure to provide records to the Department upon request was substantiated, which is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during an investigation on 02/26/26, the facility’s failure to provide records to the Department upon request was substantiated, which is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during an investigation on 02/26/26, the facility’s failure to provide records to the Department upon request was substantiated, which is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during an investigation on 02/26/26, the facility’s failure to provide records to the Department upon request was substantiated, which is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during an investigation on 02/26/26, the facility’s failure to provide records to the Department upon request was substantiated, which is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during an investigation on 02/26/26, the facility’s failure to provide records to the Department upon request was substantiated, which is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during an investigation on 02/26/26, the facility’s failure to provide records to the Department upon request was substantiated, which is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during an investigation on 02/26/26, the facility’s failure to provide records to the Department upon request was substantiated, which is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during an investigation on 02/26/26, the facility’s failure to provide records to the Department upon request was substantiated, which is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during an investigation on 02/26/26, the facility’s failure to provide records to the Department upon request was substantiated, which is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during an investigation on 02/26/26, the facility’s failure to develop, maintain, and implement an Acuity-Based Staffing Tool (ABST) was substantiated, which is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during an investigation on 02/26/26, the facility’s failure to develop, maintain, and implement an Acuity-Based Staffing Tool (ABST) was substantiated, which is a violation of Oregon Administrative Rules.

Alleged Victim (AV) relies on the facility for his/her care. On or about April 6, 2026, Narcotic pain medication 20mg 8 AM was administered. PRN pain medication 325 & PRN pain medication 650 mg suppository were not administered to AV. When AV's call light went off. Alleged Perpetrator 2 (AP2) asked Witness 6 (W6) to go with AP2 to clear the call light. AV asked for pain medication, so AP2 & W6 left AV's room. AP2 was the one assigned to work with AV. It was not W6's job to ask for AV's medications. AP2 never asked for AV's pain medication. Right after AP2 left AV's room AP2 went on his/her lunch break, which lasted 30 minutes. AP2 failed to provide service to AV, which is neglect of care and constitutes abuse. The facility failed to ensure AV received service, which is a violation of Oregon Administrative Rules.

Alleged Victim (AV) relies on the facility for his/her care needs. On or about March 3, 2025, AV was found to have skin discoloration to his/her left arm and AV said the skin discoloration occurred from improper transferring by NOC shift staff. AV is a two-person transfer; however, it is believed an unknown NOC shift staff Alleged Perpetrator 2 (AP2) may have conducting oner person transfers with AV. AP2 failed to follow AV’s care plan around AV’s two-transfer, which is neglect of care and constitutes abuse. The facility failed to assure AV’s care planned was being followed, which is a violation of Oregon Administrative Rules.

The facility failed to ensure the service plan was reflective of the resident's needs as identified in the evaluation. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to have a safe medication and treatment administration system. An investigation determined this is a violation of Oregon Administrative Rules.

The facility allegedly failed to assure the Alleged Victim rights. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to keep the interior free from unpleasant odors in accordance with OAR 411-054-0200(4)(h); per complainant, there is a strong smell of urine near the main living area, which is a violation of Oregon Administrative Rules.

The facility failed to promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the re-occurrence of abuse in accordance with OAR 411-054-0028(3); per complaint there are discrepancies in details of what happened to the resident and there is no documentation related to the incident with injuries, 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. 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 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 document that they have observed and evaluated the individual's ability to perform safe medication and treatment administration unsupervised. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day in accordance with OAR 411-054-0040(2); per complaint the resident had a fall with injury and facility staff did not document the incident and injuries, which is a violation of Oregon Administrative Rules.

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

The facility failed to ensure the facility administrator, or designee, must immediately notify the local Department office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation in accordance with OAR 411-054-0028(2)(b); per complaint resident had multiple falls with injury that were not reported to APS and a res to res was not reported to APS, which is a violation of Oregon Administrative Rules.

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

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

The facility failed to fully implement and update an acuity-based staffing tool. The facility’s failure 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. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to ensure the preparation, completeness, accuracy, and preservation of resident records. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to evaluate behavioral symptoms which negatively impact the resident and others in the community and initiate and coordinate outside consultation or acute care when indicated. An investigation determined this is a violation of Oregon Administrative Rules.

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

The facility failed to individually identify residents' rooms to assist residents in recognizing their room. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to immediately notify the local Department office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to carry out medication and treatment orders as prescribed. An investigation determined no licensing violation or abuse occurred.

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.

According to documentation Alleged Perpetrator 2 (AP2) failed to provide a safe medication administration system to ensure the Alleged Victim’s medication was administered as ordered. The failure resulted in AV experiencing unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to ensure a safe medication administration system, which is a violation of Oregon Administrative Rules.

The facility failed to exercise reasonable precautions against any condition that may threaten the health, safety, or welfare of the residents in accordance with OAR 411-054-0025(4) per complaint that the facility is not screening visitors when entering the facility.

The facility failed to exercise reasonable precautions against any condition that may threaten the health, safety, or welfare of the residents in accordance with OAR 411-054-0025(4) per complaint that staff are not wearing masks in the facility and the facility is not screening visitors as they enter the building.

The facility failed to complete quarterly evaluation of service plan in accordance to OAR 411-054-0036(2)(a)(B) per the complaint that the service plan has been out of date for 5+ months.

The facility failed to provide services in a manner that protects the resident ' s privacy in accordance with OAR 411-054-0027(1)(g).

The facility failed to policies and procedures in place to assure the prevention and appropriate response to any incident in accordance with OAR 411-054-0028(1). Per a complaint that reportable instances of abuse or neglect are occurring but going unreported.

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 resident pulled his/her call light and it took over 2 hours for assistance.

Facility failure to provide assistance with toileting and bowel and bladder management per OAR 411-054-0030(e)(G) as stated in complaint resident is not receiving assistance emptying his/her catheter.

The allegation that the facility failed to have a training program that includes methods to determine competency of direct care staff in accordance with OAR 411-054-0070(2)(a) per complaint that the facility did not train caregiver before leaving them on the floor alone was verified.

The allegation that the facility failed to exercise reasonable precautions against any condition that may threaten the health, safety, or welfare of the residents in accordance with OAR 411-054-0025(4) per complaint that staff are assisting residents that are COVID positive without appropriate PPE was verified.