Magnolia Gardens Memory Care

Alleged Victim (AV) has a history of multiple resident-to-resident altercations. AV service plan indicates Av’s behaviors are known to be spontaneous. AV has a list of interventions for staff to apply when AV is showing agitation. Behavior/Safety Plan for AV dated March 26, 2024, indicates close proximity of other residents may also trigger anxiety, nervousness, confusion, and influence concerning behaviors. Staff must know of AV’s location at all times and relay information to other staff members. Per video on or about April 3, 2024, Witness 1 (W1) and AV are sitting in the common area. AV got up opens a window and sits back down. W1 gets up and closes the window. AV approaches W1 and starts to swing at W1, to which W1 responds by pushing/kicking h/h leg at AV and making contact with AV’s right knee. AV responds and swings at W1, making contact. AV then grabs a large puzzle board and flings it at W1 making contact with W1’s hand resulting in a skin tear. AP1 did not have staff watching AV at the time of this incident on April 3, 2024. The facility failed to follow the Behavior/Safety Plan for AV dated March 26, 2024, which indicates Staff must know of AV’s location at all times and relay information to other staff members. The facility failed to provide a safe environment to AV and W1 knowing AV behaviors are spontaneous, which is a violation of resident rights is neglect of care and constitutes abuse.

On or about January 1, 2024, Alleged Victim (AV) entered Witness 1 (W1's) room. W1 became upset, grabbed AV by h/h wrist and arms and shook AV. Staff intervened and redirected the residents. Both AV and W1 were upset by the interaction. AV is independent with ambulation and frequently wanders into other residents' rooms. W1 has significant past trauma that is triggered by other residents entering h/h room, causing h/h distress. W1 is able to lock h/h door independently and staff are to help make sure W1's door is locked. Staff checked in with W1 in h/h room 5-15 minutes prior to the resident-to-resident with AV. Incident reports from January 1, 2024 indicate that AV's and W1's service plans were followed at the time of incident, but W1's door was not locked as per h/h service plan. The facility failed to follow the care plan, placing AV at risk of harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) is a high fall risk and uses a walker. Witness 1 (W1) has a history of resident to resident altercations. On or about November 15, 2023, AV was slowly walking in the common area without h/h walker, while W1 was walking the opposite direction (towards AV). As they approached each other, W1 shoved AV which resulted in AV falling to the ground resulting in back pain. Due to the needs of all residents and combined with staff schedules, AP1 lacked the necessary staff to provide a safe environment and supervision to AV and W1 at the time of the incident.

On or about July 29, 2023, Alleged victim (AV was found on the floor, with no injuries, on or about August 04, 2023, AV was found on the floor with a an abrasion to the forehead, on or about August 6, 2023, AV was found on the floor with an abrasion to the right side of h/h forehead, on or about August 12, 2023, AV was found on the floor without injury, on or about August 21, 2023, AV had a fall with injury that required sutures. on or about August 25, 2023, AV sustained a fall with injury with that resulted with skin tear to h/h knuckle, on or about August 29, 2023, AV sustained a fall resulting in a laceration approximately 2" long requiring sutures. (AV) relies on the facility for his/her care. AV has a history of falls. The facility failed to appropriately care plan and implement reasonable interventions to address AV’s falls, which is violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for a safe environment. AV is known to be territorial of h/her dining room table where h/she always sits. AV has history of resident-to-resident altercations. Witness 1 (W1) has history of wandering and going around collecting coffee cups or silverware. On or about July 30, 2023, W1 wandered up to AV table and was touching things. AV snatched the hat off W1 head and fell when turning to leave resulting in AV breaking h/h right hip requiring surgery. The Facility failed to provide adequate supervision and a safe environment for AV and W1, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for a safe environment. Witness 1 (W1) has history of behavioral changes including aggressive behaviors. W1 and AV have history of resident-to-resident altercations with other residents. W1 has history of refusing medications. On or about July 28, 2023, W1 began unlocking the wheelchair of a resident at AV's table. AV kicked W1. W1 then hits AV twice striking h/h in the face, which resulted in redness and an imprint of glasses to AV face. The Facility failed to provide adequate supervision and a safe environment during mealtime for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for a safe environment. Witness 1 (W1) has had a prior Resident-to-Resident altercation. Staff know they must always be in the dining room when residents are present. On or about August 28, 2023, AV crossed the dining room and began unlocking the wheelchair of another resident at W1's table. W1 kicked AV, AV then hit W1 twice striking h/h in the face. The Facility failed to provide adequate supervision and a safe environment during mealtime for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) has a history of taking coffee mugs from other people, including pulling it directly from their grasp, leading to incidents of aggression. On or about June 7, 2023, AV video observations of the dining room; Witness #1 (W1) is sitting at a table, AV attempts to pick up a cup off the table. W1 and AV are seem pulling at the cup and at each other’s hands, W1 hits AV with a closed fist before AV walks away with the cup. The facility failed to properly plan care and implement reasonable interventions to address AV’s continued behavior, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) has a history of wandering the facility and into other residents' rooms. AV was on alert charting and monitoring for a prior resident incident and had a TSP for frequent safety checks on AV’s location and wellbeing. On or about January 13, 2023, AV was found in Witness #1 room, sitting next to W1 on h/h bed, and W1 was fondling AV whose shirt was unbuttoned. AV does not have capacity to consent to the interaction with W1. The facility failed to follow the care plan which is a violation of resident’s rights is neglect of care and constitutes abuse.

INITIAL: The facility failed to provide appropriate care and services according to Alleged Victim (AV) needs and failed to complete a change of condition. AV was admitted into the facility on or around December 05, 2022, with a stage two pressure wound. On or around December 31, 2022, AV was admitted into the hospital with a diagnosis of sepsis with encephalopathy, acute osteomyelitis, and malodorous sacral ulcer stage four. Alleged Perpetrator #2 (AP2) failed to follow medical treatment orders, by packing AV wound with barrier cream, and did not administer PRN pain medication to AV when AV was noted to be in pain during wound care. AP2’s actions are a violation of resident rights, are considered neglect of care and constitute abuse. Alleged Perpetrator #3 (AP3) failed to assess, complete a change of condition, and ensure AV was receiving wound care services, when AV’s wound was noted to be malodorous and worsening. AP3’s actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility failure to ensure adequate supervision and oversight of AV’s care, resulted in AV experiencing increased pain and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse. AMENDED: The facility failed to provide appropriate care and services according to Alleged Victim (AV) needs. AV was admitted into the facility on or around December 05, 2022, with a stage two pressure wound. Alleged Perpetrator #2 (AP2) failed to administer PRN pain medication to AV when AV was noted to be in pain during wound care. AP2’s actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility failure to ensure adequate supervision and oversight of AV’s care, resulted in AV experiencing increased pain and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) uses incontinence garments which are purchased by AV's family for AV's exclusive use. It was discovered by investigation, interviews and documents provided to the department the facility (AP1) would run out of incontinence garments for other residents, and the staff would use incontinence garments belonging to AV. The facility did not replace or reimburse the supplies taken from AV. Facility management acknowledges that this did occur, and house stock of incontinence garments was not always available. Alleged Perpetrator 3 (AP3’s) job description dose not specifically have responsibility for ensuring adequate supplies are on hand for the facility and residents. AP3 was found Not Substantiated. Alleged Perpetrator 4 (AP4’s) job description specifically includes responsibility for ensuring adequate supplies are on hand. The facility and AP4’s actions are a violation of resident rights, is considered neglect of care and constitutes financial abuse.

The Alleged Victim (AV) relies on the facility for his/her care. Facility management received a written statement on or about December 05, 2022, regarding allegation of Alleged Perpetrator #2 (AP2) exposing AV on a video call. No action was taken on the statement until December 20, 2022, when directly asked by APS investigator about a written statement. The written statement was produced in a sealed envelope from Witness #1 (W1's) personal items. The facility failed to immediately investigate an allegation of abuse from approximately December 04, 2022, to December 20, 20022. AP2 allegedly failed to assure the AV resident rights, an investigation inconclusively determined no abuse occurred. The facility failed to ensure the residents rights/safety was being followed, which is a violation of Oregon Administrative rules.

The facility failed to provide appropriate services according to the Alleged Vitim (AV)’s needs. AV has a diagnosis that requires specialized attention to h/her feet and toenails. On or about December 08, 2022, it was reported that AV was not receiving nail care. Documentation provided shows AV last seen h/h podiatrist on or about May 2022. Witness #5 (W5) asked the facility to send AV out for toenail care. Staff are to document nail care on shower sheets. AV reported long toenails and unreasonable discomfort. AV frequently refuses bathing. Documentation provided to the department indicates AV refused showers throughout the months of October, November, and December 2022. AV care plan dated November 23, 2022, indicates AV will refuse services. Staff are to attempt showers three times, try change of face, and if AV still resistant to care, report to MT and they need to report issues to ED/RSM/PCP. The only notification AV PCP received of lack of showers was on February 23, 2023. The facility failed to implement reasonable interventions and services to address AV nail care and refusal of showers which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) is a high fall risk and has history of falls. AV is care planned for assistance to and from all meals, and staff are to toilet AV immediately following each meal. On or about October 26, 2023, AV was found on the flour from an unwitnessed fall in the dining room after breakfast. AV hit h/h head, sustaining a head injury, laceration and was transported to the emergency room by EMS. The facility failed to follow AV care plan, which is a violation of resident’s rights is neglect of care and constitutes abuse.

Alleged Victim (AV) has a history of resident-to-resident altercations. AV is serviced planned for redirection when AV is within four (4) feet of other residents. On or about August 05, 2022, and August 27, 2022, AVs service plan was not being followed which resulted in non-injury resident-to-resident altercations. The facility failed to follow AVs care plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness 1 (W1) has a long history of exit seeking, and violent behaviors with staff and other residents. W1 requires extensive staff assistance with reminders, supervision, and redirection. W1 is care planned with interventions that include one-on-one. On or about July 07, 2022, W1 entered Alleged Victims (AVs) room, while AV was in bed. W1 threw a vase at AVs window breaking it. AV had glass in h/h bed causing risk of serious harm. The facility failed to follow the care plan and provide one-on-one, due to staff shortage, which is a violation of resident rights is neglect of care and constitutes abuse.

Alleged Victim (AV) AV has a long history of violent behaviors with staff and other residents. AV requires extensive staff assistance with reminders, supervision, and redirection. AV is care planned with interventions that include one-on-one. On or about July 07, 2022, AV took utensils from dining room to use as weapons against h/h-self and others and broke a window. The facility failed to follow the care plan and provide one-on-one, due to staff shortage, which is a violation of resident rights is neglect of care and constitutes abuse.

AV has a history of falls. On or about June 11, 2022, AV was found on the floor, resulting in a fracture to h/h right Humerus. 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.

Alleged Perpetrator 2 (AP2) failed to provide a safe medication administration system. On or about June 02, 2022, AP2 placed Alleged Victim (AV) on Alert charting for rash under the left and right chest fold, and documented s/he faxed the PCP for treatment orders. It was discovered the fax was not sent to the PCP until on or about June 09, 2022. AP2’s actions are a violation of resident rights, are considered neglect of care and constitutes abuse. On or about June 11, 2022, the pharmacy faxed AP1 as the prescription was a non-covered medication. AP1 failed to follow up with AV’s PCP to address different medication options, leaving AV in pain and discomfort. The facilities failure 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, related to service plans and medications, which resulted in AV falling and being transported to the hospital. AV sustained bruising to face, knees, and a lump on the forehead, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #2 (W2) has a history of aggressive behaviors with other residents and visitors. On or about April 28, 2022, (W2) threw a flowerpot hitting Alleged Victim (AV) on the wrist/hand. The facility failed to appropriately care plan and implement reasonable interventions to address AV’s increasing and ongoing aggressive behaviors which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #1 (W1) started having increase aggressive behavior towards facility staff and residents on or around February 2022. On or about April 21, 2022, Alleged Victim (AV) and W1 engaged in an altercation leading to W1 punching AV. AP1 contacted W1 PCP on or about February 23, 2022, to complete a medication assessment for increased aggression but no further follow up is documented, and interventions used by AP1 leading up to W1 and AV altercation were not person specific, and generic in nature. The facility failed to properly plan care and provided interventions appropriate to mitigate W1 aggressive behaviors towards other residents which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility for his or her safety. AV’s service plan is noted for elopement risk and exit seeking behaviors. On or about April 18, 2022, AV eloped from the facility, and walked into traffic. AV was brought back to the facility by Law enforcement. The facility failed to provide a safe environment and prevent elopement, which is a violation of resident’s rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) wallet containing $107.00, went missing from Alleged Perpetrator #2 (AP2) locked desk drawer. The allegation that AP2 failed to protect AV from theft was investigated and the determination was not substantiated. The facility failed to basic securing and handling of AV's funds resulting in theft, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) Personal Incidental Funds (PIF) $100.00, went missing from Alleged Perpetrator #2 (AP2) locked desk drawer. The allegation that AP2 failed to protect AV from theft was investigated and the determination was not substantiated. The facility failed to basic securing and handling of AV's funds resulting in theft, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility and Alleged Perpetrator #2 (AP2) failed to provide a safe medication administration system to ensure the medication entered was safe to administer to Alleged Victim (AV). The failure resulted in AV being transported to the hospital for treatment, which is a violation or residents rights, is considered neglect of care and constitutes abuse. The allegation Alleged Perpetrator #3 (AP3) failed to provide a safe medication administration system for the AV was investigated and the determination was not substantiated.

On or around March 2022, it was discovered the Alleged Perpetrator 2 (AP2) administered Alleged Victim (AV) medication to another resident, leading to loss of AV's prescribed medication. resulting in financial exploitation. AP2’s actions are a violation of resident rights, are considered neglect of care and constitute financial abuse. AP1 failed to ensure adequate supervision, and oversight of the medication administration system, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) had approximately six (6) falls in one month, from which AV sustained, pain, abrasions, head injury, and underwent surgery for a fractured hip. 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.

Alleged Victim (AV) relies on the facility to administer his/her medications. On or about February 02, 2022, AV was transported from the hospital to the facility as a new resident. AV’s medications were not ordered prior to AV arriving to the facility. AV went without his/her medications for approximately four days. The facility failed to provide a safe medication administration system, 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 Victims (AV) medication orders were administered as prescribed. It was discovered that AV was not administered h/h heart medication as scheduled for twelve (12) days. Investigation and interviews show the MAR was placed on hold without a medical provider’s order placing AV at risk of harm. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) did not receive h/h PIF and Stimulus money in the amount off $1, 752.00 from August 2021 through January 2022. Per interviews and documentation provided to the department, corporate office applied AV’s money to h/h room and board. AV made numerous requests for PIF money to purchase personal items without response. Corporate office sent Alleged Perpetrator 2 (AP2) three checks totaling $ 1, 598.00, in which AP2 was responsible for cashing and reimbursing AV. As of February 01, 2022, AV has received a refund in the amount of $983.00. AP2 and the facility are responsible for financial exploitation and failure to protect the resident from theft, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) self-propels in AV's wheelchair only short distances and doesn't have the strength to go longer distances due to a shoulder issue and chronic disease. On or about April 16, 2025, AV was in the dining room, rolling AV's self away from a dining table when AP2 approached AV, wheeled AV back to the dining table, and locked both left and right rear wheels of AV's wheelchair. AP2 locked AV's wheels because AV had been attempting to leave the dining area. AV's wheelchair locks are low to the ground, at the rear of the chair, with the hand mechanism just above relatively small wheels. AV is unable to operate the locks independently and has never been observed intentionally or accidentally locking the wheels. AP2 did not follow state guidelines for resident rights 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 was being followed, which is a violation of Oregon Administrative rules.

Alleged Victim (AV) has experienced several falls, some with injury. AV is impulsive, with a tendency to not wait for staff to provide assistance. For this reason, AP1 has implemented a pressure alarm. On or about September 26, 2024, AV had an unwitnessed fall and was found on the floor. AP2 did not follow the plan to ensure a response to the pressure alarm going off. Although no injuries were noted at the time of the fall, latent bruising showed up on AV's hands later that day. Staff have been given specific instructions for expectations with the pressure alarm. The pad should be under AV wherever AV is positioned. A staff person is to be carrying the receiver for the alarm at all times and respond as soon as possible. If the person carrying the receiver is unavailable, another staff person should be notified. AP1 had provided all training appropriate to AP2's role, including specific instruction for reading and following service plans and temporary service plans. AP2 did not read the Interim Service Plan. AP2 was given instruction and did understand the requirement to hand off the receiver when going to lunch, AP2 put it in the hub instead. 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.

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

Alleged Victim (AV) has history of falls, poor gait, weakness, and poor balance. Interventions for falls have been implemented, including frequent checks and assisting with toileting and brief changes overnight, to prevent AV from getting up independently. Two (2) staff members split the rooms of Alleged Perpetrator 1 (AP1/facility) on NOC shift. On or about February 21, 2024 February 22, 24, Alleged Perpetrator 2 (AP2) was responsible for AV's side. AP2 is tasked with completing frequent checks. At approximately 5:30 am, Witness 4 (W4) found AV on the floor in h/h room with an abrasion to h/h left knee and complaining of pain all over. AV's body and bed were wet. It was discovered that AV had not been checked on since shift change on about February 21, 2024, at approximately 10:00 pm. AP2 told staff s/he had checked on AV around 2:00 am, to ensure AV's needs were met. AP2 should've checked on AV before then, at approximately 12:00 am, and then again around 4:00 am. Per video footage, AP2 was not witnessed checking in on AV at all, either by opening the door and viewing AV, or physically entering the room and checking for wetness. AP2 signed off on checks completed each hour from 10:00 pm to 4:00 am. This information does not align with the statement that one check was done at 2:00am. AP2 understood to check AV every couple of hours. 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.

On December 7, 2023, at 1:20 pm, the facility's activity room kitchen stove top was observed to have had a box, bingo wheel and roll of wrapping paper laying on top of it. In an interview on December 7, 2023, at 11:41 pm Staff 1 (Executive Director) stated the stove in the activity room is plugged in but not in use. In an interview on December 7, 2023, at 1:30 pm Staff 2 (Activities Director) stated "the stove is never used in that kitchen and extra stuff just gets left near or around it." During a site visit on 12/07/23, it was confirmed the facility failed to exercise reasonable precautions that may threaten the health, safety, or welfare of residents by using the activity room kitchen stove top as storage.

Alleged Victim (AV) is care planned for doctor-ordered mechanical soft diet with thin liquids. AV has a history of choking requiring the Heimlich maneuver, after eating foods not on h/h Mechanical soft diet. AV continues to order pizza delivery, shop and purchase h/h own foods including salami. On or about March 06, 2023, AV came out of h/h room choking requiring the Heimlich maneuver. AV became unconscious, without a pulse, chest compressions were started, and AV was transported to the hospital. The facility failed to appropriately care plan and implement reasonable interventions to address AV’s ongoing non-compliance to 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 resulting in a staff member using vulgar language in front of a resident, and making negative judgements about residents with other staff members, and for smoking marijuana on the job, which is a violation of Oregon Administrative Rules.

The facility failed to exercise reasonable precautions against any condition that may threaten the health, safety, or welfare of the residents resulting in an empty syringe used to administer Haldol being left in the common dining area exposing resident to potential harm, which is a violation of Oregon Administrative Rules.

The facility failed to implement a system for tracking controlled substances, and for disposal of all unused outdated or discontinued medications administered by the facility resulting in a staff member leaving a Fentanyl patch in a resident's room and exposing resident to potential harm, which is a violation of Oregon Administrative Rules.

On or about December 27, 2022, Alleged Victim (AV) was refusing medication. Alleged Perpetrator #2 (AP2) attempted to force a pill into AV mouth. AV spit the pill out on the floor and bit AP2, who picked up the pill from the floor and again attempted to put it into AVs mouth. AP2's actions are a violation of resident rights, are considered neglect of care and constitute physical abuse. The facility failed to ensure the residents rights/treatment was being followed, which 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) that accurately reflected the resident population and their needs. 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. Corrective Action taken on related allegation.

Review of staffing schedules for June and July 2022, posted staffing plan, ABST summary, and service plan for Resident #1. The ABST shows the facility needs 5 caregivers (CG) and 1 med tech (MT) for Days and Swing shift, and 1 CG and 1 MT for NOC shift. The posted staffing plan shows that they have 2.5 CG and 1 MT for Days and Swing shifts, and 1 CG and 1 MT for NOC shift.

Review of staffing schedules for June and July 2022, posted staffing plan, Acuity Based Staffing Tool (ABST), service plans and progress notes for Resident #1, and the appointment calendar. The facility is not staffing per the ABST.

The facility failed to carry out medication orders as prescribed resulting in the facility administered the wrong dosage of medication to resident, which is a violation of Oregon Administrative Rules.

Review of staffing schedules for May and June 2022, posted staffing plan, shower schedule/sheets, timecards for 06/07/22-06/09/22, and Resident #1-3s service plans. The facility is not staffing per the posted staffing plan. There were instances when they had a staff member come in to fill the NOC shift med tech (MT) position, that was not trained as a MT. Showers are not being completed and documented per the shower schedule and service plans.

In review of Residents #1-4s progress notes, medication administration records (MARs) for May and June 2022, and policy and procedures for medication administration, Resident #4 did not receive a scheduled 12am medication on 06/09/22 and no initials or comment in the MAR as to why it was not administered. Resident #3-4s MAR also revealed multiple instances when the medications were not given due to not having the medications available at the facility. Medications are not being given as ordered.

In review of completed staff training packets for 3 staff members who pass medications, it was found that Staff #3 has not completed any training at the facility as a med tech. In separate interviews on 06/14/22, Staff #1 and Staff #3 stated that Staff #3 has not completed any MT training at the facility. They confirmed that they have been working as a MT and passing medications without completed training.

In review of service plans, shower schedule, and shower sheets for Residents #1-3. Residents do not appear to be getting showers per the schedule and service plans.

CS reviewed Policy and procedures for infection control practices. The facility is not following their policy regarding masks. During walkthrough on 06/14/22, CS observed Staff #1 in their office with a resident sitting next to them, and they were not wearing masks. During visit, other staff members were observed with their masks pulled down below their noses.

In review of Residents #1-4s progress notes, medication administration records (MARs) for May and June 2022, and policy and procedures for medication administration, Resident #4 did not receive a scheduled 12am medication on 06/09/22 and no initials or comment in the MAR as to why it was not administered. Resident #3-4s MAR also revealed multiple instances when the medications were not given due to not having the medications available at the facility. Medications are not being given as ordered.

On or about June 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 May 1, 2022 to May 31, 2022, for a total of 30 days.

The allegation that the facility failed to have sufficient staff to meet the scheduled and unscheduled needs of the residents in accordance with OAR 411-054-0070(1) per complaint that there is not enough staff to assist residents with showers was verified.

The allegation that The facility failed to include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility in accordance with OAR 411-054-0045(1)(b) per complaint that the facility nurse is out indefinitely and the facility has no one doing assessments or other nursing services was verified.

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.