Wildflower Lodge Assisted Living Community

The Alleged Victim (AV) relies on the facility for his/her care. AV was care planned for staff to make all arrangements for transportation and appointments. According to an investigation, AV's medical appointment was rescheduled due to lack of staff, resulting in continued unreasonable discomfort. The facility failed to provide appropriate services, 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 Victims (AV) medication orders were administered as prescribed. It was discovered that AV did not receive injectable blood sugar lowering medication as scheduled. The facility did not re-order the medication timely, and did not have medication available, placing the AV at risk of serious harm. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide a safe medication administration system to ensure the Alleged Victims (AV) medication orders were administered as prescribed. AVs pain medication orders were changed on or about November 22, 2022, with instructions to administer four doses of pain medication to AV per day. Documentation provided indicates the facility did not give the AV the prescribed amount of pain medication from approximately November 22, 2022, through November 28, 2022, resulting in AV experiencing “terrible” amount of pain in h/h shoulder. 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. Documentation shows in the month of July 2022 AV pushed call light for assistance and waited over forty-five (45) minutes on 12 calls, and in the month of August 2022 waited over forty-five (45) minutes on 10 calls. The extended wait times for assistance resulted in unreasonable discomfort. The facility failed to answer call light in a timely manner, which 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 the AV’s medication orders were administered as ordered. It was discovered that AV had not received his/her medication for approximately seven (7) doses. 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 AV’s medication was administered as ordered. It was discovered that AV missed two dosages of h/h insulin in the month of August 2022, due to it being out. It was also discovered that AV was out of h/h vitamin, however the medication was signed for when it was out of the facility per chart notes. 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 Victims (AV) medication orders were administered as prescribed. AV was prescribed a new pain medication on or about August 02, 2022. AV did not receive the pain medication until approximately August 23, 2022, which resulted in AV being in pain for an extended period of time. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to follow the care plan and provide appropriate services according to the Alleged Victim (AV)'s needs relating to showers. AV is care planned to be given two showers a week on Sunday and Thursday. It was discovered in the month of August 2022 AV was given four showers in four weeks. This failure 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 (AV)’s needs, resulting in AVs loss of dignity. Documentation provided to the department shows AV had a Move-in Assessment, but no care plan. AV was found twice (2) in soiled brief for an unknown amount of time. AV call light was pushed for assistance and AV waited for 34 minutes and 44 minutes. Approximately several days of soiled laundry was found in AV shower, and trash was not emptied for approximately three (3) days. 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 and failed to obtain medication order. It was discovered Alleged Victim (AV) injectable medication was not placed on the eMAR, a prescription was not obtained from AV provider, prescription was not filled, and AV did not receive h/h injectable medication. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) oversaw their own medication and switched to using the facility's medication staff. Since switching, AV's medications have been late, or medications not given due to being out. AV did not receive h/h medication for 9 days and it caused AV pain and discomfort. The facility failed to provide a safe medication administration system which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) did not receive medication as ordered, which caused AV unreasonable discomfort. The facility failed to provide a safe medication administration system to ensure AV's medications were available and 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 administer his/her medications. AV’s physician ordered a pain patch on or about July 12, 2022, Facility received the medication from the pharmacy on or about July 14, 2022, however medication was not administered to AV until on or about July 25, 2022, due to facility internal procedure. AV reported to be in pain as a result of not receiving the pain medication. The facility failed to provide a safe medication administration system which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) is care planned to be showered twice weekly and staff are to evaluate h/h skin every time he/she receives a shower and skin issues are to be reported immediately. Documentation AV was found to have skin breakdown, and no documentation or reporting was completed as care planed. The facility failed to follow the care plan which is a violation of resident’s rights is neglect of care and constitutes abuse.

Alleged Victim (AV) was not administered his/her medication for pain management and high blood pressure on multiple occasions, putting AV at risk of potential harm. The facility failed to provide a safe medication administration system to ensure AV was administered prescribed medications which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to answer call lights in a timely manner. Alleged Victim (AV) pushed the call light for assistance on multiple occasions and waited more than forty-five (45) minutes approximately on fifteen (15) occasions, causing loss of dignity, 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 (AV)'s needs. AV is care planned for rotation and shift of weight while in chair and bed to prevent further skin breakdown, scheduled and stand-by assist with toileting, and requires assistance with meals. On several occasions, AV was noted to be left in h/h recliner for long periods of time and soiled, which resulted in pressure ulcers. AV went without two meals due to inability to independently feed h/h self. 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 h/h care. The facility failed to provide a safe medication administration system to ensure AV medications where reordered in a timely manner. AV was not administered his/her medication for approximately 2 days, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Facility failed to have medication(s) available to ensure the Alleged Victims (AV) medication orders were administered as prescribed. On multiple occasions, it was discovered that AV did not receive h/h medication(s) as order due to the medication not being stocked in facility, causing unreasonable pain and discomfort. 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. Concerns are reported regarding AV not receiving care in a timely manner after using call pendent. Call logs for the month of May show approximately nine (9) response times exceeding an hour. On or about May 31, 2022, AV pushed call light for assistance to the bathroom and did not have a timely response which resulted in AV having an incontinence episode in h/h wheelchair causing loss of dignity. The facility failure to answer call lights in a timely manner have resulted in AVs care needs not being met, which is a violation of resident rights, is neglect of care and constitutes abuse.

The facility failed to provide appropriate services according to Alleged Victim (AV)'s needs, relating to his/her medications, timely response to call pendent, activities of daily living, and keeping his/her room free of odors. 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 Victims (AV) medication was administered as prescribed. From approximately January 13, 2022, to May 07, 2022, AV was administered medication daily instead of Monday, Wednesday, and Friday. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide assistance with bathing to the Alleged Victim (AV), resulting in AV going without a shower, experiencing unreasonable discomfort. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) ran out of incontinence supplies and has experienced increased incontinence episodes while waiting for facility staff to respond to h/h call light for assistance, resulting in AV sitting in soiled garments causing redness, pain, and unreasonable discomfort. The facility failed to appropriately care plan and implement reasonable interventions to address AV’s increased need for assistance with incontinence care, which is 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 April 18, 2022, AV pushed call light for assistance to the bathroom, and waited approximately an hour, causing unreasonable discomfort. The facility failed to answer call light in a timely manner, which 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 the Alleged Victims (AV) medications were administered as prescribed. It was discovered that during the month of April 2022 AV missed multiple medications due to medication not available or not in the facility. AV experienced a hard time with sleeping and had some anxiety when going to bed. 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 Victims (AV) medications were administered as prescribed. It was discovered that AV did not receive all prescribed medications on or about April 09, 2022, and the facility did not have AVs medication in the facility on or about April 11, 2022, to April 25, 2022. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) is care planned to have assistance putting compression socks on daily. AV was observed not having compression socks on resulting in discoloration of lower anterior leg and swelling of veins in lower leg. The facility failed to follow the care plan which is a violation of resident’s rights is neglect of care and constitutes abuse.

Alleged Victim (AV) is care planned to have assistance putting compression socks on daily. AV was observed not have compression socks on March 04, 2022, and on March 07, 2022 resulting in swelling of AVs legs. The facility failed to follow the care plan which is a violation of resident’s rights is neglect of care and constitutes abuse.

Alleged Perpetrator #2 (AP2) failed to provide a safe medication administration system for Alleged Victim (AV). AP2 discontinued AVs medication without a verified doctor's discontinuation order. AP2 is responsible for neglect of care which constitutes abuse. The facility failed to provide oversight and a safe medication administration system, 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 Victims (AV) medication orders were administered as prescribed. On multiple occasions, it was discovered that AV was administered the incorrect dose and/or did not receive the medication as scheduled, causing unreasonable pain and discomfort. 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. Between December 1st, 2021, through January 30th, 2022, call light response from staff took over 30 minutes on 15 occasions. The facility failed to answer the call light in a timely manner, which is a violation of resident rights, if neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. On or about January 07, 2022, AV pushed call light pendant nine (9) times with no response from the facility. AV was found on the flour when staff delivered a room tray to AV. AV was transported to the hospital for a head injury requiring two staples. The facility failed to answer call light in a timely manner, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) is care planned to wear compression socks and receive assistance putting them on. It was observed that AV’s lower legs and feet appeared swollen, and he/she did not have compression socks or wraps on his/her feet. AV reported staff does not assist with compression socks or stocking. AV reported his/her feet hurt from the swelling. 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) is care planned to have assistance putting compression socks on daily. On or about December 22, 2022 AV did not have h/h compression socks on h/h feet, causing AVs legs to swell. The facility failed to follow the care plan which is a violation of resident’s rights is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. Concerns were reported regarding AV not receiving care in a timely manner. There is notation where AV complained that he/she rang for assistance, received no response from staff and fell to the floor. On or about August 6, 2021, AV reported he/she rang the button again and yelled for help and it took two (2) hours to get a response. Notes added as an intervention to the fall indicate that staff are to respond to the call light. Since then, AV calls Witness 1 (W1), crying, and W1 will have to call the facility to tell them AV needs assistance due to no response from the call button. Between October 1st through November 30, 2021, AV pressed the call button and had a wait time of anywhere from 15 minutes up to 10 hours on approximately 274 occasions. The facility failed to answer the call light in a timely manner, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) is care planned to receive frequent checks during the nighttime hours due to occasional incontinence and to receive brief change assistance. On or about November 3, 2021, it was discovered AV had an open sore on AV’s right buttock measuring 1 cm in length and 2 cm in width. On or about November 18, 2021, it was noted that AV’s bed was saturated in urine and AV had not been out of bed in a week, on November 10, 2021, AV was discovered to be in urine saturated and feces-stained sheets. At this time AV’s pressure ulcer was examined and it was noted there was deep tissue injury present as evidence by a purple appearance. AV often denied needed change and would usually refuse to allow staff to change him/her. The facility failed to care plan around AV’s frequent refusal on incontinence change, 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 medication. AV was prescribed narcotics for pain. This medication was discontinued in October 2021, AV’s personal care physician (PCP) sent a fax to the facility and sent a copy of the paperwork with AV after an appointment. However, the facility had requested a refill on or about October 12, 2021, which they received on November 3, 2021, which the facility continued to administer. The Medication Administration Record (MAR) has all but two days in the month of November 2021 initialed indicating that the medication was given twice a 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 Alleged Victim (AV) new bottle of soap went missing, from his/her room. The items were taken by an unknown Alleged Perpetrator #2 (AP2) and this person is responsible for theft of property, which is considered financial exploitation and constitutes abuse. The facility failed to ensure a safe environment and protect AV from financial exploitation which is a violation of Oregon Administrative Rules.

The facility failed to implement safe medication and treatment administration systems that are approved by a pharmacist consultant. 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 comply with masking requirements. An investigation determined this is a violation of Oregon Administrative Rules.

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 facility failed to keep the interior of the facility must be free from unpleasant odors. 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 a safe medication and treatment system that is approved by a pharmacist consultant, registered nurse, or physician. An investigation determined this is a violation of Oregon Administrative Rules.

On or about September 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 August 1, 2022 to August 31, 2022, for a total of 30 days.

Based on interview, record review and observation it was confirmed that the facility failed to fully implement and update an acuity-based staffing tool (ABST). Findings include but not limited to: During interview on 09/07/2022 Staff #1 (S1) stated: Facility's census is 34 residents They only have 24 hours of care scheduled between two caregivers (CG) and one med aid (MA) for day shift. A review of facility's ABST and staff schedule for September 2022 revealed: 32 residents had been entered into their ABST. ABST indicates they have 27 hours of care needed during Wednesday day shift. Two CGs and one MA are scheduled on day shift for a total of 24 hours. Compliance Specialist (CS) observed two CGs and one MA working during day shift.

Based on record review and interview it was confirmed that the administrator failed to be responsible for ensuring adequate professional oversight of the medication and treatment administration system. Findings include but not limited to: A review of Resident #1 (R1), Resident #2 (R2) and Resident #3 (R3)'s MARs and progress notes for July - September 2022 revealed that all three of these residents have missed doses of medications due to facility running out of medications and not being delivered by pharmacy. During interview Staff #7 (S7) stated: Not all Med Aids order new medications when they are supposed to. Residents run out of medications sometimes. R1 had been out of a medication for 4 days.

Based on record review and interview it was confirmed that the facility failed to have the service plan readily available to staff and provide clear direction regarding the delivery of services and include a written description of who shall provide the services: During an unannounced site visit on 09/07/2022 Compliance Specialist (CS) requested a service plan for Resident #6 (R6). No document was able to be produced for this. During interview, Staff #1 stated that R6 did not have a service plan because they only lived there for 3 days.

Based on interview and record review it was confirmed that the facility failed to have sufficient staff to meet the scheduled and unscheduled needs of the residents. Findings include but not limited to: During separate interviews, Staff #1 (S1), Staff #6, Staff #9 and Resident #1-Resident #3 stated: Sometimes showers get pushed to next shift. I did not get a shower for 10 days. Sometimes there is only 1 CG working on swing shift. We are trying to hire more staff. Wait times are very long when you push the call light. We need more staff. A review of R1's shower sheets for August and September 2022 revealed that R1 did not receive a shower from 8/28/2022- 09/07/2022. A review of the facility's Acuity Based Staffing Tool on 09/07/2022 revealed the need for 27 hours of care staff during day shift that day, though only 24 hours were scheduled.

Based on interview, record review and observation it was confirmed that the facility failed to fully implement and update an acuity-based staffing tool (ABST). Findings include but not limited to: During interview on 09/07/2022 Staff #1 (S1) stated: Facility's census is 34 residents They only have 24 hours of care scheduled between two caregivers (CG) and one med aid (MA) for day shift. A review of facility's ABST and staff schedule for September 2022 revealed: 32 residents had been entered into their ABST. ABST indicates they have 27 hours of care needed during Wednesday day shift. Two CGs and one MA are scheduled on day shift for a total of 24 hours. Compliance Specialist (CS) observed two CGs and one MA working during day shift.

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

Based on interview and record review it was confirmed that facility failed to have a training program that includes methods to determine competency of direct care staff. Findings include but not limited to: During an interview with Staff #6 (S6) they stated that they did not recall any staff competency checklist being completed prior to working independently. They reported that they had to walk out on their first shift because the other staff member sat in the break-room for a large portion of the shift. When they returned several days later, they worked without supervision on their third day. During an interview with Staff #8 they reported that S6 worked the first shift independently on 05/15/2022 which was confirmed on their calendar. A review of S6's training documents revealed that training competencies were not completed and initialled until 05/17/2022.

Based on interview and record review it was confirmed that the facility failed to have sufficient staff to meet the scheduled and unscheduled needs of the residents. Findings include but not limited to: During separate interviews, Staff #1 (S1), Staff #6, Staff #9 and Resident #1-Resident #3 stated: Sometimes showers get pushed to next shift. I did not get a shower for 10 days. Sometimes there is only 1 CG working on swing shift. We are trying to hire more staff. Wait times are very long when you push the call light. We need more staff. A review of R1's shower sheets for August and September 2022 revealed that R1 did not receive a shower from 8/28/2022- 09/07/2022. A review of the facility's Acuity Based Staffing Tool on 09/07/2022 revealed the need for 27 hours of care staff during day shift that day, though only 24 hours were scheduled. These findings were reviewed with and acknowledged by Staff #1 on 09/08/2022 who was in agreement.

Based on record review and interview it was confirmed that the facility failed to carry out medication orders as prescribed. Findings include but not limited to: A review of Resident #1-Resident #3 and Resident #6 MARs and progress notes for July, August and September 2022 revealed many instances of medications being given late and medications not being given because the med was not in the facility. These findings were reviewed with and acknowledged by Staff #1 on 09/07/2022 who was in agreement.

Based on record review and interview it was confirmed that the facility failed to orient staff to the resident, including the resident's service plan. Findings include but not limited to: During an unannounced site visit on 09/07/2022 Compliance Specialist reviewed service plans available in facility's "service planning binder" which is available to all floor staff. CS noted that many of these service plans had not been reviewed or acknowledged by floor staff including those belonging to Resident #1-Resident #5. Resident #6 had no service plan. Additionally, many of the Temporary Service Plans available were only signed by 1 person. During interview, Staff #6 stated that there is supposed to be a shift change meeting but that it has only happened one time since they started. These findings were reviewed with and acknowledged by Staff #1 on 09/07/2022 who was in agreement. ED to audit all service plans to confirm they are up to date, available to staff and acknowledged by 9/16/2022.

Based on record review and interview it was confirmed that the facility failed keep an accurate Medication Administration Record (MAR). Findings include but not limited to: A review of Resident #1's MAR for September 2022 indicated that resident was out of a medication beginning on Saturday 09/03/2022. The MAR indicated that this med was given on 09/04/2022 and then it was not administered again on 09/05/2022 and 09/06/2022. R1's progress notes revealed resident was placed on alert for missing this medication on 09/04/2022. During separate interviews R1 and Staff #7 reported that the facility had been out of this medication since 09/03/2022.

Based on record review and interview it was confirmed that the facility failed to develop the service plan by a Service Planning Team that consists of the resident, the resident's legal representative, if applicable, any person of the resident's choice, the facility administrator or designee and at least one other staff person who is familiar with, or who is going to provide services to the resident. Findings include but not limited to: A review of Resident #1-#3 service plans revealed that they were only signed by Executive Director. Resident #6 had no service plan. These findings were reviewed with and acknowledged by Staff #1 on 09/07/2022 who was in agreement and was unable to provide any additional documentation that service planning meetings occurred.

Based on interview and record review it was confirmed that the facility failed to perform resident services to assist resident in performing activities of daily living. Findings include but not limited to: During separate interviews Staff #1 (S1), Staff #6, Staff #9 and Resident #1-Resident #3 stated: Sometimes showers get pushed to next shift. I did not get a shower for 10 days. Sometimes there is only 1 CG working on swing shift. We are trying to hire more staff. Wait times are very long when you push the call light. We need more staff. A review of R1's shower sheets for August and September 2022 revealed that R1 did not receive a shower from 8/28/2022- 09/07/2022.

Based on observation and interview it was confirmed that the facility failed to exercise reasonable precautions that may threaten the health, safety, and welfare of residents. Findings include but not limited to: During an unannounced site visit on 09/07/2022, Compliance Specialist (CS) observed several staff members not wearing masks while on a tour of the facility

The allegation that the facility failed to exercise reasonable precautions against any condition that may threaten the health, safety, or welfare of the residents in accordance with OAR 411-054-0025(4) was verified.

The allegation that the facility failed to license, maintain, and operate the assisted living facility as a separate and distinct facility in accordance with OAR 411-054-0010(3) was verified.

The allegation that the facility failed to keep all interior materials and surfaces clean in accordance with OAR 411-054-0300(4)(i) per a complaint there was garbage everywhere and food on floor was verified.

The allegation that the facility failed to treat residents with dignity and respect in accordance with OAR 411-054-0027(1)(a) Per a complaint a resident was found with spilled food and debris on clothes and shoes was verified.

The allegation that the facility failed to develop and implement a resident's service plan to include a written description of who shall provide the services and what, when, how, and how often the services shall be provided in accordance with OAR 411-054-0036(2)(c) per a complaint the resident's service plan omits how often toileting assistance is to be provided was verified.

The allegation that the facility failed to provide direct care staff sufficient in numbers to meet the scheduled and unscheduled needs of each resident in accordance with OAR 411-054-0070(1) Per a complaint that the facility has an alarming shortage of PCA staff everyday after hours, & especially on weekends and holidays was verified.

On or about May 17, 2022, it was discovered that Alleged Perpetrator (AP2) put two (2) right shoes on Alleged Victim (AV). AV reported to AP2 the wrong shoe was uncomfortable on h/h foot, to which AP2 did not correct or check AV’s shoes for any issues. AV went to an appointment outside the facility with the right shoe on his/her left foot, causing unreasonable discomfort. AP2’s failure to properly dress AV is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility’s failure is a violation or Oregon Administrative rules.

The facility failed to have enough staff to meet the scheduled and unscheduled needs of the residents. 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 have a training program that includes methods to determine the competency of direct care staff. An investigation determined this is a violation of Oregon Administrative Rules.