Pacific Grove Memory Care

Alleged Victim (AV) relies on the facility for a safe environment. AV has a history of wandering into other residents’ rooms. Witness #1 (W1) has history of behaviors and altercations when other residents head towards or go into W1’s room. W1's service plan indicates if other residents head towards W1's room, facility staff need to immediately intervene due to W1 past physical behaviors. On or about July 25, 2023, AV wandered into W1 room and W1 followed AV in telling h/h to get out. Both W1 and AV grabbed each other and tumbled to the ground, resulting in AV having redness to ear, knee areas, and redness, tearing to arm area, with bruising to facial area. The facility failed to provide a safe environment and redirect AV. The facility failed to follow W1 care plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness 1 (W1) has history of arguing and being aggressive with another roommate, and staff. Alleged Victim (AV) and W1 have history of a previous physical altercation resulting in AV sustaining an injury. The facility failed to adjust the service plan for W1’s continued aggressive behavior. On or about September 02, 2022, W1 and AV were involved in a verbal altercation which led to a physical altercation resulting in AV being hit with an assistive device sustaining a skin tear to h/h. The Facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

The Alleged Victim (AV) has a history of falls and wandering. Facility has a protocol for the courtyard door to be locked when the outside temperature is above 90 degrees. On or about August 29, 2022, the temperature outside was above 90 degrees and the door to the courtyard was propped open. AV was found in the courtyard on the ground. AV was weak and unable to stand or walk. Facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

The Alleged Victim (AV) family moved all AVs belongings into the facility on or about August 10, 2022. On or about August 12, 2022, the facility moved AV belongings to another room with AVs family consent. It was discovered by family on or about August 14, 2022, AV had two belt buckles missing. The allegation that AP2 failed to protect AV from theft was investigated and the determination not substantiated. The facility failed to locate AV’s belt buckles, resulting in theft, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim relies on the facility for his or her safety. On or about March 10, 2022, AV climbed out of an unsecure dining room window and was redirected back inside. Then the following early morning AV eloped from the facility by climbing out the same unsecured window and jumping a locked gate. AV was found by LEA and brought back to the facility without injury. The facility failed to provide a safe environment, which is a violation of resident’s rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for h/h care. AV was found in urine-soaked clothing and AVs room smelled of urine and rotten food. The facility failed to appropriately provide care and services which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility allegedly failed to protect, report abuse and investigate all reports of abuse and suspected abuse for the Alleged Victim. Alleged Victim experienced injury falls on 10/10/25 and 11/15/26, however, those falls were not reported to the local Adult Protective Services office. An investigation determined this is a violation of Oregon Administrative Rules.

The facility allegedly failed to administer medication as ordered for the Alleged Victim. An investigation determined this is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during a site visit on 07/10/25 and 07/11/25, the facility’s failure to evaluate the resident, refer to the facility nurse, and document the change, and update the service plan was substantiated for 1 of 1 sampled resident (#1). Findings include, but are not limited to: A review of Resident 1's Hospital Discharge After Visit Summary dated 07/01/25, indicated instructions for skin tear to the left shoulder: "If there is a dressing or bandage, change it when it gets wet or dirty;" "Otherwise, leave it on for the first 24 hours, then change it once a day, or as often as the healthcare provider says;" and "After three days, you can keep the bandages off the wound, unless told otherwise, or there is continued drainage; allow the wound to be open to the air." A review of Resident 1's Progress Notes dated 07/02/25 through 07/14/25 indicated the following: On 07/02/25, Interim Service Plan was created regarding Resident 1's fall on 07/01/25, with instructions for staff to report any concerns of increased pain, bruising, or further injury to the area to the Med Tech (MT), Licensed Nurse, (LN) or Medical Doctor (MD). Frequency as needed or requested; On 07/03/25, Skin Note that LN cleaned and changed the dressing; On 07/05/25, Alert Chart indicated the Resident had pain when lying on his/her left side; 07/05/25, Alert Charting indicated the Resident had expressed a couple of complaints of pain in certain positions. No other concerns and skin tear is being followed by the nurse. Removing this alert at this time; 07/08/25, Alert Charting notes indicated Resident's skin tear was uncovered with sterile strips on it. His/her skin tear looked very infected. Staff informed LN; 07/08/25, Interim Service Plan created with instructions that the resident has a skin issue on the left side shoulder; staff to report any complaints of infections, redness, odor, swelling, drainage, or temperature above 100 degrees Fahrenheit to the MT or LN; and 07/11/25, Skin Note, late entry for 07/08/25, LN provided wound care and new dressing. LN noted white slough present to the upper area of the wound. In an interview on 07/10/25, Staff 3 (RN) stated the following: "We have standing orders to provide wound care;" In response to being asked if the wound care was on Resident 1's MAR Staff 3 responded, "No, but I can add instruction to the MAR/TAR now;" and "Staff are not trained to provide wound care. I am monitoring it." The resident was experiencing pain per progress notes, which was part of the instructions to monitor. There was no indication of nurse follow-up or that information was provided to the nurse or physician to treat the resident's pain. Alert Charting was removed on 07/05/25, before resolution. It was determined that the facility failed to evaluate the resident, refer to the facility nurse, document the change, and update the service plan.

Based on interview and record review, conducted during a site visit on 07/10/25 and 07/11/25 the facility's failure to develop and maintain an Acuity Based Staffing Tool (ABST) was substantiated for1 of 3 sampled residents (#1). Findings include, but are not limited to: A review of the Facility ABST and the facility census indicated the facility census was 44. A review of Resident 1’s service plan, dated 07/02/25, and his/her ABST last edited on 07/02/25, indicated the following: Resident 1's service plan indicated that staff assistance with monitoring a change in behavior and time spent cueing and redirecting due to cognitive impairments was required; and There was no time in Resident 1's ABST profile for assistance with those Activities of Daily Living. In an interview on 07/10/25, Staff 1 stated Staff 6 was responsible for updating the ABST. A review of the facility posted staffing plan and staff schedule for 07/03/25 through 07/10/25 indicated the facility was staffed to the posted staffing plan. No missed needs were observed. The facility failed to accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Corrective Action taken on related allegation

Based on interview and record review, conducted during a site visit on 09/16/25, the facility’s failure to ensure behavioral symptoms that negatively impact the resident and others in the community must be evaluated and included on the service or care plan was substantiated for 1 of 1 sampled resident(s). Findings include, but are not limited to: A review of Resident 1’s Interim Service Plan, dated 06/08/25, indicated the following: Resident 1 is known to hoard food and will sometimes feed other residents. In an interview Staff 2 stated s/he was unable to locate a behavioral evaluation for Resident 1 and stated there was no behavioral assessment on file. The facility’s failure to ensure behavioral symptoms that negatively impact the resident and others in the community must be evaluated was substantiated.

The findings contained in this report are in response to Condition No. RCFCD24-00266, following the facility's assertion of compliance on 04/01/25. Based on observation, interview, and record review, conducted during a site visit on 04/17/25, the licensee’s failure to be responsible for the operation of the facility and the quality of services rendered in the facility was substantiated. The facility has been out compliance since 02/07/24 through 04/17/25 in the following areas, findings include, but are not limited to: Reporting and Investigating Abuse- OAR 411-054-0028(2)(b); Staffing Requirements and Training – OAR 411-054-0070; Acuity-Based Staffing Tool – OAR 411-054-0037(1-7); and Service Plans: General – OAR 411-054-0036(2)(g). It was determined the licensee failed to be responsible for the operation of the facility and the quality of services rendered in the facility. An investigation determined this is a violation of Oregon Administrative Rules. The facility was notified of the licensing violation by telephone on 04/22/25.

The findings contained in this report are in response to Condition No. RCFCD24-00266, following the facility's assertion of compliance on 04/01/25. Based on interview and record review, conducted during a site visit on 04/17/25, the facility’s failure to immediately notify the local Department office, or the local AAA, of any incident of abuse or suspected abuse was substantiated for 1 of 1 sampled resident (# 3). Findings include, but are not limited to: An incident report for Resident 3, dated 04/10/25, indicated s/he had suffered an unwitnessed fall with injury. It further indicated Resident 3 had not been using his/her walker per his/her service plan. Resident 3's service plan, dated 02/07/25, indicated s/he required a walker while ambulating. Staff 1 (Executive Director) stated the facility had ruled out neglect or abuse but acknowledged the incident report indicated Resident 3's service plan was not being followed. There was no documented evidence the facility reported the incident to the Department or the local AAA, despite their investigation indicating Resident 3's service plan was not being followed during the incident. It was determined the facility failed to immediately notify the local Department office, or the local AAA, of any incident of abuse or suspected abuse. 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. This is a repeat violation.

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.

The findings contained in this report are in response to Condition No. RCFCD24-00266, following the facility's assertion of compliance on 04/01/25. Based on observation, interview, and record review, conducted during a site visit on 04/17/25, the facility’s failure to ensure the service plan reflected the residents’ needs and to ensure the implementation of services was substantiated for 3 of 4 sampled residents (#s 2, 3, and 4). Findings include, but are not limited to: 1. Resident 2’s physician orders, dated 03/04/25, indicated s/he required a pureed diet. Resident 2’s service plan, dated 02/28/25, indicated s/he was to receive a mechanical soft diet. 2. Resident 3’s service plan, dated 02/07/25, indicated s/he used a wheelchair as an assistive device and was to be evacuated in a wheelchair in case of emergency. Resident 3 was not observed to have a wheelchair. Staff 3 stated Resident 3 did not have a wheelchair. 3. Resident 4’s service plan, dated 01/27/25, indicated s/he required two staff members to assist him/her with transferring. At approximately 11:00 am, Staff 16 requested assistance toileting Resident 4 over the radio. At approximately 11:03 am, Staff 16 stated Resident 4 needed his/her briefs changed. A second staff member did not assist Staff 16 with Resident 4’s needs until approximately 11:39 am. It was determined the facility’s failure to ensure the service plan reflected the residents’ needs and ensure the implementation of services was substantiated. The findings of the investigation were reviewed with and acknowledged by Staff 1, Staff 2, Staff 3, Staff 4, Staff 5, and Staff 6. An investigation determined this is a violation of Oregon Administrative Rules.

The facility’s failure to immediately notify the local Department office, or the local AAA, of any incident of abuse or suspected abuse, and promptly investigate all reports of abuse and suspected abuse and treatment orders was substantiated. An investigation determined this is a violation of Oregon Administrative Rules.

The facility allegedly failed to provide a therapeutic diet for the Alleged Victim. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

The facility allegedly failed to provide safe environment for the Alleged Victim. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

Based on observation, interview, and record review, conducted during a site visit on 10/21/24 the facility’s failure to carry out medication and treatment orders as prescribed was substantiated for 1 of 1 sampled resident (# 1). Resident 1’s physician orders, dated 07/23/24, indicated s/he was to receive a pureed diet and use a “Safestraw” with liquids. On 10/21/24, Resident 1 was observed to be served a mechanical soft diet. Staff were not observed assisting Resident 1 with his/her Safestraw. Staff 5 (LPN) stated staff had “confused” Resident 1’s plate with another resident’s. The facility’s failure to carry out medication and treatment orders as prescribed was substantiated.

The facility is responsible for administering Alleged Victim's (AV's) medications. On or about September 27, 2024, at around 2PM Alleged Perpetrator #2 (AP2) administered AV 40mg of narcotic medication instead of the prescribed 10mg dose. AV was aware there were four pills instead of one but did not alert anyone at the time. The facility was not aware of the medication error until the following day when AV alerted staff to it. AV refused to go to the hospital. AP2 has been trained by the facility in medication administration. AP2 has been disciplined for a medication error previously. AV had no negative outcome. The facility failed to provide a safe medication administration system and administer medication as ordered which is a violation of Oregon Administrative Rules.

The facility failed to ensure the implementation of services. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

On or about September 11, 2024, an audit was conducted by a facility nurse at which point it was discovered that AV missed medications that had been ordered by the ER on August 28, 2024. On or about August 28, 2024, AV was seen in the ER for shortness of breath and sent home with 2 different prescriptions for exacerbation. Upon return the same day, Witness 3 (W3) sent the after-visit summary noting new medications to the pharmacy via fax. On or about August 29, 2024, the pharmacy responded noting that the pharmacy could not dispense the medications because the faxed orders were unsigned. AV did not get the new medication until September 6, 2024 when AV's PCP provided an order during AV's follow up appointment. The facility failed to provide a safe medication administration system and administer medication as ordered 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 carry out medication and treatment orders as prescribed. 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 carry out medication orders as prescribed. The facility’s failure is a violation of Oregon Administrative Rules.

On or about August 11, 2024, at 8:00 AM, 12:00 PM, 8:00 PM, 0.5 mg of anxiety medication was given to AV instead of 1 mg. On or about August 12, 2024, August 13, 2024, and August 15, 2024,, at 8:00 PM, 0.5 mg of anxiety medication was given instead of 1 mg. August 21, 2024,, at 6:00 AM AV's pain medication was missed and not administered. The facility had a responsibility to provide medication administration to AV. The facility is to administer one 1 mg tablet by mouth three times daily and one 0.5 mg tablet by mouth every two hours as needed for anxiety or agitation. The facility is to administer one tablet of pain medication by mouth three times daily for generalized pain. There was no indication of increased agitation, behaviors, or reaction due to AV receiving the incorrect dose of anxiety medication. The facility failed to administer medication as ordered which is a violation of Oregon Administrative Rules.

The facility failed to carry out medication and treatment orders as prescribed. The facility’s failure 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. Corrective Action taken on related allegation.

The facility failed to ensure an RN assessed all residents with a significant change of condition in a timely manner. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to ensure the resident's right to receive proper notification if requested to move-out of the facility. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to carry out medication orders as prescribed. Resident was administered the wrong dose of their medication. An investigation determined this is a violation of Oregon Administrative Rules.

It was confirmed the facility failed to carry out medication orders as prescribed for 15 of 15 sampled residents (#s 2, 3, 4, 7, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, and 19). In an interview on 04/16/24 at 10:42 am, Staff 7 (Med Tech) stated there were issues with the prior nurse where s/he wasn't passing medications. A review of residents' Medication Administration Records (MARs), dated 03/01/24-03/31/24, and progress notes, dated 03/06/24-03/20/24, indicated the following medications were missed on 03/06/24: a. Resident 2: one missed dose of Cefpodoxime used to treat infection and one dose of Melatonin used to treat delayed sleep. b. Resident 3: one missed dose of Trazodone used to treat insomnia; one dose of Preparation H cream used to treat rectal itching and pain; and one dose of Salicylic Acid patch used to treat skin disorder. c. Resident 4: one missed dose of Depakote used to treat seizure disorder and one dose of Quetiapine used to treat Alzheimer's. d. Resident 7: one missed dose of Metformin used to treat diabetes; one dose of Olanzapine used to treat agitation; one dose of Senna used to treat constipation; and one dose of Trazodone used to treat insomnia. e. Resident 9: one missed dose of Atorvastatin used to treat cholesterol. f. Resident 10: one missed dose of Quetiapine used to treat Alzheimer's. g. Resident 11: one missed dose of Refresh Optive Ophthalmic Gel used to treat eye irritation. h. Resident 12: one missed dose of Clopidogrel used to treat stroke prevention; one dose of Donepezil used to treat Alzheimer's; one dose of Melatonin used to treat delayed sleep; one dose of Namenda used to treat dementia; and one dose of Hydraguard Silicone cream used to treat skin breakdown. i. Resident 13: one missed dose of Enulose Solution used to treat constipation. j. Resident 14: one missed dose of Tamsulosin used to treat enlarged prostate. k. Resident 15: one missed dose of Donepezil used to treat Alzheimer's. l. Resident 16: one missed dose of Acetaminophen used to treat pain. m. Resident 17: one missed doses of Cosopt Ophthalmic used to treat glaucoma; one dose of Melatonin used to treat delayed sleep; one dose of Memantine used to treat dementia; and one dose of Methylphenidate used to treat depression. n. Resident 18: one missed dose of Memantine used to treat dementia; one dose of Mirtazapine used to treat major depressive disorder; and one dose of Trazodone used to treat delayed sleep. o. Resident 19: one missed dose of bedtime skin cleanse treatment used to treat candidiasis of skin.

It was determined the facility failed to keep an accurate Medication Administration Record (MAR) of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber for 15 of 15 sampled residents (#s 2, 3, 4, 7, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, and 19) whose MARs were reviewed. A review of Resident 2's MAR, dated 03/01/24-03/31/24, indicated missing signatures for the following medications: * One dose of Cefpodoxime used to treat infection on 03/06/24. * One dose of Melatonin used to treat delayed sleep on 03/06/24. A review of Resident 3's MAR, dated 03/01/24-03/31/24, indicated missing signatures for the following medications: * One dose of Trazodone used to treat insomnia on 03/06/24. * One dose of Preparation H cream used to treat rectal itching and pain on 03/06/24. * One dose of Salicylic Acid patch used to treat skin disorder on 03/06/24. * One dose of Carbidopa used to treat Parkinson ' s disease on 03/13/24. A review of Resident 4's MAR, dated 03/01/24-03/31/24, indicated missing signatures for the following medications: * One dose of Depakote used to treat seizure disorder on 03/06/24. * One dose of Quetiapine used to treat Alzheimer ' s disease on 03/06/24. A review of Resident 7's MAR, dated 03/01/24-03/31/24, indicated missing signatures for the following medications: * One dose of Metformin used to treat diabetes on 03/06/24. * One dose of Olanzapine used to treat agitation on 03/06/24. * One dose of Senna used to treat constipation on 03/06/24. * One dose of Trazodone used to treat insomnia on 03/06/24. * One dose of Fluoxetine used to treat depression on 03/30/24. * One dose of Lisinopril used to treat hypertension on 03/30/24. * One dose of Melatonin used to treat insomnia on 03/30/24. * One dose of Trazodone used to treat insomnia on 03/30/24. A review of Resident 9's MAR, dated 03/01/24-03/31/24, indicated missing signatures for the following medications: * One dose of Atorvastatin used to treat cholesterol on 03/06/24. A review of Resident 10's MAR, dated 03/01/24-03/31/24, indicated missing signatures for the following medications: * One dose of Quetiapine used to treat Alzheimer's disease on 03/06/24. * One dose of Acetaminophen used to treat osteoarthritis on 03/13/24. A review of Resident 11's MAR, dated 03/01/24-03/31/24, indicated missing signatures for the following medications: * Six doses of Refresh Optive Opthalmic Gel used to treat eye irritation on 03/06/24, 03/14/24, 03/20/24, 3/27/24, 3/28/24, and 3/30/24. * Three doses of Camphor-menthol lotion used to treat dry skin on 3/20/24, 3/27/24, and 3/28/24. * Three doses of Eucerin Cream used to treat dry skin on 3/20/24, 3/27/24, and 3/28/24. A review of Resident 12's MAR, dated 03/01/24-03/31/24, indicated missing signatures for the following medications: * One dose of Clopidgrel used to treat stroke prevention on 03/06/24. * One dose of Donepezil used to treat Alzheimer ' s disease on 03/06/24. * One dose of Melatonin used to treat delayed sleep on 03/06/24. * One dose of Namenda use to treat dementia on 03/06/24. * One dose of Hydragaurd Silicone cream used to treat skin breakdown on 03/06/24. * Two doses of Clotrimazole cream used to treat chronic dermatitis on 03/27/24 and 03/28/24. A review of Resident 13's MAR, dated 03/01/24-03/31/24, indicated missing signatures for the following medications: * One dose of Enulose Solution used to treat constipation on 03/06/24. A review of Resident 14's MAR, dated 03/01/24-03/31/24, indicated missing signatures for the following medications: * One dose of Tamsulosin used to treat enlarged prostate on 03/06/24. A review of Resident 15's MAR, dated 03/01/24-03/31/24, indicated missing signatures for the following medications: * One dose of Donepezil used to treat Alzheimer ' s disease on 03/06/24. A review of Resident 16's MAR, dated 03/01/24-03/31/24, indicated missing signatures for the following medications: * Three doses of Acetaminophen used to treat arthritis pain on 03/04/24, 03/05/24, and 03/06/24. A review of Resident 17's MAR, dated 03/01/24-03/31/24, indicated missing signatures for the following medications: * One dose of Cosopt Opthamalic used to treat glaucoma on 03/06/24. * One dose of Melatonin used to treat delayed sleep on 03/06/24, 3/14/24, 3/24/24, 3/30/24. * One dose of Memantine used to treat dementia on 03/06/24. * One dose of Methylphenidate used to treat depression on 03/06/24. A review of Resident 18's MAR, dated 03/01/24-03/31/24, indicated missing signatures for the following medications: * One dose of Memantine used to treat dementia on 03/06/24. * One dose of Mirtazapine used to treat major depressive disorder on 03/06/24. * One dose of Trazodone used to treat delayed sleep on 03/06/24. * Three doses of Camphor-menthol lotion used to treat dry and itching skin on 3/26/24 and 3/27/24. A review of Resident 19's MAR, dated 03/01/24-03/31/24, indicated missing signatures for the following medications: * Six doses of skin cleanse treatment used to treat candidiasis of skin on 03/06/24, 3/20/24, 3/24/24, 03/27/24, 03/28/24, and 03/30/24.

Resident 1's incident report dated, 02/22/24 at 10:49 PM, indicated information related to a resident to resident altercation had occurred earlier that evening. The altercation resulted in yelling, two areas of open skin/scratches to Resident 2 and open handed hit to the head of Resident 1. First aid was given. The incident was self reported to the local Seniors and People with Disabilities office on 02/28/24, six days after the incident occurred.

On February 13, 2024, medical transport came to the facility to pick up Alleged Victim (AV) from the locked facility. Witness 4 (W4) called Alleged Perpetrator 2 (AP2) to verify whether AV could leave, and AP2 told W4 to allow AV to leave to h/h appointment. At approximately 10am, the clinic called the facility to see who was picking AV up as AV did not have an appointment. Medical transport was called to pick AV up, but when transport arrived, AV was not at clinic. AV was later found by LEA and brought back to the facility. AP2 and The facility failed to provide a safe environment, which is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during a site visit on 02/07/24 through 02/13/24, it was confirmed the facility failed to immediately notify the local Department office of an incident of abuse or suspected abuse for 1 of 1 sampled residents (# 29).During an interview on 02/07/24, Staff 8 stated s/he had deleted the incident report and interim service plan as s/he "didn't think it was a real incident. "S/he stated the facility had not reported the incident to the local Seniors and People with Disabilities (SPD) office. During an interview on 02/07/24, Staff 1 confirmed the facility had not reported the incident to the local SPD. It was determined the facility failed to immediately notify the local Department office or the local AAA of any incident of abuse or suspected abuse.

Based on observation and interview, conducted during a site visit on 02/07/24 through 02/13/24, it was confirmed the facility failed to establish and maintain infection prevention and control protocols. During a site visit on 02/07/24, it was observed the facility had signs posted on the entrance doors of the facility notifying that there was active COVID in the building as of 02/05/24. Staff 1 and Staff 6 were observed not wearing a mask in the facility. On 02/09/24, used personal protective equipment was observed overflowing from a garbage can and strewn across a chair in a common area. There was no documented evidence the facility had notified the Safety, Oversight and Quality unit until 02/07/24. It was determined the facility failed to maintain infection prevention and control protocols.

Based on observation and interview, conducted during a site visit on 02/07/24 through 02/13/24, it was confirmed the facility failed to implement a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility for 1 of 1 sampled resident (# 1). It was determined the facility failed to implement a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility.

Based on interview and record review, conducted during a site visit on 02/07/24 through 02/13/24 it was confirmed the facility failed to implement a policy for the referral of residents who may be victim of acute sexual assault examiner for 1 of 1 sampled residents (#29).There was no documented evidence the facility had referred Resident 29 to a trained sexual assault examiner within 86 hours of the incident according to rule. It was determined the facility failed to implement a policy for the referral of residents who may be victims of acute sexual assault to the nearest trained sexual assault examiner for a potential sexual assault.

Based on observation, interview and record review, conducted during a site visit on 02/07/24 through 02/13/24, it was confirmed the facility failed to implement a written policy that prohibits the falsification of records. A record review of a fire drill checklist dated 02/08/24 indicated a fire drill took place at 2:20 pm in the memory care. The following information was documented on the Fire Drill checklist: - The report indicated the number of participants evacuating was 55; - The escape route used was "courtyard;" and - There were 11 staff members listed on the drill as participants and at least one of those staff members was an employee of the Assisted Living Facility. No residents or staff were observed evacuating the facility. During an interview on 02/08/24, after the fire drill had been completed, Staff 1 stated "I don't know why he wrote that, no one evacuated." It was determined the facility failed to implement a written policy that prohibits the falsification of records and falsified a document regarding a fire drill.

Based on interview and record review, conducted during a site visit on 02/07/24 through 02/13/24, it was confirmed the facility failed to ensure the preparation, completeness, accuracy, and preservation of resident records for 1 of 1 sampled resident (# 29).During an interview on 02/07/24, Staff 9 stated s/he had created an incident report and interim service plan regarding potential sexual abuse for an altercation involving Resident 29 and another resident on 01/29/24. During an interview on 02/07/24, Staff 8 stated s/he had deleted the incident and interim service plan for Resident 29 as s/he "did not think it was an incident. "There was not documented evidence of an incident report or temporary service plan for Resident 29 involving the alleged incident on 01/29/24.

Based on interview and record review, conducted during a site visit on 02/07/24 through 02/13/24, it was confirmed the facility failed to ensure the preparation, completeness, accuracy, and preservation of resident records for 1 of 1 sampled resident (# 29). During an interview on 02/07/24, Staff 9 stated s/he had created an incident report and interim service plan regarding potential sexual abuse for an altercation involving Resident 29 and another resident on 01/29/24. During an interview on 02/07/24, Staff 8 stated s/he had deleted the incident and interim service plan for Resident 29 as s/he "did not think it was an incident." There was not documented evidence of an incident report or temporary service plan for Resident 29 involving the alleged incident on 01/29/24.

Based on interview and record review, conducted during a site visit on 02/07/24 through 02/13/24, it was confirmed the facility failed to ensure the implementation of services for 1 of 1 sampled residents (#18 ).It was determined the facility failed to ensure the implementation of services and follow care instructions in the residents service plan.

Based on observation, interview, and record review, conducted during a site visit on 02/07/24 through 02/13/24, it was confirmed the facility failed to ensure the implementation of services for 1 of 1 sampled residents (# 15).It was determined the facility failed to provide twice a week showers for Resident 15.

Based on interview and record review, conducted during a site visit on 02/07/24 through 02/13/24, it was confirmed the facility failed to immediately notify the local Senior and People with Disabilities or the local AAA of an incident of multiple instances of abuse or suspected abuse for 1 of 2 sampled residents (# 16). It was determined the facility failed to investigate and immediately notify the local department office of multiple instances in which unwitnessed injury falls occurred.

Based on interview and record review, conducted during a site visits 02/07/24 through 02/13/24, it was confirmed the facility failed to immediately notify the local Seniors and People with Disabilities (SPD) or the local AAA of an incident of abuse or suspected abuse for 1 of 1 sampled resident (# 30). A Suspected Abuse or Unexplained Injury Reporting Form for Resident 30 was signed and dated 12/29/23, for an incident that occurred on 12/22/23. It was confirmed the facility failed to immediately notify the local SPD office or the local AAA of an incident of abuse or suspected abuse.

Based on observation, interview, and record review conducted during a site visit on 02/07/24 through 02/13/24, 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 and left units unstaffed.During the site visit it was observed the facility would leave hallways between adjoining wings open during night shift so that one caregiver was responsible for two wings. Caregivers did not have a line of sight between adjoining wings.

Based on interview and record review, conducted during a site visit on 02/07/24 through 02/13/24, 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 and left units unattended.

Based on interview and record review, conducted during a site visit on 02/07/24 through 02/13/24, it was confirmed the facility failed to fully implement and update and Acuity-Based Staffing Tool (ABST). It was determined the facility had not updated their ABST to reflect resident's acuity

Based on interview and record review, conducted during a site visit on 02/07/24 through 02/13/24, it was confirmed the facility failed to immediately notify the local Seniors and People with Disabilities (SPD) or the local AAA of an incident of abuse or suspected abuse for 1 of 1 sampled resident (# 27). failed to investigate and immediately notify the local department office of an unwitnessed injury fall.

The facility failed to ensure that facility personnel may not act as a resident's guardian, conservator, trustee, or attorney-in-fact, resulting in a former facility staff member obtained POA from memory care residents, which is a violation of Oregon Administrative Rules.

The facility failed to ensure a separate area with closed containers was available which allowed for the storage and handling of soiled linens and clothing and provide a one-way flow of soiled items from the soiled area to the clean area.

The facility failed to report an injury of unknown cause and conduct an immediate investigation resulting in resident with multiple bruises on his/her hands and arms that could not be explained, and a resident sent to the ER for leg pain for unknown cause, which is a violation of Oregon Administrative Rules.

ABST Condition RCFCD23-00880 Imposed 7/27/2023 no further action required. ABST Condition was closed on 10/2/2023

The facility failed to immediately notify the local Department office of any incident of abuse or suspected abuse. An investigation determined no licensing violation or abuse occurred.

The facility failed to promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent re-occurrence of abuse. An investigation determined this is a violation of Oregon Administrative Rules.

The allegation that the facility failed to provide a safe and homelike environment in accordance with OAR 411-054-0027(1)(r) per complaint that resident is sleeping on mattress with no bedding and light bulbs in room are out and not replaced was verified.

The allegation that the facility failed to exercise reasonable precautions against any condition that may threaten the health, safety, or welfare of the residents in accordance with OAR 411-054-0025(4) per complaint that facility door does not latch close, there are used depends on resident rooms floor, and kitchen is left open and unattended allowing memory care residents to go through cabinets was verified.

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) was verified.

The allegation that the facility failure to ensure adequate professional oversight of the medication and treatment administration system per OAR 411-054-0055(1)(a) was verified.

The allegation that the facility failure to carry medication and treatment orders out as prescribed per OAR 411-054-0055(1)(f) was verified.

The allegation that the facility failure to keep medications secure between set-up and administration of medications per OAR 411-054-0055(1)(d) was verified.