Sunnyside Meadows

The facility failed to provide appropriate services according to the Alleged Victim’s (AV) care needs and wound care. Based on facility documentation and interviews, in March or April 2025, AV experienced a change of condition which left AV bed bound. On April 25, 2025, AV was found to have an open wound on his/her coccyx area. The investigation determined that the facility failed to put a Temporary Service Plan in place for AV's change of condition until after wound was found not when AV was documented as being bed bound. The facility's failure to provide basic care and services necessary to maintain the health and safety of AV, resulted in AV’s condition worsening causing further unreasonable discomfort, which is a moderate violation of resident rights, is considered neglect of care and constitutes abuse.

On March 30, 2025, Alleged Victim (AV) was observed in the common area with Witness 1's (W1) hands inside AV's shirt. AV and W1 are both diagnosed with cognitive deficits which include confusion and AV is unable to protect AV's self. W1 had known inappropriate behaviors, and the facility failed to care plan according to those behaviors. Based on facility documentation and interviews, facility was aware of W1's sexual behavioral expressions on March 22, 2025, but did not initiate an alert until March 25, 2025. The facility alert did not include behavior monitoring, hourly safety checks, and a relocation to a different room/unit for W1 until April 8, 2025. The facility's failure to respond timely to W1's care needs exposed AV to sexual abuse. The facility failed to provide intermittent interventions, supervision, and staff support to mitigate W1's behavioral symptoms which ultimately led this incident in W1 made inappropriate sexual contact with AV causing AV emotional harm and unreasonable discomfort, which is considered a moderate violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement appropriate interventions and provide adequate supervision related to the Alleged Victim’s (AV) known history of falls. On or about February 15, 2025, AV experienced an unwitnessed fall in AV's room and suffered a skin tear to AV's right elbow. Based on facility documentation and interviews, AV suffered a fall the day prior, that caused multiple injuries to AV. It was determined AV was experiencing a significant change of condition and had a decreased in mobility; however, no further interventions for falls were implemented for AV at that time. The facility 's failure to provide the basic care and services necessary to maintain the health and safety of AV, caused AV to experience a fall with injury causing AV unreasonable discomfort which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about February 13, 2025, Witness 2 (W2) was found in the common area standing behind Alleged Victim (AV) while AV was sitting. W2 was observed to have his/her hands on AV's chest area. Based on facility documentation and interviews, W2 was known to have inappropriate sexualized behaviors, and the facility staff were directed to monitor W2, by "keeping eyes on W2". Facility staff stated that incidents involving W2 were becoming more frequent, and staff concerns were reported to facility's leadership team regarding the need for one-on-one care to prevent W2 from sexually abusing other residents. The facility failed to provide one-on-one care to prevent more incidents of sexual abuse by W2. An investigation determined that the facility failed to staff appropriately for W2's care needs and failed to put sufficient interventions in place to address W2's sexualized behaviors in order to protect others which ultimately led to an incident where W2 made inappropriate sexual contact with AV by touching that resident’s breast. The facility’s failure to put sufficient interventions in place for W2 is a violation of resident rights, is considered neglect of care and constitutes abuse

On or about February 13, 2025, Witness 1 (W1) was discovered in Alleged Victim's (AV) room attempting to kiss AV. Based on facility documentation and interviews, W1 and AV lack the cognitive capacity to consent to an intimate relationship. W1 has a history of engaging in sexually inappropriate behaviors towards other residents. W1 ambulates without issue and is able to quickly engage in inappropriate behaviors with other residents. An investigation determined it is impossible for staff to always keep eyes on W1 as there are routinely two caregivers in W1's living area and there are residents who require two-person assistance with tasks, which leaves W1 unsupervised. The facility failed to staff appropriately for W1's care needs and failed to put sufficient interventions in place to address W1's sexualized behaviors in order to protect others which ultimately led to an incident where W1 committed inappropriate sexual behaviors by kissing AV and grabbing AV resulting in AV experiencing unreasonable discomfort and pain. The facility’s failure to put sufficient interventions in place for W2 is a violation of resident rights, is considered neglect of care and constitutes abuse

Alleged Victim (AV) is care planned to be a two-person, hands on assist for all transfer. Alleged Perpetrator 2’s (AP2’s) signature was not on AV’s service plan. On or about February 3, 2025, AP2 attempted to transfer AV by them self and as a result, AV sustained bruising to his/her left hip and both forearms and his/her left elbow. AV also sustained a kin tear to his/her left eyebrow. AP2 failed to assure the care plan was followed, which is neglect of care and constitutes abuse. The facility failed to assure the care plan was followed, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) is care planned to receive skin cheeks during care. On or about November 21, 2024, AV was discovered to have a skin tear of unknown origin on his/her left forearm. Although AV is service planned for skin checks, the facility has not place interventions in place to prevent skin tears on AV, only to monitor skin for new skin issues. The facility failed to care plan around AV’s skin care, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) has a known history of falls. On or about November 30, 2024, staff saw AV on the shower floor laying on his/her side with his/her head against the shower wall. No walker was in sight or close to AV. AV did not have his/her non-skid socks on or glasses on his/her face. Blood was noticed coming from AV’s head. AV complained his/her head hurt and also his/her hip and right shoulder. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

On or about October 28, 2024, the facility failed to provide a safe medication administration system to ensure The Alleged Victim’s (AV) received his/her narcotic pain medication as ordered. The failure resulted in AV experiencing unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse. Alleged Perpetrator 2 (AP2) allegedly neglected AV at time of incident. An investigation determined no abuse occurred. Alleged Perpetrator 3 (AP3) allegedly neglected AV at time of incident. An investigation determined no abuse occurred.

Alleged Victim (AV) has a known history of falls. On or about September 27, 2024, at 6:20am, staff found AV on the floor with a skin tear on his/her knee. On or about September 28, staff went to AV’s room and found AV on the floor experiencing chest pain. There are no interventions in place to alert staff when AV attempts to stand, transfer, or walk independently in his/her room, and AV is unable to utilize the call light effectively to call for help. The facility failed to properly plan care around AV’s known history of falls, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) is care planned for the facility to complete AV’s nail care. On or about September 11, 2024, AV was observed scratching his/her own right hand while getting changed. During this event AV’s fingernails were noticed to be long and untrimmed. The facility was unable to provide evidence as to when the last time AV was provided nail care as stated in the care plan. As a result of the long nails, AV sustained a skin tear to his/her right hand. The facility failed to follow the care plan, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. On or about July 2, 2024, at approximately 7:30 AM, staff went to AV’ room to conduct an assessment and discovered sugar ants in AV’s room/bed and on AV’s face, neck and torso. The facility was aware of the ant problem since at least June 2, 2024, and the facility was not treated for ants until July 3, 2024. The facility failed to provide timely service to AV around the ants in AV’s room, which is a violation of resident rights, is neglect of care and constitutes abuse.

The facility failed to provide appropriate services according to the Alleged Victim’s (AV) care needs. AV has a history of bruising and receiving skin tears on his/her arms and legs. Based on facility documentation, outside provider notes state to have AV wear long sleeves, pants and/or elastic stockings during awake hours as an intervention to prevent bruising and skin tears. On April 30, 2024, AV was observed wearing long sleeves but did not have pants or elastic stockings on his/her legs. AV also had a bruise on his/her left arm. The facility's failure to appropriately care plan AV’s care needs, caused AV unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about April 28, 2024, Alleged Victim (AV) fell in their bathroom after Alleged Perpetrator 2 (AP2) left AV alone to grab some clothes. AV suffered a laceration one inch deep to his/her head and suffered redness to his/her back of shoulder as a result of the fall. AV was sent to the hospital for treatment, medical glue was applied to AV's head wound, and the facility placed AV on alert charting for 72 hours after his/her return from the hospital. AV suffered another fall, on or about April 29, 2024, in their bedroom and was found on the floor next to their bed. Based on facility documentation and interviews, at time of both incidents, AV's service plans were not available to staff resulting in staff not having clear instructions on how to properly care for AV. The facility failed to appropriately provide instruction to caregivers regarding AV's care needs resulting in unreasonable discomfort. The facility's failure to provide a safe environment is a violation of resident rights, is considered neglect of care, and constitutes abuse. AP2 allegedly neglected AV. An investigation determined no abuse occurred by AP2.

The facility failed appropriately monitor Witness 1 (W1) according to his/her known behavior and prior altercations. On or about March 14, 2024, Alleged Victim (AV) and W1 were in the facility's dining hall for an activity. W1 slapped AV when AV attempted to collect W1's dish resulting in AV sustaining redness to his/her face. The facility's failure resulted in a physical altercation, causing unreasonable discomfort to the AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to appropriately monitor Witness 1 (W1) according to his/her known inappropriate sexualized behavior. On or about February 29, 2024, W1 groped Alleged Victim's (AV) upper body without permission which caused AV emotional harm. Based on facility documentation and interviews, this was W1's first time being inappropriate with a resident; however, W1 has a known history of touching the staff's upper body and lower areas below the waist. Prior to this incident, staff were directed to monitor W1 for inappropriate behavior and redirect W1 accordingly. The facility's failure to adequately supervise W1, caused emotional harm to AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about February 20, 2024, Alleged Victim (AV) fell onto the floor of his/her room while attempting to sit on a chair. At time of incident, AV's room was dark, no lights were on. Based on facility documentation and interviews, AV suffers from blurred and distorted vision and is care planned to have a soft, non-glaring light on at night. AV's care plan was not being followed as all lights in AV's room were off. The facility's failure to follow AV's care plan, resulted in AV falling, suffering unreasonable discomfort which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to appropriately care plan related to the Alleged Victim's (AV) care needs. The failure resulted in AV experiencing an unwitnessed fall on or about January 31, 2024, in which AV was found wrapped in blankets on the floor next to his/her bed. Based on facility documentation and interviews, AV's care plan does not mention a fall mat; however, AV normally has a fall mat due to having a history of falls and being a fall risk. AV's fall mat was not present at time of AV's fall because staff moved the fall mat to another resident's room. The facility's failure caused AV unreasonable discomfort which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately care plan related to the Alleged Victim's (AV) fall history. The failure resulted in AV experiencing an unwitnessed fall on or about January 23, 2024, was transferred to the hospital and required staples in his/her head, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately monitor Witness 1 (W1) and Alleged Victim (AV) according to their known behavior and prior altercations. On or about November 5, 2023, AV wandered into W1's room and laid on W1's bed. AV and W1 started yelling and W1 slapped AV in the face twice, causing unreasonable discomfort to the AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about October 9, 2023, in the early morning hours, Alleged Victim (AV) was found lying on their right side next to his/her bed. AV was noted to have a laceration on his/her scalp and was sent to the hospital for treatment. Medical staples were used to close the laceration on AV's scalp. Based on facility documentation and interviews, AV is a full assist with mobility and a two-person transfer assist. At time of investigation, facility staff could not identify staff on shift to determine if AV's safety plan was being followed at time of incident. The facility's failure to ensure AV's care plan was being followed resulted in AV ambulating without assistance causing AV to fall and suffer a head injury, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately care plan related to the Alleged Victim's (AV) fall history. The failure resulted in AV experiencing a fall on or about September 30, 2023, was transferred to the hospital and was diagnosed with a lumbar spine fracture. Based on facility documentation and interviews, prior to the September 30, 2023 incident, AV had multiple falls and the facility failed to service plan AV for fall risk, despite AV having 3 falls prior to incident. The facility's failure caused AV to suffer avoidable pain and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about September 24, 2023, Alleged Victim (AV) suffered an unwitnessed fall and was found on the floor in the bathroom, next to the shower, with shower curtain almost completely pulled off, with blood on AV's bathmat and the floor of the shower. AV had two bump abrasions on the left side of AV's forehead. AV was sent to the hospital for treatment. Based on facility documentation and interviews, prior to this incident, AV suffered another fall with injuries three days prior to this incident. The investigation determined the facility failed to provide appropriate services according to AV's care needs by not developing and/or maintaining a comprehensive care plan for AV's fall risk and by not ensuring staff were properly trained on AV's care needs before leaving AV alone. The facility's failure caused AV unreasonable discomfort when AV fell and hit their head. The facility's failure is a violation of resident rights, is considered neglect of care, and constitutes abuse.

On or about October 14, 2023, Alleged Victim (AV) had an unwitnessed fall in his/her bedroom. AV was found on the floor, confused with the lights turned off. Based on facility documentation and interviews, AV was identified as a fall risk prior to incident and had recently returned to the facility on October 4, 2023, after an extended hospital stay due to AV's previous fall which was on September 24, 2023. AV was identified as having a significant change of condition resulting in more weakness, confusion and overall decline in most Activities of Daily Living needs. The investigation determined the facility failed to implement appropriate fall interventions to mitigate AV's fall risk, failed to properly train staff on identifying factors that could increase AV's fall risk, failed to provide oversight and monitoring of AV's change of condition, and failed to appropriately care plan related to AV's fall history. The failure resulted in AV experiencing an unwitnessed fall ten days after returning to the facility as result of another fall that occurred at facility which required hospital treatment. The facility's failure caused AV continued pain and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide Alleged Victim (AV) with the basic care or services necessary after AV was injured after a fall by not getting AV prompt medical attention. On or about December 14, 2023, AV was found sitting on the floor in the common area, complained of right arm pain. AV was diagnosed on December 16, 2023, with a broken wrist. The facility's failure to provide a service resulted in AV experiencing unreasonable discomfort which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to assess and intervene Alleged Victim's (AV) change of condition. Based on facility documentation and interviews, AV had two documented injury falls on or about September 8, 2023, and facility failed to provide appropriate health assessment, oversight and monitoring in a timely manner. AV was sent to the hospital on or about September 11, 2023, and was diagnosed with a UTI and fractured pelvis. The facility's failure caused AV unreasonable discomfort which 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’s (AV) care needs resulting in AV skin breakdown. The facility's failure resulted in AV’s condition worsening causing unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide adequate care for Alleged Victim (AV) by leaving AV in urine-soaked briefs resulting in unreasonable discomfort to AV. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide adequate care for Alleged Victim (AV), resulting in AV experiencing unreasonable discomfort. Based on facility documentation and interviews, on July 27, 2023, AV was found in bed covered with ants. AV's July 27, 2023, progress note indicates ants had also been found in AV's room prior to incident. The facility did not eradicate the ants in a timely manner. As a result of the ant infestation, AV was found covered in ants causing AV to experience unreasonable discomfort due to red, irritated skin, 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 Victim’s (AV) medications were administered as ordered. Based on facility documentation and interviews, AV did not receive his/her blood pressure medication as ordered from June 24, 2023 through July 17, 2023. As a result of AV not getting his/her prescribed blood pressure medication, AV's blood pressure increased to an unhealthy range and AV was taken to the hospital and was diagnosed with having a stroke. The facility's failure resulted in unreasonable discomfort and hospitalization, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about July 7, 2023, the facility failed to provide basic care and supervision resulting in a resident-to-resident altercation that caused harm to Alleged Victim (AV) when Witness 1 (W1) was being sexually inappropriate with AV. W1 has a history of inappropriate sexual behaviors. On multiple subsequent occasions, W1 was observed having sexual contact with AV. The facility did not respond to W1's repeated inappropriate sexual contact with AV. Based on facility documentation and interviews, AV was noted to have a change in behavior as a result of W1's inappropriate sexual behaviors towards AV. The facility failed to properly care plan for W1's in appropriate behaviors causing an unsafe environment for AV which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately care plan related to The Alleged Victim’s (AV) known behaviors and increase of altercations. Based on facility documentation and interviews, AV initiated several resident-to-resident altercations towards Witness 1 (W1) between July 2023 and September 2023. The facility failed to sufficiently implement interventions to protect AV from risk of harm or prevent AV from harming other residents. The failure resulted unreasonable discomfort to AV and W1, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to monitor and provide appropriate supervision related to the Alleged Victim’s (AV) known history of falls. On or about August 13, 2023, AV experienced a fall that resulted in a carpet burn on his/her right knee and bleeding from AV's upper lip and right eyebrow which caused unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to monitor and provide appropriate supervision related to the Alleged Victim’s (AV) known history of falls. On or about June 11, 2023, AV experienced a fall that resulted in a skin tear, swelling, and bleeding to his/her forehead causing unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) has a history of wandering, an elopement risk, and identified as a high fall risk. According to an investigation, on or about February 10, 2023, AV eloped from the facility after a visitor entered the building. The AV was found on the ground by a pedestrian who contacted EMT’s. EMT’s found the AV bleeding, notified facility, and took AV to the hospital. AV had a laceration to the scalp that required staples, a head injury, lip laceration, contusion of the face and a closed fracture of a nasal bone. The facility failed to provide a safe environment, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) has a history of falls, was a fall risk and care planned to always wear proper footwear. The facility failed to implement interventions or appropriately care plan. Based on an investigation, on or about January 1, 2023, the AV was found on the ground with an eye injury and a bruise and was not wearing proper footwear. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility to provide a safe environment. Witness 1 (W1) had a known history of altercations. On or about December 28, 2022, W1 and AV were in the hallway when W1 grabbed AV’s arm and pulled AV down, which resulted in skin tears to AV’s arm. Facility staff failed to monitor W1, which resulted in the facility failing to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

According to an investigation, the facility failed to provide a safe environment. The Alleged Victim (AV) and Witness 1 (W1) have history of resident-to-resident altercations and W1 is known to be protective of his/her own space. On or about December 12, 2022, staff sat AV next to W2 in the dining room. A resident-to resident altercation occurred and resulted in AV receiving an injury to his/her left hand and face. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) has a history of falls. The facility failed to provide appropriate services according to the Alleged Victim (AV)'s needs, relating to his/her change of condition, number of falls with lack of appropriate interventions. AV experienced multiple falls from approximately October 1, 2022, and December 12, 2022, with the majority being unwitnessed, and resulted in AV experiencing repeated unreasonable discomfort. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness 1 (W1) had a known history of sexually inappropriate behaviors. During the investigation, it was discovered that the Alleged Victim (AV) reported to multiple witnesses that W1 had inappropriately touched him/her, which resulted in AV experiencing unreasonable discomfort and a loss of dignity. The facility failed to provide a safe environment for AV by failing to protect AV from W1's sexualized behavior, which is a violation of resident rights, is neglect of care and constitutes abuse.

The facility failed to implement interventions or appropriately care plan for Witness 1’s (W1) known behaviors. On or about November 24, 2022, the Alleged Victim (AV) and W1 had a resident-to-resident altercation when AV walked into W1’s room, which resulted in scratches to AV’s face. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions or appropriately care plan for Alleged Victim’s (AV) behavior to wander the halls, entering other resident’s rooms and Witness 1 (W1) not wanting people in his/her room. On or about November 21, 2022, AV entered W1’s room, which resulted in W1 scratching AV’s face. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide a safe medication administration system to ensure The Alleged Victim’s (AV) medications were administered as ordered. Based on facility documentation and interviews, the facility failed to correctly administer AV's diabetic medication for a prolonged period. There was no negative outcome to AV. The facility's failure to provide a safe medication administration for AV is a violation of Oregon Administrative Rules.

Based on observation, interview, and record review, conducted during a site visit on 04/08/25 and 04/09/25, the facility’s failure to exercise reasonable precautions against any condition that may threaten the health, safety, or welfare of residents was substantiated.

Based on observation, interview, and record review, conducted during a site visit on 04/08/25 and 04/09/25, the licensee’s failure to ensure adequate administrative oversight of facility operations including supervision and training of staff, which posed a risk to the safety of residents, was substantiated.

Based on observation, interview, and record review, conducted during a site visit on 04/08/25 and 04/09/25, the facility’s failure to ensure the service plan reflected the resident's needs and to ensure the implementation of services was substantiated.

Based on observation, interview, and record review, conducted during a site visit on 04/08/25 and 04/09/25, the facility’s failure to evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed was substantiated.

Based on observation, interview, and record review, conducted during a site visit on 04/08/25 and 04/09/25, the facility’s failure to carry out medication and treatment orders as prescribed was substantiated

Based on observation, interview, and record review, conducted during a site visit on 04/08/25 and 04/09/25, the facility’s failure to assess all residents with a significant change of condition was substantiated for sampled resident. This posed an immediate jeopardy situation that could threaten the health, safety, and welfare of residents.

Based on observation, interview, and record review, conducted during a site visit on 04/08/25 and 04/09/25, the facility’s failure to have an emergency preparedness plan was substantiated for sampled resident.

Based on interview and record review, conducted during a site visit on 04/08/25 and 04/09/25, the facility’s failure to make records available to the Department upon request was substantiated.

Based on observation and record review, conducted during a site visit on 04/08/25 and 04/09/25, the facility’s failure to not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional, ensure psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use, and ensure psychotropic p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results was substantiated

Based on observation, interview, and record review, conducted during a site visit on 04/08/25 and 04/09/25, the facility’s failure to carry out medication and treatment orders as prescribed was substantiated.

Based on interview and record review, conducted during a site visit on 04/08/25 and 04/09/25, the facility’s failure to provide and document delegation and teaching by a RN was substantiated for sampled residents. This posed an immediate jeopardy situation that could threaten the health, safety, and welfare of residents.

The facility failed to provide records to the Department upon request. The facility's failure is a violation of Oregon Administrative Rules.

On or about April 3, 2025, Alleged Victim (AV) did not receive his/her insulin as ordered. Based on facility documentation and interviews, Alleged Perpetrator 2 (AP2) failed to administer AV's 4:30PM scheduled dose of insulin. As a result, AP2 was investigated for neglect. An investigation determined AV did not experience a negative outcome from missing this dose and determined no abuse occurred by AP2. The facility failed to provide a safe medication administration system 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 provide records to the Department upon request. The facility's failure 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.

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 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 document that they have observed and evaluated the individual's ability to perform safe medication and treatment administration unsupervised in accordance with OAR 411-054-0070(5)(b)(G); per complaint staff are not properly trained and are working on the floor unsupervised due to a staffing shortage.

The facility failed to provide direct care staff sufficient in numbers to meet the scheduled and unscheduled needs of each resident; per complaint staff are working without a schedule and are understaffed on all shifts due to walk-outs.

The facility failed to document that they have observed and evaluated the individual's ability to perform safe medication and treatment administration unsupervised; per complaint staff are not properly trained and are working on the floor unsupervised due to a staffing shortage.

The facility failed to immediately notify the local Department office, or the local AAA, of any incident of abuse or suspected abuse; per complaint the facility has failed to report multiple resident incidents.

The facility failed to provide records to the Department upon request. 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 provide the requested information/documentation by the Department.

Based on interview and record review, conducted during an offsite review on 03/06/25, the facility’s failure to make records available upon request was substantiated.

Based on interview and record review, conducted during an offsite review on 03/06/25, the facility’s failure to make records available upon request was substantiated. Findings include, but not limited to: - On 01/13/25, the Department received notice of a complaint that qualified for an ABST review. - On 02/13/25, Witness 1 (ODHS LCU Staff) sent an email to the facility requesting records, which included the following: · Copy of the posted staffing plan; · Staff roster with position titles; · Resident roster with room numbers; and · Facility schedule for the direct care staff for the date of 01/11/25. - On 03/06/25, the Department did not receive any of the requested records. In a telephone interview on 03/13/25, Staff 1 and Staff 2 stated they started at the facility on or about 02/27/25. Staff 1 confirmed his/her email address and stated there were approximately six known ABST record request-related emails pending response. The facility failed to provide records to Department personnel upon request which is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during an offsite review on 03/06/25, the facility’s failure to make records available upon request was substantiated. Findings include, but not limited to: On 01/13/25, the Department received notice of a complaint that qualified for an ABST review. On 02/18/25, Witness 1 sent an email to the facility requesting records, which included the following: · Copy of the posted staffing plan. · Staff roster with position titles. · Resident roster with room numbers; and · Facility schedule for the direct care staff for the date of 01/19/25. On 03/06/25, the Department did not receive any of the requested records which is a violation of Oregon Administrative Rules.

The facility failed to provide records to the Department upon request. 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.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide documentation upon request. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide records to the Department upon request. The facility's failure is a violation of Oregon Administrative Rules.

The facility failed to provide records to the Department upon request. The facility's failure is a violation of Oregon Administrative Rules.

The facility failed to provide records to the Department upon request. The facility's failure is a violation of Oregon Administrative Rules.

The facility failed to provide records to the Department upon request. The facility's failure is a violation of Oregon Administrative Rules.

The facility failed to provide records to the Department upon request. The facility failure is a violation of Oregon Administrative Rules.

Based on observation, interview, and record review, conducted during a site visit on 3/3/25 to 3/4/25, the facility’s failure to implement a service plan that reflect the resident’s needs was substantiated for resident.

The facility failed to provide records to the Department upon request. 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.

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

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

The facility failed to implement appropriate interventions related to the Alleged Victim’s (AV) known history of falls. On or about October 1, 2024, AV was found by facility staff on the floor leaning against AV's bed. Prior to incident, AV reportedly had just returned to the facility from a recent hospitalization on September 30, 2024. AV was hospitalized due to continued falls and complaints of chest and rib pain. Based on facility documentation and interviews, facility staff had completed a safety check on AV, with no identified concerns ten minutes prior to incident. AV's service plan dated September 14, 2024, states AV experienced 18 falls since May 2024. AV did not experience pain, harm, or negative outcome as a result of the incident. However, AV is a known fall risk, and had just returned to the facility after a hospitalization for falls. The facility failed to implement appropriate interventions for AV's fall risk, resulting in AV experiencing repeated falls since May 2024. The facility's failure to properly care plan for AV's fall risk 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. An investigation determined this is a violation of Oregon Administrative Rules.

On or about September 17, 2024, Alleged Perpetrator 2 (AP2) did not give Alleged Victim (AV) a scheduled blood pressure, cognitive impairment, and heart medication during evening shift. Based on facility documentation and interviews, AP2 did not receive a complete training on medication administration. AP2's training documentation show 9 out of the 13 trainings were not completed prior to September 17, 2024. Medications are to be administered by trained staff, yet the facility placed AP2 on duty to pass medications on day of incident. AV experienced no adverse effects of missing medications; however, the facility failed to appropriately train AP2 to administer medication which resulted in AV not getting his/her medication as ordered. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules. AP2 allegedly neglected AV. An investigation determined no abuse occurred by AP2.

On or about September 17, 2024, Alleged Perpetrator 2 (AP2) did not give Alleged Victim (AV) a scheduled blood pressure medication during evening shift. Based on facility documentation and interviews, AP2 did not receive a complete training on medication administration. AP2's training documentation show 9 out of the 13 trainings were not completed prior to September 17, 2024. Medications are to be administered by trained staff, yet the facility placed AP2 on duty to pass medications on day of incident. AV experienced no adverse effects of missing medications; however, the facility failed to appropriately train AP2 to administer medication which resulted in AV not getting his/her medication as ordered. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules. AP2 allegedly neglected AV. An investigation determined no abuse occurred by AP2.

On or about September 17, 2024, Alleged Perpetrator 2 (AP2) did not give Alleged Victim (AV) a scheduled blood pressure, epilepsy, and cognitive impairment medication during evening shift. Based on facility documentation and interviews, AP2 did not receive a complete training on medication administration. Medications are to be administered by trained staff, yet the facility placed AP2 on duty to pass medications on day of incident. AV experienced no adverse effects of missing medications; however, the facility failed to appropriately train AP2 to administer medication which resulted in AV not getting his/her medication as ordered. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules. AP2 allegedly neglected AV. An investigation determined no abuse occurred by AP2.

On or about September 17, 2024, Alleged Perpetrator 2 (AP2) did not give Alleged Victim (AV) a scheduled epilepsy, and cholesterol medication during evening shift. Based on facility documentation and interviews, AP2 did not receive a complete training on medication administration. Medications are to be administered by trained staff, yet the facility placed AP2 on duty to pass medications on day of incident. AP2's training documents show 9 of 13 trainings were not completed prior to the day of the incident. AV experienced no adverse effects of missing medications; however, the facility failed to appropriately train AP2 to administer medication which resulted in AV not getting his/her medication as ordered. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules. AP2 allegedly neglected AV. An investigation determined no abuse occurred by AP2.

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.

On or about July 22, 2024, Alleged Victim (AV) fell in the facility's dining room when Alleged Perpetrator 2 (AP2) assisted AV to the dining room for his/her mealtime. Based on facility documentation and interviews, AP2 became distracted with another resident while actively assisting AV, and left AV standing up on his/her own without completing the task of transferring AV to the dining room chair. As a result of AP2's actions, AV immediately lost balance and fell to the floor, hitting his/her head. AV experienced vomiting, head pain, and right hip pain as result of the fall. AV was sent to the hospital for treatment and later returned to the facility with a diagnosis of head injury and emesis. AP2's actions is considered neglect of care which constitutes abuse. The facility is responsible for the supervision and overall conduct of staff when staff are acting within the scope of his/her employment duties. The facility failed to provide a safe environment for AV which is a violation of Oregon Administrative Rules.

On or about May 25, 2024, Alleged Victim (AV) did not receive his/her morning dose of medication prescribed to treat his/her seizure order. Based on facility documentation and interviews, Alleged Perpetrator 2 (AP2) was not properly trained by facility which caused this error. AV did not have any adverse effects from missing his/her morning dose. The facility failed to provide adequate staff training which resulted in AP2 marking AV's dose of seizure medication as given when it was not administered to AV. The facility's failure to provide a safe medication administration system is a violation of Oregon Administrative Rules. Alleged Perpetrator 2 (AP2) allegedly neglected AV. An investigation determined no abuse occurred by AP2.

Based on observation, interview, and record review, conducted during Licensing Compliant Unit (LCU) site visit on May 13, 2024, and May 14, 2024, it was determined that the facility failed to immediately notify the local Department office, or the local AAA, of any incident or abuse or suspected abuse for sampled resident Alleged Victim (AV). AV suffered an unwitnessed fall that was not properly investigated to rule out abuse. The facility's failure to notify local Department office, or the local AAA, of any incident of abuse or suspected abuse is a violation of Oregon Administrative Rules.

Based on observation and interview, conducted during a site visit on May 13, 2024, and May 14, 2024, it was confirmed the facility failed to keep all interior materials and surfaces clean, and in good repair. During observation, the rubber threshold between a carpeted area and a linoleum area was loose from the floor and determined to be a tripping hazard. The facilty's failure to provide a safe environment is a violation of Oregon Administrative Rules.

Based on observation, interview, and record review, conducted during a Licensing Complaint Unit (LCU) site visit on May 13, 2024, and May 14, 2024, it was determined that the facility failed to ensure Alleged Victim's (AV) service plan was reflective of resident needs and properly implemented by staff. LCU determined inconsistencies on AV's service plan dated May 7, 2024. During an observation on May 14, 2024, staff was observed attempting to help AV stand. While assisting AV, staff stated loudly that he/she wasn't sure what to do. AV's service plan noted "AV requires assistance from one care team member with mobility for safety per PT on November 10, 2023. AV is able to walk independently but needs guidance with his/her escorts due to poor safety awareness". On May 13, 2024, a wheelchair was observed in AV's room with a note that stated the wheelchair was for transport. A review of a fall investigation initiated on May 11, 2024, revealed AV had a fall after sitting in an unlocked wheelchair. The use of a wheelchair was not mentioned in AV's service plan. The facility's failure to properly care plan 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. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to make service plans readily available to staff and provide clear direction regarding the delivery of services. An investigation determined this is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during a Licensing Compliant Unit (LCU) site visit on May 13, 2024, and May 14, 2024, it was determined the facility failed to ensure Alleged Victim's (AV) monitoring and reporting system was implemented 24-hours a day. A review of AV's progress notes dated April 3, 2024, through May 13, 2024, and Temporary Service Plans dated April 6, 2024, through April 30, 2024, revealed on April 18, 2024, that AV's PCP was contacted related to concern for a urinary tract infection and other skin issues, and that on April 20, 2024, AV was also treated for constipation. Based on facility documentation, there was no documented evidence of written communication of AV's change of condition, and any required interventions, for direct care staff on each shift. The facility's failure to provide oversight and monitoring when AV's condition changed by ensuring staff knew how to follow-up on AV's change of condition is a violation of Oregon Administrative Rules.

On or about March 22, 2024, when facility staff were conducting a narcotic count, the staff found a discrepancy in Alleged Victim's (AV) Oxycodone count. Based on facility documentation and interviews, AV's narcotic count showed 3mL of AV's Oxycontin was missing. It was unclear what caused the discrepancy in AV's narcotic count. AV suffered no negative side effects as a result of the narcotic error; however, the facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules. Alleged Perpetrator 2 (AP2) and Alleged Perpetrator 3 (AP3) allegedly financially exploited AV. An investigation determined no abuse occurred by AP2 and AP3.

Based on interview and record review, conducted during a site visit on May 13, 2024, and May 14, 2024, it was confirmed the facility failed to carry out medication orders as prescribed. A review of Alleged Victim's (AV) signed physician orders dated March 19, 2024, revealed an order for Levothyroid once daily. A review of AV's MAR dated March 1, 2024, through March 31, 2024, revealed AV missed one dose of the medication on March 21, 2024. The facility failed to carry out AV's medication orders as prescribed 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. An investigation determined this is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during a Licensing Complaint Unit site visit (LCU) on May 13, 2024, and May 14, 2024, it was confirmed the facility failed to administer medications as prescribed to Alleged Victim (AV). A review of AV's signed physician orders dated November 12, 2023, revealed an order for dementia medication. A review of AV's MAR dated February 1, 2024, through February 29, 2024, revealed AV missed on dose of his/her medication on February 12, 2024. The facility failed to administer AV's medication as prescribed which is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during Licensing Complaint Unit (LCU) during a site visit on May 13, 2024, and May 14, 2024, it was determined that the facility failed to carry out medication orders as prescribed. A review of Alleged Victim's (AV) signed physician order dated February 2, 2024, revealed an order for anxiety medication. A review of AV's MAR dated February 1, 2024, through February 29, 2024, revealed AV missed one dose of the medication on February 2, 2024. The facility's failure is a violation of Oregon Administrative Rules.

On or about January 25, 2024, Alleged Perpetrator 2 (AP2) used physical force against Alleged Victim (AV) while working as AV's caregiver as an employee of the facility. Based on facility documentation and interviews, AP2 was assisting AV with toileting when AV became combative. AP2 failed to follow AV's care plan regarding how to approach AV when AV's is exhibiting behaviors. Instead of requesting assistance from other caregivers, AP2 allowed the situation to escalate by not following AV's care plan resulting in AP2 pushing AV which caused AV to lose his/her balance resulting in AV falling and hitting his/her on the closet door. AP2's actions is considered physical abuse which constitutes abuse. The facility failed to provide a safe environment for AV which is a violation of Oregon Administrative Rules.

The facility failed to follow Alleged Victim's (AV) physician orders for a chest x-ray and oxygen that facility received on January 15, 2024. Based on facility documentation and interviews, AV did not have a chest x-ray until January 29, 2024, and AV did not receive oxygen until January 19, 2024. The facility's failure to ensure a service was provided is a violation of Oregon Administrative Rules.

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.

The facility failed to keep the inside of the facility free from unpleasant odors. The facility's failure is a violation of Oregon Administrative Rules.

The facility failed to properly administer Alleged Victim's (AV) medications. According to documentation, AV experienced no negative outcome. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.

The facility failed to properly administer Alleged Victim's (AV) medications. According to documentation, AV experienced no negative outcome. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.

The facility failed to properly administer Alleged Victim's (AV) hypertension medication and dementia medication as ordered. According to documentation, AV missed these medications, five days in November 2023; however, AV did not experience a negative outcome. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.

The facility failed to have have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident in accordance with OAR 411-054-0070(1) per complaint that no staff were visible, supervising residents and a caregiver mentioned that there were not enough people because people had called out sick. The failure is a violation of Oregon Administrative Rules.

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 in accordance with OAR 411-054-0070(1) per complaint that the facility is constantly short staffed on NOC shift, and staff are not able to adequately assist the residents. The failure is a violation of Oregon Administrative Rules.

Alleged Victim (AV) is an elopement risk. On or about October 18, 2023, AV was found standing alone outside of the front door of the community. AV exited the facility without assistance. According to documentation, there was no injury to him/her. The facility failed to provide a safe environment, which is a violation of Oregon Administrative Rules.

The facility failed to document that they have observed and evaluated the individual's ability to perform safe medication and treatment administration unsupervised in accordance with OAR 411-054-0070(6)(b)(G) per complaint that " a MT claims to not have learned how to complete steps to prevent, respond or document med errors.", which is a violation of Oregon Administrative Rules.

The facility failed to properly administer Alleged Victim's (AV) narcotic medication. According to documentation, AV experienced no negative outcome. The Facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules. Alleged Perpetrator 2 (AP2) allegedly neglected AV. An investigation determined no abuse occurred by AP2.

On or about September 1, 2023, Alleged Perpetrator 2 (AP2) neglected Alleged Victim (AV) by failing to provide services necessary to maintain safety of AV when AP2 gave AV a cold and rough bed bath. Based on facility documentation and interviews, AV was in bed due to a broken hip and as a result of the rough treatment by AP2 as he/she assisted AV with his/her Activities of Daily Living, AV experienced pain and unreasonable discomfort. AP2 was observed pulling, pushing and scrubbing AV in a rough manner during the bed bath. AP2's action is considered neglect of care which constitutes abuse. The facility failed to provide a safe environment for AV which is a violation of Oregon Administrative Rules.

On or about August 25, 2023, Alleged Perpetrator 2 (AP2) assisted Alleged Victim (AV) with toileting, left AV standing alone to find wipes, which resulted in AV falling with injury. AV was sent to the hospital for treatment and was diagnosed with a head laceration and hip fracture. AP2's actions is considered neglect of care which constitutes abuse. The facility failed to provide a safe environment for AV which is a violation of Oregon Administrative Rules.

The facility failed to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned in. Based on facility documentation and interviews, staff do not know how to appropriately turn and position residents. The facility's failure to provide a safe environment is a violation of Oregon Administrative Rules.

The facility failed to implement policies and procedures to assure the prevention and appropriate response to any incident. Based on interviews and facility documentation, the facility failed to investigate and report incidents of abuse. The facility's failure to provide a safe environment is a violation of Oregon Administrative Rules.

The facility failed to develop a service plan that is reflective of the resident's needs. Based on interviews and facility documentation, no behavior interventions were developed or implemented. The facility's failure to properly care plan is a violation of Oregon Administrative Rules.

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. The facility's failure to provide a safe environment is a violation of Oregon Administrative Rules.

The facility failed to carry out medication orders as prescribed. Per complaint, a resident did not receive his/her medication between 06/19/23 and 07/05/2023. The facility's failure to provide a safe medication administration system is a violation of Oregon Administrative Rules.

On or about May 19, 2023, the facility failed to administer Alleged Victim's (AV) medication as ordered. Based on facility documentation and interviews, AV was prescribed an antibiotic for 5 days that was not administered because it was not entered correctly on AV's MAR. The facility's failure to provide a safe medication administration system is a violation of Oregon Administrative Rules.

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. Based on facility documentation and interviews, call lights go off for 45-50 minutes resulting in residents' needs not being met in a timely manner. The facility's failure to provide a safe environment 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 needs. Inconsistencies were identified between the resident roster, care plans, posted staffing plan and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to adopt and fully implement an Acuity-Based Staffing Tool (ABST). An investigation determined this is a violation of Oregon Administrative Rules.

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

The facility failed to update service plans as required by Rule. An investigation determined this is a violation of Oregon Administrative Rules.

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

The facility failed to promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent reoccurrences of abuse. The facility's failure to provide a safe environment is a violation of Oregon Administrative Rules.

The facility failed to implement a service plan reflective of resident's needs. The facility's failure to properly care plan is a violation of Oregon Administrative Rules.

On or about November 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 for a total of 30 days.

The facility failed to have policies and procedures in place to assure the prevention and appropriate response to any incident. The facility's failure to provide a safe environment is a violation of Oregon Administrative Rules.