Waterhouse Ridge Memory Care Community

According to documentation, on or about February 14, 2024, the facility failed to provide a safe environment. The Alleged Victim (AV) was restrained in h/h wheelchair without Doctor’s orders and experienced a fall resulting in a skin tear and bruises on h/h hands. 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 the Alleged Victim’s (AV) medication was administered as ordered. On or about December 23, 2023 – December 26, 2023, AV went without H/H Morphine causing AV to experience unreasonable discomfort. 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 the Alleged Victim’s (AV) medication was administered as ordered. According to documentation, AV went without H/H medication several days resulting in AV to experiencing unreasonable discomfort. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to Administer the correct dosage of medication to Alleged Victim (AV) for blood clots. AV didn’t receive the correct dosage of medication on or about December 5, 2023 - December 10, 2023, resulting in AV at experiencing unreasonable discomfort. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to documentation the facility failed to follow the Alleged Victim’s (AV) care plan. AV’S care plan is set for AV to be monitored for skin conditions three times per day. On or about November 23, 2023, AV was found to have blisters on h/h inner thighs. The failure resulted in AV experiencing pain and unreasonable discomfort. The facility failed to ensure care plans were followed, which is a violation of resident’s 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. On or about October 10, 2023, AV suffered an unwitnessed fall, resulting in a fractured rib. The failure resulted in AV experiencing pain and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to administer medication as ordered for the Alleged Victim’s (AV). AV is to be given a blood-thinner daily depending on AV’S weekly test at H/H Anti-Coagulation clinic. According to documentation AV went without the medication from on or about August 24, 2023, and August 26, 2023, and August 29, 2023, putting AV at risk of serious harm. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility to ensure a safe environment. Witness 1 (W1) have a history of resident-to-resident altercations. On or about September 6, 2023, AV and W1 had a physical altercation, resulting in AV being hit causing pain and discomfort. The facility failed to ensure a safe environment for AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to properly care plan for the Alleged Victim’s (AV) history of repeated falls. On or about August 17, 2023, the AV suffered a fall in their restroom. The facility staff found the AV in their restroom and immediately called emergency services. The AV was transported to the hospital and was diagnosed with a broken collar bone, 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. On or about August 2, 2023, AV suffered an unwitnessed fall. The failure resulted in AV suffering an injury to h/h right hip and experiencing pain and unreasonable discomfort, 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 medication. On or about May 28, 2023, AV missed two (2) doses of his/her insulin due to not having needles available. Staff called the pharmacy around 10:30am and requested a stat order. The order did not arrive until after 10pm. The PM med tech was not able to administer AV’s scheduled dose due to this. As a result of the missed medication, AV was sent to the hospital due to AV’s blood glucose being high and was not returned from the facility until the next day. 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 facility failed to implement interventions and appropriately care plan related to the Alleged Victim’s (AV) fall history. On or about May 17, 2023, AV suffered an unwitnessed fall in the common bathroom. The failure resulted in AV suffering a rib injury and experiencing pain and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) is a resident of the facility and relies on the facility to provide a safe environment. Witness 1 (W1) has a history of sexual behaviors. On or about May 9, 2023, AV was found by staff in W1’s room, W1 had their hand on AV’s chest and their other hand on AV’s groin. AV had prior incidents of sexual behaviors on or about September 6, 2022, January 24, 2023, and February 15, 2023. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) has a history of elopement and requires monitoring when outside of the facility. On or about April 24, 2023, AV had eloped out of the facility and was out in the community by a gas station located down the street from the facility. It was discovered that a secured door has not been locking and required maintenance, which AV was able to use and elope from the facility putting AV is risk of serious harm. The facility failed to provide a safe environment for AV but not assuring the door was secured, 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. AV’s service plan states AV is a fall risk and requires interventions to help minimize the risk of falls. AV utilizes a walker for mobility assistance and tends not to use it when moving around in the room. On or about March 19, 2023, a staff found AV with no brief on, so the staff member went to grab a brief and when they came back, AV fell and landed on their hip and sustained a skin tear. The facility failed to provide a safe environment for AV, 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. AV’s service plan states AV is a fall risk and requires interventions to help minimize the risk of falls. On or about March 29, 2023, a staff member found AV sitting on the floor next to their bed, as a result AV sustained a skin tear and bruising. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Between September 21, 2022, through February 15, 2023, Alleged Victim (AV) has sustained approximately five (5) falls resulting in injuries. On or about March 15, 2023, AV was found on the floor of their bedroom with a blanket on the ground next to them. AV also had bowel movement all over their bed and their floor. As a result of the fall, AV sustained a head injury. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse. `

Alleged Victim (AV) requires 24/7 care by the facility. On or about February 20, 2023, AV followed another resident’s family member out of the facility. Visitors of the facility reported a person matching AV’s description walking down the street. AV was located by the police 30 minutes after leaving the facility and had crossed a street, which exposed AV to potential risk of harm. The facility failed to provide a safe environment for AV, 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 February 15, 2023, AV was found on the floor bleeding from his/her head. AV was aware that he/she fell and hit his/her head. As a result, AV was sent to the hospital and received stiches to close the wound. The facility failed to provide a safe environment, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) is a high fall risk and has been experiencing heightened weakness. On or about February 14, 2023, at around 10am, AV was found on the floor with his/her back sitting up against the bed. AV’s feet were in front of him/her stretched out. As a result of the fall, AV sustained a skin tear to the left elbow and bruising to the right buttock. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) has a known fall history which have led to injuries. On or about December 18, 2022, AV appeared to have re-opened a skin laceration on his/her left arm from a previous fall. AV appears to have re-opened skin tears before and no measures were put in place at that time to help heal the injury. The service plan does not mention AV being a fall risk nor that AV has a history of falls, nor were there any measure listed to help reduce risk of falling, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) has a known history of falls. Between August 9th through November 5, 2022, AV sustained approximately eight (8) falls. On or about November 25, 2022, AV was found on the ground with his/her upper body resting on the bed. AV was found with a laceration to their right elbow. Despite the falls the facility did not put sufficient measure in place to help reduce AV's risk of falling, no measure was mentioned to the investigator nor were there any temporary service plans provided with the exception for a fall in question that happened on November 5, 2022. The facility failed to properly care plan and mitigate AV’s known history of falls, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) has had an increase in falls. AV had a fall on or about November 19, 2022, leading to a skin tear to the right elbow and a small cut to the right knee. On or about November 20, 2022, AV sustained another fall. On or about November 24, 2022, AV sustained a third (3rd) fall leading to another skin tear to the right elbow. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) resides in the facility where the facility has a responsibility to provide a safe environment. AV sustained falls that led to injury on or about September 5th, 12th, and October 10th, 2022, and non-injury falls on or about September 7th, 23rd, October 4th and 5th, 2022. On or about October 17, 2022, AV suffered a fall which causes skin tears to the elbow and knee, as well as bruising to AV’s wrist. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) is a known fall risk and has sustained several injury and non-injury falls. On or about October 10, 2022, AV was found on the floor near the doorway in their room. AV was found bleeding from the back of their head; AV sustained a laceration as a result of the fall. On or about October 12, 2022, AV was once again found of the floor and was taking to the hospital. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) resides in a facility that is tasked with providing the appropriate level of care, safety, and oversight. AV has sustained several falls almost back-to-back where they were found down on the floor and transported to the hospital each time for further evaluation due to injuries and hitting of their head. The facility’s main intervention for the AV’s falls were to remind them to use their walker which appears to have been ineffective due to the numerous falls the AV sustained over and over again. The facility failed to put adequate interventions in place to mitigate AV’s risk of falls, which resulted in AV experiencing ongoing falls with injury, and which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim’s (AV’s) care plan states AV requires a gait belt with all transfer and ambulation assistance and staff are to ensure AV has gait belt on at all times, AV requires escort to all activities and requires wearing a gait belt around him/her when up and moving around. On or about September 5, 2022, AV suffered a fall and sustained injuries to his/her right elbow and right side of the head. The fall occurred in the facility’s courtyard while AV was ambulating without staff assistance. On or about September 13, 2022, AV was found on the floor in his/her room in front of the closet. AV was laying on his/her right side and sustained a skin tear to his/her right elbow. The facility failed to assure AV’s care plan was being followed regarding AV’s ambulation, which is a violation of resident rights, is neglect of care and constitutes abuse.

The facility failed to provide a safe environment. Witness 1 (W1) has a history of behaviors. On or about August 31, 2022, W1 and the Alleged Victim (AV) were involved in a resident-to-resident incident where W1 grabbed AV’s wrist, resulting in unreasonable discomfort. The facility’s failure is a violation of resident rights, is neglect of care and constitutes abuse.

The facility failed to provide a safe environment. Witness 1 (W1) has a history of behaviors and had not been receiving his/her behavior medication for several days. On or about August 26, 2022, W1 and AV were involved in a resident-to-resident incident where W1 hit AV on the arm, resulting in unreasonable discomfort. The facility’s failure is a violation of resident rights, is neglect of care and constitutes abuse.

The facility failed to provide a safe medication administration system to ensure Alleged Victim (AV)’s behavior medication transferred properly into a new system. AV did not receive his/her behavior medication as ordered for approximately seven days, resulting in AV experiencing increased behaviors. 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 for his/her care. AV has a history of skin issues and is service planned to have skin remain warm, dry, and intact. AV has been witnessed soaked in urine on multiple occasion exposing AV to potential harm of skin issues, however, the care plan does not require staff assistance with toileting. The facility failed to adequately care plan for AV’s toileting needs, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility to administer his/her medications. On or about July 13, 2022, AV mistakenly was given the wrong dosage of (common anti-anxiety medication). The same medication error occurred on June 20, 2022. 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 facility failed to implement interventions and appropriately care plan related to AV’s history of falls. AV experienced approximately five falls, with the majority being unwitnessed, from approximately March 23, 2022, to May 30, 2022, resulting in AV experiencing unreasonable discomfort. 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 elopement. On or about May 7, 2022, facility staff discovered AV was not in the facility and was found sitting at the bus stop down the road. The facility failed to provide a safe environment for AV which is a violation of resident rights, is neglect of care which constitutes abuse.

The Alleged Victim (AV) has a history of elopement. On or about April 17, 2022, facility staff discovered AV was not in the facility and was found sitting at the bus stop down the road. The facility failed to provide a safe environment for AV which is a violation of resident rights, is neglect of care which constitutes abuse.

The facility failed to provide a safe environment and appropriately care plan, related to the Alleged Victim's (AV) fall history. On or about, April 14, 2022, AV suffered a fall that resulted in a head injury and skin tear. 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 AV's medications were administered as ordered. Approximately five times, between March 7, 2022, and March 24, 2022, AV was given a medication that he/she should not have been given due to a reduced heart rate, leaving 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 facility failed to provide appropriate services according to Alleged Victim (AV)'s needs. The Alleged Victim (AV) was care planned for a weekly shower and assisted with compression stockings twice daily. On or about, March 17, 2022, the Alleged Victim (AV) was found to have a laceration and infection to his/her toe, which resulted in unreasonable discomfort. The failure 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 medication. On or about February 23, 2022, Alleged Perpetrator 2 (AP2) was training Alleged Perpetrator 3 (AP3) to be a med tech. AP2 handed another resident’s medication to AP3 who then gave that medication to AV. The next day AV was vomiting, had a hard time to wake and open his/her eyes, had pale skin, and had a hard time eating. The facility, AP2 and AP3 failed to provide a safe medication administration system for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility to administer his/her medications. On or about November 21, 2021, AV went to the ER for altered mental status. AV was on (cognitive disease medication) at that time, which causes AV confusion. AV’s PCP cancelled that medication and changed to a different medication. On or about December 1, 2021, AV was discharged with orders to the facility for a medication change. On or about December 29,2021, AV returned to the ER with altered mental status again. The facility did not discontinue the (cognitive disease medication) which caused for AV to return to the hospital once again with altered mental status. The facility failed to provide a safe medication administration system for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

The Alleged Victim (AV) was found to have soaked incontinence briefs on multiple occasions. AV's wheelchair seat was also found to be wet through a pad on the wheelchair. AV was care planned to be checked multiple times per shift for incontinence care. AV went to his/her primary care physician in October 2021 and was found to have an ulcer on his/her buttock, consistent with being exposed to prolonged moisture. The facility failed to ensure toileting needs were completed for AV, leaving AV at risk for harm. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to fully implement and update an acuity-based staffing tool. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to fully implement and update an acuity-based staffing tool. An investigation determined this is a violation of Oregon Administrative Rules.

The facility allegedly failed to properly plan care for the Alleged Victim. An investigation determined this is a violation of Oregon Administrative Rules.

The facility allegedly failed to administer medication as ordered for the Alleged Victim (AV). According to an investigation, AV experienced no negative outcome. The failure is a violation of Oregon Administrative Rules.

The facility allegedly failed to provide a safe medication administration system for the Alleged Victim. An investigation determined this is a violation of Oregon Administrative Rules.

According to an investigation, on or about July 5, 2024, the facility failed to provide medical treatment as ordered for the Alleged Victim (AV). AV experienced no negative outcome. The failure is a violation of Oregon Administrative Rules.

The facility failed to ensure a safe medication administration system in accordance with OAR 411-054-0055(1).

The facility failed to ensure a system for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility. An investigation determined no licensing violation or abuse occurred.

Alleged Victim Service Plan indicates AV requires use of a wheelchair for mobility. AV is non-ambulatory. AV will need one person assist with transfers. Unlicensed assistive personnel to physically assist AV through transfer. AV is a high risk of falls due to poor safety awareness, cognitive deficiencies and being on diuretic. On or about April 24, 2024, Alleged Perpetrator 2 (AP2) AP2 checked on AV and noticed AV was soaked in urine. AP2 went to assist AV into wheelchair and grabbed AV by AV's hands and pulled AV up, resulting in a skin pulling away from left hand. AV is slow to move and requires staff to be in front of AV to guide transfers. Staff are to use under the arm technique for transfer or gait belt as needed. Care Partner Training and Competency Check List has Transferring and Gait Belts listed as part of training requirements. AP2 initialed section as acknowledging completion of training, dated April 26, 2022, Pre-Service Dementia Care Training for Direct Care Staff completed on February 23, 2024, by AP2. Updated Care Partner Description with list of responsibilities and requirements signed on March 21, 2024, by AP2. AP2 knew that there was a gait belt in facility or could have called for a second staff but felt AP2 could lift AV on own without assistance or assistive devices. AP2 failed to assist a resident transfer from one place to another using generally accepted techniques, and provide a safe environment when transferring, the facility failed to provide a safe environment when resident is transferring, which is a violation of Oregon Administrative Rules.

The facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules. Facility on Condition.

The facility failed to carry out medication and treatment orders as prescribed in accordance with OAR 411-054-0055(1)(f).

On or about February 21, 2024, medication cart audits were completed AP1 at which time it was discovered AV's morphine had issues with the appearance. The pharmacy complete additional med cart audits, to find other missing/tampered with narcotics. Unknown Alleged Perpetrator 2 (AP2) diverted the medications. The Unknown AP2’s actions are a violation of resident’s rights, are considered neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system and failed to protect AV from financial exploitation which is a violation of Oregon Administrative Rules.

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

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

Alleged Victim (AV) resides in a secure facility that has a responsibility to provide care and a safe environment. AV is prescribed multiple scheduled and as needed medications and a trained med tech is responsible for ordering, storing, and administering all of AV's medications per physician orders. On or about February 21, 2024, a medication cart audit was completed, and narcotic discrepancies was found. These discrepancies involved inaccurate counts as well as missing/tampered with bottles of morphine. AV's morphine was determined to be watered down. AP1 failed to ensure a safe, adequate medication administration system, which resulted in AV's prescribed morphine being diverted by an unknown Alleged Perpetrator (AP2). AP2’s actions are a violation of resident rights, are considered neglect of care and constitutes abuse. The facility failure is a violation or Oregon Administrative rules.

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

The allegation that the facility failed to protect the Alleged Victim (AV) from financial exploitation was investigated and the determination was not substantiated. The allegation that the Unknown Alleged Perpetrator (AP2) failed to protect AV from financial exploitation was investigated and the determination was Substantiated.

Alleged Victim (AV) resides in a secure facility that has a responsibility to provide care and a safe environment. AV is prescribed multiple scheduled and as needed medications and a trained med tech is responsible for ordering, storing, and administering all of AV's medications per physician orders. On or about February 21, 2024, a medication cart audit was completed, and narcotic discrepancies was found. These discrepancies involved inaccurate counts as well as missing/tampered with bottles of Haldol. AV's Haldol was determined to be diverted . AP1 failed to ensure a safe, adequate medication administration system, which resulted in AV's prescribed Haldol being diverted by an unknown Alleged Perpetrator (AP2). AP2’s actions are a violation of resident rights, are considered neglect of care and constitutes abuse. The facility failure is a violation or Oregon Administrative rules.

The facility failed to carry out medication orders as prescribed in accordance with OAR 411-054-0055(1)(f).

The facility failed to immediately notify the local Seniors and People with Disabilities (SPD) office, of any incident of abuse or suspected abuse in accordance with OAR 411-054-0028(2).

The facility failed to establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment in accordance with OAR 411-054-0050(1).

The facility failed to ensure adequate professional oversight of the medication and treatment administration system, carry out medication orders as prescribed, and keep an accurate Medication Administration Record (MAR) for 18 of 18 sampled residents. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to exercise reasonable precautions against any condition that could threaten the health, safety, or welfare of residents. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to determine or document actions or interventions, communicate actions or interventions to staff, monitor a residents condition, or evaluate the resident and refer to the facility RN for 2 of 2 sampled residents. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to ensure the delegation and supervision of special tasks of nursing care was completed in accordance with the Oregon State Board of Nursing (OSBN) Division 47 Rules, for 1 of 1 sampled residentThe facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to provide adequate staff to meet the scheduled and unscheduled needs of residents for 11 of 11 sampled residents. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to ensure direct care staff had demonstrated satisfactory performance in any duty they were assigned prior to performing work duties independently, for 5 of 5 sampled staff. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to develop an individualized nutrition plan based on the resident's needs for 1 of 1 sampled resident. The facility’s failure is a violation of Oregon Administrative Rules.

The licensee failed to ensure adequate administrative oversight of facility operations including supervision and training of staff, which posed a risk to the safety of residents. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to treat residents with dignity and respect and/or provide a safe and homelike environment. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 9 of 9 sampled residents whose MARs, controlled substance medications and Controlled Substance Drug Disposition Logs were reviewed. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to establish and maintain infection prevention and control protocols in accordance with OAR 411-054-0050(1).

The facility failed to immediately notify the local Department office, or the local AAA, of any incident of abuse or suspected abuse and failed to promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the re-occurrence of abuse in accordance with OAR 411-054-0028(2)(b) and (3).

The facility failed to fully implement an Acuity Based Staffing Tool in accordance with OAR 411-054-0037.

The facility failed to document the use of supportive devices with restraining qualities in the resident's service plan in accordance with OAR 411-054-0060(4).

The facility failed to ensure a safe medication administration system in accordance with OAR 411-054-0055(1).

The facility failed to carry out medication orders as prescribed in accordance with OAR 411-054-0055(1)(f).

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).

The facility failed to carry out treatment orders as prescribed in accordance with OAR 411-054-0055(1)(f).

The facility failed to document the use of supportive devices with restraining qualities in the resident's service plan in accordance with OAR 411-054-0060(4).

Facility failed to follow medications orders as prescribed in accordance with OAR 411-054-0055(1)(f).

The facility failed to ensure adequate professional oversight of the medication and treatment administration system in accordance with OAR 411-054-0055(1)(a).

The facility failed to ensure that written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer in accordance with OAR 411-054-0055(1)(g).

The facility failed to ensure the implementation of services in accordance with OAR 411-054-0036(2)(g).

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).

The facility failed 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 in accordance with OAR 411-054-0055(1)(e).

The facility failed to have a training program that includes methods to determine competency of direct care staff through evaluation, observation, or written testing in accordance with OAR 411-054-0070(2).

The facility failed to establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment in accordance with OAR 411-054-0050(1).

The facility failed to implement a service plan that reflects the resident's needs as identified in the evaluation in accordance with OAR 411-054-0036(2)

The facility failed to report an injury of unknown cause and conduct an immediate investigation in accordance with OAR 411-054-0028(b)(d).

The facility failed to immediately notify the local Department office, or the local AAA, of any incident of abuse or suspected abuse and failed to promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the re-occurrence of abuse in accordance with OAR 411-054-0028(2)(b) and (3).

The facility failed to have an accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility in accordance with OAR 411-54-0055 (2).

The facility failed to carry out medication orders as prescribed in accordance with OAR 411-054-0055(1)(f).

The facility failed to have policies and procedures in place to assure the prevention and appropriate response to any incident in accordance with OAR 411-054-0028(1).

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).

The facility failed to establish and maintain infection prevention and control protocols in accordance with OAR 411-054-0050(1).

The facility failed to ensure that residents may not be locked out of or inside of their rooms at any time in accordance with OAR 411-057-0170(9)(a).

Alleged Victim (AV) relies on the facility to administer his/her medication. Between December 8th through December 28th, 2022, AV received double the daily dose of a warfarin medication. On or about December 28, 2022, AV was transported to the ER and diagnosed with poisoning by warfarin. Alleged Perpetrator 2 (AP2) authorized a MAR with incorrect warfarin dosing instructions. AP2 failed to provide a safe medication administration system, which is neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system, which is a violation of Oregon Administrative Rules.

The facility failed to carry out medication and treatment orders as prescribed, which is a violation of Oregon Administrative Rules.

he facility failed to carry out medication and treatment orders as prescribed, which is a violation of Oregon Administrative Rules.

The facility failed to allow resident to send and receive mail unopened, which is a violation of Oregon Administrative Rules.

The facility failed to provide a call system that connects resident units to the care staff center or staff pagers, which is a violation of Oregon Administrative Rules.

Alleged Victim (AV) is care planned as a two-person assist for all transfers. On or about June 14, 2022, the Alleged Perpetrator 2 (AP2) did not follow AV's care plan and assisted AV to the toilet and AV was left alone, which resulting fall causing a laceration and a hip injury. AP2's actions are considered neglect and constitutes abuse. The facility failed to ensure care plans were followed which is a violation of Oregon Administrative Rules.

On or about March 1, 2022, the Oregon Health Authority reported to the Department that Respondent failed to comply with weekly reporting requirements of vaccinated individuals, residents and staff, to the proper authority as required by law. This failure has been ongoing from February 1, 2022 to February 28, 2022, for a total of 27 days.

The facility failed to exercise reasonable precautions against any condition that may threaten the health, safety, or welfare of the residents in accordance with OAR 411-054-0025(4) per complaint that staff are not wearing masks in the facility.

The facility failed to exercise reasonable precautions against any condition that may threaten the health, safety, or welfare of the residents in accordance with OAR 411-054-0025(4) per complaint that staff are not wearing masks in the facility.

Alleged Victim (AV) relies on the facility to administer his/her medications. On or about November 12, 2021, staff heard Alleged Perpetrator 2 (AP2) make derogatory remarks to AV. AP2 admitted to making derogatory reports to AV. AP2 failed to protect AV from verbal abuse, which is neglect of care and constitutes abuse. The facility failed to protect AV from verbal abuse, which is a violation of Oregon Administrative Rules.