Wildflower Lodge

The Alleged Victim (AV) and Witness 1 (W1) rely on the facility for their care. W1 has a history of expressing h/h self sexually toward other residents of the facility. According to an investigation, on or about 6/27/2025, W1 was found in the AV's room with h/h hand up the AV's shirt. The facility failed to provide a safe environment which is a violation of resident rights, is neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility for his/her care. Witness 1 (W1) has a history of being sexually inappropriate with other residents. According to an investigation, on or about June 26, 2025, W1 kissed AV. The facility failed to provide a safe environment, which is a violation of resident rights, is neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility for his/her care. Witness 1 (W1) has a history of being sexually inappropriate with other residents. According to an investigation, on or about June 25, 2025, W1 attempted to kiss AV. The facility failed to provide a safe environment, which is a violation of resident rights, is neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility for their care. AV and W1 have a known history of wanting to be together. According to an investigation, on or about May 1, 2025, W1 kissed AV and put a hand up AV's shirt, placing AV at risk of harm. The facility failed to provide a safe environment to AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide a safe medication administration system to ensure the Alleged Victims (AV) medication orders were administered as prescribed. It was discovered that AV missed two doses of diabetes medication as the facility was out of the medication. 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 to ensure the Alleged Victim (AV)’s medications were administered as ordered. It was discovered that AV had not been administered h/h diabetes and cholesterol medication as the facility ran out of the medication. AV reports feeling “terrible” when s/he did not receive prescribed medication. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. AV is care planned to be checked every 2 hours for incontinence care. AV has been found on more than one occasion sitting in urine-soaked clothing, causing unreasonable discomfort. The facility failed to follow the care plan which is a violation of resident’s rights is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for a safe environment. AV has history of behavioral changes including aggressive behavior towards staff and other residents. AV had approximately three (3) physical and verbal resident-to-resident altercations approximately in the month of August 2022. On or about August 23, 2022, AV was outside h/h room unprovoked and engaged in physical and verbal altercations (grabbed, hit, punched, kicked, and threaten to kill) other residents, staff and LEA. Resulting in AV receiving medication administered EMS and restrained by LEA and transported to the hospital. The facility failed to provide a safe environment and failed to adjust, and implement reasonable interventions to address AV’s continued aggressive behavior, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for a safe environment. Witness 1 (W1) has history of behavioral changes including aggressive behavior towards staff and other residents. W1 and AV have history of physical and verbal resident-to-resident altercations including three from August 15, 2022, to August 23, 2022. The facility failed to adjust the service plan for W1 leading to continued aggressive behavior. On or about August 23, 2022, W1 pushed AV down unprovoked resulting in scratches and scrapes to the side of AVs forehead and left jaw. 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 history of aggressive and assaultive behavior towards staff, and other residents. W1 and Alleged Victim (AV) have had prior resident to resident altercations with each other. On or about August 19, 2022, AV was standing in hallway next to W1 room. W1 pushed AV to the ground. The facility failed to properly plan care and provided interventions appropriate to mitigate ongoing resident to resident altercations between W1 and AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide a safe medication administration system to ensure the Alleged Victims (AV) medication orders were administered as prescribed. On multiple occasions, it was discovered that AV did not receive h/h medication as scheduled, causing unreasonable discomfort. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) has history of aggressive and assaultive behavior towards staff, and other residents. On or about August 15, 2022, staff found Witness #1 (W1) laying on the ground and AV walking towards h/h room. W1 had bruising and a scratch on h/h wrist and was transported to the ER. Interventions in place were not effective as AV was still experiencing behaviors that resulted in altercations. The facility failed to properly plan care and provided interventions appropriate to mitigate AV aggressive behaviors towards other residents which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for a safe environment. Witness 1 (W1) has history of behaviors including verbal and physical aggressiveness towards other residents. W1 and AV have history of physical and verbal resident-to-resident altercations. The facility failed to adjust the service plan for W1 leading to continued aggressive behaviors. On or about July 26, 2022, W1 and AV were seen pushing and shoving each other. W1 was seen striking AV in the face with a closed fist resulting in scratches to AVs face. 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 agitation/aggression towards other residents and members of the care team. Alleged Victim (AV) has history of wandering around the facility and into other residents’ rooms. On or about July 14, 2022, AV wandered into W1 room where an altercation occurred and W1 hit AV in the eye causing swelling and bruising. The facility failed to properly plan care and provided interventions appropriate to mitigate AV wandering and W1 aggressive behaviors towards other residents which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide a safe medication administration system to ensure the Alleged Victims (AV) medication orders were administered as prescribed. It was discovered that AV did not receive the medication as scheduled, causing loss of dignity and exposure to potential harm. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #1 (W1) and Alleged Victim (AV) have history of Resident-to-Resident altercations and agitation/aggression towards other residents. On or about July 08, 2022, W1 became agitated and pushed AV to the ground causing injury. The facility failed to properly plan care and provided interventions appropriate to mitigate W1 aggressive behaviors towards other residents which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide a safe medication administration system to ensure the Alleged Victims (AV) medication orders were administered as prescribed. On or about June 26, 2022, and June 27, 2022, AV missed prescribed medication, and was involved in a Resident-to-Resident altercation on or about June 27, 2022, causing risk of serious harm. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #1 (W1) has history of agitation/aggression and Resident-to-Resident altercations. On or about July 08, 2022, W1 became agitated and pushed AV to the ground, stomped and kicked AV causing unreasonable discomfort and risk of serious harm. The facility failed to properly plan care and provided interventions appropriate to mitigate W1 aggressive behaviors towards other residents which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #1 (W1) has a history of agitation and aggression towards other residents. On or about June 26, 2022, W1 had aggressive behavior towards Alleged Victim (AV), which lead to a resident-to-resident altercation. W1 grabbed AV by the wrist causing bruising. The facility failed to appropriately care plan and implement reasonable interventions to address W1’s increasing and ongoing behaviors, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide assistance with toileting and hygiene to the Alleged Victim (AV), resulting in AV being soiled through his /her clothing, experiencing unreasonable discomfort. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide oversight and monitoring of Alleged Victims (AV) change of condition. The failure resulted in AV not receiving timely medical attention which resulted in increased behaviors and unreasonable discomfort. Based on interviews and facility documentation AVs PCP ordered a Lab urinalysis on March 02, 2022. The order was not followed up on until AV was sent to the Emergency room for unrelated incident on or about May 06, 2022. AV was diagnosed with a UTI and experienced unreasonable discomfort. The facility failure is a violation or resident rights, is considered neglect of care and constitutes abuse.

Alleged Perpetrator #2 (AP2) failed to provide a safe medication administration system for Alleged Victim (AV) by discontinuing a medication without a doctor’s order. AV did not receive the ordered medication for approximately one (1) month. AP2’s actions are a violation of resident rights, are considered neglect of care and constitutes abuse. Approximately in March 2022 and April 2022 AV had a total of twenty (20) different missed medications. The facility failed to provide a safe medication administration system, which 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 medications. AV was not administered approximately six (6) medications, including twelve (12) doses of a benzodiazepine and two (2) does of an antipsychotic. AV presented with hallucinations and difficulty communicating. The facility failed to provide a safe medication administration system to ensure AV medications where available and in stock, which is a violation of resident rights, is considered neglect of care and constitutes abuse

Witness #1 (W1) has a history of verbal/physical disruptive, aggressive, and inappropriate behaviors. On or about, April 10, 2022, Alleged Victim (AV) was visiting with another resident when W1 smacked AV in the face with a bowl. The facility failed to properly plan care, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) service plan dated 12/07/2021 indicates Minimal assist and verbal prompts/cues for toileting tasks. AV had a change in toileting needs and refusal behaviors. The facility failed to appropriately reassess and care plan according to AVs needs, which is a violation of resident’s rights is neglect of care and constitutes abuse.

Alleged Victim (AV) service plan indicates 2 persons for transferring, one on each side of h/h using a gait belt. Facility is using a Hoyer lift sling to transfer AV, resulting in bruising on right side of perineal area. The facility failed to properly plan care for use of Hoyer lift, and failed to train staff using Hoyer Lift, 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. The facility failed to provide oversight and monitoring of AV change of condition. The failure resulted in AV not receiving interventions being put into place which resulted in dehydration, pressure wounds and AV being sent to the hospital. The facility failure is a violation or resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) is care planned for medication assistance. AV has history of medications being found in AVs room. On or about March 11, 2022, AVs family members found medication in AV room when moving AV out. The facility failed to provide a safe medication administration system which is a violation of resident rights, is considered neglect of care and constitutes abuse.

AV is care planned to ensure AV is using h/h walker or wheelchair. On or about January 03, 2022, AV was involved in resident-to-resident conflict and was pushed to the floor resulting in AV hitting head on floor. AV was not using h/h walker or wheelchair at time of altercation. The facility failed to follow the care plan which is a violation of resident’s rights is neglect of care and constitutes abuse.

Alleged Victim (AV) is care planned to have assistance putting compression socks on every day. On several occasions AV did not have h/h compression socks as specified in h/h care plan resulting in AV legs swelling and appearing more purple in color. The facility failed to follow the care plan which is a violation of resident’s rights is neglect of care and constitutes abuse.

Witness 1 (W1) has a known history of disruptive, aggressive, or socially inappropriate behavior. On or about December 9, 2021, Alleged Victim (AV) was going to breakfast and got turned around and ended up outside of W1’s room. W1 got agitated when his/she opened the door to find AV outside of the room. W1 then hit AV with a picture frame causing a scratch to AV’s arm. 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 nerve/pain medication three times daily. Between September 1st through November 30th, 2021, AV did not receive his/he medication for a total of nine (9) days and the facility listed the reasoning as, “medication is noted as not available, not in facility and/or reordered”. AV went without medication for three (3) to four (4) days starting on November 26, 2021, and states he/she was miserable and could not sleep due to restless legs. 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) and Witness 1 (W1) have a known history of resident-to-resident altercation. On or about November 20, 2021, AV and W1 were in a resident-to-resident altercation resulting in AV receiving a small skin tear on his/her left hand. The facility failed to provide a safe environment, which is a violation of resident rights, is neglect of care and constitutes abuse.

The facility failed to reorder Alleged Victim (AV) medication and AV was not administered h/h medication for approximately several weeks. Documentation shows AV having signs of confusion and placed AV at risk of harm. The facility failed to provide a safe medication administration system, which is violation of resident’s rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. On or about November 4, 2021, AV had been observed yelling in the hallway. Witness 1 (W1) was observed walking the hallway, staff heard yelling and when they approached, W1 was holding AV’s arm and was hitting AV’s other arm. AV sustained a three-inch scratch on his/her arm. 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) has a known history of falls. On or about October 15, 2021, staff heard yelling coming from the dining room. AV was found on the floor on their back. AV was transported to the hospital and had staples to close up a wound to his/her 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.

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

The facility failed to provide direct care staff sufficient in number to meet the scheduled and unscheduled needs of the residents. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to fully implement and update an Acuity Based Staffing Tool (ABST). An investigation determined this is a violation of Oregon Administrative Rules.

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

The facility the facility failed to establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment including protocols to prevent the development and transmission of communicable diseases. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to update care plan quarterly. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed adopt and implement an acuity-based staffing tool (ABST) to determine appropriate staffing levels for the facility. An investigation determined this 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.

Based on observation and interview it was confirmed that the facility failed to keep all equipment in good repair. Findings include but not limited to: During an unannounced site visit on 09/08/2022 Compliance Specialist (CS) observed the facility scale in an activity room, dismantled and tucked into a corner. Staff #1 and Staff #2 were unable to make the scale work at that time and were in agreement that scale was not working.

Based on observation and interview it was confirmed that the facility failed to keep all equipment in good repair. Findings include but not limited to: During an unannounced site visit on 09/08/2022 Compliance Specialist (CS) observed the facility scale in an activity room, dismantled and tucked into a corner. Staff #1 and Staff #2 were unable to make the scale work at that time and were in agreement that scale was not working.

Based on record review and interview it was confirmed that the facility failed to ensure the implementation of services. Findings include but not limited to: A review of Resident #1 (R1)'s service plan dated 08/12/2022 revealed that R1 is to be weighed every Monday. Compliance Specialist requested documentation of weights from Staff #1-Staff #3 (S1-S3) who were unable to produce these records. During interview, S1-S3 indicated that the weights had not been entered.

Based on observation, interview, and record review it was confirmed that the facility failed to assist the resident in performing all activities of daily living, on a 24-hour basis with toileting assistance. Findings include but not limited to: During an unannounced site visit on 09/08/2022 Compliance Specialist (CS) heard Resident #4 (R4) screaming from behind a closed door in their room. CS was unable to locate a staff member for some time. CS checked on resident to verify safety and resident was yelling and requesting a brief change stating that they were messy and wanted to get up. CS found Staff #5 (S5) and requested assistance for resident. During separate interviews, Staff #4 (S4) and S5 stated that staff are very busy and do not have time to help with hygiene, showers, or toileting as much as residents need. Neither could say if R4 had assistance with brushing their teeth. A review of R4's service plan dated 08/12/2022 revealed resident requires assistance with hygiene/grooming. A review of Resident #1 (R1's) shower sheets revealed that resident did not receive a shower between 08/11/2022 and 08/22/2022. A review of the facility's Acuity-Based Staffing Tool (ABST) revealed that the facility has 55 hours of care needed during the day. A review of the staff schedule for September 2022 revealed that the facility only scheduled two caregivers and 1 Med Aid for a total of 24 hours of care on day shift.

Based on observation and interview it was confirmed that the facility failed to exercise reasonable precautions against any condition that may threaten the health, safety, or welfare of the residents. During an unannounced site visit on 09/08/2022, Compliance Specialist (CS) observed multiple staff members not wearing masks appropriately as they were down around staff's chins and not covering nose and mouth.

Based on observation and interview it was confirmed that the facility failed to keep all interior materials and surfaces clean. Findings include but not limited to: During an unannounced site visit on 09/08/2022, Compliance Specialist (CS) toured facility and noticed a black film on the shower floor as well as a wet and crumbly spill at the base of a recliner in Resident #3 (R3)'s room.

Based on observation, interview and record review it was confirmed that the facility failed to assist the resident in performing all activities of daily living, on a 24-hour basis with toileting assistance, brushing teeth and showering. Findings include but not limited to: During an unannounced site visit on 09/08/2022 Compliance Specialist (CS) heard Resident #4 (R4) screaming from behind a closed door in their room. CS was unable to locate a staff member for some time. CS checked on resident to verify safety and resident was yelling and requesting a brief change stating that they were messy and wanted to get up. CS found Staff #5 (S5) and requested assistance for resident. During separate interviews, Staff #4 (S4) and S5 stated that staff are very busy and do not have time to help with hygiene, showers, or toileting as much as residents need. Neither could say if R4 had assistance with brushing their teeth. A review of R4's service plan dated 08/12/2022 revealed resident required physical assistance with grooming/personal hygiene. A review of Resident #1 (R1's) shower sheets revealed that resident did not receive a shower between 08/11/2022 and 08/22/2022. A review of the facility's Acuity-Based Staffing Tool (ABST) revealed that the facility has 55 hours of care needed during the day. A review of the staff schedule for September 2022 revealed that the facility only scheduled two caregivers and 1 Med Aid for a total of 24 hours of care on day shift.

Based on observation, interview, and record review it was confirmed that the facility failed to provide direct care staff sufficient in number to meet the scheduled and unscheduled needs of the residents. Findings include but not limited to: During an unannounced site visit on 09/08/2022 Compliance Specialist (CS) heard Resident #4 (R4) screaming from behind a closed door in their room. CS was unable to locate a staff member for some time. CS checked on resident to verify safety and resident was yelling and requesting a brief change stating that they were messy and wanted to get up. CS found Staff #5 (S5) and requested assistance for resident. During separate interviews, Staff #4 (S4) and S5 stated that staff are very busy and frequently do not have time to help with hygiene, showers, or toileting as much as residents need. A review of the facility's Acuity-Based Staffing Tool (ABST) revealed that the facility has 55 hours of care needed during the day. A review of the staff schedule for September 2022 revealed that the facility only scheduled two caregivers and 1 Med Aid for a total of 24 hours of care on day shift. A review of Resident #1 (R1's) shower sheets revealed that resident did not receive a shower between 08/11/2022 and 08/22/2022.

Based on observation, interview, and record review it was confirmed that the facility failed to assist the resident in performing all activities of daily living, on a 24-hour basis with toileting assistance. Findings include but not limited to: During an unannounced site visit on 09/08/2022 Compliance Specialist (CS) heard Resident #4 (R4) screaming from behind a closed door in their room. CS was unable to locate a staff member for some time. CS checked on resident to verify safety and resident was yelling and requesting a brief change stating that they were messy and wanted to get up. CS found Staff #5 (S5) and requested assistance for resident. During separate interviews, Staff #4 (S4) and S5 stated that staff are very busy and do not have time to help with hygiene, showers, or toileting as much as residents need. A review of the facility's Acuity-Based Staffing Tool (ABST) revealed that the facility has 55 hours of care needed during the day. A review of the staff schedule for September 2022 revealed that the facility only scheduled two caregivers and 1 Med Aid for a total of 24 hours of care on day shift.