Brookdale Geary Street

According to the documentation, the facility failed to care plan for increased ADL needs for the Alleged Victim (AV) after they sustained an injury fall which increased their care needs. On or about December 29, 2024, the AV sustained an injury fall down the stairwell. After this fall, the AV required more assistance with ADLs and assistance with transferring to use the bathroom. Staff were to check on the AV 8 times a shift to ensure the resident did not try to self-transfer and to assist with the restroom. A service plan update indicated the AV was at a higher risk of skin breakdown due to their change of condition and staff were to notify the appropriate staff if there were signs of skin breakdown. On or about January 06, 2025, the AV was found to be sitting in a pool of loose liquid stool and a stage 2 pressure sore was found in the AV’s groin area. The facility failed to implement appropriate interventions to ensure skin breakdown did not occur, leading to a new pressure sore, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to properly care plan appropriate interventions for the Alleged Victim’s (AV) known history of falls resulting in injury. On or about December 23, 2024, the AV’s service plan was updated with a change in cognitive status and an increase in hallucinations. On or about December 28 and 29, 2024, the AV experienced two injury falls, one on each date resulting in skin tears and other injuries. The facility knew AV had a change of condition which increased their risk of falls but did not properly care plan to prevent future falls, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to provide showers appropriately to the Alleged Victim (AV). During interviews with the AV, it was determined the AV requested showers at least three times a week. it was documented the facility is providing the AV with one shower a week. The failure to provide weekly showers per the AV request has resulted in unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to follow doctor’s orders to provide a cushion for the Alleged Victim’s (AV) wheelchair to prevent skin breakdown. On or about October 30, 2024, the AV received orders for a cushion. There was no documented evidence the facility ordered the cushion until approximately December 16, 2024. The failure to follow doctor’s orders and provide a seat cushion put the AV at risk of harm to develop or have their current wounds worsen, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to administer prescribed blood pressure medication for the Alleged Victim for approximately four days. From approximately November 05, 2024, through November 08, 2024, the facility failed to administer the AV blood pressure medication due to ordering it late from the pharmacy. When the medication was delivered, the medication was misplaced so it was not accounted for. The facility did not monitor the AV’s blood pressure placing them at risk for serious harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to administer prescribed medication to the AV, leading them to miss many doses of the medication. In the month of October of 2024, it was documented the facility failed to administer approximately 16 dosed of the AV blood pressure medication. The facility documented the medication as being out of stock as the reason it was not administered. The facility failed to have medication on hand and administered the medication as prescribed, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to administer the Alleged Victim’s muscle relaxant medication as prescribed, leading to increased pain. On or about November 05, 2024, the AV asked for their as needed muscle relaxant medication as they were experiencing pain. The facility did not have the medication on hand and were unable to administer the medication as prescribed causing the AV to experience pain, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to follow the care plan for incontinence care to the Alleged Victim (AV) after experiencing periods of incontinence. On multiple occasions, the AV was found with dried feces and urine on them. Documentation shows there was an incident where feces was found on the AV’s catheter tube. The facility failed to follow the care plan for incontinence care for the AV, causing pain and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to provide a safe medication administration system for the Alleged Victim (AV) to ensure they received their medications as scheduled. From about August 23, 2024, through August 29, 2024, the AV was not administered Approximately three medication causing nausea, vomiting and withdrawal like symptoms. The AV was transported to the local hospital for treatment. The failure to provide a safe medication administration system is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to properly train staff to safely transfer the Alleged Victim (AV). On or about August 21, 2024, facility staff noticed bruises on the AV’s arms. The facility conducted an internal investigation and determined the bruises were likely to come from staff transferring the AV in a manner that led to the bruises. The facility’s failure to properly train staff on safe transfer techniques resulted in bruising to the arms of the AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to care plan appropriate fall interventions for the Alleged Victim’s (AV) known fall history. From approximately April 01, 2024, through June 29, 2024, the AV experience approximately nine injury and non-injury falls with no interventions to prevent falls. On or about July 26, 2024, at approximately 8:40 pm, the AV was found on the floor in their apartment. After evaluations, the AV was found to have sustained abrasions to their elbow and knee. The failure to properly care plan appropriate fall interventions to prevent injury is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to provide a safe medication administration system by administering the Alleged Victim’s (AV) pain medication later than scheduled. From approximately July 15, 2024, through July 19, 2024, the facility administered the AV’s pain medication over an hour late, causing the AV to experience increased migraine headache pain, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to provide a safe medication administration system for the Alleged Victim (AV) by failing to train the Alleged Perpetrator 2 (AP2) appropriately for medication administration. On or about July 14, 2024, (AP2) administered the AV another residents’ medications. Review of the documentation proved the facility failed to properly train the AP2 on medication systems before allowing them to administer medications. The AV suffered unreasonable discomfort due to the medication error, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to properly care plan appropriate fall interventions for the Alleged Victim’s (AV) known fall history. From approximately March 28, 2024, through June 26, 2024, the AV suffered approximately five falls with the only updates to the service plan was to ensure the AV’s apartment was free of clutter and encourage them to wear non-slip footwear. On or about June 27, 2024, the AV suffered another fall causing pain and unreasonable discomfort. The facility’s failure to implement appropriate fall interventions to prevent pain or unreasonable discomfort is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to ensure the timely re-order of the Alleged Victim’s (AV) narcotic medication. On or about April 17, 2024, the facility ran out of the AV’s prescribed narcotic medication and could not get the prescription refilled until approximately April 18, 2024. The failure resulted in the AV to miss approximately six scheduled doses of their narcotic medication which caused pain and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is a high fall risk with approximately 6 falls since January 2024. On or about March 11, 2024, AV was found laying face down next to his/her wheelchair bleeding from his/her head. AV was sent to the emergency room where he/she received stitches in his/her head. The facility's failure to ensure sufficient interventions were in place to ensure AV's safety from falling is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to properly care plan appropriate fall interventions for the Alleged Victim’s (AV) known fall history. On or about February 06, 2024, the AV experienced an unwitnessed fall, hitting their head. The AV has a history of falls suffering two falls previously on approximately December 05, 2023, and January 20, 2024, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to implement appropriate interventions for the Alleged Victim’s (AV) known fall history. On or about February 04, 2024, the AV experienced a fall, and the next day was found to have a large bruise on their back. The interventions put into place by the facility were not effective in preventing the AV from falling resulting in a large bruise and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to properly care plan for the Alleged Victim’s (AV) repeated falls resulting in the AV sustaining injuries. On or about April 16, 2024, the AV was suffered a fall and sustained an injury to their head. The AV’s service plan noted AV as a fall risk and needed assistance with transfers. The AV had been self-transferring which led to numerous falls with and without injury. The facility failed to properly care plan appropriate interventions to prevent the AV from falling, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide a safe environment to the Alleged Victim (AV). On or about December 14, 2023, AV was found outside the facility, without staff knowledge, resulting in a head laceration. AV was sent to the Emergency Department for treatment. AV experienced pain and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately care plan related to the Alleged Victim’s (AV) fall history. On or about November 10, 2023, AV suffered an unwitnessed fall, resulting in an injury to h/h hip. The failure resulted in AV experiencing pain and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide a safe environment and proper supervision according to the Alleged Victim’s (AV) wandering behavior. On or about October 16, 2023, AV wandered into other residents' room, engaging in a physical altercation, resulting in AV being scratched on h/h nose causing pain and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about June 28, 2023, the facility failed to ensure the Alleged Perpetrator 2 (AP2) (unknown) administered the Alleged Victim (AV) medication as ordered. According to documentation AV did not receive h/h behavioral medication and experienced unreasonable discomfort. AP2’s actions are considered neglect of care and constitutes abuse. The facility failed to ensure medication was administered as ordered, which is a violation of Oregon Administration Rules.

The facility failed to provide appropriate services for the Alleged Victim (AV). On or about July 28, 2022, approximately around 12:00am-12:30am, AV was found on the floor displaying agonal breathing. AV didn’t receive emergency services until approximately 1:26am. The facilities failure placed AV in risk of serious harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to documentation, On or about June 25, 2022, the facility failed to follow the Alleged Victim’s (AV) plan for a two person assist while changing AV’s briefs and AV’s care plan states staff is to reapproach AV if AV gets angry during the changing. The failure resulted in AV becoming angry with the care giver that came to assist AV and continued to assist while AV was angry. AV experienced unreasonable discomfort and a loss of dignity, which is a violation of resident rights, is considered neglect of care and constitute abuse.

The facility failed to administer medication as ordered for the Alleged Victim’s (AV). AV is to be given insulin daily two to three times a day depending on blood sugar levels. According to documentation H/S went without the medication on or about April 13, 2022, and April 20, 2022, putting AV at risk of serious harm. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse. The allegation that AP2 failed to provide medication as ordered was investigated and the determination was not substantiated.

The facility failed to provide appropriate services according to the Alleged Victim's (AV) needs. The failure resulted in AV being transported to the hospital for treatment, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to documentation the facility failed to follow The Alleged Victim (AV) care plan for assistants with eating. The failure resulted in AV losing weight and experiencing unreasonable discomfort. The facility failed to ensure care plans were followed, which is a violation of resident’s rights, is considered neglect of care and constitutes abuse.

The facility failed to provide a safe medication administration system to ensure Alleged Victim (AV) medication for pain was administered daily. He/she went without the pain medication on or about December 12, 2021, and December 13, 2021, resulting in AV at experiencing unreasonable discomfort. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide a safe medication administration system to ensure the Alleged Victim’s (AV) pain medication was available to be administered as ordered. He/she went without medication on at least six (6) occasions putting AV at risk of withdrawal symptoms and causing unreasonable discomfort. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide a safe medication administration system to ensure the Alleged Victim’s (AV) pain medication was available to be administered as ordered. He/she went without medication on at least ten (10) occasions putting AV at risk of withdrawal symptoms and causing unreasonable discomfort. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness 1 (W1) has history of inappropriate behaviors. On or about November 18, 2021, W1 had inappropriate contact with the Alleged Victim (AV). The facility failed to appropriately care plan and implement reasonable interventions causing risk of harm, or loss of dignity, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement, and appropriately care plan related to the Alleged Victim's (AV) skin condition on h/her head. The failure resulted in AV experiencing unreasonable discomfort and a loss of personal dignity, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility for a safe medication administration system. According to documentation AV frequently refused h/her medication, resulting in medications not being administered on a regular basis, placing AV at risk of harm. The facility failed to ensure a safe medication administration system, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to follow Alleged Victim’s (AV’S) care plan to assist with basic care needs, including bathing, and grooming. According to documentation AV’S dentures were not removed, and cleaned regularly, resulting in AV experiencing unreasonable discomfort and a loss of personal dignity. The facility failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Perpetrator 2 (AP2) made inappropriate verbal comments toward the Alleged Victim (AV) causing a loss of personal dignity. AP2 actions are considered neglect of care and constitutes abuse. The facility failed to protect AV from inappropriate verbal comments made by staff and the failure is a violation or Oregon Administrative Rules.

The facility failed to provide a safe medication administration system to ensure the Alleged Victim's (AV) medication was administered as ordered. The failure resulted in several incidents of AV not receiving his/her medication or receiving an additional dose causing risk of harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to documentation, the facility and AP3 failed to protect AV from involuntary seclusion; by failing to implement appropriate interventions, and providing adequate supervision and documentation, related to concerns of increased behaviors exhibited by W1. The failure resulted in AV going approximately one month without the ability to visit W1, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to documentation, the facility and AP4 failed to protect AV from involuntary seclusion; by failing to implement appropriate interventions, and providing adequate supervision and documentation, related to concerns of increased behaviors exhibited by W1. The failure resulted in AV going approximately one month without the ability to visit W1, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately care plan related to Witness 1’s (W1) known behaviors. On or about October 16, 2021, W1 was found inappropriately touching the Alleged Victim (AV) causing a loss of personal dignity, which is a violation of resident rights, is considered neglect of care which constitutes abuse.

The facility failed to implement interventions and appropriately care plan related to Witness 1’s (W1) known behaviors. On or about October 16, 2021, W1 was found inappropriately touching the Alleged Victim (AV) causing a loss of personal dignity, which is a violation of resident rights, is considered neglect of care which constitutes abuse.

The facility failed to implement interventions and appropriately care plan related to Witness 1’s (W1) known behaviors. On or about October 16, 2021, W1 was found inappropriately touching the Alleged Victim (AV) causing a loss of personal dignity, which is a violation of resident rights, is considered neglect of care which constitutes abuse.

The facility failed to have a safe medication administration system in place that was approved by a pharmacist consultant, registered nurse, or physician in accordance with OAR 411-054-0055(1); per complainant, a resident who self-administers was provided medication for another resident by the facility.

The facility failed to provide three daily, nutritious, palatable meals in accordance with OAR 411-054-0030(1)(a); per complaint the facility’s food is unpalatable and the facility forgets to order food for residents.

The facility failed to have a safe and homelike environment in accordance OAR 411-054-0027(1)(r); per complaint the kitchen manager can be heard yelling obscenities and making lewd comments during mealtimes.

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

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

The facility failed to fully implement and update an Acuity Based Staffing Tool (ABST) in accordance with OAR 411-054-0037.

The facility failed to ensure the implementation of services in accordance with OAR 411-054-0036(2)(g); per a complaint facility is not providing showers per service plan and residence preference.

The facility failed to provide direct care staff sufficient in numbers to meet the scheduled and unscheduled needs of each resident in accordance with OAR 411-054-0070(1); per a complaint there is only once caregiver on dayshift during the weekends.

The facility failed to provide three daily nutritious, palatable meals seven days a week in accordance to OAR 411-054-0030(1)(a); per complaint that the facility runs out of food.

The facility failed to provide three daily nutritious meals with snacks available seven days a week, in accordance with OAR 411-054-0030 (1) (a) per complaint the facility does not provide meals to residents when requested and as outlined in the service plan.

The facility failed to fully implement an Acuity-Based Staffing Tool (ABST). Time and frequency were unable to be determined by the facility's current internal assessment tool for all required 22 ADLs with staff time required to complete the care needs. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to develop and maintain acuity-based staffing in accordance with OAR 411-054-0037(1).

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

The facility failed to fully implement an Acuity-Based Staffing Tool (ABST). Time and frequency were unable to be determined by the facility's current internal assessment tool for all required 22 ADLs with staff time required to complete the care needs. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to carry out medication orders as prescribed in accordance with OAR 411-054-0055(1)(f) per complaint that a resident missed a dose of their medication.

The facility failed to fully implement an Acuity-Based Staffing Tool (ABST). Time and frequency were unable to be determined by the facility's current internal assessment tool for all required 22 ADLs with staff time required to complete the care needs. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to fully implement an Acuity-Based Staffing Tool (ABST). Time and frequency were unable to be determined by the facility's current internal assessment tool for all required 22 ADLs with staff time required to complete the care needs. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide three daily nutritious, palatable meals with snacks available seven days a week in accordance with OAR 411-054-0030(1)(a).

The facility failed to ensure a resident monitoring and reporting system is implemented 24-hours a day in accordance with OAR 411-054-0040(2).

The facility failed to provide a daily program of social and recreational activities in accordance with OAR 411-054-0030(1)(c).

The facility failed to ensure that the staff person who administers the medication must visually observe the resident take the medication in accordance with OAR 411-054-0055(1)(c).

The facility failed to provide three daily nutritious, palatable meals seven days a week in accordance with OAR 411-054-0030(1)(a).

The facility failed to make snacks available seven days a week in accordance with OAR 411-054-0030(1)(a).

The facility failed to complete background check in accordance with OAR 411-054-0025(2)(a)(C).

The facility failed to have a minimum of one-week supply of dry storage staple foods and store a minimum of two days' supply of perishable foods in accordance with OAR 411-054-0300(7)(e)(A-B). Per a complainant "the kitchen manager left employment last week and over the weekend the food supply was very limited because the facility did not place a food order with their vendor."

The facility failed to provide three daily, palatable meals in accordance with OAR 411-054-0030(1)(a) per a complainant residents are waiting so long for meal delivery breakfast is served after 10:00 am. Food delivered is cold.

The facility failed to have an appropriate hot water temperatures in accordance with OAR 411-054-0300(9)(a) per complaint of some residents not having hot water.

The facility failed to provide or arrange for transportation for social purposes in accordance with OAR 411-054-0030(2)(a) per complaint that there has been no activities bus/transportation available the past 9 months.

The facility failed to keep clean all interior and exterior materials and surfaces in accordance with OAR 411-054-0300(4)(i) per complaint that resident's room has not been cleaned in 3 weeks and common areas are dirty.

The facility failed to provide three daily nutritious, palatable meals with snacks available seven days a week in accordance with OAR 411-054-0030(1)(a) per complaint that the resident did not receive breakfast or lunch.

The facility failed to keep clean all interior and exterior materials and surfaces for the health, safety, and comfort of the resident in accordance with OAR 411-054-0300(4)(i) per complaint that the dining room and kitchen are dirty, and the dining room has not been cleaned in two weeks, and the staff are not washing the dining tables, and this is making people sick.

The facility failed to provide direct care staff sufficient in number to meet the scheduled and unscheduled needs of the residents in accordance with OAR 411-054-0070(1) per complaint that low staffing is a big problem, and call lights often go completely unanswered, and the residents soil themselves.

The facility failed to complete quarterly service plans after the resident moves into the facility in accordance with OAR 411-054-0036(4)(a) per complaint that the facility has never reviewed or updated the resident's service plan.

The facility failed to keep clean all interior and exterior materials and surfaces in accordance with OAR 411-054-0300(4)(i) per complaint that housekeeping staff keeps quitting and rooms are never cleaned, and residents' rooms are filthy with food scraps left all over and the floors are sticky.

Facility failed to make records available to the Department upon request per OAR411-054-0105(1)(a).

The facility failed to provide three daily nutritious, palatable meals with snacks available seven days a week in accordance with OAR 411-054-0030(1)(a) per complaint that the food quality at the facility is so bad that the resident cannot even eat anymore, and for breakfast they hardly got any breakfast, and their toast was so hard they couldn't eat it, and everything was cold.

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

The facility failed to fully implement an Acuity-Based Staffing Tool (ABST). Not all required ADLs are accounted for by the facility's current internal assessment tool. The ABST was unable to produce staff time required for each of the ADLs individually. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

The facility failed to complete service plans quarterly. An investigation determined this is a violation of Oregon Administrative Rules.

Facility failed to make records available to the Department upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide three daily nutritious, palatable meals seven days a week in accordance with OAR 411-054-0030(1)(a) per complaint that the food is terrible and there is not much of it.

The facility failed to provide or arrange for transportation for medical and social purposes in accordance with OAR 411-054-0030(2)(a) per complaint that no bus is available to take residents shopping so they are unable to get the items they need and want.

The facility failed to provide direct care staff sufficient in number to meet the scheduled and unscheduled needs of the residents in accordance with OAR 411-054-0070(1) per complaint that a resident call for help and no one seems to come assist them for long periods of time

The facility failed to provide direct care staff sufficient in number to meet the scheduled and unscheduled needs of the residents in accordance with OAR 411-054-0070(1) per complaint that a resident rang the call light at 2:00, but it was not answered until about 3:30.

Facility failure to have awake qualified direct care staff sufficient in number to meet the scheduled and unscheduled needs of residents per OAR 411-054-0070(1)(a), per complaint of significantly low staffing resulting in late meals.

The facility failed to provide three daily nutritious, palatable meals with snacks available seven days a week in accordance with OAR 411-054-0030(1)(a) per complaint that meals are being served 2 to 3 hours late.

The facility failed to have all interior and exterior materials and surfaces (e.g. floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident must be kept clean and in good repair. in accordance with OAR 411-054-0300(4)(i) per complaint the call light system in not in full working order, boxes are stacked up in hallways, and the garbage's in the laundry rooms are overflowing.

The facility failed to have enough staff to meet the scheduled and unscheduled needs of the resident as required by 411-054-0070(1). Per complainant the facility is always short the number of staff needed and scheduled.

On or about August 1, 2022, the Oregon Health Authority (OHA) 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 July 1, 2022, to July 31, 2022, for a total of 30 days. The Department sent a letter to you in June 2022, which informed you of the failure to report for previous days, and that if you did not report to OHA by July 31, 2022, you would be receiving a penalty in the amount of $7,500.00. The facility has failed to comply with this request for the month of July 2022, resulting in a Civil Penalty.

The facility failed to keep all interior materials and surfaces clean in accordance with OAR 411-054-0300(4)(i) per complaint that residents room is dirty.

The facility failed to provide household services in accordance with OAR 411-054-0030(1)(g) per complaint that the facility is not providing housekeeping services.

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.

The allegation that the facility failed to have sufficient staff to meet the scheduled and unscheduled needs of the residents in accordance with OAR 411-054-0070(1) per complaint that it takes staff a long time to respond to call lights was verified.

Based on interview, observation, and record review, it was confirmed the facility does not have enough staff to meet the scheduled and unscheduled needs of the residents. Findings include: Record review for site visit on 8/31/2022 of the staff schedule for August 2022, timecards for August 15th-16th, the posted staffing plan and call light logs from 8/22/2022-8/26/2022. Review of the call light logs reveal 169 times where the call lights exceed a 16-minute response time. Out of the 169 times 10 of them exceeded an hour with the longest response time being 1:58:42 wait time. Review of the staff schedule shows multiple days where they were understaffed. Compliance Specialist (CS) observed 2 caregivers (CG) and 2 med aides (MA) to be on duty during site visit on 8/31/2022, which does not reflect the posted staffing plan or the ODHS ABST. During separate onsite interviews on 8/31/2022, Staff #1 (S1) stated that there was a 3-week time where there was no housekeeper and services were missed. Staff #4 (S4) stated that showers regularly get missed and room tidies do not get done. S4 stated that there was a day in the beginning of the month were there was only one CG working who felt overwhelmed. Resident #2 (R2) stated it can take over 20 minutes to respond to call lights.

Based on interview, observation, and record review, it was confirmed that the facility failed to fully implement and update an acuity-based staffing tool (ABST). Findings include: Interview with Staff #1(S1) and Staff #2 (S2) on 08/31/2022 stated the facility is using their own ABST. S2 stated they could provide print outs of the ABST including sample residents showing the 22 ADLs used. Two email attempts made to S2 on 09/06/2022 for documentation to be provided no later than end of day 09/06/2022. Documentation of the ABST has not been provided as of 09/09/2022.

The facility failed to have sufficient staff to meet the scheduled and unscheduled needs of the residents in accordance with OAR 411-054-0070(1) per complaint that there was no staff for a couple of hours.

The Facility failed to comply with safe medication administration or treatment practices as required by OAR 411-054-0055 (1)(f), per complaint that medication was not administered over the weekend.

The facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident in accordance with OAR 411-054-0070(1)(a) per complaint that the facility is understaffed due to high turnover.