Brookdale Troutdale

According to the documentation, the facility failed to care plan appropriate interventions to prevent the Alleged Victim (AV) from falling. On or about May 27, 2025, the AV attempted to self-transfer out of their wheelchair, resulting in a non-injury fall. A temporary service plan (TSP) was created to instruct staff to have eyes on the AV at all times. The staff confirmed this TSP was not able to be followed due to staff needing to step away to assist other residents. on or about May 30, 2025, the AV experienced an unwitnessed fall. The facility failed to care plan appropriate interventions to prevent the AV’s known history of falls, 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) increased falls. From approximately February 09, 2025, through April 13, 2025, the AV experienced three known falls and sustained injuries such as abrasions, hitting their head and pain and unreasonable discomfort. there is no documented evidence the facility care planned interventions to help prevent the AV from falling, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to properly service plan appropriate interventions for Witness 1’s (W1) physical altercation to the Alleged Victim (AV). On or about June 07, 2024, and June 18, 2024, W1 and the AV were involved in two physical resident to resident altercations where W1 slapped the AV. The facility failed to properly care plan appropriate interventions to prevent further altercations. On or about February 10, 2025, W1 was seated next to the AV and W1 slapped the AV in the face. The intervention to seat the AV and W1 separately was not updated on their service plans, placing the AV at risk of harm, 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 Witness 1’s (W1) history of inappropriate touching of the opposite gender. On or about February 09, 2025, the Alleged Victim (AV) and (W1) were both in the living room and W1 was observed to be touching the AV’s genitalia. Staff immediately separated the two residents to ensure the inappropriate touching stopped immediately. W1 exhibited this behavior before with another AV, but there were no interventions placed on their service plan to prevent this from happening, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the Alleged Perpetrator 2 (AP2) failed to create a service plan update for Witness 1’s (W1) service plan for their known non-consensual sexual touching of other residents. On or about February 09, 2025, Witness 3 (W3) witnessed W1 touching the Alleged Victim (AV) in an inappropriate manner without consent. On or about October 14, 2024, W1 engaged in non-consensual touching of another resident. AP2 is responsible for updating the service plans to implement appropriate interventions. There was no documented evidence the AP2 implemented appropriate interventions, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to ensure their service plans were updated when appropriate, leading to repeated inappropriate behavior, 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 the Alleged Victim (AV) to prevent falling out of bed. On or about February 06, 2025, the AV was found on the floor of their room next to their bed on a routine safety check. It was discovered the AV’s wedge pillow used to prevent the AV from rolling out of bed was not put in place when the AV went to bed. The failure caused the AV to fall out of their bed and received skin tears and bruising, 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, progressive interventions for the Alleged Victim’s repeated falls. From about December 31, 2024, through January 16, 2025, the AV experienced approximately four (4) falls resulting in pain and unreasonable discomfort. There was no documented evidence the facility implemented progressive interventions to prevent the AV from falling. The failure to properly care plan resulted in multiple falls causing bruising, 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 follow the care plan for the Alleged Victim (AV) and Witness 7 (W7) to be always separated. On or about May 29, 2024, AV and W7 were involved in a physical altercation with one another. On or about 06/18/2024, the AV and W7 were involved in another physical altercation with one another. Numerous witness statements indicate the AV and W7 should be kept always separated, 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 (AV) who had a change of condition. The AV was diagnosed with a UTI and the facility was unable to produce any documentation outlining a plan of care and interventions for side effects or a treatment plan of the infection. The AV had experienced approximately two falls on or about April 17, 2024, and April 22, 2024. There was no documentation of progressive interventions for the AV’s known fall history. On or about May 12, 2024, the AV was found in their room lying on their back. emergency services were called, and they were transported to the hospital. The AV was diagnosed with a fractured hip which required surgery. On or about May 15, 2025, the AV passed away due to complication from the surgery which was required by the fall. The facility’s failure to properly care plan appropriate interventions after the AV experienced a change of condition is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to provide a secured environment for the Alleged Victim (AV) to prevent elopement. According to the documentation, the facility knew the fire exits needed to be relocked after staff unlocked to ensure the alarms would sound. On or about July 20, 2023, at approximately 14:10, two staff saw the AV outside under the shade of a tree and immediately contacted the facility to notify them AV was outside of the secured facility, 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) pressure sores which caused them to worsen. On or about July 15, 2022, Hospice services started for a left heel pressure wound. On or about September 1, 2022, a new heel wound was found on the AV’s left heel. After the new wound developed, Hospice advised the facility staff to have the AV’s heels floated at all times using a pillow or wedge, to wear protective booties at all times, to transfer by means of not allowing pressure to be put on their feet and to not let their feet rest on the floor to ensure no pressure is put on their feet. According to staff interviews, staff stated they used a stand and pivot transfer for the AV, they did not always float the AV’s heels using a pillow or foam wedge and have the AV’s feet rest on the floor while wearing the protective booties. On or about October 17, 2022, a new pressure wound was discovered on the AV’s right heel. By the end of October, AV’s left, and right heel wounds deteriorated and went to the bone causing prolonged pain and unreasonable discomfort, 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’s (AV) care plan. AV’s care plan AV needs assistants with transfers and requires them to be done slowly and carefully. On or about July 14, 2022, AV was transferred quickly and roughly. The failure resulted in AV experiencing pain and 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.

According to the documentation, the Alleged Perpetrator 2 AP2) and Alleged Perpetrator 3 (3) failed to provide a safe environment for the Alleged Victim (AV) by following facility policy and protocol by searching outside if a door alarm went off. On or about August 19, 2025, a door alarm went off and the AV eloped from the facility. AP2 and AP3 responded to the alarm and shut it off. Facility policy and protocol states the outside perimeter of the facility needs to be observed in case someone eloped from the facility. AP2 and AP3 did not search the outside of the facility. The AV was found at the drug store and local police returned the AV to the facility. AP2 and AP3 failed to provide a safe environment which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to provide a safe environment which is a violation of Oregon Administrative Rules.

The facility failed to develop, maintain, and implement an Acuity Based Staffing Tool, which is a violation of Oregon Administrative Rule.

The facility failed to develop, maintain, and implement an Acuity Based Staffing Tool which is a violation of Oregon Administrative Rule.

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

The facility failed to fully implement and update an acuity-based staffing tool which is a violation of Oregon Administrative Rule.

The facility failed to provide direct care staff sufficient in numbers to meet the scheduled and unscheduled needs of each resident which is a violation of Oregon Administrative Rule.

The facility failed to ensure the implementation of services which is a violation of Oregon Administrative Rule.

The facility failed to develop, maintain, and implement an Acuity Based Staffing Tool, which is a violation of Oregon Administrative Rule.

The facility failed to develop, maintain, and implement an Acuity Based Staffing Tool, which is a violation of Oregon Administrative Rule.

The facility failed to provide appropriate staffing, which is a violation of Oregon Administrative Rule.

The facility failed to carry out medication orders as prescribed in accordance with OAR 411-054-0055(1)(f); per complaint that the facility did not follow prescribed orders resulting in the resident missing multiple medications from 01/28/25 through 02/03/25.

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.

According to the documentation, an Unknown Perpetrator (AP2) failed to protect the Alleged Victim (AV) from financial exploitation. On or about July 29, 2024, administrative staff completed a narcotic count for the AV’s medication and discovered five narcotic pills were missing. A narcotics count was conducted on July 27, 2024, and was found to be accurate at that time. The AP2’s failure to protect the AV from financial exploitation is a violation of resident rights, is considered neglect of care and constitutes financial abuse. The facility’s failure to protect the resident from financial exploitation is a violation of Oregon Administrative Rules.

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 is not enough staff to assist resident with needs, during a staff meeting, which is a violation of Oregon Administrative Rules.

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

On or about May 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 April 1, 2022 to April 30, 2022, for a total of 30 days.

On or about April 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 March 1, 2022 to March 31, 2022, for a total of 30 days.