Washington Gardens Memory Care

The Alleged Victim (AV) and Witness #1 (W1) have a history of altercations. On or about June 4, 2025, W1 hit AV in the face, causing AV unreasonable discomfort, became upset and cried. W1 had been upset earlier in the day, and staff had tried to re-direct W1. W1 was to be routinely monitored by staff to ensure the safety of others due to W1's behavioral symptoms. Respondent failed to ensure a safe environment. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

The Alleged Victim (AV) is a known fall risk. On or about May 23, 2025, AV suffered a fall where he/she suffered red marks on his/her face and head. AV had suffered multiple falls in March, April and May of this year, prior to this fall. The facility failed to put interventions in place to reduce the risk of falls. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) had a history of falls. On or about March 11, 2025, AV was found on the floor in front of his/her recliner. Staff had last checked on AV and offered to re-position AV in his/her recliner, however, AV declined repositioning. AV was reported to have a significant change of condition regarding mobility, however, no documentation was completed to ensure the facility was addressing AV's changing needs. AV's care plan was not updated nor were any new interventions put into place between January 15, 2025 and March 9, 2025 when AV was experiencing an increase in falls. After AV's fall on March 11, 2025, AV was sent to the hospital and diagnosed with a fractured rib and a red mark on AV's forehead. The facility's failure to properly care plan regarding AV's risk of falls is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about November 11, 2024, the Alleged Victim (AV) was to receive his/her medication that controls blood sugar. The facility did not have enough of the medication to give AV his/her full dosage. Staff failed to track AV's medication to ensure there was enough medication and re-order his/her medication timely. AV did not receive a full dose of his/her medication as ordered, which 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.

The Alleged Victim (AV) receives his/her medication which controls blood sugar from the facility. The facility missed dispensing AV's medication approximately 11 times from August 2024 to November 2024. On or about November 10, 2024, AV did not receive his/her medication as ordered, as the facility was out of his/her medication. AV was found to have high blood glucose due to missing his/her medication, placing 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.

On or about May 21, 2023, the Alleged Victim (AV) left the facility through a gate in the courtyard. The gate had a mechanical issue with a magnet and/or spring, which allowed AV to open the gate and exit the secured area. AV was found outside by a caregiver seeing him/her through the window of another residents room. AV was outside, unattended for approximately 7 minutes, placing AV at risk for harm. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #1 (W1) had known behavioral problems with inappropriately touching others. On or about April 16, 2023, W1 approached the Alleged Victim (AV) from behind and grabbed his/her upper chest. The facility failed to have interventions in place to assure AV's safety. The facility failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #1 (W1) had known behavioral problems with inappropriately touching others and the Alleged Victim (AV). On or about June 23, 2023, AV approached W1 at his/her room and W1 grabbed AV's chest area. AV notified facility staff. The facility failed to assure AV's safety. The facility failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is care planned to have leg protectors on his/her legs to ensure safety and protect his/her legs. On or about January 2, 2023, AV was found to have a skin tear on his/her lower leg. AV's leg protectors were not in place to protect his/her legs from injury. 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 a known fall risk and has suffered approximately 14 falls in 45 days. The facility had interventions in place, however, they were not sufficient to keep AV from falling. On or about December 29, 2022, AV was found to have 3 large bruises on his/her torso. The facility's failure to properly care plan is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) was observed to have multiple bruises and scratches of unknown cause on multiple occasions. It is believed that AV suffered these injuries due to bumping into walls or windowsills. The facility failed to properly care plan to protect AV from skin injuries, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about October 4, 5, and 6, the Alleged Victim (AV) was found with a skin tear, bruising to arms and legs, and his/her hand on three separate occasions. Staff were retrained how to properly transfer AV, however, after the training, AV was still being found with bruising. AV is care planned to have geri sleeves on, however on two separate occasions, AV was seen without the geri sleeves. The facility failed to follow AV's care plan, placing him/her at risk for skin tears and bruising. The facility failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is a known fall risk and has suffered multiple falls leading to injury. On or about September 14, 2022, AV was found face down in a pool of blood, with an open injury to his/her forehead. AV was transferred to the hospital for treatment, The facility's failure to properly care plan is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is a known fall risk and suffered falls with injury at least 3 times during the month of August. On or about August 29, 2022, AV had an unwitnessed fall, suffering a bruise to his/her eye. The facility's failure to properly care plan regarding AV's falls is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about July 27, 2022, the Alleged Victim (AV) suffered a fall while he/she was trying to get things down from on top of his/her wardrobe. AV stood on a table and fell, suffering a skin tear to his/her leg. The facility failed to implement interventions to ensure AV's safety. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) was prescribed a mood behavior medication. On or about June 3, 2022, AV was to receive 1/2 tab of the medication prior to a dental appointment, with the ability to have the second half of the tab if the first half was not effective. AV received two entire tabs prior to his/her procedure, which was double the amount of medication he/she should have received. 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.

On or about May 26, 2022, the Alleged Victim (AV) suffered a scratch to his/her forehead by scratching him/herself. AV's fingernails had not been cut for 3-4 months, even though family had repeatedly requested the nails to be cut. The facility's failure to provide service for AV is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) was found with a bruise on his/her chest of unknown origin. The facility could not determine the cause of the bruise, although AV was a fall risk and has fallen from bed on more than one occasion. The facility failed to provide a safe environment, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to develop, maintain, and implement an Acuity Based Staffing Tool in accordance with OAR 411-054-0037(1-7), which is a violation of Oregon Administrative Rules.

The facility failed to develop, maintain, and implement an Acuity Based Staffing Tool in accordance with OAR 411-054-0037(1-7), which is a violation of Oregon Administrative Rules.

The facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident in accordance with OAR 411-054-0070(1), which is a violation of Oregon Administrative Rules.

The facility failed to develop, maintain, and implement an Acuity Based Staffing Tool in accordance with OAR 411-054-0037(1-7), which is a violation of Oregon Administrative Rules.

The facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident in accordance with OAR 411-054-0070(1), which is a violation of Oregon Administrative Rules.

The facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident in accordance with OAR 411-054-0070(1), which is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) is a known fall risk and is not to be left alone when toileting. On or about May 4, 2025, Alleged Perpetrator #2 (AP2) was assisting AV with toileting and left AV unattended to get gloves when another distraction occurred of another resident trying to leave the facility unattended. While AP2 was away from AV, AV tried to stand up, resulting in a fall, which is it believed that AV hit his/her head on the sink. AV was sent to the hospital for evaluation. AP2 left AV unattended and also did not put on the breaks to AV's walker, further placing AV at risk for harm. AP2's actions are a violation of resident rights, are considered neglect of care and constitute abuse.

The facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident in accordance with OAR 411-054-0070(1), which is a violation of Oregon Administrative Rules.

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

The facility failed to provide a call system that connects resident units to the care staff center or staff pagers per a complaint the facility's call system malfunctioned on 09/11/24, and no updates were provided to Department staff after requests for confirmation their system is fixed or a safety plan had been developed and implemented, which 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 have a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated, or discontinued medications administered by the facility per complaint there were numerous discrepancies found with the narcotics including missing medications and signed out medications for residents who were deceased.

The facility failed to ensure the staff person who administers the medication must visually observe the resident take the medication per complaint that a resident's medication was found on the floor, possible spit out, which is a violation of Oregon Administrative Rules.

Facility failure to ensure the staff person who administers the medication must visually observe the resident take the medication per complaint staff are not visually observing the residents take their medication, and loose medication has been found in resident rooms, which is a violation of Oregon Administrative Rules.

The facility failed to carry out medication orders as prescribed per complaint that a resident was administered medication that should have been withheld, which is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) is care planned for full care with all activities of daily living. AV is a known fall risk and has suffered falls in the past. On or about June 24, 2023, Alleged Perpetrator #2 (AP2) was assisting AV back to his/her room. At some point, AP2 left AV alone and AV suffered a fall, and was found by AP2 lying face down. AP2 was seen via camera surveillance being unresponsive to AV's requests for assistance and when AV asked for a blanket, AP2 was seen to toss the blanket to AV, and not cover him/her or show any compassion to AV while waiting for emergency services to arrive. AV was sent out to the hospital for evaluation and returned with a minor head trauma, a contusion to his/her shoulder and a urinary tract infection. AP2's actions are a violation of resident rights, are considered neglect of care and constitute abuse.

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 provide delegation to staff administering medication requiring delegation, which is a violation of Oregon Administrative Rules.

The facility failed to orient direct care staff to the resident, including the resident's service plan prior to providing personal care, which is a viiolation of Oregon Administrative Rules.

On or about September 1, 2022, the Oregon Health Authority reported to the Department that Respondent failed to comply with weekly reporting requirements of vaccinated individuals, residents and staff, to the proper authority as required by law. This failure has been ongoing from August 1, 2022 to August 31, 2022, for a total of 30 days.

On or about August 11, 2022, Alleged Perpetrator #2 (AP2) announced to staff that he/she had already changed and toileted the Alleged Victim (AV). AV's spouse alerted a caregiver that AV had dried feces on him/her, down his/her leg and on the floor. AV's skin had become red and irritated, causing AV unreasonable discomfort. AP2's actions are a violation of resident rights, are considered neglect of care and constitutes abuse. The facility failed to ensure AV's services were completed, which is a violation of Oregon Administrative Rules.

The facility and Alleged Perpetrator #2 (AP2) allegedly failed to protect the Alleged Victim (AV) from mental or emotional abuse. On approximately August 6, 2022, AP2 got frustrated while providing care for AV and was very curt with AV, causing AV emotional distress. AP2's actions are a violation of resident rights, are considered neglect of care and constitutes mental / emotional abuse. An investigation determined no facility abuse occurred.

On or about July 5, 2022, the Alleged Victim (AV) was experiencing behaviors, for which AV has medication for. AV is known to refuse medications. On this date, Alleged Perpetrator #2 (AP2) held AV's arms down to administer medication to AV. AV was flailing, turning his/her head and stating "no". AP2 placed medications in AV's mouth even though he/she was refusing. AP2's actions are a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to protect AV from Chemical restraint, which is a violation of Oregon Administrative Rules.

The facility failed to carry out medication and treatment as prescribed, which is a violation of Oregon Administrative Rules.