Willamette Springs Memory Care

Alleged Victim (AV) lived in the Respondent’s facility and depended on facility staff to ensure AV’s basic care and safety. AV’s service plan indicated that AV required facility staff assistance to order, store, and safely administer prescribed medications. On or about October 12, 2025, AV did not receive prescribed cardiac health medication #1 or prescribed cardiac health medication #2, as both were documented as not available for administration. The Respondent failed to maintain a safe medication and treatment administration system and failed to administer medications as prescribed. This constitutes abuse by neglect as defined in OAR 411-020-0002(1)(b)(A)(ii).

Alleged Victim (AV) resides at the Respondent’s facility and relies on facility staff to provide the necessary services to maintain AV’s health and safety. AV has a known history of wandering into other residents’ rooms, including documented incidents in September 2025 and October 2025. AV’s service plan has interventions and requires staff to conduct checks on AV no fewer than six times per shift, to redirect AV if observed entering other residents’ rooms, and to ensure resident doors remain locked. Facility staff failed to ensure resident doors were locked and did not complete required safety checks on AV. On or about October 11, 2025, AV entered W1’s room. W1 struck AV in the face with a shoe and told AV to leave. As a result, AV sustained red markings and two scratches on the face. AV was last observed at approximately 5:00 p.m. in the main hub before the incident, which occurred around 6:30 p.m., and W1’s door was not locked. Respondent failed to follow interventions. This constitutes abuse by neglect.

Alleged Victim (AV) and Witness 1 (W1) live at Respondent’s facility and relies on the facility staff to provide safety. W1 has a history of anxiety, agitation resident-to-resident, and staff altercations. AV and W1 have a romantic relationship, however, AV has expressed no longer feeling safe around W1. W1's interim service plan reflects W1 was put on a 1:1 for aggressive behavior. However, facility staff failed to follow W1 interim service plan for 1:1 placing AV at risk of serious harm. On or about October 10, 2025, Witness 3 (W3) came on shift and the 1:1 was nowhere to be found. AV's door was cracked open and W1 was in AV's room. Respondent failed to follow W1 service plan and interventions. This constitutes abuse by neglect.

Alleged Victim (AV) resides in the Respondent’s memory care facility and is dependent on facility staff for all care needs and safety. AV has cognitive decline and is oriented only to self. Facility staff failed to provide adequate supervision and a secured environment for residents, including AV, while conducting activities. On or about October 9, 2025, AV was participating in an arts and crafts activity when AV obtained a pair of scissors and cut AV’s left index finger. Respondent failed to maintain a safe environment and adequate oversight. This constitutes abuse by neglect.

Alleged Victim (AV) lives at Respondent’s facility and relies on facility staff for all care needs. AV uses a wheelchair for mobility, and is a two person assist with transfers. AV has a history of falls, including incidents in August 2025, and September 2025. The facility failed to develop sufficient interventions to mitigate risk to AV. On or about October 5, 2025, facility staff found AV on the floor in AV's apartment, AV had fallen and scooted towards the air conditioner. Respondent failed to develop and implement suitable interventions. This constitutes abuse by neglect.

Alleged Victim (AV) resides in the Respondent’s facility and depends on facility staff to meet AV’s daily care needs. AV is frequently disoriented and demonstrates poor recent memory. AV and Witness 1 (W1) have a known history of a relationship as well as repeated verbal and physical altercations, including ten documented incidents between June 2025 and September 2025. As of September 15, 2025, AV’s interim service plan directs facility staff to encourage AV and W1 to spend time apart and requires staff oversight whenever they are together. On September 20, 2025, W1’s interim service plan instructs facility staff to remind W1 that AV has ended their relationship, to check on W1 no less than four times per shift, to encourage W1 to socialize with other individuals, and to ensure W1 does not possess items in W1’s apartment that could be used for self-harm. On or about September 24, 2025, AV and W1 were in AV’s room with facility staff member (W4) present. During this time, W1 alleged that another staff member intended to rape AV and threatened to physically harm facility staff. W1 then produced a homemade weapon fashioned from a fork and made additional threats toward staff. W4 exited the room, after which W1 barricaded W1 and AV inside AV’s room and locked the door. Law enforcement was contacted to assist in de-escalating the situation. AV required PRN medication for anxiety following the incident. Respondent failed to ensure a safe environment for AV, which constitutes abuse by neglect.

Alleged Victim (AV) resides in the Respondent’s facility and relies on facility staff to meet AV’s daily care needs. AV’s service plan specifies that facility staff are responsible for administering AV’s medications in accordance with the prescribing physician’s orders. AV is prescribed a medication patch, with the physician’s order directing that AV is to receive a new patch daily. Facility staff failed to re-order AV’s medication in a timely manner, resulting in AV missing scheduled doses from September 5, 2025, through September 7, 2025. The Respondent’s failure to ensure the availability of required medication constitutes neglect of care and meets the definition of abuse.

Alleged Victim (AV) lives at Respondent’s facility. AV's service plan reflects facility will store, administer all medications per PCP orders. Facility staff are to order medications 7 days prior to medication running out. On or about September 14, 2025, AV did not receive h/h scheduled behavioral health medication because the facility did not have it available. AV went without h/h behavioral health medication from September 14, 2025, through September 19, 2025. Missing six consecutive doses was likely to cause AV behavioral changes and instability. Respondent failed to provide a safe medication administration system to ensure AV received medication as ordered, which constitutes abuse by neglect.

Alleged Victim (AV) lived at Respondent’s facility from June 18, 2025, through September 11, 2025, and relied on facility staff to provide cares and services necessary to ensure the safety of AV. AV's service plan reflected that AV had history of skin breakdown including being at risk for pressure ulcers. The facility staff failed to follow the service plan which led to AV not receiving regular skin checks, hygiene care, and repositioning. On or about September 11, 2025, witness #3 (W3) removed AV's socks after seeing serous fluid saturated on the bed sheet through AV's socks. W3 found open pressure wounds on AV's right heel and left heel. Facility called EMS and AV was transferred to the emergency room department and admitted to the hospital. Respondent failed to provide adequate oversight and supervision of facility staff and Respondent staff failed to follow AV's service plan. This constitutes abuse by neglect as defined by OAR 411-020-0002(1)(b)(A)(i).

Alleged Victim (AV) lived at Respondent’s facility from June 18, 2025, through September 11, 2025, and relied on facility staff to provide cares and services necessary to ensure the safety of AV. AV's service plan reflected that AV had history of skin breakdown including being at risk for pressure ulcers. The facility staff failed to follow the service plan which led to AV not receiving regular skin checks, hygiene care, repositioning and placement of cushions. On or about August 5, 2025, AV received a waffle cushion to use while in AV"s recliner. On August 21, 2025, AV had a waffle cushion and gel pad for facility staff to place under AV while AV was sitting in the recliner, however, witness 5 (W5) did not see the waffle cushion under AV. On August 25, 2025, new wounds to AV's left buttock were found, and by September 11, 2025, when AV was transferred to the hospital the wounds to AV's buttock developed into a pressure ulcer. Respondent failed to provide adequate oversight and supervision of facility staff and Respondent staff failed to follow AV's service plan. This constitutes abuse by neglect as defined by OAR 411-020-0002(1)(b)(A)(i).

Alleged Victim (AV) and Witness 1 (W1) live and at Respondent’s facility and rely on facility staff to provide care and supervision. W1 has a history of resident-to-resident altercations with other residents at Respondent's facility, including incidents that occurred in June and August 2025. On or about August 26, 2025, W1 wandered the halls and approached AV, a brief verbal exchange occurred, W1 swung, attempted to kick AV, and grab AV's throat. Respondent failed to develop and implement suitable interventions which constitutes abuse by neglect.

Alleged Victim (AV) and Witness 1 (W1) live at the Respondent’s facility and depend on facility staff to ensure that basic care, safety, and supervision requirements are met. AV and W1 have a known history of resident-to-resident altercations involving other residents in the facility and have established interventions in place to reduce risk to themselves and others. On or about August 26, 2025, AV and W1 were involved in a resident-to-resident altercation in the dining room. AV became agitated while seated at a dining table and began hitting the table loudly. W1, was seated at the same table with ice cream, became agitated by AV’s behavior, threw the ice cream at AV, and a physical altercation between AV and W1 ensued. The Respondent failed to follow the service plan, implement the interventions, and provide adequate supervision for AV and W1. This constitutes abuse by neglect as defined in OAR 411-020-0002(1)(A)(i).

Alleged Victim (AV) and Witness 1 (W1) are residents of a memory Care unit and require support from facility staff to meet their personal care, safety, and supervision needs. AV's service plan dated on or about June 6, 2025, indicates AV is oriented to self, is known to get into other resident's space and does not have awareness of boundaries, staff are to redirect or provide activities. W1 service plan dated on or about July 17, 2025, indicates W1 is oriented to person and place, becomes confused at times and needs cues/reminders. W1 has interventions in place resulting from an interaction on or about June 30,2025, related to W1 touching/groping resident of opposite gender. Interventions include redirect W1 from opposite gender residents, use structed, meaningful activities, if upset, offer walk or snack. W1 is noted to stalk other residents and requires redirection. W1 has history of masturbating in hallways and public spaces, interventions include staff to remind W1 that sexual behavior must occur privately in h/h room. On or about August 13, 2025, AV was walking down the hallway, W1 was standing outside W1 room, W1 and AV had a brief conversation then entered W1 room at approximately 3:37pm. Staff entered W1 room at approximately 4:40pm and found W1 with hands down h/h pants masturbating, in front of AV. AV was escorted out of W1's room. The facility failed to put effective interventions in place to address W1 know sexual behaviors resulting in loss of personal dignity to AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) lives at Respondent’s facility. AV service plan reflects AV relies on facility staff to order, store, and safely administer all medications. AV is at risk of strokes if AV's blood pressure medication in missed. AV went without AV's blood pressure medication from August 12, 2025, to August 15, 2025. Respondent staff failed to follow AV service plan, and ensure AV's medications were properly ordered and available for AV. This constitutes abuse by neglect as defined by OAR 411-020-0002(1)(b)(A)(i).

Alleged Victim (AV) and Witness 1 (W1) are residents of AP1 and rely on AP1 staff to ensure basic care, safety, and supervision requirements are met. W1 has a history of resident-on-resident altercations. There is no history of resident-to-resident altercations between W1 and AV. It is known that W1 can become agitated easily, and It is not uncommon for W1 to hit people with W1's walker. Interventions outlined in W1's service plan include; AP1 staff are to provide frequent checks on W1 to know W1’s location, following meals AP1 staff should offer to escort W1 to W1’s room, or another common area where W1 is comfortable to rest. On or about August 9, 2025, W1 was sitting in the dining room when W1 saw AV get up and walk out of the dining room to AV’s apartment . W1 followed AV down the hallway, screaming “I’m going to get you!” W1 got in AV’s face continuing to scream at AV and AV turned to try to get away, W1 lifted up the front legs of W1’s walker and slammed it against AV’s legs. The facility failure to provide adequate supervision, escort W1 to W1 room after meals and provide a safe environment for AV, resulted in a resident-on resident altercation, placing AV at risk of harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV), Witness 1 (W1), and Witness 2 (W2) reside at the Respondent’s facility and rely on facility staff to meet their basic care, safety, and supervision needs. AV is known to wander the halls frequently during the day and to enter apartments when doors are open. W1 has a documented history of resident-to-resident altercations, including six incidents between July 2025 and August 2025. W2 is known to yell, which is a known trigger for agitation in W1. W1 and W2’s rooms are located across the hall from one another, and both are situated around the corner from AV’s room. On or about August 8, 2025, W1 and W2 engaged in a verbal altercation in the hallway. AV entered W1’s room. W1 returned to h/h room and blocked the doorway with h/h wheelchair, preventing AV from exiting. A physical altercation occurred, during which W1 physically removed AV from the room. AV sustained a bleeding scratch on the right cheek and red marks on the throat. Respondent failed to develop and implement appropriate interventions to address known risks. This constitutes abuse by neglect.

Alleged Victim (AV) and Witness 1 (W1) live at Respondent’s facility rely on the facility staff to ensure AV's and W1's basic care, safety and supervision requirements are met. W1 has a history of sexually touching AV and seeking AV out, including incidents that occurred in July 2025. W1's service plan reflects that W1 has history of touching and groping residents of the opposite gender, and if seen hugging or touching them, staff should redirect W1. On or about August 6, 2025, W1 was seen standing in front of AV masturbating, and on August 7, 2025, facility staff witnessed W1 in the courtyard across from AV while W1 masturbated and stared at AV. The Respondent failed to develop and implement suitable person-centered interventions which constitutes abuse by neglect.

Alleged Victim (AV) and Witness 1 (W1) are residents of the facility and rely on staff to meet all care needs. W1 has history of resident-to-resident altercations. On or about July 20, 2025, W1 and AV were involved in a resident-to-resident altercation where W1 smacked AV in the face. AV complained of mild pain to the right side of AV's face and had a slight red mark. The facility failed to provide a safe environment for AV and failed to implement person centered interventions for W1, which is a violation of resident rights, is considered neglect of care and constitutes abuse. which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) and Witness 1 (W1) are residents of the facility and rely on staff to meet all care needs. AV and W1 have a history of altercations on or about June 27, 2025, and July 08, 2025, resulting in injury to AV. An intervention was put in place on June 27, 2025, if staff observe AV and W1 in the same area staff are to redirect AV and W1 to another location and offer a snack. An intervention was put in place on July14, 2025 stating each shift during waking hours staff will provide one-on-one care for AV and W1. On July 16, 2025, AV and W1 had an altercation in the dining room. W1 patted AV on the side to get AV to notice W1, AV hit W1 in the back, causing W1 to turn around and hit AV in the face. The facility failed to follow the care plan for one-on-one intervention and provide clear written description to staff on who shall provide the services and what, when, how, and how often the services shall be provided. The failure is a violation of resident’s rights is neglect of care and constitutes abuse.

AV is dependent on the facility to ensure a safe environment, and provide services necessary for AV's health and safety. AV has a documented history of falls and balance-related issues. According to AV’s care plan, the following fall prevention interventions are in place: Staff are to ensure that AV’s environment is free of clutter; AV is to use a 4-wheel walker for all ambulation; If AV is observed ambulating without the walker, staff are to immediately cue AV to sit and retrieve the walker before AV continues ambulating. On or about July 14, 2025, AV was walking through the front entrance of the hub without wearing shoes and without the use of h/h 4-wheel walker. At the time, another resident had experienced an accident resulting in a puddle on the floor. Staff were attending to that resident and had not yet cleaned the puddle off the floor, AV slipped in the puddle, fell, and struck the back of their head on the floor. A bruise was later observed on the upper right posterior area of AV’s head. The facility did not maintain a safe environment by failing to promptly clean up the puddle, and facility staff did not ensure that AV was using the required assistive device, as outlined in AV’s care plan, which is a violation of resident’s rights is neglect of care and constitutes abuse.

Alleged Victim (AV) and Witness 1 (W1) are residents of a secured memory care facility. Both individuals rely on Alleged Perpetrator 1 (AP1) for their safety and to meet their care needs. AV and W1 have a documented history of a prior resident-to-resident altercation that occurred on or about June 27, 2025, during which AV sustained bruising and increased redness to the left side of the face and nose. Following that incident, specific interventions were implemented to prevent further altercations. These included staff being instructed to redirect AV and W1 away from each other if observed in the same common area and to offer a snack as a distraction. Despite these interventions, on or about July 8, 2025, AV was seated in a common area when W1 approached and began ramming AV with W1’s walker. As both residents fell to the floor, W1 struck AV in the face, causing a laceration above the eyebrow and bruising to the cheek. AV was transported to the emergency room, where the laceration required medical closure. AP1 was aware of the prior altercation between AV and W1, and the interventions outlined in the service plan. However, AP1 failed to implement these safety measures, resulting in a preventable resident-to-resident altercation between W1 and AV. AV sustained injuries requiring medical treatment. AP1 failure to follow the established care plan is a violation of resident rights is neglect of care and constitutes abuse.

Alleged Victim (AV) resides in the Respondent’s facility and depends on facility staff to meet AV’s daily care needs. AV has a documented food allergen. Despite this, AV has been served and has consumed this allergen during meal service on multiple occasions, including a prior incident that resulted in hives. AV’s service plan identifies the food allergen, and the kitchen maintains a whiteboard and reference book containing resident allergen and diet information. On or about June 27, 2025, during meal service, AV was served and consumed a food item to which AV is allergic, resulting in unreasonable discomfort and risk of harm. Respondent failed to follow AV’s service plan and did not take necessary precautions to prevent serving food containing the known allergen. This constitutes abuse by neglect.

The Alleged Victim (AV) was admitted into a locked memory care facility on or about March 25, 2025, and was dependent on staff (AP1) to meet safety, supervision and AV’s daily care needs. Upon admission, AV’s service plan documented that AV was independent with eating. However, during investigation and interviews staff reported that AV required assistance during meals, indicating a discrepancy between the care plan and AV’s actual needs. AV experienced significant and progressive weight loss. Despite this, there is no documentation that the facility notified AV’s primary care provider (PCP) of the weight loss, nor are there any progress notes indicating that staff monitored the weight loss or implemented interventions to address it. The facility failed to recognize and respond appropriately to AV’s significant weight loss. No individualized or person-centered interventions were documented or implemented, which is a violation of resident’s rights is neglect of care and constitutes abuse.

Alleged Victim (AV) lives at Respondent’s facility and relies on facility staff to provide care and services necessary to ensure the safety of AV. AV has a history of falls, including a fall on April 29, 2025, while getting out of the shower which resulted in an abrasion to AV's right elbow. In additional AV fell in Witness #1 (W1) bathroom on May 21, 2025, AV was not conscious when found and seen at the Emergency Room. AV's progress notes reflect AV is unsteady while standing and needing stand by assistance with toileting. However, the facility failed to develop sufficient interventions to mitigate risk to AV. On or about May 25, 2025, AV and W1 were found by facility staff after AV and W1 had finished showering together. Respondent failed to develop and implement suitable interventions. This constitutes abuse by neglect as defined by OAR 411-020-0002(1)(b)(A)(ii).

Alleged Victim (AV) lives at Respondent’s facility and relies on facility staff to provide care and services necessary to ensure the safety of AV. AV has a history of falls, including a fall on April 29, 2025, while getting out of the shower which resulted in an abrasion to AV's right elbow. In additional AV fell in Witness #1 (W1) bathroom on May 21, 2025, AV was not conscious when found and seen at the Emergency Room. AV had two additional non-injury falls on April 28, 2025, and May 4, 2025. AV's progress notes reflect AV is unsteady while standing and needing stand by assistance with toileting. However, the facility failed to develop sufficient interventions to mitigate risk to AV. On or about June 11, 2025, AV fell in AV's room hitting AV's head. AV reports being very painful in AV's neck, left shoulder, and back. AV also has redness on AV's knees and complains of pain in AV's knees. Respondent failed to develop and implement suitable interventions. This constitutes abuse by neglect as defined by OAR 411-020-0002(1)(b)(A)(i).

Alleged Victim (AV) and Witness 1 (W1) both rely on facility staff for their health and safety. W1 has a diagnosis of dementia and exhibited agitation and combative behavior prior to admission. On or about April 27, 2025, staff noted W1 wandered frequently, entered other residents’ rooms, and interacted briefly before leaving. Staff were instructed to monitor W1. On or about May 2, 2025, a series of events took place with W1. W1 was involved in an altercation after entering another resident’s room and taking a hairbrush, resulting in W1 being struck with the hairbrush. Later that day, W1 became agitated during care. Staff stepped out to allow W1 to calm down and administered a PRN. W1’s care plan included redirection strategies such as discussing W1’s pet, calling W1’s spouse, or offering music or TV. Shortly after, Witness 6 (W6) heard a scream and found W1 in AV’s room. W1 was holding AV’s arm and then threw AV into a bedside table. AV sustained a bump on h/h head, shoulder pain, and reported fear of W1 hurting AV again. W1 has a pattern of aggressive behavior. The facility failed to implement effective, person-centered interventions, resulting in AV’s physical and emotional harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) relies on AP1 to ensure their personal care, safety, and needs are met. AV service plan indicates AV relies on AP1 for all medication management. AP1 staff are to issue a reorder of medications. AV did not receive the scheduled neurological medication due to the facility not having the medication on site from April 19, 2025. to April 25, 2025, for a total of four missed doses. At the time of the incident, there was no established policy or procedure in place to address missed medication administrations. Additionally, no investigation was conducted to determine whether the missed doses resulted in actual harm or posed a risk of harm to AV. Respondent failed to provide a safe medication system, and failed to administer AV's medications as prescribed. This constitutes abuse by neglect as defined by OAR's.

The Alleged Victim (AV) lives in a secured memory care facility and depends on staff (AP1) to help with daily care, safety, and supervision. AV has a history of falling and is at high risk due to cognitive impairment, poor balance, weakness, not using a walker, and taking medications that affect stability. AV also doesn’t use the call light for help and has a condition that increases the risk of falling. On April 10, 2025, AV was found on the floor with a bleeding head wound. It was unclear how long AV had been on the floor prior to being discovered. AV sustained a head injury and required transport to the hospital for medical evaluation and treatment. The facility failed to adequately care plan for AV’s known fall risks and did not implement reasonable, person-centered interventions to mitigate future falls, which is violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) and Witness 1 (W1) rely on facility staff to provide the necessary services for their health and safety. AV and W1 have history of resident-to-resident altercations. AV has history of wandering the facility and does not like it when other residents try to stop AV from doing a task that AV things need to be completed. Interventions include finding AV a task to stay busy, redirect AV to courtyard, and if AV is wandering the hallways holding an object, staff are to offer AV an activity in activity area. W1 dislikes other people wandering into W1's room or getting into W1's personal space in the dining room. interventions for W1 include, If staff see W1 leave W1's door open staff are to close it to help prevent other residents from looking in or wandering in which upsets W1. On or about April 6, 2025, AV walked into W1's room. AV and W1 started yelling at each other with W1 yelling at AV to get out of W1's room. AV did not leave W1's room and W1 got upset when AV continued to approach W1 and tried to pick up W1's shoes. AV pushed W1 and W1 pushed AV back, AV stumbled walking away and lost balance by the door and fell onto AV's stomach. The facility failed to follow W1 care plan, and failed to implement effective interventions in place, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) and Witness 1 (W1) relies on the facility for safety and care needs. W1 has a history for resident-to-resident altercations, as W1 is triggered if someone tries to enter W1's personal space and room. AV is serviced plan to use a wheelchair. AV is impulsive at times and forgets to use AV's wheelchair and will be seen ambulating out of AV's room into common areas without wheelchair. On or about March 30, 2025, AV was wondering, and approached W1 sitting at a table with h/h walker. AV touched W1's walker, and W1 swiped at AV causing AV to fall backwards and hit h/h head. AV reported back pain and was transported to the hospital. The facility failed to have person centered interventions in place for AV and W1, resulting in AV and W1 engaging in a resident-to-resident altercation, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) and Witness #1 (W1) live at Respondent’s facility. AV has a history of being involved in resident-to-resident altercations. W1 is triggered by people being in W1's personal space. The facility failed to develop sufficient person center interventions for AV's know history of resident-to-resident altercations and failed to develop person center interventions for W1's know trigger of other residents being in h/h personal space. On or about March 28, 2025, AV and W1 were in a resident-to-resident physical altercation. AV walked up to W1 and waved AV's hand in W1 face. W1 pushed AV away, causing AV to stumble, fall and hit AV's head on the floor resulting in a cut to AV's left eye. Respondent failed to develop and implement suitable interventions. This constitutes abuse by neglect as defined by OAT 411-020-0002(1)(b)(A)(I).

Alleged Victim (AV) is a resident of a memory care facility and relies on facility staff to ensure basic care, safety and supervision needs are met. AV's service plan dated on or about February 20, 2025, indicates AV is no longer able to manage AV's medication AP1 Staff are to order, store, and safely administer all of AV's medications per MD/PCP orders. AV takes narcotic pain medication 15 mg twice a day and has a PRN for narcotic pain medication 15 mg as necessary two times per day. On or about March 21, 2025, AV missed two doses of the scheduled narcotic pain medication. AV didn't have any scheduled or PRN narcotic pain medication left. AV was in pain and was sent to the emergency room for evaluation and pain medication. The facility failure to provide a safe medication administration system, have a supply of AVs medication in stock and administer medication as ordered, resulted in AV being in pain and transported to the emergency room, which is a violation of resident rights is considered neglect of care and constitutes abuse.

Alleged Victim (AV) was admitted into the AP1 on or about March 4, 2025. AV's service plan dated on or about March 4, 2025, indicates, medication management, AP1 administers medications, AV is no longer able to manage AV's medication routine, staff are to store, order, and safely administer all of AV's medications per AV's PCP's orders. Integumentary, skin treatments, AV is independent with all skin care and currently has redness to AV's pannus. Pain and non-drug interventions, indicates that PRN medication relieves pain, but there was no PRN medication on the MAR for AV. AV is able to express pain location and how severe it is and staff to notify MT/LN of any concerns of pain. AV's MAR indicates topical medicine to treat rash to be applied topically four times daily to rash in pannus area and to notify nurse of side effects, skin irritation, burning, itching, rash, eczema, and pain. Starting on or about March 6, 2025, AV declined the topical medicine to treat rash due to AV associating pain to AV's rash with the medication administration. On or about March 7, 2025, AV's rash increased in redness, had slightly open areas, drainage, moisture, signs of infection, pain and foul odor. AV was in pain due to AV's brief sticking to AV's skin and while pulling up the folds of AV's pannus, AV requested PRN pain medications which there were none available to AV. AV continued to refuse prescribed topical medicine for rash, and continued to complain of pain, and making suicidal statements related to the pain from the rash. On or about March 10, 2025, AV's rash was noted to be extremely red, smelled foul and be extremely painful, AV requested a PRN pain medication which was not available to AV. AV was transported to the ER on March 10, 2025, with significant pain and suicidal ideation. AP1 failed to follow up on PRN medication for AV's increased and ongoing pain, and AV's medication refusals, which resulted in AV having suicidal ideation from pain and being admitted to the hospital for increased infection, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) and Witness 1 (W1) are residents of the facility and the facility is responsible to provide safety to AV and W1. AV has a mood disorder and cognitive decline. W1 has a mood disorder, cognitive decline, and memory decline. AV has requested to have apartment door left open during waking hours. W1 has a history of hitting, wandering, exit seeking and behaviors after relative visits. On or about January 6, 2025, AV and W1 had a physical altercation that resulted in AV getting hit twice. On or about January 29, 20225, W1 attempted to attack AV, and accused AV of stealing "stuff" from W1. On February 13, 2025, AV and W1 had a resident-to-resident verbal altercation. After each incident the intervention put in place was to monitor and redirect W1. On or about February 21, 2025, W1 entered AV's room looking for a relative who had been visiting an hour earlier. AV responded verbally, W1 got upset and struck AV on the left side of AV's face. AV's glasses were knocked off and AV’s mouth started bleeding from the strike. AV and W1 continued to be verbally aggressive until staff intervened. The facility failed to implement adequate, person centered interventions, which led to AV and W1's resident-to-resident altercation resulting in AV being struck by W1 and causing AV's mouth to bleed.

The Alleged Victim (AV) and Witness #1 (W1) are known to engage in altercations with each other. AV had an intervention in place to re-direct him/her from W1, as W1's presence appeared to be a trigger for AV. On or about January 9, 2025, AV was sitting at the dining room table with W1. AV threw a pack of cookies at W1 and W1 threw the cookies back at AV, hitting him/her in the head. The facility's failure to follow interventions lead to AV and W1 engaging in an altercation. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) has a resident trust account that is kept at the front desk in an envelope in a locked drawer. AV and AV’s personal caregiver withdraw funds from the account when they go out on Thursdays. On or about December 12, 2024, the money in the envelope was counted by facility staff and there was $162.04 in the envelope. On or about December 19, 2024, AV’s personal caregiver asked for money to take AV out for the day when staff found $120 was missing, leaving AV with $42.04. The drawer was found unlocked sometime between the dates of December 12, 2024, and December 19, 2024, coinciding with the timeframe AV’s money was found to be missing. AP1 has reimbursed AV for the amount missing from AV’s account. An Unknown Alleged Perpetrator 2 (AP2) and the facility (AP1) are responsible for not securing AV's funds resulting in theft, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim's (AV) service plan, dated September 26, 2024, indicates AV has behaviors of swatting at staff and yelling. Interventions staff to take AV for a walk outside or to AV's room if AV is showing signs of being upset; staff to help AV to AV's room if AV seems to be looking for it or trying to enter another resident's room. Witness 1 (W1) Service Plan, dated September 26, 2024, indicates W1 has behavior of stomping W1 feet and yelling, impacting factor W1 does not like when people try and push W1 wheelchair and people being in W1 space. Interventions If W1 is seen propelling around the halls, staff are to offer W1 an activity; If staff observe W1 getting close to other residents where W1 can grab at them, they are to redirect and offer W1 a hot beverage; If staff observe W1 becoming frustrated or agitated, they are to ask W1 to sing a song. On or about November 27, 2024, AV was self-propelling in AV’s wheelchair in the hallways of the facility while yelling for help. AV went passed by W1’s room, W1 became agitated, W1 followed AV, grabbed AV’s wheelchair, turned AV around to face W1, and struck AV in the face leaving redness to AV's left cheek. The facility failed to follow the service plan and interventions in place for AV if AV is yelling by not offering to take AV for walk outside. The facility failed to follow the service plan and interventions for W1 by staff not supervising and redirecting W1 away from AV prior to W1 being able to grab AV and offering W1 a hot beverage or asking to sing a song to W1, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) and Witness 1 (W1) have history of altercations with other residents but not each other. W1 has a history of resident-to-resident altercations involving residents near W1’s room, occurring on September 18, 2024, and October 02, 2024. W1 Service Plan dated October 19, 2024, contains the following information, Witness 1 (W1) does not like noise from neighboring residents in the hallway by h/h room, W1 does not like any noise outside of W1's apartment while W1 is sleeping or watching television. W1 will Screaming at staff and other residents, move residents away from h/h door. Intervention includes medications, intervention dated on or about September 18, 2024, staff to keep W1's door locked as W1 allows, and intervention dated on or about October 2, 2024 staff to redirect other residents seen standing outside of W1's room to another part of the building. AV Service Plan dated on or about September 26, 2024, contains the following information, AV does not like when people try and push h/h in h/h wheelchair, active triggers people being in h/h space. On or about September 2, 2024, AV was involved in an altercation with another resident when propelling around the facility. Interventions include if AV is seen propelling around the halls, staff are to offer h/h a snack and offer to bring AV to the current activity going on. Additional interventions noted if staff observe AV getting close to other residents where AV can grab at them, they are to redirect and offer h/h hot coffee. On or about November 10, 2024, AV was in h/h wheelchair in the hallway outside of W1's door. W1 came out of h/h room and began yelling at AV. In response to W1's yelling AV began hitting the wall with h/h right hand and W1 grabbed AV by the hair. AV began swinging h/h arm behind their body in an attempt to get W1 to release h/h hair and W1 grabbed AV's hand and attempted to bite AV. Staff responded and separated AV and W1. AV stated the back of h/h head hurt after the incident. The facility failed to follow AV care plan by staff not offering h/h a snack and offer to bring AV to the current activity going on. The facility failed to follow W1 care plan by not redirecting other residents seen standing outside of W1's room to another part of the building, which is violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed and Alleged Perpetrator 2 (AP2) failed to provide appropriate services according to the Alleged Victim (AV)’s needs, resulting in AVs loss of dignity. AV needs reminders for mealtimes and is to be offered a snack and drink twice daily outside of meals. AV needs toileting assistance at the beginning, middle, and end of each shift, before and after meals. On or about September 22, 2024, Witness 3 (W3) arrived at facility and found AV lying in bed, soaked with urine. Witness 2 (W2) investigated this incident and determined that AP2 had not, changed AV all shift, and had not given AV breakfast or lunch on September 22, 2024. AV's progress notes indicate AV had redness and pain to AV's peri area since approximately July 24, 2024 and no interventions in place for skin issues that needed daily care, no oversight or hands-on training for AP2 regarding refusal of care, and refusal of meals. The facility and AP2 failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) is a 2-person assist with transfers. AV has poor short and long-term memory and is not able to call for assistance. AV has had a total of approximately eleven (11) falls from about July 12, 2023, to approximately September 10, 2024, three (3) falls resulted in injuries. Interventions in place on July 17, 2024, keep apartment door open to assist with preventing unsafe self-transfers, increase visual checks to 4-6 per shift and on August 26, 2024, AV was given a fall mat for use while AV is in bed. AV had a fall from bed on September 10, 2024, where AV was found lying on the floor, with the door shut, no lights on, and no fall mat in place. AV was reported to be covered in dried feces from AV's back all down AV's legs. AV had significant reddened areas on AV's left knee and head from lying on the floor for unknown amount of time. The facility failed to provide a safe environment, failed to appropriately care plan and implement reasonable interventions to address AV’s falls, and follow the interventions already in place at the time of AVs all on September 10, 2024, which is violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) lives at Respondent’s facility and relies on facility staff to ensure AV's basic care, safety, and supervision requirements are met. AV's service plan reflects that AV has poor recent memory, requires staff assistance with transfers due to weakness. AV has a history of attempting to transfer without staff assistance. On or about September 10, 2024, AV self-transferred from AV's bed without staff assistance, resulting in a skin tear to AV's left elbow. The facility failed to develop interventions in AV's Service Plan to address AV's history of attempting to transfer without staff assistance. Respondent failed to develop and implement suitable interventions, and this constitutes abuse by neglect.

Alleged Victim (AV) lives at Respondent’s facility and relies on facility staff to ensure AV's basic care, safety, and supervision requirements are met. AV has a history of attempting to transfer without staff assistance, including an incident that occurred on September 10, 2024. AV's service plan reflects that AV has poor recent memory, requires staff assistance with transfers due to weakness. On or about September 28, 2024, AV fell when attempting to self-transferring into AV's wheelchair, hitting AV's head, resulting in a bump on the back of AV's head. The facility failed to develop interventions in AV's Service Plan to address AV's history of attempting to transfer without staff assistance. Respondent failed to develop and implement suitable interventions, and this constitutes abuse by neglect.

Alleged Victim (AV) lives at Respondent’s facility and relies on facility staff to ensure AV's basic care, safety, and supervision requirements are met. AV has a history of attempting to transfer without staff assistance, including an incident that occurred on or about September 10, 2024, and September 28, 2024. AV's service plan reflects that AV has poor recent memory, requires staff assistance with transfers due to weakness. On or about October10, 2024, AV attempted to get up on AV's own and slipped on AV's blanket landing on AV's bottom. The facility failed to develop interventions in AV's Service Plan to address AV's history of attempting to transfer without staff assistance. Respondent failed to develop and implement suitable interventions, and this constitutes abuse by neglect.

The Alleged Victim (AV) relies on the facility for care and services. According to an investigation, the AV suffered multiple unwitnessed falls. The facility failed to implement appropriate interventions and safety precautions to prevent AV from falling, which is a violation of resident rights and is neglect, which constitutes abuse.

Alleged Victim (AV) resides in a memory care facility and has a diagnosis of dementia. AV has a history of non-injury and injury falls. AV Service Plan, dated approximately May 8, 2024, indicates AV occasionally is disoriented, but can function independently in familiar surroundings, has poor recent memory. Fall Preventions and safety measures for falls include, uses ambulation devices: no, during the last check on NOC shift if AV is awake staff are to offer to take AV to the restroom, if staff see AV wandering the halls for long periods of time assist AV to a place to sit down, staff to make sure AV's floor is free of clutter, staff to make sure AV has AV's walker with AV at all times. On or about July 14, 2024, AV fell resulting in a fractured left hip. AV returned to the facility on or about August 2, 2024, and fell on the same day of return. A pressure alarm on AV's bed was implemented. AV had a one-on-one caregiver from August 2, 2024, to August 4, 2024, due to restlessness and impulsivity. On or about August 5, 2024, AV had another fall. On or about August 6, 2024, AV was found on the floor of AV’s room near the doorway and AV’s nose was bleeding. AV was sent to the hospital for evaluation and was found to have a broken nose. After AV fell on August 2, 2024, an intervention was put into place for AV to have a bed alarm. A staff member’s pager was to go off when AV got out of bed. Based on the available information AV’s bed pad alarm was not in place and activated at the time of AV’s fall on August 6, 2024. AV was found on the floor by laundry staff, and the laundry staff member notified caregivers of AV’s fall via the radio. AV had time to crawl from where AV’s nightstand was to the door of AV’s room before staff were aware that AV had fallen. This evidence indicates that AV’s bed pad alarm was not in place and/or activated at the time of the fall . The facility failed to follow the care plan, failed to appropriately care plan and implement reasonable interventions to address AV’s increasing and ongoing falls, that lead to a fall on August 6, 2024, resulting in a broken nose, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness 1 (W1) has a history of resident-to-resident altercations, and behavior problems that include hitting, grabbing, and swatting with no specific triggers. Interventions to address W1’s behaviors include staff to sit W1 at a bistro table, as W1 allows, to eat. If staff, see W1 wandering down the hallway they are to redirect W1 to a common area and offer to get W1 an activity. Staff to sit W1 at a table where W1 cannot grab at other residents. If staff, see residents walking close to W1 they are to step in between until the other resident passes. If staff, see W1 approaching other residents they are to redirect W1 to another area and offer a snack. On or about July 28, 2024, AV and W1 are both in the dining room when W1 approaches AV and pulls AV’s hair. W1 then swats towards AV’s chest and head, resulting in a reddened mark to AV’s chest. When W1 and AV were talking, W1 appeared to be in a good mood and then W1's demeanor suddenly changed. W1 required close monitoring. The facility failed to follow W1 service plan, staff were aware that W1 was approaching AV but did not intervene and redirect W1, as is stated in W1’s service plan. which resulted in physical harm to AV when W1 and AV were involved in a resident-to-resident altercation.

Alleged Victim (AV) has a long history of choking. AV Service Plan dated on or about March 30 2024, indicates regular diet and AV able to make own choices on what to eat and drink. On or about June 25, 2024 AV had a choking episode, which resulted in AV receiving a choking procedure from staff. According to staff interviews, AV was on a mechanical soft diet at the time of incident on June 25, 2024, and there was confusion regarding AV's diet texture, and was posted differently from Service Plan and meal log posted in kitchen. AV had another choking episode on July 4, 2024, where AV choked during lunch but was able to clear the food independently. The facility failed to update AV's Service Plan in a timely manner, leading to staff confusion regarding AV's diet, conflicting diet plans and resulting in AV choking and requiring a choking [procedure] to be performed on June 25, 2024, and another choking episode on July 4, 2024, putting AV at risk of serious harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. Witness #1 (W1) has a history of agitation and aggression towards other residents and involvement in resident-to-resident altercations. W1 is care planned if staff see W1 approaching other residents they are to help direct W1 to a common area and offer a snack; if staff see W1 approaching other residents from behind, they are to redirect W1; if staff see W1 approaching other residents, trying to touch them, staff are to redirect W1 and take W1 for a walk; and during mealtimes staff are to assist W1 to a seat and if W1 is pacing near other residents, staff are to redirect W1 back to h/h seat and provide W1 with redirection to h/h food; W1 likes stuffed animals and baby dolls and if W1 is seen wandering, W1 can be given one of these items to keep h/h hands busy and free from hitting people. On or about May 3, 2024, interventions added during mealtimes staff are to assist W1 to h/h seat and redirect W1 back to h/h seat if W1 starts pacing near other residents; staff are to direct W1 out of the dining room and away from the other residents. On or about June 7, 2024, AV was sitting at a table in the dining room when W1 walked over and put a teddy bear on AV's walker. W1 then re-approached AV and pushed AV outside the dining room where an unwitnessed resident to resident altercation took place. W1 pushed AV, and AV was found on the floor in the doorway outside the dining room. AV complained of pain in h/h elbow. AV was taken Urgent Care where AV was prescribed lidocaine patches. The facility failed to follow W1 care plan or provide appropriate supervision in dining/common areas, which resulted in W1 pushing AV in the dining room and AV experiencing elbow pain which required medical intervention.

Alleged Victim (AV) Service Plan dated on or around February 28, 2024, Behavior Management: Triggers for AV include others taking items from AV, redirect AV if AV is approaching other residents, redirect AV with a walk or a snack. WItness 1 (W1) Service Plan dated on or around March 30, 2024, Behavior Management: people being in W1's space can trigger behaviours including hitting and yelling, saff are to try and redirect W1 if they see behaviors. AV and W1 were involved in a prior resident-to-resident altercation on May 16, 2024, where AV and W1 struck each other in the hall. On or about June 1, 2024 AV and W1 were involved in a resident-to-resident altercation W1 and AV were sitting near each other in the dining room. AV tried to take cake from W1, W1 grabbed AV's arm and then struck AV in the arm, AV then struck W1 in the face. Interventions were not being followed at time of incident for AV or W1. The facility failed to follow the care plan of AV and W1 resulting in a resident-to-resident altercation.

Witness 1 (W1) has history of resident-to-resident altercations. W1 service plan dated on or around February 28, 2024 indicates if staff see W1 approaching other residents they are to help redirect h/h to a common area and offer a snack. If staff see W2 approaching (other resident) from behind they are to redirect W1. If staff see W1 approaching other residents trying to touch them they are to redirect h/h and take h/h for a walk. W1 is frequently disoriented, even in familiar surroundings requires supervision. On or about June 1, 2024 W1 entered Alleged Victim (AV) private room and AV told W1 to leave. W1 struck AV in the face with open hand, resulting in AV having fear, and feeling unsafe and being afraid of W1. AV was reported as crying and being upset after the incident. The facility failed to follow W1 care plan resulting in a resident-to resident altercation.

Alleged Victim (AV) and Witness 1 (W1) have a history of resident-to-resident altercations. W1 has behavior interventions documented on W1's service plan including redirecting, offering coffee, going on walks, designating projects, reminding W1 that staff are there to help when W1 is ordering other residents around and one-on-one visits with staff. AV does not have any listed behavior interventions documented on AV's service Plan or interim service plans until after the altercation with W1 on May 23, 2024. AV and W1 were in a separate resident-to-resident altercation on May 18, 2024, where AV attempted to sit with W1 and other residents, W1 became agitated leading to W1 attempting to remove AV's chair causing the altercation resulting in AV falling on the floor. On or about May 23, 2024, AV sat next to W1 in the hub area. W1 was agitated. AV had sat down next to W1 and W1 gestured for AV to leave. W1 stood up and pushed the chair W1 was sitting in out of the way and hit AV in the back. W1 then tried to push AV out of the chair. Staff intervened, and redirected AV and W1. The Facility failed to provide a safe environment for AV, prevent the actions off W1 in spite of W1's known history, resulting in W1 getting into an altercation with AV. W1's interventions were not being followed and AV had no additional interventions in place after AV and W1's altercation on May 18, 2024. W1 is to be monitored closely in common areas and staff are to redirect if they see any other residents coming towards W1. AV and W1 were not being observed at the time of the altercation, which is a violation of resident rights, is neglect of care and constitutes abuse.

AV and W1 have history of being in resident-to-resident altercations with other residents and each other. AV has a history of wandering the facility and wandering into other resident rooms. On or about May 22, 2024 AV went into W1's room, which upset W1 leading to a resident-to-resident altercation between AV and W1. W1 has an intervention in place that if staff see W1's door open, they are to offer to shut it to help prevent people from wandering in. AV has no interventions in place in place to mitigate AV from wandering into other residents rooms. The facility failed to appropriately care plan and implement reasonable interventions to address AV’s ongoing wandering into other resident rooms and prevent resident-to-resident altercation between AV and W1, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) and Witness 1 (W1) have a history of resident-to-resident altercations. AV has current interventions in place including, going on a walk, offer AV coffee, sitting AV in the dining room away from others that AV has had an altercation with, redirecting AV, encourage AV to attend activities, and a key to AV's room to prevent others from going into AV's room. W1 has current interventions in place including, giving W1 tasks to complete to keep W1 busy, offer encouragement to W1, redirect W1 if W1 is going towards other residents, offer to take W1 on walks outside, offer coffee, and keep W1 as occupied as possible. Other interventions include if staff see W1 getting mad at another resident, they are to redirect W1 down to W1's room, and if W1 is getting close to other residents' faces to redirect and ask for assistance with an activity. On or about May 19, 2024, AV was sitting at the table in the dining room by the medication room. W1 walked up towards AV, W1 places W1's hand on AV's back, AV then grabbed W1's arm, which then W1 grabbed AV's arm. AV then swatted away W1's arm and as AV and W1 release their arms from each other, AV has a skin laceration on AV's forearm. The Facility failed to provide a safe environment for AV, prevent the actions off W1 in spite of W1's known history, resulting in W1 getting into an altercation with AV, which caused AV to experience a skin laceration to AV's arm. W1's interventions were not being followed with the altercation not being witnessed while AV and W1 were in a common area together unsupervised, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) and Witness 1 (W1) have history of aggressive behaviors and involvement in resident-to-resident altercations. From March 22, 2024 to May 7, 2024, AV was involved in five (5 )documented resident-to-resident altercations. From March 2, 2024 to May 3, 2024, W1 was involved in six (6 ) documented resident-to-resident altercations. AV's interventions for resident-to-resident altercations include the following: look for any signs of isolation, aggression, agitation, targeting other residents, outbursts, changes in appetite, and any other changes in baseline, if staff see AV's door open, they are to offer to shut it to help prevent people from wandering in, if staff observe AV trying to push residents in wheelchairs they are to intervene and let AV know that they can help, if staff see AV quickly approaching other residents, they are to intervene and walk with AV to a common area where s/he can listen to music, and if staff see residents approaching AV during times where s/he is seated with food, they are to redirect they and offer them a snack. W1's interventions for resident-to-resident altercations include the following: during mealtimes staff are to assist W1 to a seat and if s/he is pacing near other residents, they are to redirect h/h back to h/h seat and provide h/h with redirection to h/h food, Staff directed the resident out of the dining room and away from the resident, W1 tends to pace and wander along the community. W1 can be directed to sit down with a snack or juice and generally will stay for a while where s/he is directed. On or about May, 11, 2024, AV and W1 were involved in a resident-to-resident altercation in which AV was pushed to the ground and sustained a skin tear on h/h elbow. The facility failed to adjust the service plan with person-centered interventions and not providing adequate supervision for W1 leading to continued aggressive behavior, which is a violation of resident rights, is considered neglect of care and constitutes abuse. There is sufficient evidence to indicate the facility failed to provide basic care, services, and safety to AV by not providing adequate supervision or person-centered interventions to W1 which resulted in AV and W1 getting into a resident-to-resident altercation on May 11, 2024 and resulted in AV being pushed to the ground and sustaining a skin tear on h/h elbow.

On or about May 5, 2024, Alleged Victim (AV) wandered into Witness 1 (W1’s) room. W1 grabbed AV’s arm and pulled AV out of W1’s room. AV grabbed a hold of the wall to keep balance. Witness 3 (W3) walk away with AV. W1 shut W1’s door and came back into the hallway. AV and W1 both walked back towards the couch in the hallway and W3 went into another resident’s room. AV reached down onto the couch to pick up W1’s phone and W1 grabbed it back from AV and pushed AV’s left shoulder open handed and AV fell backwards and hit AV’s head on the hallway wall. AV had blood in AV’s mouth after hitting AV’s head on the wall. AV had previously been involved in resident-to-resident altercations due to attempting to take items from other residents. W1 has previously been involved in resident-to-resident altercations where W1 was upset after another resident touched his belongings. W1 specifically does not like other people to touch W1’s phone. AV has previously fallen as a result of resident-to-resident altercations. There are no interventions in place to address AV’s behavior of taking the belongings of other residents. There are no interventions in place to address W1’s trigger of other residents touching W1’s belongings and/or phone besides redirecting residents if they are seen approaching W1’s phone or wallet. The facility failed to appropriately care plan and implement reasonable interventions to address W1’s behaviors, which resulted in physical harm to AV when AV fell and hit AV’s head on the wall after being pushed by W1 during a resident-to-resident altercation, which is violation of resident rights, is considered neglect of care and constitutes abuse.

Witness 1 (W1) is oriented to person, place, and situation and relies on the facility staff to ensure that h/h personal care, safety, and supervision requirements are met. Alleged Victim (AV) does not have the ability to speak or to consent to sexual contact. W1 has a history of initiating inappropriate sexual contact with other residents. On or about April 24, 2024 W1 approached AV in the dining room and kissed AV on the head. The facility has failed to implement interventions to mitigate risk of W1's inappropriate sexual behavior. The facility failed to provide a safe environment to AV by failing to provide adequate supervision to W1, which resulted in W1 kissing AV without consent on or about April 24. 2024, which resulted in loss of personal dignity to AV.

Alleged Victim (AV) is minimally oriented and relies on the facility staff to ensure that h/h personal care, safety, and supervision requirements are met. AV does not have the ability to speak or to consent to sexual contact. Witness 1 (W1) Service plan dated on or around April 8, 2024 indicates W1 grabs at residents, kisses (other residents). W1 is oriented to person and place, but not time. There are days when W1 can be confused and need cues and reminders. W1 ISP on or about April 4, 2024 indicates to monitor W1 for signs of increased agitation, stalking other residents, increased sexual advances, or trying to kiss other residents. On or about April 17, 2024 W1 was put on alert for sexual behaviors, and ISP indicates to monitor for sexual behaviors, more frequent checks. On or about April 22, 2024 Progress notes indicate W1 kept stalking another resident no additional interventions were placed. On or about April 23, 2024 W1 was stalking AV at the beginning of shift, W1 approached AV and kissed AV. The facility failed to appropriately care plan and implement reasonable interventions to mitigate W1's ongoing inappropriate sexual behaviors and failed to provide adequate supervision to W1, which resulted in W1 kissing AV without consent.

Alleged Victim (AV) and Witness 1 (W1) have limited cognition and memory. AV's Service plan: AV is independent with ambulation, AV uses the handrails at times while walking to and from h/h apartment, AV has balance issues. Interventions in place for AV: offer AV to join activities to provide additional oversight, , if staff see AV walking to h/h room they are to offer AV assistance to h/h room and sitting in a location of AV’s choosing. W1 Service plan: if staff see W1 start to get agitated with other residents they are to offer to take W1 to h/h room to see h/h cat, Staff are to intervene and redirect when they see W1 becoming agitated with another resident in W1’s perceived space. AV and W1 have a history of resident-to-resident altercations with one another, including an altercation on January 30, 2024. On April 17, 2024 AV attempted to open the door to W1's apartment; W1 closed the door and pushed AV away from the door, causing AV to fall to the ground. The facility did not document the implementation of any behavior interventions for either AV or W1 after the altercation on January 30, 2024. The facility failed to implement behavior interventions following AV and W1's resident-to-resident altercation on January 30, 2024, which resulted in an altercation on April 17, 2024 where W1 pushed AV to the ground in the hallway.

Alleged Victim (AV) is independent in ambulation and transfers. AV has a history of injury and non-injury falls. Following AV's injury fall on March 18, 2024, an Interim Service Plan was initiated directing staff to move AV to the middle of h/h bed, if AV is observed sleeping on the edge of h/h bed. AV's Service Plan, dated February 18, 2024, already listed staff ensuring that AV is positioned in the middle of h/h bed as an active fall prevention intervention. On April 10, 2024, staff found AV on the floor of h/h room; AV had immediate bruising to h/h forehead and open bleeding abrasions to h/h forehead and bridge of h/h nose. The facility failed to appropriately care plan and implement reasonable interventions to address AV’s increasing and ongoing falls, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) is independent in transferring and ambulation and uses a walker to ambulate. AV has history of falls on or about February 02, 2024, February 26, 2024, March 31, 2024. On or about April 09, 2024 at approximately 12:00am, AV was found on the floor in AV's bathroom between the sink and toilet. AV was rubbing AV's, left leg and was saying "Ow" . AV was assessed and transferred back to bed with a determination of no injuries found. At approximately 5:00 a.m. AV was complaining of pain and could not bear any weight on AV's leg. EMS was called and AV was transported to the hospital for further evaluation and diagnosed with a hip fracture with the need for surgical repair. Interventions able to be recalled reducing AV’s risk of falls included safety checks every hour, toileting assistance, and making sure AV's walker is next to AV Although AV's service plan states AV is independent with ambulation, The incident reports for AV’s falls state, “Staff and family are aware that AV can be unbalanced” The facility failed to appropriately implement interventions and service plan for AV ongoing falls and around AV's balance issues to reduce or eliminate fall risks, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) moved into the facility in approximately mid-November of 2023. Upon move in, AV had a blister on the top of the left foot and a blister on the top of the right hand. While living at the facility AV developed skin breakdown on the h/h bottom, genitalia, a cut to the left leg, redness to the left groin, and an open wound to the right chest. On April 7, 2024, AV was sent to the hospital with concerns for altered mental status and found to have an infection. AV was admitted in the hospital. AV hospital records indicate, numerous extremity and perineal wounds, and extensive wounds on AV buttocks, genitalia, chest and legs consistent with moisture and pressure injuries. Redness to AV’s groin was first documented on January 9, 2024. The cut on AV’s left leg was first documented on January 27, 2024. The skin breakdown/open areas on AV bottom and genitalia were first documented on February 13, 2024. The wound to AV’s chest was not documented by the facility and was not known by the staff. Despite AV’s worsening wounds and skin conditions, AV’s service plan dated February 17, 2024, only mentions, a yeast infection to h/h groin. Though AV’s service plan is dated 5 days after the skin breakdown/open areas were documented on AV’s bottom and genitals, there is no mention of these concerns in the care plan and there are no interventions or instructions for care staff to follow regarding AV’s wounds. The facility failed to properly plan care and implement appropriate interventions to address AV’s skin breakdown, resulting in the development of multiple pressure and moisture related wounds.

Alleged Victim (AV) and Witness 1 (W1) both have a history of resident-to-resident altercations and aggressive behaviors. On or about April 1, 2024 AV experienced escalating behaviors over a three-hour period. At approximately 1913 AV approached a resident in a wheelchair in the dining room and told them to get up. W1 was also present in the dining room and interjected on behalf of the resident in the wheelchair. AV walked over to W1 and attempted to strike W1, W1 blocked AV’s strike and the two hit at each other. W1 then grabbed onto AV’s arms resulting in an injury to AV’s left arm consisting of a skin tear and skin discoloration. AV service plan: If AV is getting upset and agitated staff are to offer to put a movie on in h/h room and bring h/h snacks where it is quiet. If AV begins to show agitation towards other residents as displayed by yelling, cussing, or physical aggression, staff are to redirect AV away from other residents until s/he calms down. If AV continues to escalate and be agitated, one staff member will stay with h/h while another staff member calls 911 for high level of care assist. If staff see AV in the dining room standing over other residents they are to redirect h/h to a seat. Staff is to intervene, and redirect AV away from other residents, when s/he shows signs of agitation, or aggression. Staff were not present in the dining room when AV and W1 got into an altercation, indicating that staff were not monitoring AV despite h/h escalating behaviors. The facility failed to provide a safe environment and follow AV service plan, resulting in AV’s escalating behaviors, physical harm to AV when AV was involved in a resident-to-resident altercation and sustained an injury to h/h left arm.

Alleged Victim (AV) is often oriented to person and often disoriented to time and place. Witness #1 (W1) is oriented to person and sometimes situation and wanders within the facility. W1 has a history of resident-to-resident altercations and aggressive behaviors towards residents and staff. On or about April 1, 2024, W1 experienced escalating behaviors over a three-hour period. Non-pharmacological and pharmacological interventions attempted by staff to de-escalate and calm W1 were unsuccessful. W1 approaches AV while AV is seated in a chair in the dining room, and AV seems to motion with h/h hands for W1 to leave them alone. W1 then walks past AV and appears to bump into AV, and AV attempts to strike W1 with h/h arm. AV pulls back h/h arm and appears to be in pain. W1 then turns around and smacks AV in the forehead, to which AV appears to have a painful reaction. The encounter lasts approximately 32-seconds and the only staff visible in the camera footage is a dietary staff member who does not intervene . Minutes before this incident, W1 had been involved in a resident-to-resident altercation with a different resident in the other dining room. Staff were not present in the dining room when AV and W1 got into an altercation, indicating that staff were not monitoring W1 despite h/h escalating behaviors and prior resident-to-resident altercation. The facility failed to provide a safe environment with adequate supervision and interventions to address W1’s escalating behaviors, which resulted in unreasonable discomfort to AV, which is violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) has a known habit of standing over other residents when in the dining room . Witness 1 (W1) has a known history of being agitated when other residents pick up h/h items off the table, and when other residents are in h/h perceived space. On March 26, 2024, AV was wandering within the facility when s/he entered the dining room and approached W1’s table. AV picked up W1’s plate, W1 tries to take the food back from AV. AV and W1 begin swatting at each other back and forth. W1 grabs AV’s arm and does not let go until staff intervene. As a result of the altercation, AV experienced redness on h/h arm. AV and W1 have previously been involved in a resident-to-resident altercation with one another on February 12,2024. Interventions in place to mitigate W1’s behaviors include staff are to intervene and redirect if they see W1 becoming agitated. If another resident is in W1’s perceived space, to redirect other residents and if they approach W1 and attempt to touch h/h food. Interventions put into place to mitigate AV’s behaviors include staff to provide oversight when AV is in the dining room watching a movie, staff are to put a movie on in AV’s room if s/he is showing agitation, and redirect AV away from other residents until s/he calms down. The facility failed to implement appropriate person-centered interventions to address W1’s known triggers and behaviors towards other residents leading to a physical resident-to-resident altercation between AV and W1.

Alleged Victim (AV) is independent in ambulation and transfers. AV has a history of injury and non-injury falls. Following AV's injury fall on January 5, 2024, no new fall prevention interventions were implemented by the facility. On March 18, 2024, staff were alerted by another resident that AV was on the floor; staff found AV sitting on h/h bottom, leaning against h/h bed, with AV reporting that s/he had fallen while attempting to take h/h self to the bathroom. On March 22, 2024, AV was found to have bruising on the left side of h/h back. The bruising found on March 22, 2024, matches contact the AV's back made with the bed or ground with the fall on March 18, 2024. The facility failed to appropriately care plan and implement reasonable interventions to address AV’s increasing and ongoing falls, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) is a resident of the facility and relies on facility staff to ensure that h/h personal care, safety, and supervision requirements are met. AV requires hands-on staff assistance with toileting, incontinence care, showers and is known to be regularly resistive to care. On or about March 12, 2024, Alleged Perpetrator 2 (AP2) and Witness 3 (W3) were assisting AV with a shower after an episode of incontinence. Witness 2 (W2) reports responding to a request on the radio that someone needed help in AV's room. W2 reported that AP2 had one hand on AV's thigh and one hand on AV's shoulder. W3 admitted to Witness 5 (W5) that W3 was the one holding AV down and not AP2. Then W3 was told to write a statement and h/h story changed. AP2 reports W3 was holding AV down and AP2 was only washing AV's hair. AP2 reports W2 used this to retaliate against h/h for reporting concerns to management. It was reported that AV experienced significant emotional upset because of the shower. There is equal evidence that AP2 wrongfully restrained AV in the shower and that AP2 did not wrongfully restrain AV in the shower. The allegation that AP2 wrongfully restrained AV was investigated, and wrongdoing was unable to be determined. The facility failed to provide a safe environment, failed to appropriately care plan, and implement reasonable interventions to address AV’s known resistance to care, which is violation of resident rights, is considered neglect of care and constitutes abuse.

Witness 1 (W1) has a long history of resident-to-resident altercations with sixteen documented alterations reported since October 2023, and W1 is consistently refusing medications. Alleged Victim (AV) is not known to have aggressive behaviors, but has a history of trying to "help" staff by telling others what to do which has led to previous altercations with other residents. AV has an intervention in place that if staff see AV telling others what to do, staff are to thank AV for trying to help but redirecting AV. W1 and AV have a history of altercations with their last altercation on February 16, 2024. On or about March 04, 2024, AV approached W1 to tell W1 to put a dessert back which led to a resident-to-resident altercation. W1 slapped AV three times in the face and grabbed AV's shirt. Although there are interventions in place for W1, there are no additional interventions in place after altercation with AV on February 16, 2024. The facility failed to follow AV intervention and intervene when AV told W1 to put a dessert back, and the facility failed to put effective interventions in place after the last resident-to-resident altercation with AV and W1 on February 16, 2024, which caused an altercation on March 04, 2024, which is violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) uses a wheelchair for ambulation, is unable to bear any weight, and relies on multiple-person assistance with all transfers. AV has a history of falls, and behaviors. Between March, 1, 2024 and April 4, 2024, AV was documented to have been found on the floor or to have "placed h/h self on the floor" 44 times, with several resulting in injury. AV required one-to-one staff supervision during NOC shift on April 15, 2024 due to AV placing h/h self on the floor as soon as staff would leave the room. The facility did not have sufficient staffing to continue AV's one-to-one supervision. AV was on Significant Change of Condition Monitoring, but the monitoring only listed AV's regular falls/found on the floor and did not suggest or implement any interventions. There are no Interim Service Plans with behavior or fall prevention interventions documented afterMarch, 28, 2024, which asked staff to ensure that AV had stuffed animals in bed with h/h. The facility failed to implement reasonable behavior or fall prevention interventions, which resulted in AV continuing to be found on the floor after April 4, 2024.

Alleged Victim (AV) service plan indicates AV is independent in ambulation, has problems with peripheral vision and has history of falls. On or about February 01, 2024, AV was walking towards the front hallway, when another resident's walker was in the way, causing AV to trip over the walker, lose balance, and fall. The fall caused AV to hit AV's head resulting in a red mark on AV's face. Contributing Factors noted balance. No person centered interventions were updated in AV service plan from prior falls which resulted in AV falling on February 01, 2024. The facility failed to appropriately care plan and implement reasonable interventions to address AV’s increasing and ongoing falls, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

ALleged Victim (AV) has a history of resident-to-resident altercation involvement due to approaching other residents in the dining room and attempting to to remove food or items from the table. AV's Service Plan does not list any behavior interventions for AV's know behavior of taking food from other residents in the dining room. Witness 1 (W1) has a history of agitation with other residents, including residents entering W1's space or touching W1's food; all of W1's behavior interventions require staff to observe the incident occurring, or beginning, and call for staff intervention to redirect or relocate W1. AV and W1 were involved in a resident-to-resident altercation on January 30, 2024 when AV approached W1's table and attempted to take cups off the table in front of W1. -W1 took the cups from AV's hands, resulting in AV hitting W1's hands, and W1 hitting AV's hands in return. AV did not have any immediate injury, but was found to have bruising on h/h left wrist on February 1, 2024; the bruising was attributed to the altercation on January 30, 2024. The facility failed to implement reasonable behavior interventions for AV, given both AV and W1's history, and to staff failed to follow the available interventions for W1, which resulted in a resident-to-resident altercation between AV and W1, with latent bruising to AV's wrist.

Alleged Victim (AV) relies on the facility for his/her care. Witness #1 (W1) has a history of agitation and aggression towards other residents. On or about January 25, 2024, AV and W1 were involved in a resident-to-resident altercation for the first time and separated. On January 26, 2024, AV was sat next to W1 at the same table during mealtime, which lead to a resident-to-resident altercation. W1 pulled on AV's shirt and hit AV in the face. W1 has a behavior plan with interventions in place; if staff see W1 approaching other residents in dining room they are to redirect h/h to own table and provide h/h with a snack. Additional interventions in place, staff are to redirect W1 when they see another resident in W1 personal space or too close to W1. The facility failed to follow the interventions already in place for W1 which resulted in AV, being physically struck. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) service plan indicates AV is independent in ambulation, has problems with peripheral vision and has history of falls. On or about January 20, 2024 AV had experienced two falls resulting in abrasions. The first fall, AV was noted to be jogging through hallways. AV got caught up in the power cord and tripped over it falling onto right side. Contributing Factors noted balance, the need for occasional physical support and gait disturbance. The second fall, AV was wandering around the facility. AV got off balance and fell. Contributing Factors noted gait disturbance. No person centered interventions were updated in AV service plan from prior falls which resulted in AV having two falls on January 20, 2024. The facility failed to appropriately care plan and implement reasonable interventions to address AV’s increasing and ongoing falls, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) has a diagnosis of dementia with behavioral disturbances. AV's behaviors include AV yelling or screaming. AV's active trigger for h/h behaviors is being left alone. Interventions include bringing AV to an activity, sitting, and talking with AV, letting AV know s/he is safe, offering AV a snack. AV just wanting someone to sit with h/h. Staff (W3, W4, W5) reported, other staff members would intentionally ignore or delay responding to AV's call lights. AV's call light was activated a total of 172 times between the dates of December 25, 2023, and January 25, 2024. Only 54.65% of AV's call lights were resolved within 45 minutes and 11.63% of AV's call lights took longer than four hours to be resolved by staff. Witness 3 (W3) reports Management was aware of the concerns that AV's call lights were being ignored, but did not address these concerns in an impactful way and Witness 5 (W5) reports the facility has put in place one-to-one staffing for other residents with behavioral needs, but did not for AV as AV's behaviors were so consistent and there was not enough staffing to allow for staff to sit with AV. The facility failed to meet resident scheduled and unscheduled needs by evidence as being unable to respond to call lights in a timely manner, which is a violation of resident rights, is neglect of care and constitutes abuse.

Witness #1 (W1) has a history of aggressive behavior with other residents, resulting in twenty-one (21) documented resident-to-resident altercations approximately between November 1, 2023, to January 12, 2024. W1's Service Plan, created after the implementation of W1's Behavior Plan, does not include any information about W1's behaviors and does not list any instructions or interventions for staff, related to W1's behaviors. All but two of W1's behavior interventions were for staff to redirect W1 away from other residents or spaces, or redirecting residents away from W1. On or about January 16, 2024, Alleged Victim (AV) was sitting in the hallway in h/h wheelchair. W1 approached AV from behind. W1 grabbed onto AV, causing AV to fall to the ground, followed by the wheelchair collapsing on top of AV. The facility failed to properly plan care, implement new behavior interventions, and provide person centered interventions appropriate to mitigate W1 aggressive behaviors, resulting in ongoing resident-to-resident altercations which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) is incontinent in both bowel and bladder, requiring staff assistance with toileting and peri care. AV experiences a poor gait and weakness when ambulating resulting in balance issues and requires staff assistance with transfers. On January 3, 2024, Alleged Perpetrator 2 (AP2) was assisting Witness 2 (W2) provide AV with incontinence care. During the care being provided, AV complained about slipping off the edge of the bed. AP2 turned AV onto h/h stomach on AV's bed, resulting in AV's knees coming into contact with the floor. AP2 disregarded statements from staff and AV about repositioning AV. As a result of being on h/h knees, AV suffered injuries to h/h knees. AV required h/h PRN liquid pain medication for knee pain in the two days following the incident. AP2 was hired by the facility on September 27, 2023, and received training by the facility as to how to appropriately care for and interact with the residents of the facility. AP2 received a final warning due to verbally abusing residents on December 26, 2023. In the write up, the facility acknowledged that AP2 abused the other resident verbally. In the write up, AP2 was advised that s/he must treat residents with respect and dignity and that further instances could result in termination. There is no documentation that any corrective training was provided following the final warning. AP2's actions of disregarded statements from staff and AV regarding position and AV verbal discomfort and pain are a violation of resident rights, considered neglect of care and constitute physical abuse. The facility failed to protect the resident and provide a safe environment from abuse and provide additional training to AP2, which is a violation of resident rights, is neglect of care and constitutes abuse.

Witness #1 (W1) and Alleged Victim (AV) have history of altercations with other residents. W1 behaviors can be triggered by being too close to people. AV behaviors can be triggered by others being in h/h space. AV and W1 share a room and have a history of at least one altercation between each other. Both residents are triggered by other residents being in their personal space. The facility has this documented information in AV’s care plan and W1’s care plan and chose to keep then in a shared room together. On or about December 28, 2023, an altercation took place in the shared room of AV and W1. AV was heard yelling, Witness #4 (W4) and Witness #2 entered the room and witnessed W1 hit AV in the face. Staff separated AV and W1. Redness was seen to AV's face. On or about December 29, 2023, purplish bruising was noted along AV's left eyebrow and under AV's left eye. The facility failed to properly plan care, implement person centered interventions appropriate to mitigate and address the documented aggressive behaviors between AV and W1 resulting in resident-to-resident altercation, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) has a diagnosis of dementia, poor short-term memory and has a history of falls. AV suffered seven falls in the two months prior to December 19, 2023. Of the seven falls, AV experienced injuries as a result of four of them. Service Plan for AV, dated November 16, 2023, AV has a history of ambulation and transferring concerns (service plan does not note what these concerns are), AV is independent in transfers, AV may need stand by assistance with transfers on days AV is feeling weak, AV uses a walker to assist with ambulation, AV has not had falls in the last 90 days, AV has balance issues, AV is able to perform toileting tasks such as: getting to the toilet, removing pants and brief, using the toilet, peri care, changing h/h brief, and pulling up h/h pants, AV is able to use the call light to request assistance with toileting, Staff are to check on AV at the beginning, middle and end of each shift. Staff are to offer AV toileting assistance during these checks. Fall interventions include: Staff are to offer toileting assistance on last rounds, Staff are to make sure they are offering AV toileting assistance during checks, Staff are to make sure they are assisting AV with toileting prior to assisting AV to bed, Staff are to make sure that AV is in the middle of h/h bed during checks, Staff checks should occur at the beginning, middle and end of each shift. On December 19, 2023, AV experienced a fall was transported to the hospital and was found to have a laceration to h/h lower lip that required treatment, extensive bruising to h/h left arm, left flank, and abdomen, and multiple rib fractures. Also noted in hospital records AV has had recurrent falls most likely secondary to AV's chronic left hip pain and not having assistive devices available at the facility. The facility failed to appropriately care plan and implement reasonable interventions to address AV’s increasing and ongoing falls, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness 1 (W1) is known to get into altercations and have aggressive behaviors. W1 is known to wander throughout the facility. On December 15, 2023, W1 entered Alleged Victim’s (AV’s) room thinking it was h/h room. AV then told W1 that this was h/h room and W1 struck AV. AV then struck W1. As a result of the altercation, AV had scratches to h/h nose and W1 had bruising to each cheekbone and a bleeding lip. W1 has previously caused injury to other residents as a result of physical resident-to-resident altercations. Interventions in place to reduce W1’s behaviors are staff to offer to walk with W1, staff to offer W1 a snack, and staff to sit with W1 in h/h room to minimize distractions. There are no interventions in place to address W1’s wandering into other resident rooms. The facility failed to properly plan care for W1 leading to continued aggressive behavior and wandering into other resident rooms, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) is known to get into altercations and have aggressive behaviors. AV is known to wander throughout the facility. On December 15, 2023, AV entered Witness 1 (W1’s) room thinking it was h/h room. W1 then told AV that this was h/h room and AV struck W1. W1 then struck AV. As a result of the altercation, W1 had scratches to h/h nose and AV had bruising to each cheekbone and a bleeding lip. AV has previously caused injury to other residents as a result of physical resident-to-resident altercations. Interventions in place to reduce AV’s behaviors are staff to offer to walk with AV, staff to offer AV a snack, and staff to sit with AV in h/h room to minimize distractions. There are no interventions in place to address AV’s wandering into other resident rooms. W1 is known to be upset by others coming into h/h room. Interventions in place to address W1’s known triggers include: If staff see W1 leave their door open, they are to close it to prevent other residents from wandering or looking in. The facility failed to properly plan care for AV leading to continued aggressive behavior and wandering into other resident rooms and failed to place effective interventions to manage W1’s known triggers of having other residents wander into h/h room, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) has documentation indicating between January 1, 2023, and December 11, 2023, to have experienced approximately 15 falls. AV has history of a fall on October 19, 2023, when AV wandered into a peer’s room and was found lying on h/h side after attempting to sit on a recliner. Service Plan dated September 11, 2023, indicates AV requires extensive assistance in mobility and ambulation. AV has a four wheeled walker that s/he uses for ambulation; AV is known to be forgetful about using h/h walker; AV requires two-person staff assistance with transfers. AV has a history of falls, decreased awareness, and balance problems and AV has had three or more falls in the last 30 days. Fall Prevention and interventions include, staff are to provide verbal cueing and direction along with escorts to and from meals and activities; If AV is seen weak or unsteady, staff are to escort AV to a point of safety and staff are to ensure that AV is wearing proper footwear. The fall prevention interventions listed by the facility are re-worded iterations of the same concepts, including seven statements about ensuring AV is using h/h walker correctly, four statements about ensuring AV is toileted regularly, three statements about clutter or trip hazards, and two statements each about proper footwear and intervening when observing AV ambulating while weak or unsteady. On or about December 12, 2023, at approximately 1845 hours, AV fell while independently ambulating and attempting to sit in a chair; AV fell off the chair, hitting h/h head on the wall, and fell to the ground. AV reported s/he was in pain; EMS was called, and AV was transported to the ER where s/he was diagnosed with fractures to h/h T6 and T7 vertebrae. The facility failed to appropriately care plan and implement reasonable interventions to address AV’s increasing and ongoing falls, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) has aggressive behaviors and a history to get in physical resident-to-resident altercations. Interventions in place to reduce AV’s behaviors are to offer AV a snack, offer to walk with AV, offer to sit with AV, and redirect AV away from other residents until AV calms down. If the incident happens in the dining room, staff report they can intervene quickly otherwise they cannot; Staff report interventions are effective 50% of the time. AV and Witness (W1) have a history of resident-to-resident altercations with other residents and each other. AV tends to target W1 because W1 has food and other items in h/h room that AV likes. On December 9, 2023, AV and W1 were involved in a physical resident-to-resident altercation in the hallway; W1 was yelling at AV and then threw a cup of water at AV; W1 then hit AV so AV started to hit W1 back. Investigator’s review of the video did not show W1 hitting AV, but shows AV appear to hit W1 on the hands approximately 7 to 8 times. AV sustained skin tears on h/h hands and was visibly upset by the altercation. It is unknown if W1 sustained the dark purple skin discoloration on h/h left wrist and forearm from the incident. Between September 7, 2023, and December 8, 2023, AV was involved in 8 physical resident-to-resident altercations. The facility failed to provide a safe and homelike environment, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness 1 (W1) is known to get into resident-to-resident physical altercations and has aggressive behaviors. Alleged Victim (AV) and W1 have a history of resident-to-resident altercations with each other. W1 tends to target AV because AV has food and other items in h/h room that W1 likes. Interventions in place to reduce W1’s behaviors are to offer W1 a snack, offer to walk with W1, offer to sit with W1, and redirect W1 away from other residents until W1 calms down. Staff report W1 will walk around the facility all day long and it is hard to keep track of someone who is not in a wheelchair like AV. On or about December 9, 2023, AV and W1 were involved in a physical resident-to-resident altercation in the hallway. AV had been a little agitated throughout the shift. AV was sitting in h/h wheelchair in the hallway when W1 walked by. AV was yelling at W1 and then threw a cup of water at W1; a review of the video did not show AV hitting W1 but shows W1 appear to hit AV on the hands approximately 7 to 8 times. W1 sustained skin tears on h/h hands and was visibly upset by the altercation. AV sustained dark purple skin discoloration on h/h left wrist and forearm likely caused by the incident. The facility failed to appropriately adjust care plans and implement reasonable interventions to address AVs and W1s continued aggressive behaviors, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about November 27, 2023, the Alleged Victim (AV) pressed his/her call light for assistance with toileting. AV suffered unreasonable discomfort due to not receiving assistance in a timely manner. The facility's call light system has not been working properly for some time. Staff also were not sure about AV's care needs, as they were not clearly defined in AV's care plan. The facility's failure to ensure clear care planning and ensuring the facility call system was in working order is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide appropriate services according to the Alleged Victim (AV)'s needs, the facility failed to implement a service plan and interventions to address AV frequent falls. On or about November 23, 2024, AV went to the hospital due to AV having an altered mental status, right-sided weakness, slurred speech, and abnormal behavior. Upon examination, AV had healing bruises all over h/h lower legs, excoriation on nose and legs, dirt under h/h nails and AV's right hip was dislocated. The hospital attempts to relocate AV's hip was unsuccessful due to the stage of injury and healing. AV experienced pain from persistent hip dislocation and contribute to AV"s agitation and behaviors, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) Service Plan indicates AV is independent in transferring and ambulation and uses a walker to ambulate. AV has a history of falls. Hospital record on or about November 18, 2023, indicates AV had a fall two days ago and was having back pain. AV had two falls on or about November 22, 2023, requiring staples to h/h scalp. Staff observed that AV had become more unsteady approximately one week before s/he began falling on or around November 18, 2023, but the facility did not put any interventions in place to address AV’s decline in mobility. After the first fall on November 22, 2023, interventions put into place to address AV’s risk of falls include if staff see AV wandering around for long periods of time they are to offer for h/h to sit down in a chair in a common area. The intervention put into place after the first fall on November 22, 2023, was not an appropriate intervention. After the second fall on November 22, 2023, interventions put into place to address AV’s risk of falls include if staff see AV standing up to ambulate in the dining room they are to offer assistance. Interventions able to be recalled by witnesses to reduce AV’s risk of falls include frequent checks. The incident reports for AV’s falls state, “Staff and family are aware that AV can be unbalanced” . There is no service planning around AV’s balance issues and no directions are given to staff on how to assess AV for balance issues or what to do if AV is seen to be having balance issues. On or about November 23, 2023, at approximately 3:09 pm AV was found on the floor in the hallway. EMS was called to assess AV and after consulting with AV’s POA it was decided that AV should stay at the facility. On November 24, 2023, AV was sent to the hospital due to pain. After imaging, AV was found to have burst and compression fractures of the spine. AV was signed onto hospice services and returned to the facility. In AV’s evaluation dated on or about November 27, 2023, it is stated that there are “no signs of fall issues”. The interventions put into place on November 22, 2023, were not communicated clearly to staff. In AV's service plan dated October 27, 2023, and in AV's evaluation dated November 27, 2023, AV is described as independent with ambulation and transfers. There is no evidence that the new expectations that staff should assist AV if AV is seen walking for extended periods of time, and that staff should assist AV if AV is seen ambulating in the dining room, were communicated to staff. The facility failed to appropriately care plan and implement reasonable person-centered interventions to address AV’s unbalance and to mitigate the risk of further falls, which resulted in a fall on November 23, 2023, resulting in AV being transferred to the hospital on November 24, 2023, and diagnosed with compression fractures of the spine, which is violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) Service Plan indicates AV is independent in transferring and ambulation and uses a walker to ambulate. AV has a history of falls. Hospital record on or about November 18, 2023 indicates AV had a fall two days ago and was having back pain. On or about November 22, 2023 AV at approximately 6:50am was found on the floor in the bathroom of another resident’s room. AV reported s/he hit h/h head and had pain in head and back. EMS was called to assess AV and EMS did not think AV needed to be seen at the hospital. Staff observed that AV had become more unsteady approximately one week before s/he began falling, but the facility did not put any interventions in place to address AV’s decline in mobility. Interventions able to be recalled by witnesses to reduce AV’s risk of falls include frequent checks. AV has no interventions for falls in h/h service plan. The incident reports for AV’s fall state, “Staff and family are aware that AV can be unbalanced”. There is no service planning around AV’s balance issues and no directions are given to staff on how to assess AV for balance issues or what to do if AV is seen having balance issues. The facility failed to appropriately care plan and implement reasonable interventions to address AV’s unbalance and falls, which resulted in a fall on 11/22/23 at approximately 6:50am whereupon AV hit h/h head and suffered head and back pain, which is violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) Service Plan indicates AV is independent in transferring and ambulation and uses a walker to ambulate. AV has a history of falls. Hospital record on or about November 18, 2023, indicates AV had a fall two days ago and was having back pain. AV had two falls on or about November 22, 2023, at approximately 6:50 am and 6:00 pm. At approximately 6:00pm, AV was standing and talking to other residents when s/he went to step around h/h walker and fell backwards, hitting h/h head on the piano. EMS was called to assess AV and transported to the hospital, requiring staples to h/h scalp. Staff observed that AV had become more unsteady approximately one week before s/he began falling on or around November 18, 2023, but the facility did not put any interventions in place to address AV’s decline in mobility. After the first fall on November 22, 2023, interventions put into place to address AV’s risk of falls include if staff see AV wandering around for long periods of time they are to offer for h/h to sit down in a chair in a common area. The intervention put into place after the first fall on November 22, 2023, was not an appropriate intervention. AV was found on the floor at 6:50am and AV had last been seen in bed. There is no evidence that the first fall on November 22, 2023, was due to AV walking for extended periods of time. Interventions able to be recalled by witnesses to reduce AV’s risk of falls include frequent checks. The incident reports for AV’s falls state, “Staff and family are aware that AV can be unbalanced” . There is no service planning around AV’s balance issues and no directions are given to staff on how to assess AV for balance issues or what to do if AV is seen to be having balance issues. The facility failed to appropriately care plan and implement reasonable person-centered interventions to address AV’s unbalance and to mitigate the risk of further falls, which resulted in a second fall on November 22, 2023, at approximately 6:00 pm resulting in AV being transferred to the hospital and receiving staples in h/h head, which is violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #1 (W1) has documented acts of aggressive behavior with staff, other residents, and resident-to-resident altercations from approximately October 11, 2023, to November 15, 2023. W1’s care plan does not include information about W1's aggressive behaviors and does not list instructions or interventions for staff, related to W1's aggressive behaviors. On or about November 16, 2023, Alleged Victim (AV) was walking the hall and W1 was roaming the building in h/h wheelchair. W1 started yelling at AV, AV stopped to talk to W1, W1 hit AV's hand and continued to swing at AV. W1 grabbed AV's sweater causing AV to lose h/h balance and fall over. AV hit the crown of h/h head on the handrail resulting in AV reporting pain. EMS was called, AV did not need to be transported, but did have a bruise on h/h head.

Witness #1 (W1) has documented acts of aggressive behavior with staff, other residents, and resident-to-resident altercations from approximately October 11, 2023, to November 15, 2023. W1's care plan did not include interventions related to W1's acts of aggressive behavior, and care plan did not include instructions, or interventions related to resident-to-resident altercations. On or about November 16, 2023, W1 had an earlier resident-to-resident altercation with another resident. Later in the day, W1 was wheeling h/h-self down the hall when Alleged Victim (AV) was walking in the opposite direction. W1 pushed AV into the wall, causing AV to slide down onto h/h butt. W1 repeatedly tried to hit AV, resulting in AV becoming emotionally upset. It took multiple staff to separate and redirect W1. The facility failed to properly plan care, implement behavioral interventions, and provide person centered interventions appropriate to mitigate W1 aggressive behaviors, resulting in ongoing resident-to-resident altercations which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. On or about November 06, 2023, AV experienced a bout of diarrhea and pushed h/h call light for hands on assistance with cleaning and getting off the toilet. According to the facility call light log, AV pulled h/h call light twice, waiting 3hrs, 44mins, 56sec and 4hrs, 34mins, 43sec. AV attempted to clean him/her self-up but did not feel s/he did an adequate cleaning resulting in loss of personal dignity. While waiting for staff to assist AV off the toilet, AV's legs went numb causing unreasonable discomfort. The facility failed to answer call light in a timely manner, which is a violation of resident rights, is neglect of care and constitutes abuse.

On October 17, 2023, Alleged Victim (AV) was admitted to hospice. Between October 17, 2023, and October 28, 2023, AV is regularly documented to be short of breath; hospice instructions left on October 28, 2023, state that AV should receive "frequent supervision, every two hours" to monitor AV for shortness of breath, with instructions that AV should receive narcotic medication if found to be short of breath. AV received h/h scheduled medications on October 31, 2023, at 2000 hours. AV received a breakfast meal tray delivered to h/h room on November 1, 2023. Alleged Perpetrator 3 (AP3), who was assigned to AV's section during day shift of November 1, 2023, looked in AV's room at the beginning of h/h shift and AV appeared asleep in h/h chair; AP3 did not have any additional contact with or observation of AV until after AV was found deceased. AV was in the same position when found deceased as AP3 had observed AV at the beginning of the shift. Alleged Perpetrator 2 (AP2), who was responsible for AV's section on NOC shift from October 31, 2023, to November 1, 2023, could not be identified. AV can last be confirmed alive on October 31, 2023, at approximately 2000 hours, when AV received h/h scheduled medications from Witness 2 (W2). AV's time of death could not be determined, it is unclear on which shift AV died, leaving the allegations against both AP2 and AP3 inconclusive. The facility failed to update and properly plan AV’s care with h/h changing needs as AV experienced an expected decline in health and ability after starting hospice services; The facility failed to follow and implement instructions to staff following the orders from hospice staff, provided on October 28, 2023, that AV was to be frequently monitored, defined as every two hours, for AV's known shortness of breath; these failures resulted in AV going an extended period of time without any staff contact or monitoring, during which time AV died.

Witness 1 (W1) has history of behavioral disturbances, aggressive behaviors, and is known to approach other residents and get into their personal spaces. W1 service plan, indicates, if staff see W1 wandering the dining room the staff are to offer h/h a cup of coffee. On or about October 15, 2023, W1 approached and began to touch Alleged Victim’s (AV’s) s plate. AV and W1 then go back and forth, each striking each other on the arms and W1 striking AV on the face, resulting in scratches to AV’s face. The allegation that AP2 failed to follow care plan was investigated and the determination was not substantiated. The facility failed to properly plan care, provided interventions appropriate to mitigate W1’s known aggressive behaviors towards other residents leading to a physical resident-to-resident altercation, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) is minimally oriented and relies on facility staff to ensure that h/h personal care, safety, and supervision requirements are met. AV moved into the facility with a known fall history. AV has a history of getting out of bed and often gets out of bed and wanders. Most of AV’s falls are at night. Interventions in place to reduce AV’s risk of falls at the time of the incident included: If staff see AV without h/h walker for extended periods of time they are to offer for AV to switch to h/h wheelchair and get them a snack; Staff are to offer to help AV back to h/h room to rest if s/he is wandering after a meal; In the evenings when AV is wandering staff are to offer for h/h to sit with another resident in the dining room; Staff to offer to take AV back to h/h room after breakfast or to escort h/h to an activity; If staff see AV standing they are to walk directly to h/h and help AV to sit down then take h/h to the location of h/h choosing; Staff are to make sure during each check that AV's blankets are tucked in at all times; Staff to make sure they offer to change AV's clothes when putting h/h to bed as s/he allows. On October 7, 2023, staff observed AV scooting on h/h bottom in the hallway. It is believed that AV fell out of bed. AV was sent to the hospital due to a large bruise on the right forehead and altered mentation. At the hospital AV was diagnosed with a closed head injury. There is no service planning and interventions in place to mitigate the risk of AV getting out of bed at night and falling at night or instructions to staff on how to care for AV when s/he gets out of bed and wanders at night. The facility failed to provide a safe environment, appropriately care plan and implement reasonable interventions to address AV’s falls, which is violation of resident rights, is considered neglect of care and constitutes abuse.

On or about October 4, 2023, the Alleged Victim (AV) was using the restroom and pressed his/her call light for assistance. A staff member arrived and advised AV they would send someone to assist AV shortly. AV pressed his/her call light multiple times waiting for staff to arrive. After approximately a 45 minute wait, when AV was starting to feel cold and his/her bottom was numb, AV removed him/herself from the toilet and tried to clean him/herself, which he/she felt she didn't do a good job. Later a staff member did show up and assisted AV to clean him/herself better. According to staff, the call light system has been having issues and not always working. The facility's failure to ensure call lights were working properly and being answered timely resulted in unreasonable discomfort for AV. The failure is a violation of resident rights, is considered neglect of care and constitute abuse.

Witness W1 (W1) moved into the facility on September 3, 2023, and has a history of resident-to-resident altercations. W1 interventions implemented to reduce W1 of resident-to-resident incidents: September 13, 2023, if staff see W1 wandering in the dining room they are to offer W1 a cup of coffee; September 19, 2023, if staff see W1 looking into other residents’ room they are to offer to go on a walk; September 21, 2023, if staff see W1 attempting to assist other residents’ then staff are to redirect. On or about September 25,2023, Alleged Victim (AV) and W1 were involved in a physical resident-to-resident altercation. W1 hit AV with a fork under AV’s left eye resulting in a skin tear and bruising and causing AV to lose h/h balance and fall backwards and hit h/h head. The facility failed to follow the W1 interventions implement to reduce W1 or resident-to-resident altercations, failed to appropriately address W1 ongoing aggressive behaviors and plan care accordingly for the safety of other residents, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness W1 (W1) moved into the facility on September 3, 2023, and has a history of resident-to-resident altercations and is known to approach other residents and get into their personal spaces. W1s interventions implemented to reduce resident-to-resident incidents include: September 13, 2023, if staff see W1 wandering in the dining room they are to offer W1 a cup of coffee; September 19, 2023, if staff see W1 looking into other residents’ room they are to offer to go on a walk; September 21, 2023, if staff see W1 attempting to assist other residents’ then staff are to redirect. Alleged Victim (AV) is known to have behavioral disturbances and aggressive behaviors if people are too close to h/h; AV interventions include staff are to redirect residents away from AV. On or about September 25,2023, AV and W1 were involved in a physical altercation; W1 approached AV and entered h/h space; AV became upset; per video review W1 appears to hit AV on the top of the head approximately 5 times, W1 appears to hit AV on the right side of AV’s head, W1 appears to punch AV in h/h mouth causing AV’s head to snap backwards, and then W1 appears to kick at AV’s legs. W1 was also involved in a prior resident-to-resident incident on September 25,2023, where W1 hit another resident with a fork during mealtime. W1 was involved in 12 recorded resident-to-resident altercations between September 3,2023 and September 25,2023. The facility failed to follow AV interventions to redirect residents away from AV, and the facility failed to appropriately address W1 ongoing aggressive behaviors and plan care accordingly for the safety of 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 his/her care and assistance with toileting. On or about September 18, 2023, AV pushed call light for assistance in the bathroom, and waited approximately two (2) hours and thirty-nine (39) minutes, resulting in AV having to clean h/h self and causing unreasonable discomfort. The facility failed to answer call light in a timely manner, which is a violation of resident rights, is neglect of care and constitutes abuse.

The Alleged Victim (AV) is care planned for two person assist for most cares, including showers. On or about September 17, 2023, Alleged Perpetrator #2 (AP2) was showering AV by him/herself. AP2 showered AV in his/her wheelchair, and while attempting to remove AV from the shower, the wheels got caught on the shower lip and AV fell forward from his/her chair, causing a laceration to his/her scalp. AV was sent to the hospital where he/she received 13 stitches to his/her forehead. AP2 failed to follow the care plan to have a second person assist with showering AV. AP2's actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility's failure to follow the care plan and ensure enough staff are available to assist is a violation of resident rights, is considered neglect of care and constitutes abuse.

On September 1, 2023, Witness 1 (W1) moved into the facility. W1 has had 5 resident-on-resident incidents since s/he moved in. W1 Behavior Plan dated September 12, 2023, indicates if staff see W1 entering other resident’s rooms they are to offer W1 to go for a walk outside or have a cup of coffee and if W1 is not redirectable staff are to try change of face and stay with h/h to prevent altercations. On September 15, 2023, Alleged victim (AV) and W1 were engaged in a physical resident-on-resident altercation; W1 hit AV in the face causing AV to fall to the ground and sustain significant injuries to the left side of AV’s head, face, and neck area. AV complained of headaches and pain, was given PRN medication, AV was sent to the hospital and continued to complain of pain for several days. The facility failed to implement proper interventions and address W1’s known aggressive behaviors towards other residents leading to a resident-on-resident incident which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) is a resident of the facility and relies on facility staff to ensure AV's personal cares, safety, and supervision requirements are met. AV has a known, all history. Per AV care plan, AV has a poor gait and needs reminders to use AV's assistive devices , staff are to check on AV 4-times per day to see if AV needs toileting assistance, staff are to check on AV no less than 4 times per shift, staff are to ensure AV's blankets are tucked into AV's bed to prevent AV from falling. AV did not always remember to use AVs call pendant. On or about September 15, 2023, AV fell in AV's room, sustaining a skin tear to AV's right arm. AV fell when attempting to self-transfer out of AV's bed to get to the bathroom and tripped over the sheet that was dangling off the bed. The facility to follow AV's care plan, which led to AV falling and sustaining injury, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) had a history of falling when ambulating to the restroom that was known to the facility prior to September 4, 2023. AV’s care plan did not include any interventions related to preventing falls when ambulating. On or about September 4, 2023, AV was found on the floor after s/he had gotten up to go to the bathroom and in the process lost h/h balance and fell. AV suffered a head injury and a skin tear to h/h elbow. The facility failed to appropriately care plan and implement reasonable person-centered fall interventions to address AV’s prior falls, which is violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. AV has difficulty walking due to the loss of use on one side, drags one foot and is unsteady. AV’s service plan dated July 30, 2023, indicates AV is independent with transfers, ambulation; and uses a walker to assist with ambulation. AV has a fall history and had approximately thirty-six (36) falls between July 5, 2022, and August 22, 2023. On or about August 28, 2023, AV hit h/h shoulder on the door frame of the bathroom which caused AV to lose h/h balance and fall to the ground resulting in AV breaking h/h humerus bone. AV had two (2) additional falls on August 29, 2023, and a fall on August 30, 2023, all resulting in pain. The facility failed to provide a safe environment and implement appropriate interventions to mitigate AV’s falls, which is violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) lives in a locked memory care unit and relies on the facility for h/h needs and safety. AV service plan dated on or about June 19, 2023, indicates AV has poor memory, requires staff escort dinning for meals, has poor gait, uses an assistive device (AD) (cane, walker), needs reminders to use AD, and staff to ensure walker is within reach. AV is a two-person transfer, and two people assist to standing position. AV has a fall history, with interventions in place. Staff to check on AV no less than 4 times a shift, encourage AV to use walker instead of can when weak and tired, Keep AV's room free from clutter. On or about August 14, 2023, was walking in the community area without h/h walker and tripped on another resident’s walker and fell. AV his h/h head sustained a black eye and bruise to the left forearm. The facility failed to follow AV's care plan resulting in a fall resulting in injury and pain, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) has a history of falls and is not consistent with using a cane or a walker. AV Service Plan, dated June 19, 2023, indicates AV has poor gait, has an assistive device of cane or walker, staff are to make sure that AV has AV's walker next to AV or within reach for safety. And AV can choose what ambulation device. Fall prevention included staff are to check on AV no less than 4 times a shift and when AV is weak or tired encourage h/h to use walker instead of a cane. On or about September 1, 2023, AV was trying to open another resident’s door when s/he fell and hit h/h head on the doorway. AV has had previous falls when trying to enter into other residents rooms. There are no TSP to address AVs ongoing falls until September 5, 2023. The facility failed to appropriately care plan and implement reasonable interventions to address AV’s falls, which is violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) has a history of falls and is not consistent with using a cane or a walker. AV Service Plan, dated June 19, 2023, indicates AV has poor gait, has an assistive device of cane or walker, staff are to make sure that AV has AV's walker next to AV or within reach for safety. And AV can choose what ambulation device. Fall prevention included staff are to check on AV no less than 4 times a shift and when AV is weak or tired encourage h/h to use walker instead of a cane. ISP dated on or about September 5, 2023, indicates if staff see AV without h/h walk for extended periods of time they are to offer AV to switch to h/h wheelchair and get AV a snack. On or about September 9, 2023, AV was using h/h walker and walking around the facility, AV fell down after losing h/h balance and hit h/h head on the wall. The facility failed to appropriately care plan and implement reasonable person-centered interventions to address AV’s increase and ongoing falls, which is violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) has a history of falls and is not consistent with using a cane or a walker. AV Service Plan, dated September 11, 2023, indicates AV requires staff to take h/h to the dining room for meals, has poor gait, has an assistive device of walker or wheelchair, AV needs transferring assistance daily, AV is a one person transfer assist to and standing position, staff are to check on AV no less than 4 times a shift and when AV is weak or tired encourage h/h to use walker instead of a cane, After dinner staff are to walk AV back to h/h room, if staff see AV without h/h walker they are to stay with AV as they are to radio for someone else to get AV's walker. On or about September 15, 2023, TSP indicates staff are to offer to help AV back to h/h room to rest if s/he is wandering after a meal. On or about September 18, 2023, AV was in the unassisted dining room, AV was getting up from h/h chair in the dining room without using h/h wheelchair or walker, AV had socks on, and lost h/h balance falling forward and hit head on the ground. The facility failed to provide a safe environment and follow AV's care plan, which is violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) has a history of falls and is not consistent with using a cane or a walker. AV Service Plan, dated September 11, 2023, indicates AV requires staff to take h/h to the dining room for meals, has poor gait, has an assistive device of walker or wheelchair, AV needs transferring assistance daily, AV is a one person transfer assist to and standing position, staff are to check on AV no less than 4 times a shift and when AV is weak or tired encourage h/h to use walker instead of a cane, After dinner staff are to walk AV back to h/h room, if staff see AV without h/h walker they are to stay with AV as they are to radio for someone else to get AV's walker. On or about September 23, 2023, AV was brought down to the dining room for breakfast when staff noticed AV had a black eye from unknown origin. It is suspected AV walked into a wall or had an unwitnessed fall. The facility failed to provide a safe environment, which is violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) has a history of falls and is not consistent with using a cane or a walker. AV Service Plan, dated June 19, 2023, indicates AV has poor gait, has an assistive device of cane or walker, staff are to make sure that AV has AV's walker next to AV or within reach for safety. And AV can choose what ambulation device. Fall prevention included staff are to check on AV no less than 4 times a shift and when AV is weak or tired encourage h/h to use walker instead of a cane. On or about August 8, 2023, AV was attempting to enter another resident’s room when W1 tried to stop AV from entering. W1 was attempting to redirect AV by hold onto both AV hands, resulting in AV falling and sustaining a skin tear to AV's left forearm. The facility failed to appropriately care plan and implement reasonable interventions to address AV’s falls, which is violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide a safe environment and appropriate services according to the Alleged Victim (AV)’s needs, resulting in significant injury after AV fell, and hit h/h on the ground. AV was transported to the hospital and was admitted with a brain bleed. Documentation provided to the department shows On or about August 04, 2023, at approximately 8:00pm, AV was administered a dose of Behavioral Health Medication 75mg and is to be monitored for side effects that include drowsiness, dizziness, and fatigue. Staff were not present with AV when s/he was ambulating in the common area/dining room at the time of h/h fall. The facility failed to provide adequate supervision and care to AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care and assistance with toileting. On or about August 01, 2023, AV pushed call light for assistance in the bathroom, and waited approximately one (1) hour and thirty-one (31) minutes, causing physical exhaustion and unreasonable discomfort. The facility failed to answer call light in a timely manner, 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. AV service plan indicates AV has poor short-term memory, vision is diminished, has issues with h/h peripheral vision, does not wear glasses, needs assistance when sitting due to AV's vision, staff are to escort AV to meals and AV is independent in ambulation and transfers. AV is known to walk around the facility most of the day. The only intervention documented is to remind AV to use handrails while ambulating. On or about June 11, 2023, staff notice bruising of unknown origin to AV's left eye, left knee and right upper arm. Staff could provide no other explanation for AV's injuries other than that they were from AV bumping into things. The facility failed to appropriately care plan and implement reasonable interventions to address AV’s visual impairment, and ambulating of the facility, which is violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. AV has a history poor balance, decreased mobility, and falls. AV uses a walker and wheelchair for ambulation. AV has had approximately Ten (10) falls in 2023, resulting in AV hitting h/h head, compression fractures, back pain, red mark on the middle of h/h back and a skin tear on h/h right elbow and visible emotional distress related to falls. The facility failed to appropriately care plan and implement reasonable interventions to address AV’s increasing and ongoing falls, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide appropriate services according to the Alleged Victim (AV)’s needs and ensure physician orders were followed sufficiently resulting in AV significant weight loss. AV Service plan indicates AV doesn't eat independently, staff are to escort AV to meals as well as provide snacks and drink twice a day to assist with hydration and nutrition, cut food and cue AV to eat, staff should attempt to give AV bites of food, Encourage AV to sit with specific residents that AV is most likely to stay at the table and eat with. If AV gets up from eating, staff are to encourage AV to return to the meal. If AV does not eat a meal, staff should provide a peanut butter and jelly sandwich to AV. Staff should place sandwich in AV's hand and cue AV to eat. Staff are to assist with feeding AV for every meal. AV’s weight continued to decrease, facility received physician orders for enhanced nutritional shakes with staff observation to ensure consumption and ordered staff should place themselves at a lower level in front of AV when feeding AV as AV is likely to be more receptive to feeding in that manner. In a span of four months, AV lost a total of 57.6 pounds. There is sufficient information to indicates that the facility failed to ensure physician orders were followed. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility for his or her safety. The facility has no procedure for alerting staff of new residents’ arrivals except through word of mouth and no clear way to differentiate between visitors and residents. On or about February 15, 2023, AV moved into the facility, and on February 16, 2023, AV followed Alleged Perpetrator #2 (AP2) out a back door and stopped, AV told AP2 s/he forgot the code for the second door that leads outside the facility. AP2 “punched” in the code and AV walked outside. AV was found out front of the building approximately ten (10) minutes later. The facility parking lot is across from a highway. The facility failed to provide a safe environment, which is a violation of resident rights is considered neglect of care and constitutes abuse. AP2 did not receive information about AV being a new resident and did not recognize AV as a resident. The Allegation that AP2 failed to provide a safe environment was investigated and the determination was not substantiated.

Alleged Victim (AV) relies on the facility for a safe environment. Witness 1 (W1) has history of aggression with staff/residents, and wheeling AV into W1 room engaging in social misbehavior. Facility implemented a door alarm on W1 door, redirecting W1 when wandering the community and going into other resident’s room. Facility also determined that W1 required one-on-one staff supervision to ensure safety of other residents. On or about January 24, 2023, AV was found outside W1 room. Facility camera reviewed, W1 wheeled AV into W1 room for approximately 15 minutes before wheeling AV back into the hallway. 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 resident-to-resident altercations and acting as though s/he is going to “ram” other residents with h/her wheelchair. On or about November 07, 2022, W1 approached Alleged Victim (AV) aggressively; AV attempted to avoid W1 by walking faster and sideways. AV fell, hitting h/h head and sustaining a laceration to h/h forehead and an abrasion to h/h elbow. The facility failed to properly plan care and provided interventions appropriate to mitigate W1 continued aggressive behaviors towards other residents which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) has history of elopement, Self-harm, and behavioral health episodes. On or about November 01, 2022, AV exited the facility behind a visitor leaving the facility. AV walked to the highway where s/he attempted to walk into oncoming traffic while making suicidal statements. The facility failed to provide a safe environment, appropriately care plan, and have interventions in place around AV's behaviors which is a violation of resident’s rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) has history of exit seeking behaviors. On or about October 19, 2022, a TSP was put into place; engage AV with tasks, walk and provide conversation, provide a calm quiet space, and administer PRN medication. AV is documented to exit seek multiple times after TSP, threaten self-harm behavior and have aggressive behavior towards staff. On or about October 24, 2022, AV climbed out of a facility window and attempted to climb over the courtyard fence, when staff intervened. Later that day AV climbed out h/h apartment window and walked to the front door of the facility to let staff know s/he was going home. The facility failed to provide a safe environment, implement new interventions, and have an appropriate safety plan following AV's continued exit seeking behaviors and demonstrated ability to exit the facility, which is a violation of resident’s rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) has a history of wandering around the facility, wandering into other resident rooms, touching other resident’s belongings and resident to resident altercations as a result. On or about August 22, 2022, AV wandered into Witness 2 (W2) room and a verbal altercation started, between Witness 1 (W1), (W2) and AV. The situation escalated between the residents and resulted in scratches to AV face, chin, and forehead. The facility failed to properly plan care and provided interventions appropriate to mitigate AV wandering into other resident’s rooms, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about August 11 ,2022, AV eloped from the facility and was found by Witness 1 (W1). Camera show staff left one of the back doors propped open during the food delivery when AV left the facility. AV’s service plan has AV noted for wandering and history of exit seeking. The facility failed to provide a safe environment, which is a violation of resident’s rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) was diagnosed with an infection of the urinary system that contributed to four falls between, August 03, 2022, to August 07, 2022. AV experienced pain, a cut to h/h head, skin tears, and five fractured ribs. The facility failed to appropriately adjust AVs care plan and implement reasonable person-centered interventions to address AVs ongoing falls, which is a violation of resident’s rights is neglect of care and constitutes abuse.

Witness #1 (W1) has a history of inappropriate behaviors with other residents and wandering around the facility. Alleged Victim (AV) has a history of leading other residents into h/h bed. On or about June 23, 2022, W1 wandered into Alleged AVs room and were found together in AVs bed engaging in inappropriate behaviors. The facility’s failure to follow W1s care plan and to properly plan care and provide interventions appropriate to mitigate AVs inappropriate behaviors, placed both residents at risk of serious harm, 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 AV’s medication orders were administered as ordered. It was discovered that AV had not received his/her medication on at least four (4) occasion placing AV at 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 a history of inappropriate behaviors with other residents and wandering around the facility. Alleged Victim (AV) has a history of leading other residents into h/h bed. On or about June 09, 2022, W1 wandered into Alleged AV room and were found together in AVs bed placing AV at risk of serious harm. The facility failed to properly plan care and provided interventions appropriate to mitigate W1 wandering and inappropriate behaviors, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) and Witness 1 (W1) have history of verbal altercations and aggressive behavior with other residents. On or about June 06, 2022, AV and W1 behaviors escalated from verbal incident to physical incident resulting in both falling to the ground. The facility failed to appropriately adjust care plans and implement reasonable interventions to address AVs and W1s continued aggressive behaviors, 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 AV’s medication orders were administered as ordered. It was discovered that AV had not received his/her medication on at least one occasion placing AV at risk of serious harm. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide appropriate services according to the Alleged Victim (AV)'s needs, relating to his/her change of condition, rapid weight loss and behaviors. AV experienced significant weight loss, skin injuries as a result of behaviors and went without medications. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

AV has a history of falls and frequently falling forward out of h/h wheelchair. On or about March 11, 2022, AV fell forward from h/h wheelchair, and sustained a skin tear to upper lip. The facility did not have a service plan in place, which provided interventions, care and services appropriate for AVs continued falls out of h/h wheelchair, which is a violation of resident’s rights is neglect of care and constitutes abuse.

The facility and Alleged Perpetrator #2 (AP2) failed to put interventions in place to address Alleged Victims (AVs) significant change in condition and failed to provide services to care for AVs pressure ulcers. AV experienced pain and unreasonable discomfort. AP2’s actions are a violation of resident rights, are considered neglect of care and constitutes abuse. The facilities 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 has a history of falls. The facility failed to appropriately care plan regarding Alleged Victim (AV) falls to ensure safety. AV fell on or about November 22, 2021, sustaining a laceration above his/her right eye. The AV was transported to the Emergency room for treatment and received staples. The facility failed to appropriately care plan and implement reasonable interventions to address AV’s increasing and ongoing falls, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to ensure that the interior was free from unpleasant odors. An investigation determined this is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during a site visit on 09/25/25, the facility's failure to ensure behavioral symptoms that negatively impact the resident and others in the community must be evaluated and included in the service or care plan was substantiated for 1 of 1 sampled residents (# 1). The facility's failure to ensure behavioral symptoms that negatively impact the resident and others in the community must be evaluated and included in the service or care plan was substantiated.

Alleged Victim (AV) resides in the Respondent’s facility and depends on facility staff to meet AV’s daily care needs. AV’s service plan indicates that facility staff are responsible for administering AV’s medications in accordance with the physician’s orders. AV is prescribed a medication patch, and the physician’s order specifies that the previously applied patch must be removed prior to applying a new one. On or about September 19, 2025, Witness 2 (W2) was administering AV’s medication patch and discovered that AV had two patches already in place. Alleged Perpetrator 2 (AP2) had not removed the prior patch before applying a new one. As a result, AV had two previously applied patches remaining on their skin. AP2’s actions constitute neglect of care and meet the definition of abuse. Additionally, the facility failed to maintain a safe medication administration system, which is a violation of Oregon Administrative Rules.

It was determined 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. An investigation determined a licensing violation had occurred.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

Alleged Victim (AV) lives and relies on the Respondent's facility staff to ensure AV's basic care, safety and supervision requirements are met. AV has history of pain in AV's knee and back, and decreased range of motion. AV's service plan reflects staff should go slow and be attentive if AV states that something hurts during cares. However, the facility failed to ensure a safe environment for AV while receiving basic care. Alleged Perpetrator #2 (AP2) received and acknowledged receipt of trainings necessary to provide care to residents. On or about August 21, 2025, AP2 forcefully brought AV's legs up beyond what was safe or comfortable for AV while providing care to AV, causing AV pain. AP2’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failure is a violation of Oregon Administrative Rules.

Alleged Victim (AV) lives and relies on the Respondent's facility staff to ensure AV's basic care, safety and supervision requirements are met. Alleged Perpetrator #2 (AP2) is a facility staff member employed by the Respondent and is responsible to provide care to AV. AP2 received and acknowledged receipt of trainings necessary to provide care to residents. On or about August 21, 2025, AP2 and Witness #3 (W3) were providing assistance to AV, when AV started yelling in pain. AP2 was mimicking and using derogatory language towards AV. AP2’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failure is a violation of Oregon Administrative Rules.

Alleged Victim (AV) lives and relies on the Respondent's facility staff to ensure AV's basic care, safety and supervision requirements are met. Alleged Perpetrator #2 (AP2) is a facility staff member employed by the Respondent and is responsible to provide care to AV. AP2 received and acknowledged receipt of trainings necessary to provide care to residents. On or about August 21, 2025, AP2 grabbed AV's wrists and held them down against AV's chest. AP2’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failure is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to have an Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population, their needs, and all required Activities of Daily Living (ADL). Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. Facility was not 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.

Based on the interview and record review, conducted during a site visit on 08/21/25 to 08/22/25, the facility's failure to implement monitoring requirements was substantiated for 1 of 1 sampled resident (#1). Findings include, but are not limited to: A review of Resident 1’s interim service plans (ISP) for August 2025 indicated the following: 08/13/25 at 01:28 pm, ISP had not listed an event or interventions, however, included 16 staff signatures of acknowledgment. 08/13/25 at 06:10 pm ISP included 21 staff signatures of acknowledgment. A review of staff schedules for 08/13/25 through 08/16/25 indicated 12 direct care staff working who had not read and signed Resident 1's ISP dated 08/13/25 at 06:10 pm. An interview with Staff 1 (Executive Director) stated the following: Resident 1 had temporary service plans (TSP) in August 2025 with interventions. Added monitoring to Resident 1’s August 2025 medication administration record. The TSP binder is to be read and signed by staff each shift. Interview with Staff 2 (Caregiver) confirmed they are not given time to read the TSP binder each shift. The facility's failure to implement monitoring requirements was substantiated.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility’s failure to provide records to the Department upon request was substantiated.

Alleged Perpetrator 2 (AP2) failed to provide a safe medication administration system to ensure the Alleged Victim's (AV) medications were administered as ordered. On or about April 26, 2025, AP2 administered AV an additional does of metabolic medication. AP2 did not check AV's MAR before administering the medication. AV started exhibiting adverse reactions, EMS was called, and AV was transported to the hospital for observation and treatment. AP2's actions are considered neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system 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 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.

Based on interview and record review, conducted during an investigation on 07/07/25, the facility’s failure to provide records to the Department upon request was substantiated. Findings include, but are not limited to: A review of electronic communication, dated 06/04/25, indicated the Department requested documents related to the facility’s Acuity-Based Staffing Tool (ABST) alleged event date 05/30/25. The facility had not provided all requested documentation by the due date of 06/05/25. An interview with Staff 1 (Executive Director) acknowledged that the facility had received the Department's request for documentation and had not provided the documents. The facility’s failure to provide records to the Department upon request was substantiated.

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 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.

Based on observation and interview, conducted during a site visit on 07/07/25, the facility’s failure to provide a manually operated emergency call system in each toilet and bathing facility used by residents and visitors was substantiated for 1 of 1 sampled residents (#1). Findings include, but are not limited to: Compliance Specialist (CS) was unable to interview Resident 1 or make observations as s/he was no longer in the facility. The following observations were made: No manually operated emergency call system in the bathroom, where Resident 1 had resided. An interview with Staff 1 (Executive Director) was conducted. S/He indicated the facility was required to have a manually operated call system beside each resident's bed and in the bathrooms. It was determined the facility’s failure to provide a manually operated emergency call system in each toilet and bathing facility used by residents and visitors was substantiated.

Based on interview and record review, conducted during a site visit on 02/05/25, the facility’s failure to provide records to the Department upon request was substantiated. Findings include, but are not limited to: A review of electronic communication showed the Department requested documents related to the facility's APS ABST alleged event date of 11/27/24 on 12/12/24. The facility did not provide all requested documentation by the requested due date of 12/13/24. The facility’s failure to provide records to the Department upon request was substantiated.

Based on interview and record review, conducted during a site visit on 02/05/25, the facility’s failure to provide records to the Department upon request was substantiated. Findings include, but are not limited to: A review of electronic communication showed the Department requested documents related to the facility's APS ABST alleged event date of 11/29/24 on 12/12/24. The facility did not provide all requested documentation by the requested due date of 12/13/24. In an interview on 02/05/25, Staff 1 (Executive Director) acknowledged the records were not provided to the Department in a timely manner. The findings were reviewed with and acknowledged by Staff 1 on 02/05/25. The facility’s failure to provide records to the Department upon request was substantiated.

Based on interview and record review, conducted during a site visit on 02/05/25 and an email correspondence on 02/13/25, the facility’s failure to provide records to the Department upon request was substantiated. Findings include, but are not limited to: A review of electronic communication showed the Department requested documents related to the facility's APS ABST alleged event date of 01/06/25 on 02/07/25. The facility did not provide all requested documentation by the requested due date of 02/08/25. In an interview on 02/05/25, Staff 1 (Executive Director) acknowledged the records were not provided to the Department in a timely manner. The facility’s failure to provide records to the Department upon request was substantiated.

Based on interview and record review, conducted during a desk audit on 03/06/25, the facility’s failure to provide records to the Department upon request was substantiated. A review of electronic communication showed the Department requested documents related to the facility's APS ABST alleged event date of 01/09/25 on 02/14/25. The facility did not provide all requested documentation by the requested due date of 02/14/25. A phone interview on 03/06/25, Staff 1 (Executive Director) acknowledged the records were not provided to the Department in a timely manner. The facility’s failure to provide records to the Department upon request was substantiated.

On or about October 09, to October 10, 2024 AV was found soaked in urine. AV care plan indicates staff are to check AV no less than four times a shift, and reposition AV each time. During checks AV is to have brief checked for urine and stool, if AV is soiled AV is to be cleaned and changed into a new brief. Alleged Perpetrator 2 (AP2) was responsible for AV's section on or about October 09, to October 10, 2024. The facility failed to provide oversight, and make sure Alleged Victim's care plan was being followed, which violates Oregon Administrative Rules. The Alleged Perpetrator failed to follow AV care plan. AP2’s actions are a violation of resident rights, considered neglect and constitutes abuse.

The Alleged Victim (AV) is full assist with toileting and was care planned to be toileted beginning, middle and end of each shift. On or about October 9, 2024 and October 10, 2024, during night shift, AV was only checked on one time, at 2:09 AM, according to documentation. Alleged Perpetrator #2 (AP2) was working this shift and was responsible for the section that the AV was in. On the morning of October 10, 2024, AV was found soaked in urine head to toe in his/her room. AP2 had not changed AV the entire shift, leaving AV in unreasonable discomfort. AP2's actions are a violation of resident rights, are considered neglect of care and constitute abuse.

The Alleged Victim (AV) is a one person transfer assist with transferring and needs daily assistance, reminders, cues and standby for toileting and was care planned to be checked on at least 4 times per shift. On or about October 9, 2024 and October 10, 2024, during night shift, AV was not checked on during this shift at all. Alleged Perpetrator #2 (AP2) was working this shift and was responsible for the section that the AV was in. On the morning of October 10, 2024, AV was found soaked in urine head to toe in his/her room. AP2 had not changed AV the entire shift, leaving AV in unreasonable discomfort. AP2's actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility's failure is a violation of Oregon Administrative Rules.

Respondent has shown a long and repeated history of substantial non-compliance. The Department has attempted to work with Respondent to make corrections, including through participation in the FEOS program. To the extent that corrections have been made in the past, Respondent shows a pattern of renewed substantial non-compliance.

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 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 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 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.

Based on interview and record review, conducted during a desk audit on 03/06/25, the facility’s failure to provide records to the Department upon request was substantiated. A review of electronic communication showed the Department requested documents related to the facility's APS ABST alleged event date of 08/22/24 on 02/28/25. The facility did not provide all requested documentation by the requested due date of 02/28/25. A phone interview on 03/06/25, Staff 1 (Executive Director) acknowledged the records were not provided to the Department in a timely manner. The facility’s failure to provide records to the Department upon request was substantiated.

The facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules.

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

On or about May 08, 2024, Staff 1, stated Staff 7 was discovered sitting in Resident 5's recliner chair using his/her cell phone, while Resident 5 was sleeping. Record review of a Corrective Action Form, dated April 19, 2024, confirmed Staff 7 sat in Residents 5's recliner during his/her shift. It was determined the facility failed to implement a resident's right to be treated with dignity and respect.

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

The facility failed to have medical and other records kept confidential. During the investigation it was observed that two medication carts were left unattended, with the computers unlocked and residents medication administration records open. An investigation determined this is a violation of Oregon Administrative Rules.

On or about March 13, 2024, Staff 1 indicated, there had been a resident-to-resident altercation with Resident 1 and Resident 2 that had not been reported timely. A review of Resident 1's incident report for a resident-to-resident altercation which occurred on December 28, 2023, had not been reported until January 08, 2024. A review of Resident 1's progress notes dated December 20, 2023, through January 09, 2024, indicated on December 28, 2023, Resident 1 was on alert charting for a resident-to-resident altercation with Resident 2. On January 09, 2024, a skin note indicated a purplish bruising on left eye as a possible result of altercation on December 28, 2023. A review of the med tech training manual indicated [When an unusual even such as falls, injuries, or altercations, occurs, the first responder must prepare an incident report. The MT was responsible for completing the action steps, including progress notes, IPS, alert charting, notifications, and adult protective services reporting.] It was confirmed the facility failed to immediately notify the local Department office, or the local AAA, of any incident of abuse or suspected abuse.

On or about March 12th and 13th, 2024 Staff 1 indicated, there had been a resident-to-resident altercation with Resident 1 and Resident 2 that had not been reported timely. A review of Resident 1's incident report for a resident-to-resident altercation which occurred on December 28, 2023 had not been reported until January 08, 2024. A review of Resident 1's progress notes dated December 20, 2023, through January 09, 2024, indicated on December 28, 2023. Resident 1 was on alert charting for a resident-to-resident altercation with Resident 2. On January 09, 2024, a skin note indicated a purplish bruising on left eye as a possible result of altercation on December 28, 2023. A review of the med tech training manual indicated [When an unusual even such as falls, injuries, or altercations, occurs, the first responder must prepare an incident report. The MT was responsible for completing the action steps, including progress notes, IPS, alert charting, notifications, and adult protective services reporting.] It was confirmed the facility failed to immediately notify the local Department office, or the local AAA, of any incident of abuse or suspected abuse.

Alleged Victim (AV) has behaviors including screaming, spitting, hitting and kicking. Alleged Perpetrator 2 (AP2) was hired by the facility on or about September 27, 2023. AP2 received training by the facility as to appropriately care for and interact with AV and other residents of the facility. AP2’s training included abuse reporting, a commitment to kindness, harmful behavior procedures, communicating with residents, and managing burnout. On or around December 26, 2023, AP2 had disciplinary action related to AP2 told AV, “If you want to see an asshole you should look in the mirror,” and AP2 told AV that AP2 would hit AV if AV hit AP2. AP2 spoke to the residents in ways that lacked dignity and respect and was considered abusive. When Witness 1 (W1) confronted AP2 about the verbal abuse allegations, AP2 did not deny the allegations. AP2 verbally abused AV by using derogatory and threatening language towards AV when AP2 said to AV, “If you want to see an asshole you should look in the mirror,” and told AV that if AV hit AP2 that AP2 would hit AV back, which resulted in a serious loss of AV’s personal dignity. . The facility failed to protect AV from verbal/emotional abuse which is a violation of Oregon Administrative Rules.

On 12/19/23, CS observed the following: • An unsampled guest enter the facility while having said, "pew " and having pinched his/her nose with his/her fingers. • A strong odor of urine in the main common area space and throughout the hallways. During an interview on 12/19/23, Staff 3 (MT) acknowledged the facility had a strong urine smell. On 12/19/23, it was confirmed the facility failed to ensure the interior of the facility was free from unpleasant odors.

On 12/19/23, CS observed deceased Resident 1 to have 15 doses of Lorazepam 1mg and 2ml of Morphine, as well as Resident 2's four packets of Lorazepam .5mg and 21.5ml of Morphine having been stored in the medication cart.on 12/19/23, Staff 2 (MT) stated, "There are two deceased resident's Lorazepam and Morphine in my medication cart. Med techs can destroy medications that are not narcotics. The narcotics are destroyed by a Nurse and the ED." Staff 2 indicated Resident 1 had passed away on 11/30/23 and Resident 2 had passed away on 12/09/23. Staff 1 (ED) stated, "The facility does not have a specific policy and procedure for the disposal and destruction of narcotics. The facility does not have a time frame of when narcotics are to be destroyed, we will typically do it within a month. The Nurses and I have not been at the facility at the same time to have destroyed those medication yet." A review of the facility's tracking-controlled substance record book indicated Resident 1 and Resident 2's Lorazepam and Morphine had yet to be destroyed. It was confirmed the facility failed to ensure a system for disposal of all unused, outdated, or discontinued medications administered by the facility for 2 of 2 sampled residents' (#s 1 and 2).

Alleged Victim (AV) Service Plan, dated August 30, 2023, AV can understand and be understood and is occasionally disoriented to time. AV can make simple decisions, Mobility: AV is able to walk independently with walker, staff are to ensure walker is always within reach. Fall Prevention: AV has Incontinence and Balance Issues. Staff will follow a routine toilet schedule - before/after each meal, and including beginning, middle and end of shift. Toileting: AV is incontinent of bowel and bladder and needs assistance when toileting, most of the time, AV can change themself and use the restroom independently, however there may be days (very rarely) where staff will need to provide hands on assistance to AV. On or about October 20, 2023, AV stated that s/he pulled h/h call light for toileting assistance and was left waiting for an hour. The call light report does not reflect any call lights on October 20, 2023, and 1 call light of about 5 minutes on October 19, 2023. The call light system does not work in a reliable manner reported by facility staff. It is unclear if AV only used the call light once during the two-day period, or if the call light system is not recording entries properly. AV’s care plan contradicts itself when it states that AV is incontinent and needs assistance toileting and that AV only very rarely needs hands on assistance for toileting and AV’s service plan does not provide instructions to staff on how to provide care for AV when s/he has diarrhea and needs increased assistance, which is a violation of Oregon Administrative Rules.

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

on 12/19/23, Staff 1 (ED) stated, "The facility did have a covid outbreak in April, however, I was on vacation at the time. I had informed the County." A review of an email correspondence from Staff 1 to Benton County on 04/14/23 indicated the facility had notified the local public health of the covid outbreak. An email correspondence with the facility's policy analyst and the CS indicated the facility had not notified the Department of the covid outbreak in April 2023. On 12/19/23, it was confirmed the facility failed to notify the Department's Central Office immediately of the occurrence of epidemic disease in the facility. Findings include, but are not limited to:

On or about March 01, 2023, 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 for a total of 30 days.

Alleged Victim (AV) is a fall risk and is care planned to have frequent checks (beginning, middle, end of each shift and as needed). On or about November 23, 2022, AV was found on the floor of h/h room with multiple skin tears to the side and back of h/h right arm and abrasion to h/h upper right back. Alleged Perpetrator #2 (AP2) did not complete a safety check on AV for approximately five (5) hours per video review. AP2’s actions are a violation of resident rights, are considered neglect of care and constitutes abuse. The facility failed to provide a safe environment, which is a violation of Oregon Administrative Rules.

On or about November 01, 2022 the Oregon Health Authority reported to the Department that Responded 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 for a total of 30 days.

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 July 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 June 1, 2022 to June 30, 2022, for a total of 30 days.