Rosewood Park Retirement and Assisted Living Residence

Alleged Victim (AV) reports calling for assistance with using the toilet and was told to urinate in h/h brief. AV was left soaking in h/h wet brief for approximately forty-five (45) minutes. AV reports feeling uncomfortable and experiencing loss of dignity when told to urinate in h/h brief. The facility failed to provide assistance with toileting, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to administer medication as ordered. Alleged Victims (AVs) medical conditions cause AV to experience chronic pain. AV did not receive scheduled and PRN pain medications in a timely manner on multiple occasions, and resulted in AV experiencing break through pain, which is a violation of resident rights is considered neglect of care and constitutes abuse.

The facility failed to have Alleged Victims (AV) pain medication available. It was discovered that AV did not receive h/h pain medication for several days, resulting in AV being in bed with uncontrolled pain. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to have Alleged Victims (AV) blood thinning and heart medication available. It was discovered that AV did not receive h/h medications for several days, resulting in abnormal labs and placing AV at risk of serious harm. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to maintain an accurate an accurate Medication Administration Record (MAR) of all medications. 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 carry out medication and treatment orders as prescribed, a resident's medication timely and they went without. 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, a resident received their routine 9:00 pm medication at 3:00 pm. An investigation determined this is a violation of Oregon Administrative Rules.

On or about December 17, 2024, the ODHS' Licensing Complaint Unit (LCU) conducted a revisit based on facility asserting compliance on December 10, 2024, on the terms of Condition ALFCD23-00497. The investigation determined the facility failed to carry out medication orders as prescribed. The facility's failure to provide a safe medication administration system is a violation of Oregon Administrative Rules.

On or about December 17, 2024, the ODHS' Licensing Complaint Unit (LCU) conducted a revisit based on facility asserting compliance on December 10, 2024, on the terms of Condition ALFCD23-00497. The investigation determined the facility failed to carry out medication and treatment orders as prescribed. The facility's failure to provide a safe medication administration system is a violation of Oregon Administrative Rules.

Resident 4's personal medication charting indicated s/he had missed six doses of Tizanidine 4mg (muscle spasms) on March 1, 2024, and March 2, 2024. Resident 6's MAR, dated March 8, 2024, indicated the facility "did not give" his/her Hydrocodone/APAP 5-325mg tab at 7:00 am and 1:00 pm. During an interview on March 11, 2024, Staff 2 (LPN) confirmed the facility had "lost" the pharmacy delivery for eleven residents, including Residents 4 and 6.

Staff 9 stated s/he usually worked on the first floor but was sometimes asked to work on the second floor. S/he further stated s/he "did not feel comfortable" on the second floor but "got used to it." The facility failed to provide requested training records. It was confirmed the facility failed to verify direct care staff had demonstrated satisfactory performance in assigned duties.

On 02/17/24 Staff 3 had given Staff 4 the medication cart keys and instructed Staff 4 to dispense narcotics to Resident 1 and sign the narcotic log with Staff 3's initials. A review of Resident 1's narcotic log indicated Staff 3 had initialed the log on 02/17/24, when in fact it was Staff 4 who had dispensed the medication. It was determined a staff member signed out narcotics using another staff members initials

On March 11, 2024, Resident 1 stated it was "hit or miss" if s/he received his/her medication and his/her "pills sat a full week" in February after the facility had received them. Resident 1’s MAR dated February 1, 2024, through February 29, 2024, indicated on February 21, 2024, and February 26, 2024, Duloxetine DR 60 MG TAB (for nerve pain) was not administered. Notes on the MAR indicated "out of med" and "resident ran out of duloxetine." Resident 2’s MAR dated February 1, 2024, through February 29, 2024, indicated s/he did not receive his/her 7:00 am dose of Loratadine 10 MG tab (for allergies) on February 26, 2024. The MAR notes indicated "waiting on pharmacy." On February 25, 2024, and February 26, 2024, Resident 2 was not administered his/her 8:00 am dose of Caplyta 42 MG tab (for mood stabilization). MAR notes indicated "waiting on pharmacy."

Physician orders for Resident 7, dated January 3, 2024, indicated Resident 7 was to have his/her blood sugar checked at 7:00 am and 3:00 pm. Resident 7's MAR, dated February 1, 2024, through March 11, 2024, indicated ten instances in which Resident 7's blood sugar was not recorded.The facility failed to carry out medication and treatment orders as prescribed.

An incident report, dated December 10, 2023, indicated a Medication Technician had administered Oxycodone (pain medication) to Resident 11 instead of Alprazolam (anxiety medication). Staff 2 confirmed the incident had occurred. It was determined the facility failed to carry out medication orders as prescribed.

The facility failed to provide a safe medication administration system for the Alleged Victim (AV). According to documentation, AV experienced no negative outcome. The failure is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during a site visit on 10/09/23 and 10/10/23, it was confirmed the facility failed to update service plans quarterly for 8 of 16 sampled residents, ,which is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during a site visit on 10/09/23 and 10/10/23, it was confirmed the facility failed to investigate and report abuse, which is a violation of Oregon Administrative Rules.

Based on observation, interview, and record review, conducted during a site visit on 10/09/23 and 10/10/23, it was confirmed the facility failed to provide a safe and homelike environment, which is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during a site visit on 10/09/23 and 10/10/23, it was confirmed the facility failed to maintain an accurate MAR for 13 of 16 sampled residents, which is a violation of Oregon Administrative Rules.

Based on observation and interview, conducted during a site visit on 10/09/23 and 10/10/23, it was confirmed the facility failed to ensure food palatability and failed to follow food sanitation rules,which is a violation of Oregon Administrative Rules.

Based on interviews, conducted during a site visit on 10/09/23 and 10/10/23, it was confirmed the facility failed to ensure the staff person who administers medication visually observed the resident take the medication, which is a violation of Oregon Administrative Rules.

ABST Condition #ALFCD23-00075, imposed 2/2/2023, no further action required.

Based on interview and record review, conducted during a site visit on 10/09/23 and 10/10/23, it was confirmed the facility failed to ensure a 24 hour resident monitoring and reporting system, which is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during a site visit on 10/09/23 and 10/10/23, it was confirmed the facility failed to ensure the implementation of services and follow the residents service plan, which is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during a site visit on 10/09/23 and 10/10/23, it was confirmed the facility failed to carry out medication orders as prescribed for 2 of 2 sampled residents, which is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during a site visit on 10/09/23 and 10/10/23, it was confirmed the facility failed to implement a safe medication administration system for 12 of 15 sampled residents, which is a violation of Oregon Administrative Rules.

ABST Condition #ALFCD23-00075, imposed (2/2/2023), no further action required

The Alleged Victim (AV) had money taken by an unknown individual and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to protect AV’s property from theft, which is a violation of Oregon Administrative Rules.

On or about August 28, 2023, Alleged Victim (AV) reports calling for assistance with brief change in bed, Alleged Perpetrator #2 (AP2) insisted AV get out of bed to use the restroom, as a result AV fell to ground sustaining knee pain. AP2 did not respect AV rights to refuse care and failed to provide a safe environment which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to ensure a safe environment and residents rights were being followed, which is a violation of Oregon Administrative rules.

Based on interview and record review, conducted during a site visit on 09/08/23, it was confirmed the facility failed to carry out medication and treatment orders as prescribed. AV did not receive h/h medication on or about 07/15/2023 and the PCP was not notified, ,which is a violation of Oregon Administrative Rules.

The facility failed to be responsible for the supervision and overall conduct of staff when staff are acting within the scope of his or her employment duties. This placed residents at risk and constituted an immediate threat to residents' health and safety, which is a violation of Oregon Administrative Rules.

The facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents. That placed residents at risk and constituted an immediate threat to residents' health and safety, which is a violation of Oregon Administrative Rules.

During an interview and investigation on 09/08/23, it was determined a staff member had videotaped AV in his/her underwear and posted the video on social media. Facility had self-reported the incident to Seniors and People with Disability, and the staff member was terminated. An investigation determined this is a violation of Oregon Administrative Rules.

On or about March 18, 2023, Alleged Perpetrator 2 (AP2) filmed an inappropriate video Alleged Victim (AV) and posted it to AP2 social media, which is a violation of AVs dignity, respect and considered verbal/emotional abuse. The facility failed to protect AV from verbal/emotional abuse which is a violation of Oregon Administrative Rules.

On or about January 01, 2023, the Oregon Health Authority reported to the Department that Respondent failed to comply with weekly reporting requirements of vaccinated individuals, residents and staff, to the proper authority as required by law. This failure has been ongoing for a total of 30 days.

The Alleged Victim (AV) reported, $200.00 cash, went missing from his/her room. The AV reports the money was taken by Alleged Perpetrator #2 (AP2) and this person 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 Alleged Victim (AV) reported, $100.00 cash, went missing from his/her room. The AV reports the money was taken by Alleged Perpetrator #2 (AP2) and this person 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 Alleged Victim (AV) reported, $300.00 cash, went missing from his/her room. The AV reports the money was taken by Alleged Perpetrator #2 (AP2) and this person 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.

On or about October 17, 2022, the Alleged Victim (AV) told facility staff that he/she was missing money from his/her apartment. Alleged Perpetrator #2 (AP2, unknown) took money from AV’s apartment. AP2’s actions are a violation of resident rights, are considered neglect of care and constitute financial abuse. The facility’s failure is a violation of Oregon Administrative Rules.

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

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) as stated in complaint resident is receiving medications late or not receiving medications as they are not available 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.

The allegation that the facility allegedly failed to provide appropriate staffing was verified.

The allegation that the facility allegedly failed to administer medication as ordered for the Alleged Victim was verified.

The allegation that the facility allegedly failed to assure the Alleged Victim rights was verified.