Everbloom Memory Care

According to the documentation, the facility failed to follow the care plan for the Alleged Victim’s (AV) known fall history. Between approximately June 14, 2024, through August 18, 2024, the AV experienced a total of 18 falls, some including injury. The most recent service plan directs staff to conduct 2-hour safety checks and the AV is to always wear non-slip socks. Interviews with staff indicated safety checks were not being conducted and the AV was often seen without non-slip socks on. the failure to follow the care plan is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) has a history of wounds on his/her legs. AV had an order as of May 30, 2024, for compression hose to be applied every morning and removed every evening. Documentation on AV's MAR does not represent a clear, accurate picture of when compression hose were applied and removed; on 8/6, 8/9, 8/14, 8/19, 8/21 and 8/22/24, it was noted that AV's compression hose had not been applied, but that they had been removed. On or about August 3,2024, skin peeled off AV's legs when AV's compression socks were removed. The skin peeled off AV's legs when compression socks were removed because staff had left the compression socks on longer than they should have. It was reported that on or about August 7, 2024, Alleged Perpetrator (AP2) had failed to toilet AV and provide incontinence care. It was reported that AV was so wet that urine had soaked through AV's pants. It was reported that AV had sores on h/h legs at that time. AP2 failed to provide service to AV, which is neglect of care and constitutes abuse. The facility failed to provide service, which is a violation of resident’s rights is neglect of care and constitutes abuse.

The Alleged Victim (AV) suffered multiple falls between August 2, 2024, and August 25, 2024. AV fell out of bed 5 times, complaining of hip and back pain after each fall. No meaningful fall interventions were put into place to reduce the risk of falls. Respondent failed to ensure interventions were put into place to reduce AV's risk for falling. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

On July 12, 2024, the Alleged Victim (AV) fell and complained of hip and knee pain. AV was sent to the emergency room and prescribed narcotic medication. The facility failed to obtain and make medication available to AV. AV suffered unreasonable discomfort due to the facility not having medication available, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim's (AV) service plan lists several behaviors and conditions which impact AV's social and emotional wellbeing. On or about July 16, 2024, AV and Alleged Perpetrator #2 (AP2) had an interaction where AV felt emotional discomfort. According to documentation, the allegation of abuse against AP2 was not substantiated. The facility's failure to ensure AV's care plan was up to date and re-evaluated, causing AV emotional discomfort, is a violation of resident rights, is considered neglect of care and constitutes abuse.

Between approximately July 5, 2024, and July 9, 2024, daytime temperatures ranged between 103 and 106 degrees. During this time, the facility air conditioning failed, causing concerns for residents wellbeing. The Alleged Victim (AV) was sent to the emergency department for concerns of overheating. AV was sweating profusely and was flushed prior to going to the emergency department and suffered unreasonable discomfort. The facility's failure to ensure AV was kept hydrated and cool 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 dysphagia and is at risk for choking. Staff are required to sit with AV at meals and provide assistance in order to prevent AV from choking. AV has been seen with food or drink and no staff with AV to provide assistance. Agency staff don't always provide AV with the required assistance while AV eats. AV has in the past experienced choking episodes while eating. Respondent failed to provide service, and to ensure the safety of AV. This constitutes abuse by neglect, as outlined in OAR 411-020-0002(1)(b)(A)(i).

The facility failed to provide appropriate supervision to the Alleged Victim (AV) according to his/her needs. The failure resulted in AV eloping the secured building, without staff knowledge, placing him/her at risk of harm, 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 and recent increase agitation and aggression. The failure resulted in a physical altercation with the Alleged Victim, causing him/her multiple skin injuries, 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 and recent increase agitation and aggression. The failure resulted in a physical altercation with the Alleged Victim, causing him/her to be transported to the hospital with a head injury, 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 and recent increase agitation and aggression. The failure resulted in a physical altercation with the Alleged Victim, causing him/her to be struck in the head and experienced injury, 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) known behaviors and recent increase agitation and aggression. The failure resulted in AV engaging in a physical altercation causing him/her to be injured, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about May 9, 2024, the Alleged Victim (AV) was prescribed medication for bladder control. AV did not receive his/her medication until June 14, 2024. The facility failed to process the medication in the system, therefore AV did not receive it, causing unreasonable discomfort. The facility's failure to have an accurate medication administration system is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and follow the care plan related to the Alleged Victim’s (AV) fall history. The failure resulted in AV experiencing an unwitnessed fall and was transferred to the hospital, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to follow the Alleged Victim's (AV) care plan and provide appropriate checks according to AV's incontinence needs. The failure resulted in AV being found in dried feces the following day, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to provide medical treatment to the Alleged Victim’s (AV) leg wounds causing the medical condition to worsen. On or about March 20, 2024, a temporary service plan was created for staff to monitor the AV’s legs for worsening of their medical condition. On or about April 24, 2024, the AV began complaining of leg pain. The AV was receiving Home Health services. Between April 26, 2024, through May 06, 2024, no follow up was made with home health to assist with wound care. On or about May 09, 2024, Home health provided assistance with wound care and found AV’s legs to be swollen and warm to the touch. The facility failed to provide medical treatment causing the AV’s condition to worsen, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide a safe medication administration system to ensure the Alleged Victim's (AV) medication was administered as ordered. The failure resulted in unreasonable discomfort and risk of serious harm to AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide a safe medication administration system to ensure the Alleged Victim's (AV) medication was administered as ordered. The failure resulted in AV experiencing significant pain, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide appropriate supervision to the Alleged Victim (AV) according to his/her needs and exit seeking behavior. The failure resulted in AV eloping the secured building, without staff knowledge, placing him/her at risk of harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide effective and progressive interventions related to the Alleged Victim's history of falls. According to documentation, the AV experienced approximately twelve falls in a two month period, leaving AV at risk of serious harm from continued falls, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement effective interventions and appropriately care plan related to the Alleged Victim's (AV) increase in falls. The failure resulted in AV experiencing multiple falls resulting in unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide a safe medication administration system to ensure the Alleged Victim's (AV) medication was administered as ordered. The failure resulted in a delay of medical treatment causing ongoing discomfort, 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’s (AV) needs for toileting and skin checks. The failure resulted in AV’s developing a wound causing unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to follow the Alleged Victim’s (AV) care plan to supervise him/her at all times due to known behaviors. The failure resulted in a physical altercation between AV and witness 1, causing pain to AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to follow the Alleged Victim's (AV) care planned interventions to monitor him/her in the common areas due to his/her fall history. The failure resulted in AV experiencing an unwitnessed fall in the common area, causing skin injury, 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. The failure resulted in AV experiencing an unwitnessed fall in his/her room causing back pain and redness to his/her arm, 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 AV's fall history. The failure resulted in AV experiencing an unwitnessed fall causing pain to his/her head and was transported to the hospital, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide a safe medication administration system to ensure the Alleged Victim's (AV) medication was administered as ordered. The failure resulted in AV missing several doses of h/h medication and was transported to the hospital for treatment, 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) known fall history resulting in injury. From approximately August 07, 2023, through September 09, 2023, the AV suffered four (4) falls with injury, including a laceration to their head which required approximately 5 staples. There was no documented evidence the facility implemented interventions for the AV’s repeated falls with injury, 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 AV's fall history. The failure resulted in AV experiencing an unwitnessed fall causing pain to his/her head, 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’s (AV) known fall history. On or about August 25, 2023, the AV was found on the floor in their room. The AV stated they were trying to get out of bed when staff walked in. While helping the AV, staff noticed the fall mat was not placed next to the bed as outlined in their service plan. The AV complained of knee pain. The AV was given a PRN pain medication and an ice pack, which seemed to help. The failure to follow the care plan and place the fall mat next to the bed 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 appropriately care plan for Witness 1’s (W1) known history of behaviors resulting in resident to resident altercations. From approximately May 24, 2023, through August 06, 2023, W1 was involved in approximately four (4) resident to resident altercations. The interventions listed on the most recent service plan was to redirect W1 to the coloring station, but it was noted W1’s behaviors were not able to be redirected to the coloring station timely to prevent resident to resident altercations. The failure to appropriately care plan progressive interventions to prevent behaviors resulting in resident to resident altercations 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 W1's known behaviors and physical altercations. The failure resulted in a physical altercation with the Alleged Victim (AV), AV experienced no injury, but was placed at risk of harm, which is a violation of Oregon Administrative Rules.

According to the documentation, the facility failed to properly care plan for the Alleged Victim’s exit seeking behavior resulting in numerous elopements from the facility. From approximately June 12, 2023, through June 29, 2023, the AV eloped from the facility approximately 5 times and was as far away as over half mile from the facility. The failure to update the AV’s service plan to ensure the safety of the resident 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. On or about May 22, 2023, to June 20, 2023 AV experience approximately three (3) falls, resulting in bruising, and AV being sent out to the emergency room for further evaluation after hitting h/h head. 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 implement interventions and appropriately care plan related to Alleged Victim's (AV) falls from mid April to the end of May. The failure resulted in AV experiencing an unwitnessed fall on or about June 7, 2023, causing injury and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to follow Witness 1’s (W1) care plan to keep h/h away from other residents following a resident altercation with the Alleged Victim (AV). The failure resulted in a second physical altercation between W1 and AV causing injury to AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to appropriately care plan and provide supervision according to the Alleged Victim’s (AV) and Witness 1’s (W1) needs and prior physical altercations. The failure resulted in another physical altercation between W1 and AV, causing AV to fall, hit his/her head and was transported to the hospital, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to appropriately care plan and provide supervision according to the Alleged Victim’s (AV) and Witness 1’s (W1) needs and prior physical altercations. The failure resulted in a fourth physical altercation between W1 and AV, causing AV to fall, hit his/her head and was transported to the hospital, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide a safe medication administration system to ensure the Alleged Victim’s (AV) medication was administered as ordered. The failure resulted in AV going approximately two weeks without his/her medications, placing him/her at risk of harm, 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) history of unwitnessed falls. The failure resulted in AV experiencing another unwitnessed fall causing unreasonable discomfort and skin injury, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness 1 (W1) has a known history of sexually inappropriate behaviors with other residents and Alleged Victim (AV). TSP interventions are to ensure W1 keeps hands to h/h-self, no inappropriate behaviors with other residents, keep W1 out of other resident rooms and check on W1 to ensure s/he is in the common area or own room. AV TSP interventions are to ensure AV is keeping to h/h-self, no inappropriate behaviors with other residents, keep AV out of other’s rooms and check on AV to ensure AV is in the common area or in h/h own room. During the investigation, staff reported that on or about April 07, 2023, W1 and AV were not in the common area. W1 door was locked, staff unlocked door and found W1 and AV both naked, and W1 was on top of AV. The facility failed to provide a safe environment for AV by failing to protect AV from W1's sexualized behavior, and failed to follow W1 and AV TSP, which is a violation of resident rights, is neglect of care and constitutes abuse.

The facility failed to follow the Alleged Victim's (AV) and Witness 1's (W1) care plans related to their behaviors and prior altercations. The failure resulted in the residents engaging in a physical altercation where W1 hit AV in the face, causing unreasonable discomfort, 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. According to the investigation and documentation provided to the department staff normally feed AV h/h meals. On or about April 04, 2023, AV dinner tray from April 03, 2023, was still on the table untouched. It was discovered AV was not fed h/h dinner, and AV experienced discomfort. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) has a history of falls and was a fall risk. AV uses a wheelchair and requires extensive assistance with transfers and mobility. AV had approximately seven (7) falls between January 29, 2023 – March 06, 2023. The facility failed to appropriately care plan and implement reasonable interventions to address AV’s increasing falls and prevent future falls from occurring 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. Investigation and documents provided to the department indicate AV has had a rash from approximately January 01, 2023. AV was seen and treated twice for the rash in the emergency room. On or about March 1, 2023, AV had a follow up appointment with h/h PCP that was cancelled for an unknown reason by the facility and not rescheduled, resulting in AV experiencing ongoing itching, stinging, pain, and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #1 (W1) has a history of agitation and aggression towards other residents and members of the care team. W1 has history of hitting Alleged Victim (AV) before. W1 service plan indicates W1 behaviors are managed and needs redirection periodically and manages h/h agitation independently or with interventions. TSP says to redirect W1 after physical altercations with residents and remove from the area. On or about February 3, 2023, W1 was irritated and grabbed AV arm, punched, and pinched AV resulting in AV having pain, bruising and scratches. The facility failed to adjust and implement reasonable interventions for W1 ongoing aggressive behavior, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide a safe medication administration system to ensure the Alleged Victim (AV)s medication was administered as ordered. On or about December 18, 2022, documentation indicates AV received h/h insulin late resulting in risk of serious harm. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse. The allegation that Alleged Perpetrator #2 (AP2) failed to administer AV morning medication was investigated, and determined Not Substantiated.

The facility failed to follow the care plan and provide appropriate services according to the Alleged Victim (AV)'s needs relating to showers, brief changes, and peri care. On or about, June 13, 2022, AV experienced pain and was sent to the hospital where he/she was found in a urine-soaked brief, feces in h/h fingernails and diagnosed with Sepsis and a UTI. This failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to follow the Alleged Victim's (AV) care plan to physically assist during all transfers. AV fell, was transported to the hospital and diagnosed with an arm injury. The facility failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) had approximately eight (8) falls within three (3) months. AV was diagnosed with skin tears, pain and a head abrasion/bump and swelling of the head. 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 have the service plans readily available to staff and provide clear direction regarding the delivery of services, which is a violation of Oregon Administrative Rules.

The facility failed to conduct and record unannounced fire drills every other month at different times of day, evening, and night shifts in accordance with OAR 411-054-0090(1), which 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 is not currently staffing to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

The facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident, which is a violation of Oregon Administrative Rules.

The facility failed to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned within 30-days of hire, which 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 is not currently staffing to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

According to documentation, AP2 involuntarily secluded AV as defined in OAR 411-020-0002(1)(g)(A)(i) by confining AV to their room, which constitutes abuse. The facility failed to protect AV from involuntary seclusion, which is a violation of Oregon Administrative Rules.

Alleged Perpetrator 2 (AP2) failed to provide a safe medication administration system to ensure the Alleged Victim’s (AV) medications were administered as ordered. The failure resulted in AV missing a pain medication causing unreasonable discomfort. 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 awake qualified direct care staff sufficient in number to meet the scheduled and unscheduled needs of residents, which is a violation of Oregon Administrative Rules.

The facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Based on interview and record review, conducted during a site visit on 01/31/24, it was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. An investigation determined no licensing violation or abuse occurred.

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

The allegation that the facility failed to provide a safe medication administration system was investigated and the determination was not substantiated for abuse, but the failure to administer medication as ordered is a violation of Oregon Administrative Rules.

The facility failed to carry out medication orders as prescribed. Based on interview and record review, conducted during a site visit on 03/11/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident. An investigation determined no licensing violation or abuse occurred.

The facility failed to post the name of the administrator or designee in charge in a routinely accessible and conspicuous location to residents and visitors in accordance with OAR 411-054-0025(5) which is a violation of Oregon Administrative Rules

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

The facility failed to keep in good repair all equipment necessary for the health and comfort of residents in accordance with OAR 411-054-0200(4)(i) which is a violation of Oregon Administrative Rules.

The facility failed to develop a policy or a system that allows for visitor entry in accordance with OAR 411-057-0170(10)(d), which 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) which is a violation of Oregon Administrative Rules.

The Alleged Perpetrator 2 failed to provide a safe medication administration system to ensure the AV's medication was administered as ordered. The failure resulted in AV's condition worsening, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to ensure AV's medication was administered properly, which is a violation of Oregon Administrative Rules.

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

The Alleged Perpetrator 3 failed to ensure the Alleged Victim's (AV) medication was administered as ordered when s/he failed to discontinue AV's medication. The failure resulted in AV receiving two additional doses of his/her medication causing risk of harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility's failure to provide a safe medication administration system is a violation of Oregon Administrative Rules.

The facility failed to carry out medication and treatment orders as prescribed in accordance with OAR 411-054-0055(1)(f) which is a violation of Oregon Administrative Rules.

The Alleged Perpetrator 2 failed to provide a safe environment to ensure all toiletries and personal hygiene products were in a safe and locked place. The failure resulted in AV cutting h/hself with a razor causing physical harm, 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.

On or about June 26, 2023, Alleged Victim (AV) wandered into another resident room where an altercation took place between AV and Alleged Perpetrator #2 (AP2). AP2 was observed grabbing AV from behind in a bear hug and restraining AV resulting in aggressive movement and behaviors towards AV. AP2 did not follow state guidelines for resident rights/treatment and no restraints, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to ensure the residents rights/treatment was being followed, which is a violation of Oregon Administrative rules.

The Alleged Perpetrator #2 failed to provide appropriate services according to the Alleged Victim (AV)'s needs for a snack. AV reported s/he was hungry, and AP2 refused AV a snack. AV has history of wandering and has interventions in place to help prevent wandering by offering a snack/drink. After being denied a snack AV began wandering into other resident rooms, which led to AV becoming upset and a physical altercation. AP2s actions are a violation of resident rights, are considered neglect of care and constitutes abuse. The facility failed to ensure the residents rights/and services were being followed, which is a violation of Oregon Administrative rules.

The facility failed to provide a safe environment to ensure all products were out of reach of AV. The failure placed AV at risk of harm, which is a violation of Oregon Administrative Rules.

The Alleged Perpetrator 2 failed to provide a safe medication administration system to ensure the Alleged Victim's medication was administered as ordered. The failure resulted in AV receiving his/her opioid medication approximately four hours early, causing risk of harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to ensure AV's medication was administered as ordered which is a violation of Oregon Administrative Rules.

The Alleged Perpetrator 2 (AP2) failed to provide appropriate supervision to the Alleged Victim (AV) according to his/her needs. The failure resulted in AV eloping from an appointment where AP2 was responsible for his/her supervision and safety, placing AV at risk of harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to assure AV's safety which is a violation of Oregon Administrative Rules.

The facility failed to be responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of his or her employment duties which is a violation of Oregon Administrative Rules.

On or about April 28, 2023, Alleged Victim (AV) missed one dose of h/h insulin because facility staff gave AVs insulin needles to another resident when they moved out of the facility. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.

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

The facility failed to comply with masking requirements in accordance with OAR 411-054-0050(4), which is a violation of Oregon Administrative Rules.

On or about August 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 July 1, 2022 to July 31, 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.

On or about March 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 February 1, 2022 to February 28, 2022, for a total of 27 days.