Timber Pointe Senior Living Community

Facility failed to provide regular showers since October 31, 2024, resulting in sores, loss of dignity, and feeling unclean. Based on facility documentation and interviews, AV is care planned for assistance with bathing/showering twice a week due to AV being prone to rashes and skin issues. AV has a history of refusing care and care plan does not address AV's behavior. The facility's failure to follow AV's care plan caused AV unreasonable discomfort which a violation of resident rights, is considered neglect of care, and constitutes abuse. As the new owner of this facility, you are responsible for correcting any deficiencies which pre-date your ownership. You must correct violations which occurred under previous ownership, as directed by the Department. You will not be responsible for paying civil penalties incurred by previous owner(s). However, if you fail to correct identified deficiencies within the specified time you may be subject to aggravated civil penalties.

The Alleged Victim (AV) relies on the facility to manage his/her medications. According to an investigation, between approximately July 3, 2024, and July 26, 2024, Alleged Perpetrator 2 (AP2) signed out multiple doses of AV’s narcotic pain medication that AV did not request or receive, causing AV's medication to run out. AV's doctor would not refill the prescription and referred AV to pain management, causing AV emotional harm and repeated unreasonable discomfort. AP2 was responsible for financial exploitation by way of theft, which constitutes abuse. Prior to this incident, staff reported concerns with AP2’s medication administration and possible medication diversion to management. The facility failed to complete a thorough investigation regarding the allegations and did not keep AV free from financial exploitation, which is a violation of resident rights, is neglect of care which constitutes abuse.

The facility failed to provide a safe medication administration system to ensure The Alleged Victim’s (AV) medications were administered as ordered which resulted in risk of unreasonable discomfort due to ongoing symptoms of an infection not being treated by AV's medication. The failure resulted in unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse. As the new owner of this facility, you are responsible for correcting any deficiencies which pre-date your ownership. You must correct violations which occurred under previous ownership, as directed by the Department. You will not be responsible for paying civil penalties incurred by previous owner(s). However, if you fail to correct identified deficiencies within the specified time you may be subject to aggravated civil penalties.

The Alleged Victim (AV) relies on the facility to administer his/her medications. According to an investigation, on or about May 27, 2024, AV did not receive antipsychotic medication as ordered to treat anxiety disorder. AV requested but did not receive the antipsychotic medication on 5/27/2024 as it was not available, resulting in AV self-administering an unprescribed amount of over-the-counter medication and being transported to the hospital. The facility failed to provide a safe medication system, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The allegation that the Alleged Perpetrator 2 (AP2) verbally abused the Alleged Victim (AV) was investigated and determined to be inconclusive.

The facility failed to provide appropriate services according to Alleged Victim's (AV) personal hygiene care needs. Based on facility documentation and interviews, AV is care planned to have two showers a week. Facility records show that AV received 5 baths over nine weeks. The facility's failure to provide consistent bathing assistance, impacted AV's hygiene and overall wellbeing which resulted in a loss of personal dignity which is a violation of resident rights, is considered neglect of care and constitutes abuse. As the new owner of this facility, you are responsible for correcting any deficiencies which pre-date your ownership. You must correct violations which occurred under previous ownership, as directed by the Department. You will not be responsible for paying civil penalties incurred by previous owner(s). However, if you fail to correct identified deficiencies within the specified time you may be subject to aggravated civil penalties.

The facility failed to provide a safe environment for Alleged Victim (AV) which resulted in AV's shoes getting stolen from the laundry. The facility failed to ensure AV's personal items were secured, which resulted in loss of AV's shoes. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse. An unknown Alleged Perpetrator 2 (AP2) allegedly financially exploited AV. An investigation inconclusively determined no licensing violation or abuse occurred. As the new owner of this facility, you are responsible for correcting any deficiencies which pre-date your ownership. You must correct violations which occurred under previous ownership, as directed by the Department. You will not be responsible for paying civil penalties incurred by previous owner(s). However, if you fail to correct identified deficiencies within the specified time you may be subject to aggravated civil penalties.

The Alleged Victim (AV) relies on facility staff to ensure resident’s rights. On or about November 8, 2023, AV notified the facility that there were additional charges on his/her credit card statements that he/she did not agree to. The facility failed to keep AV free of financial exploitation, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The allegation that Alleged Perpetrator 2 (AP2) financially exploited AV was investigated and determined to be inconclusive.

According to an investigation, on or about, June 12, 2023, the Alleged Victim’s (AV) reported approximately $200-$300 missing from his/her wallet. AV did not have access to a lock box and/or locking drawer. The facility failed to provide a safe environment, which is a violation of resident rights, is neglect of care which constitutes abuse.

The facility failed to provide a safe environment and to ensure that the Alleged Perpetrator 2 (AP2) was properly trained to secure residents during bus transport. According to an investigation, on or about June 6, 2023, AV’s wheelchair was not properly secured in the bus, causing AV to tip over. As a result, AV experienced back pain, dizziness, and a skin injury to his/her elbow. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse. The allegation that AP2 failed to a safe environment was investigated, and the determination was not substantiated.

The facility failed to provide appropriate services according to resident needs. According to an investigation, on or about December 4, 2022, the Alleged Victim (AV) had a non-injury fall in the bathroom and pressed his/her call light for assistance. The call light was not answered in a timely manner due to lack of staff, which resulted in AV experiencing unreasonable discomfort and a loss of personal dignity. The facility’s failure is a violation of resident rights, is neglect of care which constitutes abuse.

According to an investigation, on or about October 16, 2022, the Alleged Victim (AV) had to request his/her PRN pain medication from multiple staff, due to the communication system not working properly. AV did not receive his/her PRN pain medication for approximately an hour, which caused AV to get upset and start yelling. The facility failed to provide a safe medication administration system, which is a violation of resident rights, is neglect of care and constitutes abuse.

The Alleged Victim (AV) was known to have a history of anorexia and was care planned for monthly weight checks. The facility failed to follow the care plan and provide appropriate services related to nutrition. Between April 20, 2022, and October 19, 2022, AV experienced an approximate weight loss of 15.2% and according to AV’s PCP, placing AV at risk for serious harm. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility to manage his/her medications. On or about September 28, 2022, AV did not receive his/her anti-seizure and heart medication, which resulted in AV experiencing emotional distress. The facility failed to provide a safe medication administration system to ensure AV’s medication was available to be administered as ordered. The 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 Alleged Victim (AV)’s medication was available and administered as ordered, resulting in AV not receiving his/her medication for approximately six days, resulting in AV experiencing pain and swelling. 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) medication was administered 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. The allegation that the Alleged Perpetrator 2 (AP2) failed to provide basic care and services was investigated and the determination was Not Substantiated.

The facility failed to provide appropriate services, related to safe medication administration. An unknown Alleged Perpetrator 3 (AP3), did not follow proper procedure for medications count and medications were missing. AP3's actions are considered financial exploitation and constitutes abuse. The facility failed to provide a safe medication administration system and did not keep AV free from financial exploitation, which is a violation of resident rights, is neglect of care and constitutes abuse. The allegation that AP2 financially exploited AV was investigated, and wrongdoing was unable to be determined.

The Alleged Victim (AV) is care planned to receive three stand-by assist showers weekly. According to an investigation, the facility failed to follow AV's care plan on multiple occasions regarding showers from approximately May 27, 2022, and July 15, 2022, resulting in a loss of personal dignity. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about July 4, 2022, the Alleged Victim (AV) made an allegation of potential sexual contact with Alleged Perpetrator 2 (AP2) and on or about, July 13, 2022, made another allegation of potential sexual contact with AP2. The facility failed to ensure resident rights and safety when an internal investigation was not completed on or about July 4, 2022, which placed AV at risk of additional sexual contact. This failure is a violation of resident rights, is considered neglect of care and constitutes abuse. The allegation that AP2 sexually abused AV was investigated, and the findings were determined to be not substantiated.

The facility failed to provide a safe medication administration system to ensure AV's medication were available and administered as ordered on multiple occasions. From approximately June 1, 2022, to June 30, 2022, AV was not given approximately sixteen doses of two of his/her heart medications, which resulted in AV experiencing repeated unreasonable discomfort and serious risk of harm. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to appropriately care plan for the Alleged Victim's known preferences and as a result, AV experienced unreasonable discomfort and a loss of personal dignity. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility, Alleged Perpetrator 2 (AP2) and Alleged Perpetrator 3 (AP3) failed to provide a safe medication administration system to ensure the Alleged Victim's (AV) medication was administered as ordered. AV was unresponsive, transported to the hospital and stayed overnight. The facility’s, AP2’s and AP3’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) is care planned to receive two meals a day, delivered to his/her room. On several occasions, the facility failed to deliver AV his/her meals, resulting in AV going without food or receiving only a sandwich, which resulted in unreasonable discomfort. The facility failed to provide proper food/nutrition to AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility to administer his/her medications. Between August 1st through December 3rd, 2021, AV missed several different medications due to the facility being out of stock. The facility did not order AV’s medication timely resulting AV having increased pain. The facility failed to provide a safe medication administration system, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility to manage his/her medications. On or about December 2, 2021, it was reported that AV missed his/her required medication. During the investigation, it was discovered AV missed his/her required medications on multiple occasions. The facility failed to provide a safe medication administration system to ensure AV’s medication was available to be administered as ordered. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. On or about, November 28, 2021, AV experienced a fall, which resulted in back and shoulder pain. After the fall, AV pushed the call button and waited over twenty-six minutes for care staff to respond. The facility failed to provide a safe environment by failing to provide adequate staffing, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility to manage his/her medications. From November 16, 2021, to December 13, 2021, AV was not given at least three doses of his/her scheduled medication as it was unavailable, which caused AV unreasonable discomfort. The facility failed to provide a safe medication administration system to ensure AV’s medication was available to be administered as ordered. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility to manage his/her medications. On or about October 31, 2021, AV did not receive his/her insulin medication. AV experienced emotional distress as a result of not receiving his/her medication. The facility failed to provide a safe medication administration system to ensure AV’s medication was available to be administered as ordered. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Based on interview and record review, conducted during an investigation on 01/06/26, the facility’s failure to develop, maintain, and implement an Acuity-Based Staffing Tool (ABST) was substantiated. Findings include, but are not limited to: The facility’s posted staffing plan indicated: • Day shift: 9 direct care staff; • Swing shift: 8 direct care staff; and • Night shift: 3 direct care staff. The facility’s staffing plan and staff schedules for 06/04/25 indicated the facility was not staffing to the posted staffing plan for two of the three shifts reviewed. The facility’s failure to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident was substantiated. 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, ALFCD25-00393

Based on observation, interview and record review, conducted during a site visit on 09/12/25, the facility's failure to have 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 was substantiated for 5 of 5 sampled residents (#s 1, 2, 3, 4, and 5). Findings include, but are not limited to: A review of the facility’s policies for narcotic count and discarding medications indicated the following: · Disposal of outdated, discontinued, or left behind drugs will occur no longer than 3 to 5 days after medications labeled as such; · After death, medication will be disposed of within 24 hours; and · Discarded narcotics must be viewed by two of the following staff members: the RN, Director of Health Services, the Administrator, the Executive Director, and the Med Tech. A review of the narcotic logs for Residents 1, 2, 3, 4, and 5 indicated the following: · Resident 1’s Morphine Sulfate disposition date 05/24/25 with two staff signatures, one of which was Staff 2's (Wellness Director); · Resident 2’s Morphine Sulfate disposition date 05/20/25 with two staff signatures, one of which was Staff 2's; · Resident 3’s Morphine Sulfate disposition date 05/25/25, signed by Staff 2; · Resident 4’s Morphine Sulfate disposition date 05/25/25, signed by Staff 2; and · Resident 5’s Morphine Sulfate disposition date 06/10/25, signed by Staff 2. Residents 2, 3, and 4 had passed away. Compliance Specialist observed on 09/12/25 the above medications had not been destroyed. In an interview, Staff 2 stated: Resident's 1 and 5 morphine were to be destroyed because the facility had concerns an employee had diluted the narcotic; S/He had documented the destruction of the narcotics, but had not destroyed them on the dates indicated on the disposition logs because it was "before a holiday weekend;" and S/He thought s/he would need to show the narcotics to Adult Protective Services. Department records indicated Adult Protective Services had photographed the resident's medication on 06/10/25. The facility's failure to provide a safe medication administration system is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during a site visit on 09/12/25, the facility's failure to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident was substantiated for 1 of 4 sampled residents (# 1). Findings include, but are not limited to: A review of the posted staffing plan indicated the following: · Day shift: nine direct care staff; · Swing shift: nine direct care staff; and · Night shift: three direct care staff. A review of staffing schedules dated 04/24/25 through 04/30/25 indicated the following: · Schedules unavailable or not provided for 04/26/25-04/27/25. · Facility was short-staffed by one direct care staff on the swing shift for 04/24/25, 04/25/25, 04/28/25, and 04/30/25. A review of Resident 1’s service plan dated 01/02/25 and shower sheets for April 2025 indicated the following: · Resident to receive standby assistance once per week with showering. · Shower sheets dated 04/06/25 (completed), 04/22/25 (completed), and 04/26/25 (Refusal). · Resident 1 was not getting weekly showers. · Note on 4/22/25 shower sheet indicated “Rescheduled Saturday 4/19 shower due to low staff." In an interview, Resident 1 stated the following: · There was not enough staff; · Call lights took 30-45 minutes; · Not getting showers; · Sheets/bedding wasn’t getting changed; and · “They forget about me”. In separate interviews, Staff 1, Staff 2, Staff 3, Staff 4, and Staff 5 stated the following: · Not enough staff to do two-hour checks; · Call lights could take 45 minutes to an hour; · Laundry and dishes were not getting done; · Staffing was off because the ABST (Acuity-Based Staffing Tool) was off; · Call lights were not being monitored in the past unless residents brought up a concern; and · Showers were not getting done. 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.

Based on interview and record review, conducted during a site visit on 09/12/25, the facility's failure to have a fully implemented and updated Acuity-Based Staffing Tool (ABST) was substantiated. Findings include, but are not limited to: A review of the posted staffing plan indicated the following: · Day shift: nine direct care staff; · Swing shift: nine direct care staff; and · Night shift: three direct care staff. A review of staffing schedules dated 04/24/25 through 04/30/25 indicated the following: · Schedules unavailable or not provided for 04/26/25-04/27/25. · Facility was short-staffed by one direct care staff on swing shift for 04/24/25, 04/25/25, 04/28/25, and 04/30/25. In separate interviews, Staff 1, Staff 2, Staff 3, Staff 4, and Staff 5 stated the following: · Not enough staff to do two-hour checks; · Call lights could take 45 minutes to an hour; · Laundry and dishes were not getting done; · Staffing was off because the ABST (Acuity-Based Staffing Tool) was off; · Call lights were not being monitored in the past unless residents brought up a concern; and · Showers were not getting done. 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.

Based on interview and record review, conducted during a site visit on 09/12/25, the facility's failure to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident was substantiated for 1 of 4 sampled residents (# 2). Findings include, but are not limited to: A review of the posted staffing plan indicated the following: · Day shift: eight direct care staff; · Swing shift: eight direct care staff; and · Night shift: three direct care staff. A review of staffing schedules dated 03/13/25 through 03/20/25 indicated the following: · Schedules unavailable or not provided for 03/17/25-03/18/25. · Facility was short-staffed by one direct care staff on 03/13/25. Call light response times for Resident 2 on 03/20/25 indicated three calls between 20 and 45 minutes. In an interview, Resident 2 stated the following: · There was not enough staff; · Call lights took 30-45 minutes; · Sometimes medications were late; · Laundry was not getting done weekly; and · “Sometimes I'll sit on the toilet for over 20 minutes waiting for them”. In separate interviews, Staff 1 (Executive Director), Staff 2 (Wellness Director, Staff 3 (Med Tech), Staff 4 (Med Tech), and Staff 5 (MT) stated the following: · Not enough staff to do two-hour checks; · Call lights could take 45 minutes to an hour; · Laundry and dishes were not getting done; · Staffing was off because the ABST (Acuity-Based Staffing Tool) was off; · Call lights were not being monitored in the past unless residents brought up a concern; and · Showers were not getting done. 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.

Based on interview and record review, conducted during a site visit on 09/12/25, the facility's failure to have a fully implemented and updated Acuity-Based Staffing Tool (ABST) was substantiated. Findings include but are not limited to: A review of the ABST and last edit dates indicated the facility was not updating ABST evaluations for each resident at least quarterly. A review of the posted staffing plan indicated the following: · Day shift: eight direct care staff; · Swing shift: eight direct care staff; and · Night shift: three direct care staff. A review of staffing schedules dated 03/13/25 through 03/20/25 indicated the following: · Schedules unavailable or not provided for 03/17/25-03/18/25. · Facility was short-staffed by one direct care staff on 03/13/25. Call light response times for Resident 2 on 03/20/25 indicated three calls between 20 and 45 minutes. In an interview, Resident 2 stated the following: · There was not enough staff; · Call lights took 30-45 minutes; · Sometimes medications were late; · Laundry was not getting done weekly; and · “Sometimes I'll sit on the toilet for over 20 minutes waiting for them”. In separate interviews, Staff 1, Staff 2, Staff 3, Staff 4, and Staff 5 stated the following: · Not enough staff to do two-hour checks; · Call lights could take 45 minutes to an hour; · Laundry and dishes were not getting done; · Staffing was off because the ABST was off; · Call lights were not being monitored in the past unless residents brought up a concern; and · Showers were not getting done. 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.

On or about March 19, 2025, 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. A Licensing Complaint Unit (LCU) investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation; ALFCD25-00393.

On or about March 14, 2025, the facility failed to have sufficient staff to meet the scheduled and unscheduled needs of the residents. Based on facility documentation and interviews, the facility failed to respond to Alleged Victim's (AV) call light for 52 minutes, leaving AV stranded in the bathroom and unable to remove himself/herself from the toilet due to AV needing assistance with transfers to and from the toilet. The facility failed to respond to AV's call light in a reasonable amount of time. 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.

Based on interview and record review, conducted during an investigation on 08/28/25, the facility's failure to have a fully implemented and updated Acuity-Based Staffing Tool (ABST) was substantiated. Findings include but are not limited to: A review of the ABST and last edit dates indicated the facility was not updating ABST evaluations for each resident at least quarterly. 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.

Based on interview and record review, conducted during an investigation on 08/28/25, the facility’s failure to provide records to the Department upon request was substantiated. Findings include but are not limited to: A review of electronic communication, dated 03/07/25, indicated the Department requested documents related to the facility’s Acuity-Based Staffing Tool (ABST) alleged event date 02/08/25. The facility had not provided all requested documentation by the due date of 03/10/25. The facility's failure is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during an investigation on 08/28/25, the facility's failure to have a fully implemented and updated Acuity-Based Staffing Tool (ABST) was substantiated. Findings include but are not limited to: A review of the ABST and last edit dates indicated the facility was not updating ABST evaluations for each resident at least quarterly. 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.

Based on interview and record review, conducted during an investigation on 08/28/25, the facility's failure to have a fully implemented and updated Acuity-Based Staffing Tool (ABST) was substantiated. Findings include but are not limited to: A review of the ABST and last edit dates indicated the facility was not updating ABST evaluations for each resident at least quarterly. 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.

Based on interview and record review, conducted during an investigation on 08/28/25, the facility's failure to have a fully implemented and updated Acuity-Based Staffing Tool (ABST) was substantiated. Findings include, but are not limited to: A review of the ABST and last edit dates indicated the facility was not updating ABST evaluations for each resident at least quarterly. 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.

Based on interview and record review, conducted during site visits on 03/07/25 and 03/12/25, the facility’s failure to document action or intervention needed for change of condition and to monitor until the condition resolves was substantiated for 1 of 1 sampled resident (#1). Findings include, but are not limited to: The following documents were reviewed for Resident 1: Service plan dated 12/03/24. Temporary service plans (TSPs) from 12/12/24 through 02/10/25. Progress notes dated 12/01/24 through 02/28/25. Event reports for 12/12/24, 12/29/24, and 1/27/25. Hospital discharge paperwork from 01/28/25 and 02/10/25. Monitoring case history from 12/01/24 through 03/07/25. Resident 1’s records indicated the following: Resident 1 experienced a fall on 12/12/24, 12/29/24, and 01/27/25. The facility had not documented at least weekly, until it was determined, and recorded that the conditions resolved for the falls that occurred on 12/12/24 and 12/29/24. No documented evidence that the facility monitored the status of the following injuries at least weekly until they were noted to be resolved. The resident was identified with a bump to the left shoulder blade following the fall on 12/29/24. Two bruises to the right forearm and a bruise to the left side of the forehead following the fall on 1/27/25. The facility had not fully evaluated the circumstances of the fall on 01/27/25, to determine whether the current service-planned fall interventions were adequate or whether additional interventions needed to be developed and implemented. An interview with Staff 1 and Staff 2 was conducted. Both staff acknowledged weekly monitoring had not been completed. The findings were reviewed with and acknowledged by Staff 1 on 03/07/25. The facility’s failure to document action or intervention needed for change of condition and to monitor until the condition resolves was substantiated. The facility's failure is a violation of Oregon Administrative Rules.

On October 16, 2024, Alleged Victim (AV) presented with significant discoloration on the top of his/her forehead and into hairline. This was discovered and reported by Witness 5 (W5) to Alleged Perpetrator 2 (AP2). Based on facility documentation and interviews, AP2 did not evaluate AV's physical condition/signs of injury before leaving the facility on October 16, 2024. During the investigation, AP2 stated in an interview, that injury did not seem urgent and planned to evaluate AV later in his/her shift pass but had to end his/her shift early due to an unexpected situation. AP2 went against the facility's policy regarding resident safety by not handing the task off to another staff before leaving the facility. AV showed signs of being more confused and required more hands-on assistance since the discovery of discoloration on AV's head. AP2's failure to evaluate AV in a timely manner for a head injury, caused AV increased discomfort and possibly extended injury for not receiving medical treatment. AP2's actions is considered neglect of care which constitutes abuse. The facility is responsible for the operation of the facility and the quality of services rendered in the facility. The facility failed to provide a safe environment for AV which is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during an off-site review on 02/28/25, the facility’s failure to have a fully implemented and updated Acuity-Based Staffing Tool (ABST) was substantiated. Findings include but are not limited to: A review of the staffing schedule for 09/07/24 indicated the facility was not staffed to the posted staffing plan for day shift. The facility was short staffed by one direct care staff. Findings were reviewed with and acknowledged by Staff 1 on 02/28/25. The facility failed to update an ABST for each resident no less than quarterly, and the facility failed to have enough staff to meet the scheduled and unscheduled needs of the residents. As the new owner of this facility as of 1/1/25, you are responsible for correcting any deficiencies which pre-date your ownership. You must correct violations which occurred under previous ownership, as directed by the Department. You will not be responsible for paying civil penalties incurred by previous owner(s). However, if you fail to correct identified deficiencies within the specified time you may be subject to aggravated civil penalties.

Based on interview and record review, conducted during an off-site review on 02/28/25, the facility’s failure to have a fully implemented and updated Acuity-Based Staffing Tool (ABST) was substantiated. Findings include but are not limited to: A review of the facility’s ABST indicated that not all resident-specific data had been updated at least quarterly. Two residents had not been updated since April 2024. A review of the ABST indicated the following: · Day shift: eight staff required; · Swing shift: eight and a half staff required; and · Night shift: two and a half staff required. A review of the posted staffing plan indicated the following: · Day shift: ten staff required; · Swing shift: nine staff required; and · Night shift: three staff required. A review of the staffing schedule for 09/03/24 indicated the facility was not staffed to the posted staffing plan for day shift. The facility was short staffed by one direct care staff. Findings were reviewed with and acknowledged by Staff 1 on 02/28/25. The facility failed to update an ABST for each resident no less than quarterly, and the facility failed to have enough staff to meet the scheduled and unscheduled needs of the residents. As the new owner of this facility as of 1/1/25, you are responsible for correcting any deficiencies which pre-date your ownership. You must correct violations which occurred under previous ownership, as directed by the Department. You will not be responsible for paying civil penalties incurred by previous owner(s). However, if you fail to correct identified deficiencies within the specified time you may be subject to aggravated civil penalties.

The Alleged Victim (AV) relies on the facility to ensure resident’s rights and to provide a safe environment. According to an investigation, it was discovered that an unknown, Alleged Perpetrator 2 (AP2) made an unauthorized charge to AV’s bank account. AP2’s actions are considered financial exploitation and constitutes abuse. The facility did not keep AV free from financial exploitation, which is a violation of Oregon Administrative rules.

The Alleged Victim (AV) relies on facility staff to ensure resident’s rights. On or about, October 30, 2023, it was reported that money was missing from AV’s wallet. It was also discovered that on or about October 22, 2023, an unknown Alleged Perpetrator 2 (AP2) used AV’s bank card for approximately $65.00. AP2's actions are considered financial exploitation and constitutes abuse. The facility did not keep AV free from financial exploitation, which is a violation of resident rights, is neglect of care which constitutes abuse.

The facility failed to prepare and serve food in accordance with Food Sanitation Rules. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to ensure adequate professional oversight of the medication and treatment administration system. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to ensure the preparation, completeness, accuracy, and preservation of resident records and to develop and implement a written policy that prohibits falsification of records. An investigation determined this is a violation of Oregon Administrative Rules.

According to documentation and the investigation, on or about November 5, 2021, Alleged Perpetrator 2 (AP2) engaged in inappropriate sexual contact with the Alleged Victim. AV experienced unreasonable discomfort and a loss of personal dignity. AP2's actions are considered sexual contact and constitutes abuse. The facility failed to protect a resident from inappropriate sexual contact, which is a violation of Oregon Administrative rules.

The allegation that the facility failed to carry out Medication and treatment orders as prescribed in accordance with OAR 411-054-0055(1)(f) per complaint that a resident is not receiving h/her pain medications as prescribed was verified.

The facility failed to exercise reasonable precautions against any condition that may threaten the health, safety, or welfare of residents. An investigation determined this is a violation of Oregon Administrative Rules.

The allegation that the facility failed to administer the resident ' s medication as order by their physician as required by 411-054-0055(1)(f). Per complainant the resident missed doses of prescribed medications was verified.