Lakeview Senior Living

The Alleged Victim (AV) was independent with self-administration of his/her medication. On or about September 24, 2024, while AV was at the emergency room, AV's narcotic medication was taken from his/her room. While AV was out at the emergency room, facility staff took AV's medications. Upon AV's return, the facility began dispensing AV's medication. Due to the time of the removal of AV's medications and the time that the facility started AV on med pass, AV went without doses of his/her diarrhea medication and experienced loose stools and experienced pain. The facility's failure to ensure AV's medications were given timely and complete an evaluation of to determine AV's ability to administer their own medication is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) resides at the facility and has a recent history of previous falls. AV's care plan included use of a call pendant AV would wear around his/her neck. According to an investigation, on or about September 11, 2024, AV fell in their apartment after tripping, resulting in back pain, a fractured ankle and required hospitalization and surgical repair. Fall interventions had not been determined and implemented following the previous falls to reduce the risk of falls. The facility failed to properly care plan, which is a violation of resident’s rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) is a resident of the facility and relies on facility staff to ensure basic care, safety and supervision needs are met. AV Service Plan dated on or about December 23, 2024, indicates AV requires assistance with morning and evening dental care; requires oral care several times daily; staff to soak AV's dentures at night; and Staff to rinse AV's dentures in the morning before placing them in AV's mouth. On or about February 17, 2025, staff was alert that AV's dentures had been left in overnight and that they were hard to remove. Once they were out of AV's mouth, a sore on AV's bottom gum was found. On a different day staff was alerted AV's dentures had been removed, but AV's gums were covered in adhesive and AV's mouth hadn't been cleaned the night before. The facility failed to follow the care plan for AV's oral care, which likely led to the sore on AV's gum and resulted in pain and discomfort to AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) has a history of falls, and over the past 3 months has suffered approximately 21 falls. AV has a history of hoarding and AV's room is very cluttered, which causes a lot of AV's falls. Staff are to keep AV's room free of clutter to reduce falls, however, there are no other interventions listed on AV's service plan. AV's falls have resulted in bruising, abrasions, pain and trips to the emergency room. The facility's failure to properly care plan to reduce AV's number of falls is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is independent in ambulation, transfers and toileting. AV has suffered a number of falls over recent months. AV's care plan was not updated to reflect interventions to assure AV's safety from falls. On or about January 26, 2024, AV was found in his/her bathroom, lying on the floor, partially in his/her shower. AV complained of pain in his/her head, ribs and shoulder and was transported to the emergency department for evaluation. The facility's failure to properly care plan to reduce AV's risk of falls 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 not receiving his/her medication for several days, causing pain, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) has experienced multiple falls in recent months. On or about December 26, 2023, AV experienced an unwitnessed fall and was transported to the emergency room where he/she was diagnosed with a skin tear and pain to his/her shoulder and neck. The facility's failure to implement interventions for fall prevention placed AV at risk of harm. The facility failed to properly care plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on facility staff to ensure resident’s rights. According to an investigation, on or about September 3, 2023, it was discovered that an unknown Alleged Perpetrator 2 (AP2) had taken AV’s purse, containing keys and cash. AP2's actions are considered financial exploitation and constitutes abuse. It was also determined that AV did not have access to a locking drawer. The facility did not keep AV free from financial exploitation, which is a violation of resident rights, is neglect of care which constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. AV has a history of falls and requires staff assistance with transfers and toileting. On or about September 01, 2023, AV was evaluated in the emergency room for head pain and bruising found on h/h back. Injuries are related to two unwitnessed falls occurring on or about August 26, 2023, and August 28, 2023. The facility failed to appropriately care plan and implement reasonable interventions to address AV’s ongoing falls, which is violation of resident rights, is considered neglect of care and constitutes abuse.

On or about May 9, 2023, the Alleged Victim had narcotic medication stolen from his/her apartment. It is unknown who stole the medication. The facility failed to protect AV from financial exploitation by not providing access to a lockable storage space for the safekeeping of valuable items and funds which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and follow the Alleged Victim’s (AV) care plan regarding AVs known fall risk. AVs care plan states for staff to clear AVs room of trip hazards. On or about December 4, 2022, AV had a fall that resulted in a head injury. The facility did not add interventions and update AVs care plan after that fall. On or about January 22, 2023, staff brought AV breakfast and left AVs apartment. On the way to get to the food, AV tripped over a rug in his/her apartment, resulting in a fractured wrist, hip, and nose and orbital bruising. AV was transferred to the hospital for treatment, which included surgery. The facility failed to follow AVs care plan to remove trip hazards from the room and implement interventions to mitigate AV’s increasing fall risk, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) missed approximately four (4) doses of his/her scheduled pain medication between approximately January 21, 2023 and January 23, 2023, which led to AV exhibiting multiple withdrawal symptoms, unnecessary discomfort, and to be transported to the hospital for treatment. The facility failed to provide a safe medication administration system to ensure AV’s physician orders were followed and medications were reordered timely. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. On or about November 6, 2022, AV’s narcotic pain medication was running low, and the facility gave AV partial doses at least two (2) times, causing AV physical discomfort and pain and unnecessary emotional upset. The facility failed to provide a safe medication administration system and administer medications as ordered, which is violation of resident’s rights, is considered neglect of care and constitutes abuse.

The facility failed to provide appropriate services and care plan according to the Alleged Victim’s (AV) needs. On or about August 25, 2022, AV was sent to the hospital and was diagnosed with sepsis, due to a wound. AV was admitted to ICU and despite intravenous antibiotics went into septic shock. AV was discharged on hospice and passed away approximately 2 weeks later. The facility did not have any documented notes of AVs wound, or any interventions, assessments, or notifications that they were aware of AVs wound or deteriorating condition, despite staff indicating they knew AV had a wound sometime in July 2022. The facility failed to provide appropriate services for AV, which resulted in AV passing away, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) missed approximately four (4) doses of his/her scheduled pain medication between approximately August 9, 2022 and August 11, 2022, which led to AV exhibiting multiple withdrawal symptoms, unnecessary discomfort, and to be transported to the hospital for treatment. The facility failed to provide a safe medication administration system to ensure AV’s physician orders were followed and medications were reordered timely. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Between approximately January 1, 2022, and February 2, 2022, the Alleged Victim (AV) received multiple medication doses more than one hour late, causing AV repeated unreasonable discomfort. The facility failed to administer medication as ordered, 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 Alleged Victim (AV)’s pain medication was available resulting in AV not receiving his/her pain medication as ordered. AV experienced withdrawal symptoms and was sent to the hospital for pain management. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

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

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

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

The facility failed to have 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.

It was determined the facility's failure to update resident profiles at least quarterly in an ABST was substantiated. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to have an Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population, their needs, and all required Activities of Daily Living (ADL). Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. Facility was not staffing to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

The facility failed to have an Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population, their needs, and all required Activities of Daily Living (ADL). Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. Facility was not staffing to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

Alleged Victim (AV) is independent with self-administration of their medications beginning August 5, 2024. AV went to the emergency department (ED) on September 24, 2024 and September 28, 2024 for leg pain. AV left their purse behind in their room while they were at the hospital. AV reports that during their visit to the ED on September 24, 2024, their narcotic medication was taken out of their room by an unknown person. It is not known how or when the Unknown Alleged Perpetrator 2 (AP2) was able to gain access to AV's room. The unknown AP2 is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect AV from financial exploitation 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 was not staffing to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

The facility failed to have an Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population, their needs, and all required Activities of Daily Living (ADL). Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. Facility was not staffing to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

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

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

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

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

Based on interview and record review, conducted during a site visit on 06/12/24, it was confirmed the facility failed to have a training program that includes abuse and reporting requirements. Findings include, but are not limited to: During separate interviews on 06/12/24, Staff 1 (ED) indicated the facility was cited during their survey conducted on 05/21/24 for incomplete training records including abuse and reporting. The facility will have an all-staff training on Friday 06/14/24 to go over abuse and reporting practices. When Staff 6 (MT) was asked the procedure for abuse and reporting, Staff 6's response was to contact the RCC, and s/he was not familiar with the correct policy and procedure for reporting. A review of the facility policy and procedure for elder abuse, neglect, and exploitation dated 12/09/21 indicated all personal care attendants will receive in-service training on elder abuse incidents, signs and symptoms of abuse, and reporting requirements during initial orientation. A review of Staff 3 (MT), Staff 4 (MT), and Staff 5's (CG) 30-day competency training records indicated Staff 3 and Staff 4 had complete training which included when to fill out incident report and call 911. The facility could not provide Staff 5's competency checklist. The three staff had completed the Relias training which included preventing, recognizing, and reporting abuse. It was confirmed the facility failed to have a training program that includes abuse and reporting requirements, no licensing violation occurred.

Based on interview and record review, conducted during a site visit on 06/12/24, it was confirmed the facility failed to ensure the staff person who administers the medication must visually observe the resident take the medication for 1 of 3 sampled residents (#1). Findings include, but are not limited to: During an interview on 06/12/24, Staff 1 (ED) indicated there had been issues with staff not observing residents take his/her medications. Staff 1 stated s/he had planned to request an order from Resident 1's physician to allow medications to be left at bedside, as this was Resident 1's preference. S/he acknowledged there was no current order. During an interview on 06/12/24, Resident 1 stated, "There have been times staff has left my medication on the counter since it takes me awhile to take my medication in the morning." A review of the service plan for Resident 1 dated 05/17/24, indicated the resident required assistance with medication two times a day. It was confirmed the facility failed to ensure the staff person who administers the medication must visually observe the resident take the medication.

Based on interview and record review, conducted during a site visit on 06/12/24, it was confirmed the facility failed to implement a service plan that reflects the resident's needs for 3 of 3 sampled residents (#'s1, 2, and 3). Findings include, but are not limited to: During an interview on 06/12/24, Staff 1 (ED) indicated the facility was cited during their survey conducted on 05/21/24 for service plans not being person centered. Staff 1 indicated s/he and Staff 2 (RCC) had been working on changing and updating all resident service plans. A review of service plans indicated the following; • Resident 1 service plan dated 05/17/24, indicated resident was independent with showers. Staff are to provide stand by assistance with showers to help reduce falls. • Resident 2 service plan dated 04/22/24, indicated resident was a one-person full assist twice per week. • Resident 3 service plan dated 04/30/24, indicated resident was a two-person full assist twice per week. A review of the shower schedule indicated the following; • Resident 1 scheduled for showers on swing shift for Monday and Wednesdays. • Resident 2 scheduled for showers on swing shift for Sunday and Thursdays. • Resident 3 scheduled for showers on day shift for Wednesday and Saturdays. A review of shower sheets from 04/01/24 through 06/05/24 provided from the facility indicated the following; • Resident 1 had not been provided eighteen of twenty showers during the timeframe. • Resident 2 had not been provided fifteen of eighteen showers during the timeframe. A shower sheet on 04/20/24, noted residents’ hair was matted and scalp was irritated and scabby. • Resident 3 had not been provided five of nineteen showers during the timeframe. It was confirmed the facility failed to implement a service plan that reflects the resident's needs.

The facility failed to have an Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population, their needs, and all required Activities of Daily Living (ADL). Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. Facility was not staffing to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

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 observe the resident take medication. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to answer call lights in a timely manner. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to have sufficient staff to meet the scheduled and unscheduled needs of the residents. It was determined the lack of staff is leading to needs not being met or taking extended periods of time to be met. Facility is not currently staffing to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to 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 have sufficient staff to meet the scheduled and unscheduled needs of the residents. It was determined the lack of staff is leading to needs not being met or taking extended periods of time to be met. Facility is not currently staffing to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules.

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

The facility failed to include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to have Delegation and Teaching. Delegation and teaching must be provided and documented by a RN. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to have sufficient staff to meet the scheduled and unscheduled needs of the residents. It was determined the lack of staff is leading to needs not being met or taking extended periods of time to be met. Facility is not currently staffing to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to 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 have a service plan must reflect the resident's needs. An investigation determined this is a violation of Oregon Administrative Rules.

Facility failure to have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to answer the call light in a timely manner. An investigation determined this is a violation of Oregon Administrative Rules.

The Facility failed to comply with safe medication administration or treatment practices. The facility’s failure is a violation of Oregon Administrative Rules.

Facility failure to provide effective methods for resolving resident complaints. The facility’s failure is a violation of Oregon Administrative Rules.

Facility failed to make records available to the Department upon request. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to provide a lockable storage space. The facility’s failure is a violation of Oregon Administrative Rules.

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

The facility failed to keep clean and in good repair all interior and exterior materials and surfaces, and all equipment necessary for the health, safety, and comfort of the resident. The facility’s failure is a violation of Oregon Administrative Rules.

According to an investigation, when AV expressed that he/she had been afraid during a transfer by Alleged Perpetrator 2 (AP2), AP2 threw a blanket at the AV and landed over AV’s head, which caused AV emotional distress and loss of personal dignity. AP2’s actions are a violation of resident rights, are considered neglect of care and constitutes verbal abuse. The facility failed to protect AV from emotional abuse, which is a violation of Oregon Administrative Rules.

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

On or about October 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 September 1, 2022 to September 30, 2022, for a total of 30 days.

On or about September 1, 2022, the Oregon Health Authority reported to the Department that Respondent failed to comply with weekly reporting requirements of vaccinated individuals, residents and staff, to the proper authority as required by law. This failure has been ongoing from August 1, 2022 to August 31, 2022, for a total of 30 days.

The facility allegedly failed to assure timely medical treatment. An investigation determined no abuse occurred. The facility failed to retain resident records and provide documents upon request which is a violation of Oregon Administrative Rules.

Alleged Victim (AV) relies on the facility for his/her care. AV is care planned to have toileting assistance and not be left unattended. On or about March 11, 2022, Alleged Perpetrator #2(AP2) was assisting AV to the restroom and left AV unattended. AV fell while standing to wash his/her hands and sustained a head injury that required four (4) staples. AP2 failed to follow the care plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to ensure the care plan was being followed, which is a violation of Oregon Administrative Rules.

Alleged Perpetrator #2 (AP2), who is unknown, took between $50.00 and $300.00 from the Alleged Victim (AV), on or around March 5, 2022, which is considered financial exploitation and constitutes abuse. The facility failed to protect AV from financial exploitation which is a violation of Oregon Administrative Rules.