Greenridge Estates

The Alleged Victim (AV) is a known fall risk with a history of falls. According to an investigation, AV experienced a change of condition on or about October 16, 2023, and on or about January 22, 2024, AV experienced a fall that resulted in an injury to AV’s face and forehead. The facility failed to provide appropriate services according to Alleged Victim’s needs, relating to care planning, lack of appropriate interventions and instruction, to mitigate the risk of injury due to AV's increase in falls. This failure is a violation of resident rights, is neglect of care which constitutes abuse.

The Alleged Victim (AV) resides at the facility and has a history of previous fall and medication changes. Fall interventions documented in AV's clinical assessment included to advise AV to stand slowly, drink water to stabilize blood pressure and call for assistance. According to an investigation, on or about December 31, 2023, AV fell in their apartment after sitting up at the edge of the bed, resulting in a fractured back. AV required hospitalization and now requires full assistance with care. The fall interventions in the clinical assessment had not been added to the service plan and were not available to staff. The facility failed to properly care plan, which is a violation of resident’s rights, is neglect of care and constitutes abuse.

The facility failed to provide a safe medication administration system to ensure AV's medications were administered as ordered. According to an investigation, AV did not receive several of his/her medications according to the doctor’s orders on multiple occasions, placing AV at risk for harm. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide a safe medication administration system to ensure the Alleged Victim's (AV) medications were administered as ordered and to ensure that the Alleged Perpetrator 2 (AP2) was properly trained to pass medications. According to an investigation, on or about December 5, 2022, AV did not receive his/her diabetic medication according to the doctor’s orders. AV experienced unstable blood sugar and confusion and had to be sent to the hospital for treatment. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse. The allegation that AP2 failed to provide care to AV was investigated, and the determination was not substantiated.

The facility and staff failed to provide a safe medication administration system. AV's medication being stolen by an unknown individual and this person is responsible for theft of medications, which is considered financial exploitation and constitutes abuse. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to ensure resident rights and appropriately care plan according to AV's needs and prior conflict(s) with AP2. The failure resulted in AV experiencing unreasonable discomfort and a delay in medical care, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Based on interview and record review conducted during a site visit on 03/26/26, the facility’s failure to update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly as required was substantiated, which is a violation of Oregon Administrative Rules.

Based on interview and record review, the facility failed to develop and maintain an Acuity-Based Staffing Tool (ABST). The facility’s failure is a violation of Oregon Administrative Rules.

Based on interview and record review conducted during a site visit on 03/26/26, the facility’s failure to update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly as required was substantiated, which is a violation of Oregon Administrative Rules.

On or about August of 2025, Alleged Victim (AV) gave Witness 4 (W4) AV's property (a wedding ring, necklace, bracelet, and $8) in a pink pouch for W4 to hold for safekeeping. AV's missing property was established to have been in AV's possession, a month before it went missing. W4 has a lock box and understands how to lock it with the key, but W4 didn't place AV's property in W4's lock box. During the timeframe that AV's property went missing from W4's room, W4's guests had access to AV's property, and the facility staff had keys to W4's room. AV had a loss of a wedding ring, bracelet, necklace, and $8; it is believed an unknown Alleged Perpetrator 2 (AP2) may have taking AV’s belonging, which is neglect of care and constitutes abuse. The facility failed to protect AV from financial exploitation, which is a violation of Oregon Administrative Rules.

Alleged Victim (AV) was care planned to received PRN pain medication due to chronic pain issues. On or about February 19, 2025, AV waited for several hours and had to use the call light to get PRN pain medication. AV made a request to Alleged Perpetrator 2 (AP2) for PRN pain medication, however, AP2 stated AP2 got busy and forgot to tell the med tech that AV wanted PRN pain medication. AP2 was annoyed and rude to AV when AV called again for the PRN pain medication. AV normally requested PRN pain medication in four (4) to eight (8) hour intervals in the day but had to wait for almost 12 hours and as a result, AV was in pain for several hours. AP2 failed to follow AV’s care plan around AV’s pain medication, which is neglect of care and constitutes abuse. The facility failed to provide assure AV’s care plan was being followed, 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.

The facility failed to keep all interior and exterior materials and surfaces clean and in good repair. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to ensure the service plan was reflective of the resident's needs. The facility’s failure is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) relies on the facility to administer his/her medications. According to an investigation, on or about April 29, 2024, multiple doses of AV's pain medication was missing. The unknown Alleged Perpetrator 3 (AP3) did not report the missing doses, resulting in AV being without pain medication for several days and causing unreasonable discomfort. AP3's actions are a violation of resident's rights, are considered neglect of care and constitutes financial exploitation. The facility failed to protect AV from financial exploitation, which is a violation of Oregon Administrative Rules. The allegation that Alleged Perpetrator 2 (AP2) financially exploited AV was investigated and determined to be not substantiated.

The facility failed to administer mediation as ordered for the Alleged Victim (AV). According to an investigation, AV experienced no negative outcome. The failure is a violation of Oregon Administrative Rules. The allegation that Alleged Perpetrator 2 (AP2) neglected AV was investigated and determined to be not substantiated.

The facility failed to provide residents with all of their daily meals causing them to miss meals. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to document that they have observed and evaluated the individual's ability to perform safe medication and treatment administration unsupervised. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to provide and document delegation and teaching by a RN. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed keep an accurate Medication Administration Record (MAR). The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to carry out medications and treatment orders. The facility’s failure is a violation of Oregon Administrative Rules.

The facility allegedly failed to maintain thresholds and floor junctures to allow for the passage of wheelchairs and to prevent a tripping hazard. The facility’s failure is a violation of Oregon Administrative Rules.

The facility allegedly failed to ensure the completeness and accuracy of resident records. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to obtain background checks on all subject individuals. 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 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 provide three daily palatable meals. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to carry out medications and treatments as prescribed in accordance. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to keep an accurate MAR. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to post the current facility staffing plan. An investigation determined this is a violation of Oregon Administrative Rules.

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

The facility failed to ensure adequate professional oversight of the medication and treatment administration system by the administrator. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide assistance with bathing and washing hair. 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 that there is not enough staff leading to needs not being met, or taking extended periods of time to be met. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

The facility failed to have an Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their needs. 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. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

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

The facility failed to provide three daily nutritious, palatable meals. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to comply with masking requirements. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide three daily nutritious, palatable meals. 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 and their needs. 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. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

The facility failed to keep in good repair all equipment necessary for the health, safety, and comfort of the resident. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to maintain hot water temperature within a range. An investigation determined this is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) had a prescription for pain medication. The Alleged Perpetrator #2 (AP2) was a medication aide at the facility with access to the medication cart. AV's prescription medication was signed out and not given to AV on 3 occasions between September 9, 2022 and September 10, 2022. AP2 was working during the time AV's medication was signed out. AP2 refused to give a handwriting sample to rule him/her out as a suspect in this case. AP2's actions are a violation of resident rights, are considered neglect of care and constitutes financial abuse. The facility failed to protect AV from financial abuse, which is a violation of Oregon Administrative Rules.

The facility failed to prevent the entry of rodents. An investigation determined this is a violation of Oregon Administrative Rules.

On or about September 7, 2022, it was reported to facility administration that the Alleged Victim’s (AV) narcotic log was incorrect. Alleged Perpetrator 2 (AP2) was found to have forged signatures to dispense 8 doses of AV’s narcotic medication. AP2’s actions are a violation of resident rights, are considered neglect of care and constitute financial abuse. The facility failure is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) had a prescription for pain medication. The Alleged Perpetrator #2 (AP2) was a medication aide at the facility with access to the medication cart. AV's prescription medication was signed out with a forged signature on 2 occasions on September 3, 2022. AP2 was working during the time AV's medication was signed out. AP2 refused to give a handwriting sample to rule him/her out as a suspect in this case. AP2's actions are a violation of resident rights, are considered neglect of care and constitutes financial abuse. The facility failed to protect AV from financial abuse, which is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) had a prescription for pain medication that was discontinued on August 28, 2022. The Alleged Perpetrator #2 (AP2) was a medication aide at the facility with access to the medication cart. AV's prescription medication was signed out with a forged signature on 19 occasions between August 28, 2022 and September 6, 2022. AV's remaining 26 doses were transferred to another page in the medication log and signed out with a forged signature. AP2 was working during the times AV's medication was signed out with a forged signature. AP2 refused to give a handwriting sample to rule him/her out as a suspect in this case. AP2's actions are a violation of resident rights, are considered neglect of care and constitutes financial abuse. The facility failed to protect AV from financial abuse, which is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) had a prescription for pain medication for ease with his/her breathing. The Alleged Perpetrator #2 (AP2) was a medication aide at the facility with access to the medication cart. AV's prescription medication was signed out with a forged signature on 22 occasions between August 26, 2022 and September 3, 2022. AP2 was working during the times AV's medication was signed out with a forged signature. AP2 refused to give a handwriting sample to rule him/her out as a suspect in this case. AP2's actions are a violation of resident rights, are considered neglect of care and constitutes financial abuse. The facility failed to protect AV from financial abuse, which is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) had a prescription for pain medication. The Alleged Perpetrator #2 (AP2) was a medication aide at the facility with access to the medication cart. AV's prescription medication was signed out and not given to AV on 3 occasions on September 6, 2022. AP2 was working during the time AV's medication was signed out. AP2 refused to give a handwriting sample to rule him/her out as a suspect in this case. AP2's actions are a violation of resident rights, are considered neglect of care and constitutes financial abuse. The facility failed to protect AV from financial abuse, which is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) had a prescription for pain medication. The Alleged Perpetrator #2 (AP2) was a medication aide at the facility with access to the medication cart. AV's prescription medication was signed out and not given to AV on 4 occasions between September 10, 2022 and September 11, 2022. AP2 was working during the time AV's medication was signed out. AP2 refused to give a handwriting sample to rule him/her out as a suspect in this case. AP2's actions are a violation of resident rights, are considered neglect of care and constitutes financial abuse. The facility failed to protect AV from financial abuse, which is a violation of Oregon Administrative Rules.

On or about August 9, 2022, Alleged Perpetrator 3 (AP3) did not follow proper procedure and left medication unattended, which resulted in the Alleged Victim (AV) taking medication that did not belong to him/her. On or about August 10, 2022, Alleged Perpetrator 2 (AP2) did not follow proper procedure and left medication unattended, which resulted in AV taking medication that did not belong to him/her. AV experienced side effects due to the medication errors. AV was AP2 and AP3's actions are considered neglect and constitutes abuse. The facility failed to provide a safe medication administration system which violates Oregon Administrative Rules.

On or about August 9, 2022, Alleged Perpetrator 3 (AP3) left medication unattended, which resulted in another resident taking the Alleged Victim's (AV) medication and AV not receiving his/her medication, leaving AV at risk for harm. On or about August 10, 2022, Alleged Perpetrator 2 (AP2) left medication unattended, which resulted in another resident taking the Alleged Victim's (AV) medication and AV not receiving his/her medication, leaving AV at risk for harm. AP2 and AP3's actions are considered neglect and constitutes abuse. The facility failed to provide a safe medication administration system which violates Oregon Administrative Rules.

Based on observation, interview and record review it was confirmed that facility failed to fully implement and update an Acuity Based Staffing Tool (ABST), condition issued 2/14/2023

Based on observation, interview and record review it was confirmed that the facility failed to provide direct care staff sufficient in number to meet the scheduled and unscheduled needs of the residents, condition issued 02/14/2023.

The allegation that the facility failure to have medical and other records kept confidential except as otherwise provided by law per OAR 411-054-0027(1)(i) as stated in complaint that facility nurse is waving confidential medical information in front of residents allowing others to see the information was verified.

The allegation that the facility failed to employ an administrator who has obtained a full "Residential Care Facility Administrator" license from the Health Licensing Office in accordance with OAR 411-054-0065(1) per complaint that the facility does not have a licensed administrator starting January 1, 2022 was verified.

The allegation that 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 administer residents anticoagulation medication was verified.

The allegation that 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) per complaint that the facility has high turnover and only one care staff working on NOC shift for 60-70 residents was verified.

The allegation that the facility failed to ensure meals are prepared and served as required by Food Sanitation Rules in accordance with OAR 411-054-0030(1)(a)(C). Per a complaint the kitchen has no handwash sink or hand soap was verified.

The allegation that the facility failed to prepare and serve meals in accordance with Food Sanitation Rules and failed to inform residents in advance of menu changes as required by OAR 411-054-0030(1)(a)(B)and(C) per complaint that the facility is not taking temperatures of food and menus are changed without notice was verified.

The allegation that the facility failed to complete service plan quarterly in accordance with OAR 411-054-0036(4)(a) per complaint that service plans are not up to date was verified.

The allegation that the facility failed to carry out medication orders as prescribed in accordance with OAR 411-054-0055(1)(f) per complaint that the facility administers medications late was verified.

The allegation that the facility failure to provide reasonable precautions against any condition that may threaten the health, safety, or welfare of residents per OAR 411-054-0025(4) per complaint that staff is not wearing and/or correctly wearing masks was verified.

The facility failed to keep a written record that document fire drills. An investigation determined this is a violation of Oregon Administrative Rules.