Village at Valley View

The Alleged Victim (AV) is a known fall risk. On or about November 26, 2024, AV slid out of bed and sustained a skin tear due to an object protruding from AV's bed. AV was to have on non slip socks, which he/she did not and a bed alarm in place, however, the bed alarm was not working. The facility's failure to ensure AV was safe from falls is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) has a known history of falls with injury. According to an investigation, on approximately September 24, 2024, the AV fell or was found on the floor three times, resulting in unreasonable discomfort and a fractured hip. There was no evidence fall interventions were implemented for the AV. Alleged Perpetrator 2 (AP2) instructed staff to assist the AV to a couch after the third fall without visually observing or conducting an evaluation of the AV. The AP2’s actions are a violation of resident rights, considered neglect, and constitutes abuse. The facility failed to appropriately care plan for the AVs known fall risk, which is a violation of resident’s rights, is neglect of care, and constitutes abuse.

The Alleged Victim (AV) relies on the facility for a safe environment. Witness 1 (W1) has a known history of aggressive behaviors. The facility failed to appropriately care plan and/or implement specific interventions in place to monitor the AV and W1. The facility failed to ensure W1 was administered their scheduled behavior medication. According to an investigation, on or about, September 24, 2024, W1 threw the AV against a wall, resulting in injury and unreasonable discomfort. The AV was sent to the hospital with a contusion to the head. The facility failed to provide a safe environment, which is a violation of resident’s rights, is neglect of care, and constitutes abuse.

The Alleged Victim (AV) 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 change of condition and number of falls with lack of interventions. According to an investigation, the AV experienced approximately 20 falls between July 9, 2024 and October 4, 2024, resulting in repeated discomfort from skin tears, bruising, head injuries, and pain. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) has a history of physical aggressive behaviors. On or about June 28, 2024, witness 1 (W1) and AV were involved in a second physical altercation where AV called W1 “stupid”, and it led to W1 and AV hitting each other. As a result, W1 was afraid to sleep in W1’s room with AV after the altercation on June 18, 2024. 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 physical aggressive behaviors. On or about June 28, 2024, Alleged Victim (AV) and W1 were involved in a second physical altercation where W1 called AV “stupid”, and it led to AV and W1 hitting each other. As a result, AV was afraid to sleep in AV’s room with W1 after the altercation on June 28, 2024. 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 states he/she can ambulate independently and can transfer in and out of bed. It also states he/she is independent with toileting. Between August 25th, through December 4, 2023, AV sustained multiple falls. Some of the falls occur while AV was self-toileting and in one of the falls while self-toileting, AV sustained a laceration which required AV to receive 16 staples. The facility failed to care plan arounds AV, known history of falls, 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 November 27, 2023, Witness 1 (W1) was sitting in his/her recliner on his/her side of the room; AV tried to step over W1’s feet, moving towards W1’s bed; W1 pushed AV back, then appeared to be talking with AV, while pointing to AV’s side of the room. W1 then hit AV in the stomach causing AV to lose his/her balance, stumble, and fall onto his/her left side. On or about November 30, 2023, W1 came out of his/her room and told staff AV was in his/her recliner; staff went in and redirected AV to his/her side of the room; AV then went back to W1’s chair and W1 smacked AV in the head. 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 sexual behaviors. On or about November 14, 2023, W1 was found touching an opposite gender resident in an inappropriate sexual manner. On or about November 22, 2023, W1 was found in the common area with his/her hand down Alleged Victim’s (AV’s) shirt. When the video footage was checked, staff realized that W1 did the same thing to another resident as well. 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 sexual behaviors. On or about November 14, 2023, W1 was found touching an opposite gender resident in an inappropriate sexual manner. On or about November 22, 2023, W1 was found in the common area with his/her hand down the shirt of an opposite gender resident. When the video footage was checked, staff realized W1 did the same to Alleged Victim (AV) first. W1 moved to the side of AV who was seated near the other resident, reached over, and began touching AV’s chest. 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) is known to make sexually inappropriate actions towards care staff of the opposite gender. W1 is care planned to be monitor by staff for his/her sexually inappropriate behavior pattern. On or about November 14, 2023, per video that was reviewed, W1 was touching AV’s bottom and groin area. The video show W1 pulling on AV’ right hand as to get AV close to him/her. W1 begins to reach to AV’s bottom and to grab AV bottom repeatedly. W1 grabbed AV’s groin area only once. During the video, AV appears to try and get away from W1 while W1 continues to keep AV close to him/her by their hand. During the entire altercation, there was no staff member insight until AV is able to walk away from W1, and even when staff approach, they appear to be unaware of the situation of W1’s behavior towards AV. The facility failed to provide a safe environment for AV, which put AV is risk of harm, 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. Between July 5th, through October 15th, 2023, AV had sustained approximately 18 falls, AV suffered injuries during 12 of those falls. On or about October 10, 2023, AV was asleep in a chair in the common area, his/her walker was not in the common area near him/her. AV had visible abrasion injuries to his/her forehead above and including his/her left eye, visible abrasions above and including his/her left eyebrow, the bridge of his/her nose, just below the bridge of his/her nose, and there was a long open wound from the inside corner of his/her left eye, diagonal to his/her upper left forehead. This was all documented in a photograph taken of 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.

The Alleged Victim (AV) is a known wanderer. AV has been involved in multiple altercations due to his/her wandering and bothering other residents. Documentation provided shows that AV should be checked on 16 times per shift, checklists provided either did not show AV being checked every 30 minutes and times and dates were not correct. AV has been the target of multiple acts of aggression by other residents. The facility failed to provide a safe environment, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness 3 (W3) has a history of aggressive behaviors towards staff and other residents who bother W3. On or about September 5, 2023, while Alleged Victim (AV) was trying to get up from the couch, W3 elbowed AV. During the incident Witness 2 (W2) approached W3 two times to hit W3 with the back of his/her hand trying to protect AV from W3. 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) has a history of aggressive behaviors towards staff and other residents who bother AV. AV requires supervision and monitoring to help AV manage or redirect destructive or abusive behaviors, per AV’s care plan. On or about September 5, 2023, while Witness 1 (W1) was trying to get up from the couch, AV elbowed W1. During the incident Witness 2 (W2) approached AV on two (2) occasions attempting to hit AV with the back of his/her hand. Staff did not intervene or redirect AV or W2 during the incident per the video surveillance observed. The facility failed to follow the care plan, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim’s (AV’s) care plan states he/she is a full assist with toileting and transfers. On or about July 5, 2023, Alleged Perpetrator 2 (AP2) assisted AV to the restroom and left AV to dispose of a brief. AV was then left alone in the restroom when AP2 did not return for over three hours. As a result of being left alone, AV was found on the floor of the restroom. AP2 failed to follow the care plan for AV, which is neglect of care and constitutes abuse. The facility failed to assure the care plan was being followed, 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 July 24, 2023, video footage showed AV standing in the living area. Witness 1 (W1) then passed by AV, W1 and AV exchanged words, AV then began to walk away and W1 hit AV on the posterior of AV’s right shoulder with an open hand. There was a prior altercation between W1 and AV on or about July 23, 2023, in which W1 came up behind AV and slapped AV in the right shoulder. 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 July 18, 2023, Alleged Perpetrator 2 (AP2) gave AV blood pressure medication that was prescribed to another resident. As a result, AV was transported to the hospital and his/her blood pressure dropped while at the hospital. 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 Oregon Administrative Rules.

Alleged Victim (AV) relies on the facility to administer his/her medication. AV’s depression medication was not administered for 42 days between July 16th through August 27th, 2023. AV’s dementia medication was not administered between July 26th, through August 27, 2023. The facility did not follow up with the pharmacy; AV’s adult child or the VA to acquired AV’s medication. The facility has not been timely reporting the need to refill medication to AV’s adult child. 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) is care planned to be a fall risk resident. On or about March 15, 2023, AV suffered a fall out of bed. On or about March 27, 2023, AV suffered a fall out of bed once again. AV then suffered an unwitnessed fall on or about June 4, 2023. On or about June 7, 2023, AV suffered a fall while attempting to undress and use the restroom, as a result, AV experienced knee pain following this fall. On or about June 19, 2023, AV suffered an unwitnessed fall and as a result AV sustained a head injury leading to bleeding coming from his/her head. The facility failed to provide a safe environment, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim’s (AV’s) care plan states he/she is a fall risk; AV requires full assistance with transfers and is rarely or never able to communicate with or understand other. On or about May 21, 2023, AV had an unwitnessed fall with injuries; AV attempted to stand up and fell, hitting the side of his/her face on the bedside stand. As a result, AV sustained an abrasion to his/her cheek, both calves, and below his/her knee. AV was also injured in the right shoulder from the fall. On or about May 24, 2023, AV was found to have an abrasion/bruise from AV's right cheek area to under the right side of AV’s right eye; the abrasion/bruise was very red, with both bruising and scabbed area. The facility failed to provide a safe environment for AV, resulting in harm to 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. When AV moved into the facility, AV’s PCP was not available and no hold orders for AV’s insulin were obtained from the doctor. The facility should have pursued getting a doctor’s order for this when the doctor became available. Typically, the short-acting insulin would be held if the blood sugar was at or below 70, long-acting insulin should not have been held. Staff have been confused about the insulin administration and have been holding AVs scheduled long-acting insulin. As a result of the unclear directions for insulin administration, AV has been hospitalized related to blood sugars many times, putting AV in risk of serious harm. The facility to provide a safe medication administration system, which is a 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 May 1, 2023, Alleged Victim (AV) was trying to get into his/her room; AV’s door was locked and at this time, W1 walked up behind AV and punched AV in the face near his/her cheekbone with a closed fist. As a result, AV was shaken and confused and had redness on his/her cheek. The facility failed to provide a safe environment for AV, leading to AV sustaining an injury, which is a violation of resident rights, is neglect of care and constitutes abuse.

Witness 1 (W1) has a schedule PRN medication for agitation. On or about April 3, 2023, W1 was agitated and reported pain to staff. W1’s service plan stated that if he/she shows signs of anxiety or agitation, staff are to implement interventions for W1. On the morning of April 3, 2023, W1 hit a staff member. W1 was not administered any PRN medication on this day. Hospice was not informed of the physical aggression from W1 towards staff. On the evening of April 3, 2023, Alleged Victim (AV) was observed getting upset with W1 and W1 not listening to AV’s request. W1 then hit AV in the face causing redness to AV’s face. The facility failed to follow W1’s care plan regarding his/her PRN, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) requires full assistance with toileting, incontinence products, and cleanup; staff are also instructed to toilet AV before and after meals. Facility staff were not changing AV like they were supposed to. AV has been found soaked in his/her bed on different occasions. AV was found in March 2023 by his/her spouse in tears because no one had toileted AV and he/she urinated in his/her clothing. AV has a documented history of multiple falls, some including injury and hospital visits. On or about February 10, 2023, AV was sent to the hospital after a fall resulting in a head injury, on or about February 11, 2023, AV had slurred speech, inability to concentrate, drowsiness, drooling and no expression. On or about February 13, 2023, AV was reported as being “a little draggy” and out of normal baseline as a result of the fall from February 10, 2023. On or about March 30, 2023, Alleged Perpetrator 2 (AP2) was scheduled to work NOC shift from 10pm to 6:30am the next morning. AP2 went home at 3 am on March 31, 2023, and had not done toilet or safety checks on any of his/her residents. AP2 and the facility failed to provide service, which is a violation of resident rights, is neglect of care and constitutes abuse.

Witness 1 (W1) has a history of physical aggression. On or about March 25, 2023, W1 slapped Alleged Victim (AV) on the face and as a result, AV had face redness. W1 and AV were involved in a prior resident-to-resident altercation. On or about March 3, 2023, staff made a request to facility management for additional staff to watch W1 due to his/her known history of aggression. It was not until the incident of March 25, 2023, that the facility assigned a one-on-one caregiver to watch W1. The facility failed to provide a homelike environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Witness 1 (W1) has a history of physical aggression toward other residents of the facility. On or about March 25, 2023, W1 and Alleged Victim (AV) were involved in a resident-to-resident altercation resulting in W1 striking at AV. W1 and AV were involved in prior altercations on or about March 3rd and 14th, 2023. The facility failed to provide a home like environment for AV, resulting in three resident-to-resident altercations within a month putting AV a risk of harm, 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 12, 2023, AV tried to get out of bed and fell; AV was found lying on his/her back on the ground, “stuck” between the wheelchair and another object. AV had hip pain on the right side and was sent to the hospital where it was determined that AV had sustained a hip fracture. AV did not return to the facility until February 18, 2023. On or about February 24, 2023, AV was found once again on the floor in his/her room, laying on his/her back. AV was confused and scared. On or about February 26, 2023, AV was found on the floor at the end of his/her bed; AV was trying to reach out to his/her wheelchair. On or about March 19, 2023, AV rolled out of the bed, wrapped in blankets. AV complained of pain in his/her neck and head. 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) relies on the facility for his/her care. On or about January 26, 2023, AV was found on the ground, face up on his/her room. On or about March 7, 2023, at 6:53am, AV slid off their bed and was found sitting on the floor wearing a shirt and no pants. On that same day, at 11:40pm, a staff received a fall alert, AV was found on the ground, face up not wearing shoes or socks. On or about March 14, 2023, at 3am, AV slipped out of bed and fell to the ground. On or about March 21, 2023, at 12:24pm, AV was found sitting on the floor next to his/her bed. As a result, AV suffered a skin tear on his/her left elbow. 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) relies on the facility for his/her care. On or about February 26, 2023, AV had a fall and as a result, he/she was sent to the hospital and sustained a skin tear on his/her upper right arm and a large bruise, a laceration on his/her forehead, and a skin tear on AV’s left elbow. AV has had approximately three (3) other falls within the prior month. 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) has a history of altercations with Witness 1 (W1) and other residents. On or about October 29, 2022, AV wandered into W1’s room and started to touch things and walk around. W1 grabbed AV by the throat and choked AV leaving redness on AV’s throat/neck. The facility failed to provide a homelike environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) is care planned as a high fall risk resident. Between June 30th through October 8th, 2022, AV sustained approximately nine (9) falls. The facility did not implement new interventions after the falls that occurred on or about August 18, 2022, to prevent further falls from occurring. The fall that occurred on or about September 11, 2022, was noted as avoidable because staff should have walked closely with AV after he/she refused to use the wheelchair. 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) relies on the facility for his/her care. On or about August 16, 2022, AV yelled “ouch” and staff ran over to see what was happening. AV had blood on his/her right pant leg. Staff lifted AV’s pant leg and saw a large skin tear. Witness 1’s (W1’s) foot was on top of AV’s foot. Staff asked if W1 kicked AV and W1 said yes. On or about August 18, 2022, W1 once again kicked AV in the leg. W1 has a history of other resident-to-resident 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 for his/her care. AV was using a “spare” wheelchair from the facility that did not fit his/her size and staff would leave AV’s feet flat on the floor instead of on the chair’s footrest. AV would “scoot” him/herself around the facility in the wheelchair resulting in injuries to AV’s leg due to one leg being pulled underneath. On or about July 26, 2022, staff notes in facility documents that AV has three (3) bruises and a scab on his/her rights foot and that AV’s right foot is “always getting caught” under his/her wheelchair; staff also found a scabbed wound on top of AV’s foot and AV would “grunt” when staff touched his/her foot. AV has a pressure alarm that will alert staff if he/she attempts to self-transfer. AV’s chair/bed alarm was on occasions broken or staff wouldn’t move it from wheelchair to bed or from bed to wheelchair, causing AV to fall several times a day. The facility failed to provide service to AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

On or about March 25, 2022, Alleged Victim (AV) and Witness 1 (W1) had a resident-to-resident altercation in which W1 struck AV in the mouth and chest causing AV to sustain a skin tear to his/her chest. Based on interviews and facility documentation, W1 has a history of being physically aggressive towards other residents. The facility failed to follow W1's care plan care regarding following interventions to respond to W1 increasing behaviors, The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Perpetrator 2 (AP2) made an harsh verbal comments and roughly handled the Alleged Victim (AV) during a transfer. AP2 is responsible for verbal abuse and neglect. The facility failed to protect AV from harsh verbal comments made by staff and rough treatment, the failure is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately monitor the Alleged Victim (AV) and Witness 1 (W1) according to their known behavior and prior altercations. The failure resulted in multiple physical altercations between AV and W1 throughout the month of February, causing unreasonable discomfort and putting AV at risk of serious harm. This failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility neglected Alleged Victim (AV) by actively or passively failing to provide the basic care and services necessary to keep AV safe when AV was pushed down by Witness 1 (W1) causing potential risk of harm to AV. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide a safe medication administration system for Alleged Victim (AV) by failing to give AV the correct medication according to dosage, frequency and time as described in AV's doctor order. The facility's failure is a violation of resident rights is considered neglect of care and constitutes abuse. The allegation that Alleged Perpetrator 2 (AP2) neglected AV was investigated and findings determined there was no wrongdoing by AP2.

On or about December 27, 2021, the facility neglected Alleged Victim (AV) by actively or passively failing to provide the basic care and services necessary to keep AV safe when Witness 1 (W1) hit AV and threw coffee at AV. The facility failed to properly care plan and initiate interventions to respond to W1 behaviors, which is a violation to resident rights, is considered neglect of care and constitutes abuse.

The facility neglected Alleged Victim (AV) by actively or passively failing to provide the basic care and services necessary to keep AV safe from aggressive interactions involving Witness 1 (W1). The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility neglected Alleged Victim (AV) by actively or passively failing to provide the basic care and services necessary to keep AV safe from aggressive interactions between AV and other residents including Witness 1 (W1). The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about November 25, 2021, Alleged Victim (AV) and Witness 1 (W1) had a resident-to-resident altercation that caused injury to AV when W1 grabbed AV's left arm causing a skin tear. W1's has a known history of resident-to-resident altercations. The facility's failure to provide a safe environment for AV is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about November 25, 2021, Alleged Victim (AV) and Witness 1 (W1) engaged in a resident-to-resident altercation which caused injury to both AV and W1. An investigation determined that both W1 and AV have a history of resident-to-resident altercation and on the day of the incident facility failed to provide adequate staffing to ensure W1's care needs were met. 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 4, 2021, Alleged Victim (AV) was found on the floor of another resident's bathroom by facility staff. An investigation determined that facility staff had been putting another resident to bed when AV was found in that resident's bathroom on the floor and facility staff did not know how long AV was on the floor prior to being found. The facility's failure to provide a safe environment for AV is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about October 28, 2021, Alleged Victim (AV) and Witness 1 (W1) had a resident-to-resident altercation that caused injury to AV when W1 slapped AV on the right side of AV's face. An investigation determined that W1 has a history of aggressive behaviors/resident altercations. The facility's failure to provide a safe environment for AV is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility to administer his/her medication. On or about May 12, 2023, Alleged Perpetrator 2 (AP2) administer the wrong insulin to AV when they did not verify the medication against the MAR. AP2 failed to provide a safe medication administration system, which is a neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system, which is a violation of Oregon Administrative Rules.

Alleged Victim (AV) relies on the facility for his/her care. On or about April 3, 2023, Alleged Perpetrator 2 (AP2) was told to wait before transferring AV but went ahead and did it on his/her own. as a result, AP2 caused AV really bad pain and AV suffered a skin tear on his/her elbow. Later that day, AV’s hand appeared bruised and swollen. AP2 failed to provide AV with a safe environment, which is neglect of care and constitutes abuse. The facility failed to assure AV was provided with a safe environment, which is a violation of Oregon Administrative Rules.

Alleged Victim (AV) is care plan for staff to do safety checks on AV 48Xs per day(or 30 minutes safety checks), AV is a high fall risk. On or about March 30, 2023, Alleged Perpetrator 2 (AP2) was scheduled to work NOC shift from 10pm to 6:30am the next morning. AP2 went home at 3am on March 31, 2023, and had not done toilet or safety checks on AV. AV was found soaked in urine by another staff member after AP2 had left. AP2 failed to follow the care plan, which is neglect of care and constitutes abuse. The facility failed to assure the care plan was followed, which is a violation of Oregon Administrative Rules.

Alleged Victim (AV) is scheduled to be taken to the bathroom every two (2) hours and AV needs hands on assistance when going to the bathroom. On or about March 30, 2023, Alleged Perpetrator 2 (AP2) was scheduled to work NOC shift from 10pm to 6:30am; AP2 went home at 3am on March 31, 2023 and had not done toilet or safety checks on any of his/her residents. AP2 failed to provide basic care and services necessary to maintain the health and safety of AV, by not toileting AV every two (2) hours as care planned, which is neglect of care and constitutes abuse. The facility failed to assure the care plan was followed, which is a violation of Oregon Administrative Rules.

Alleged Victim (AV) is care plan to be a 2-person transfer. On or about March 25, 2023, Alleged Perpetrator 2 (AP2) tried to put AV to bed but was rushing and claiming he/she could do it by him/herself. AP2 did not know how to do a proper transfer and would not listen to facility staff. As a result, AV was screaming in pain, and suffered two skin tears in the process. AP2 failed to follow the care plan, which is neglect of care and constitutes abuse. The facility failed to assure the care plan was being followed, which is a violation of Oregon Administrative Rules.

Alleged Victim (AV) is care planned to have full assistance with showers. AV had a fall while taking a shower and hit his/her elbow. As a result, AV sustained a scape to the elbow. Alleged Perpetrator 2 (AP2) was supposed to be with AV when AV was showering but left AV alone. AP2 failed to follow the care plan, which is neglect of care and constitutes abuse. The facility failed to assure AV’s care plan was being followed, which is a violation of Oregon Administrative Rules.

The facility allegedly failed to provide safe environment for the Alleged Victim. An investigation determined no licensing violation or abuse occurred.

The facility allegedly failed to provide or maintain the Alleged Victim care equipment. An investigation determined this is a violation of Oregon Administrative Rules.