Wiley Creek Memory Care

Witness #1 (W1) has a history of aggressive behavior, being physical towards staff, Alleged Victim (AV) and other residents leading into resident-to-resident altercations. W1 has been known to shake h/h cane in an aggressive manner at other residents. W1 and AV share a bathroom. W1 has history of screaming, cursing, and beating on the bathroom door when staff take AV to the bathroom. W1 has history of repeatedly entering AV’s room without permission, destroying AV’s property and messing up AV’s room. Interventions in place for W1, if staff notice W1 becoming agitated or verbally aggressive, staff to offer to sit down with W1 and have a conversation about how W1 is feeling, redirect, offer stuffed animal, turn on TV. On or about July 3, 2024, a discussion was had with W1's family the facility does not believe it can ensure the safety of W1 and the other residents due to W1's aggressive behavior, noncompliance with medications, and interventions and the need to start searching for a more appropriate placement for W1. On or about September 13, 2024, W1 was found in AV's room screaming at AV and pointing W1's cane inches away from AV's face resulting in AV being scared, not wanting to be in AV’s room and staff having to sit with AV until AV fell asleep. The facility failed to provide a safe environment for AV, properly plan care, and provided interventions appropriate to mitigate W1 aggressive behaviors, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness 1 (W1) has a history of agitation, physical aggression towards staff and residents, and involvement in resident-to-resident altercations. On or about September 12, 2024, Alleged Victim (AV) reported that s/he is unable to get any sleep at night due to W1 pounding on the walls that separate AV and W1 room. AV reports this happens every night. AV reported on or about October 9, 2024, in an interview with APSS, that W1 continues to bang on the wall every night, which causes AV to lose sleep and causes AV emotional distress. W1 interventions mostly rely on staff redirection, staff to offer 1:1 activity or removing other residents from the area. The facility failed to assure resident rights and failed to appropriately care plan addressing W1 behaviors (pounding on the wall, and yelling) keeping AV up at night, and AV being in fear of W1, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to intervene when the Alleged Victim ‘s (AV) condition changed. AV relies on the facility for his/her care. On or about September 3, 2024, AV tested positive for a viral infection. AV experienced weakness as a result of the viral infection, AV declined, AV was no longer able to take themselves to the bathroom and required increased staff assistance. AV's service plan dated on or about September 6, 2024 indicates AV has poor gait, weakness, poor balance, increased generalized weakness due to falls, is incontinent, needs staff to assist AV with one-person, walker or wheelchair to transfer/ambulate to the toilet at least two times per shift and right before bedtime. AV was found on multiple occasions during September 2024, to be soaked in urine, and it appeared as though AV had not been checked on in a long time. The investigation determined there was sufficient evidence that the facility neglected AV by failing to respond to AV’s change in condition of continued decline, eventually becoming bedridden, and needing a two person assist , resulting in unreasonable discomfort when AV was found to be soaked in urine on multiple occasions in September of 2024.

Alleged Victim's (AV's) diagnosis include dementia and weakness. AV displays behaviors, has incontinence, balance issues, takes medications affecting balance. AV is easily distracted, has periods of altered perception or awareness of surroundings, has short-term memory loss, can be impulsive, has poor judgement and does not call for staff assistance or wait for staff to arrive prior to attempting to get up which leads to falls. AV has significant history of falls with and without injury. AV service plan indicates, one person stand-by assist for all transfers and ambulation with walker, staff to place non-slip socks on or socks and shoes. Staff to continue to stay with AV while ambulating/transferring AV to AV's preferred destination. Interventions in place include staff to remind AV to put on shoes or nonskid socks when walking in AV's room or around the community, staff to ensure that AV is wearing call pendant around AV's neck and if AV does not have pendant, staff to find it and place it around AV's neck. On or about September 07, 20 24 AV tried to pick up a paint brush, lost balance and fell. AV reported neck and head pain and was bleeding from a head injury. AV has an extensive history of falls with and without injury, with the falls having similar circumstances of AV attempting to pick up items, move items, or ambulate without a mobility device with AV becoming dizzy, showing symptoms of progression of dementia, and not calling for assistance when necessary, the facility failed to appropriately care plan and implement reasonable interventions to address AV’s increasing and ongoing falls, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim's (AV's) diagnosis include dementia and weakness. AV displays behaviors, has incontinence, balance issues, takes medications affecting balance. AV is easily distracted, has periods of altered perception or awareness of surroundings, has short-term memory loss, can be impulsive, has poor judgement and does not call for staff assistance or wait for staff to arrive prior to attempting to get up which leads to falls. AV has significant history of falls with and without injury. AV service plan indicates, one person stand-by assist for all transfers and ambulation with walker, staff to place non-slip socks on or socks and shoes. Staff to continue to stay with AV while ambulating/transferring AV to AV's preferred destination. Interventions in place include staff to remind AV to put on shoes or non skid socks when walking in AV's room or around the community, staff to ensure that AV is wearing call pendant around AV's neck and if AV does not have pendant, staff to find it and place it around AV's neck. On or about September 10, 2024, AV asked to eat dinner in AV's room and instructed staff to put dinner on AV's bed. AV later decided AV wanted AV's own food and got out of bed, started walking, got dizzy and tripped and fell over the fall mat, resulting in a thoracic spine fracture and re-opening a head laceration. AV has fallen over 10 times in a 4-month period with similar circumstances of becoming dizzy, showing symptoms of progression of dementia, and not calling for assistance when necessary. The facility failed to appropriately care plan and implement reasonable interventions to address AV’s increasing and ongoing falls, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV)'s diagnoses include dementia and weakness. AV displays behaviors, has incontinence, balance issues, takes medications affecting balance, has a diagnosis that contributes to falls. AV is easily distracted, has periods of altered perception or awareness of surroundings. AV has short-term memory loss, AV can be impulsive, has poor judgement and does not call for staff assistance or wait for staff to arrive prior to attempting to get up. AV service plan indicates AV will need one person stand by assist for all transfers and ambulation with walker. Staff to place on non-slip socks or socks and shoes. Staff to continue to stay with AV while ambulating/transferring AV to AV's preferred destination. AV has history of injury and non-injury falls. On or about July 21, 2024, AV fell in h/h room and showed signs of increased confusion and could not tell staff how s/he fell. AV had pain in back and head and went out with EMTs On or about July 22, 2024, AV was in AV's room self-ambulating when something fell under the bed and AV tried to pick it up, lost balance and fell resulting in a skin tear on AV's right arm and pain in the head . The facility failed to put into place person-centered interventions to prevent AV from falling. AV had fallen the day before in similar circumstances. AV was showing signs of increased confusion, has short-term memory loss and a history of falling in AV's apartment. The intervention of AV using a pendant to call for assistance was proven ineffective in a situation where AV drops an item and attempts to pick it up, then loses balance and falls. The facility did not address AV's behavior of falling, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #1 (W1) has a history of agitation, aggression and resident-to-resident altercation towards other residents and Alleged Victim (AV). W1 had interventions put into place after a resident-to-resident altercation on or about June 1, 2024, that include if staff notice W1 becoming agitated or verbally aggressive, staff to offer to sit down with W1 and have a conversation about how W1 is feeling. After a resident-to-resident altercation on or about July 3, 2024, Alleged Perpetrator 1 (AP1/Facility) acknowledged the lack of ability to provide the services necessary for W1 and for the safety of AV and other residents and AP1 was facilitating a search for better placement for W1. On or about September 5, 2024, AV was ambulating independently in the hallway. W1 was being verbally aggressive towards AV. W1 started shaking W1's cane at AV. AV attempted to turn around and walk away, W1 followed AV, W1 hit AV on the left side of the face with W1's box of tissues, and W1's body hit AV's left hand. AV complained of pain in h/h left hand, was emotional and tearful. The facility failed to provide a safe environment for AV and adjust the service plan for W1 leading to continued aggressive behavior, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) has a history of falls, balance problems, physical weakness and decreased awareness. AV is on hospice, does not know how to use call button or utilize call system and has a four wheeled walker but refuses to use it. AV service plan dated on or about July 19, 2024, indicates AV ambulates independently within the community but requires occasional staff assistance with balancing. Staff to provide assistance by walking AV to meals and activities. If AV observed unbalanced, staff to assist with hands on steadying, walk with AV to destination, and encourage AV to sit down and rest. Staff to assist AV to bathroom upon rising, before and after meals, at bedtime, as needed and at least once per night shift. Fall interventions include nonskid socks, rubber soled shoes, ensuring shoes are tied, ensuring AV feels chair behind AV before sitting, ambulation with walker when AV allows, redirection, proper positioning in chairs and bed, apartment free of clutter and ensuring AV isn't wrapped in blankets, during the night staff to ensure that AV's bathroom light is on and bathroom door is open for AV to have more visualization. AV continued to fall with interventions of frequent check, toileting schedule, clear pathways, lighting, and fall mat. On August 21, 2024, intervention in place was to hire staff for 1:1 care for AV to prevent future falls. AV had an additional two falls on August 24, and 26, 2024 prior to the fall on August 29, 2024, when AV woke up and attempted to get out of bed tripping over the fall mat. The facility recognized AV needed 1:1 care to prevent falls, but did not implement intervention. The facility failed to appropriately care plan and implement reasonable interventions to address AV’s increase and ongoing falls, which is violation of resident rights, is considered neglect of care and constitutes abuse.

Prior to August 6, 2024 Alleged Victim (AV) was independent with ambulation. According to staff, AV placed themself on the floor the night of approximately August 5, 2024, and stayed on the floor until approximately 8:44 am the next morning August 6, 2024. AV was found to have an altered mental status, multiple abrasions, and skin tears over h/h body. AV was sent to the emergency room on August 6, 2024, for evaluation and admitted. AV was diagnosed as having muscle tissue breakdown from being down on the ground for an extended period of time. The injuries appeared to be likely due to AV falling out of bed and being left on the floor. Facility Documentation was drafted six days after AV was out of the facility, reported as a late entry but stated the start date of AV placing themselves on the floor was prior to AV being found on the floor. There is no indication that AV was being assisted off of the floor or being checked on throughout the night of August 5, 2024, given the severity of AV's injuries. The facility failed to provide a safe environment for AV, which resulted in multiple abrasions and muscle tissue breakdown on August 5, 2024, when AV was left on the floor, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) has history of wandering into other residents’ rooms, and taking other residents’ belongings. Witness 1 (W1) does not like when other people come into W1’s room and will get frustrated when this happens. W1 has reported that AV had been in W1's room before. Interventions in place for AV wandering is to remind AV to not enter other residents’ rooms without permission. AV and W1 have a history of resident-to-resident altercations and had previously been in one altercation with each other. On or about August 3, 2024, staff heard yelling from the hallway. AV entered W1's room without permission, W1 pushed AV out of W1’s room. W1 threw ceramic plates/dishes at AV resulting in a bruise on AV right eyebrow. The facility failed to provide appropriate supervision and effective interventions to address AV's known wandering behaviors leading to a resident-to-resident altercation, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) is independent with ambulation and transfers though does display an unsteady gait. AV does not have a history or exit-seeking or elopement behaviors. On June 8, 2024, AV was able to push open the window and kick out the screen to elope from the facility bruising h/h arm in the process. AV was found sitting on a bench at the business next door by a staff member. The silicone on the window that was supposed to prevent the window from opening had failed and allowed AV to be able to elope out of the window. The facility failed to provide a safe environment, and provide AV with adequate supervision, resulting in AV eloping from the facility on June 8, 2024, and sustaining a bruise to h/h forearm , which is a violation of resident’s rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) has poor gait, weakness, poor balance, and decreased mobility. AV is a one-person assist with transfers and has a 4WW but will often not use it and walk independently. AV has history of multiple falls with the last occurring on April 9, 2024 when AV fell and hit AV’s head. On or about April 13, 2024 AV had an injury fall that resulted in AV falling and hitting AV’s head, resulting in a scratch to the right side of AV’s face. Interventions put into place prior to the fall on April 13, 2024 include: If staff observe AV crouching down as if AV is going to sit ensure AV has a stationary chair behind AV; When AV is stationary in AV’s wheelchair, staff to ensure AV’s footrests are moved out of the way to allow AV’s feet to rest on the floor in case AV wants to stand up independently; If AV is observed ambulating without AV’s walker staff are to have AV sit down in a safe spot in the community and staff are to grab AV’s 4WW; When staff observe AV getting up, they are to ensure that AV’s walker brakes are locked and then unlocked when AV is ready to start walking; and During the night staff are to leave AV’s bathroom door open with the light on to allow more visualization for AV to see. On April 13, 2024 AV fell because AV got up from AV’s wheelchair and tripped over the left leg rest of the wheelchair and fell hitting AV’s head on one of the chairs. The intervention to move AV’s footrests out of the way to allow AV’s feet to rest on the floor in case AV wants to stand independently was already in place at the time of the fall on April 13, 2024. AV’s service plan was not being followed on April 13, 2024, which led to AV’s fall and AV hitting AV’s head on a chair. 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 a high fall risk. AV has increased confusion at times and does not call for staff assistance or wait for staff to arrive to help h/h. On or about March 30, 2024, AV was found on the floor by AV’s bed. AV attempted to transfer out of the bed independently. There were no additional interventions in place after the second fall by AV on March 29, 2024. Facility was aware of the recent fall history including falls on March 22, 2024, March 28, 2024, and twice on March 29, 2024, and did not implement additional interventions to prevent AV from falling on 03/30/2024. The facility failed to appropriately care plan and implement reasonable interventions to address AV’s ongoing falls, which is violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) Service Plan- Dated on or about March 20, 2024, Mobility/Transferring AV is independent with all transfers and ambulation, uses a four-wheeled walker for ambulation and is independent with use of four wheeled walker. If staff see AV without walker, staff are to remind h/h to use the walker. Fall Prevention: AV has a history of falls with balance problems and physical weakness. AV uses a four-wheeled walker for ambulation. AV has had three or more falls in the past 90 days. Staff are to ensure AVs room is clear of clutter and spills and remind AV to use four-wheeled walker when ambulating outside of the apartment. Staff are to provide safety checks for AV during the night at least two times per shift and if AV is awake during the night staff are to ask h/h if they need to use the bathroom and assist AV with ambulation to the bathroom. If staff observe AV picking up walker and walking with it off the ground, kindly remind AV to put it back on the ground fully. AV had documented falls occurring on approximately March 06, 2024, March 08, 2024, and March 18, 2024. AV's fall on or about March 18, 20244 occurred because of AV picking up h/h walker off the ground to walk with it and lost balance hitting/h head, requiring transportation to the hospital for further evaluation . Although the Facility could not have foreseen or predicted AV falling in the hallway of the facility as AV was independent in ambulation with four-wheeled walker and transfers at the time of the fall, AV has an extensive history of falls with falls on March 06, 2024, March 08, 2024, and March 18, 2024. AV's recent update to the service plan, has no change in condition, transfers, or ambulation. No additional interventions were implemented after March 06, 2024. The facility failed to provide person centered interventions and a safe environment, which resulted in AV falling, hitting head, and being sent to ER.

Alleged Victim (AV) Service Plan indicates AV is independent with ambulation and the use of a 4-wheeled walker, but relies on staff to remind h/h to use 4-wheeled walker Service Plan. AV has a has exit seeking behaviors and has a history of elopement from Facility. On or about March 03, 2024, at approximately 5:40 p.m. AV went into another resident's room, took the window out of the tracks, kicked the screen out, and eloped from facility. There is a history of three elopements from Facility on or about February 12, 2024, February 15, 2024, and 03/03/2024. There are no new interventions implemented after elopements documented, and one-to one staff intervention was not implemented until March 03, 2024. One-to-one intervention was not implemented in a timely fashion and with only limited times, leading to AV elopement on March 3, 2024. The facility failed to implement appropriate interventions after prior elopements, and failed to have a safe environment placing AV at risk of serious harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) service plan indicates AV requires supervision outside the facility. On or about February 3, 2024 AV was documented to be exit seeking and attempting to leave through the exits. On or about February 4, 2024 AV was exit seeking and successfully eloped from the facility on evening shift. On or about February 7, 2024 AV was documented to be exit seeking. On or about February 12, 2024, AV broke a window in the activity room in an attempt to leave the facility; AV sustained a cut to h/h elbow from broken glass. The intervention implemented after the elopement attempt on February 12 2024 indicate when AV is escalating, as evidenced by continuing to exit seek, stating, “I want to get out of here.”, shouting, or a loud voice, staff are to continue with a calm demeanor and ask AV to have a discussion in a private area if safe to do so. these interventions focus on concerns of AV's aggression and do not provide increased interventions related to elopements. On or about February 15, 2024, at approximately 1223 hours, AV opened the window next to the window s/he broke on February 12, 2024 and kicked out the screen; AV climbed out the window, leaving h/h walker in the facility. At approximately 1234 hours staff observed AV outside the building and ran to AV, returning AV to the facility without injury. AV was documented to continue h/h exit seeking behaviors following the elopement attempt on February 12, 2024. The facility failed to implement appropriate elopement prevention interventions following AV's successful elopement on February 4, 2024 and elopement attempt with injury on February 12, 2024, placing AV at serious risk of harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) has a poor gait, decreased ROM, weakness, poor balance and decreased mobility. AV has a history of falls with a broken hip. AV is blind and has [progressive eye disease]. AV is only able to see shadows. AV utilizes a wheelchair and a walker for assistance with ambulation and transfers. AV can't remember to press the button [on the call light]. Staff report AV has never been able to use the call light themself to ask for help. On or about January 13, 2024, documentation indicates AV has been having issues with pendant, AV can’t feel the button to call staff when needing assistance. AV needs help going to the bathroom but can’t get ahold of staff due to not being able to see how to push pendant due to being blind. According to AV’s service plan, interventions in place at the time of the fall included ensuring that AV’s dresser is against the wall and farther from h/h bed so that AV is unable to get h/h foot stuck, staff to ensure all liquid is cleaned from AV’s apartment floor prior to standing or ambulating, and staff to ensure that AV has a clean brief in place prior to leaving the bathroom and make sure AV had the call light or pendent. On or about January 26, 2024, at approximately 0615 AV was found on the floor next to h/h closet sitting on h/h bottom scooting towards the bed/door area. AV had been confused the night prior and had refused assistance to go to bed. AV had been toileted at 0530 prior to the fall, it is believed that AV had tried to transfer themselves out of their wheelchair. Interventions put into place include staff to provide safety checks for AV upon rising, before and after meals and at bedtime, which were not much different than interventions put into place on or after January 17, 2024, fall that included Staff to assist AV to the bathroom at bedtime and no less than 2 times per night shift as well as AV request or as needed. On or about January 26, 2024, at approximately 0830 AV was found on the floor of h/h room next to h/h wheelchair. At the time of the falls on January 26, 2024, AV did not report pain and staff were unaware that AV had an injury as a result of the falls. On or about January 28, 2024, AV began reporting pain in h/h side. On or about January 31, 2024, AV was taken to urgent care where s/he was diagnosed with rib fractures. The facility failed to plan care around AV’s needs, implement reasonable effective interventions that are person-centered to mitigate AV’s ongoing falls with injury, resulting in two falls on January 26, 2024, one of which resulted in physical harm to AV when s/he experienced pain in h/h side and fractured ribs.

Alleged Victim (AV) has a poor gait, decreased ROM, weakness, poor balance and decreased mobility. AV has a history of falls with a broken hip. AV is blind and has [progressive eye disease]. AV is only able to see shadows. AV utilizes a wheelchair and a walker for assistance with ambulation and transfers. AV can't remember to press the button [on the call light]. Staff report AV has never been able to use the call light themself to ask for help. On or about January 13, 2024, documentation indicates AV has been having issues with pendant, AV can’t feel the button to call CP when needing assistance. AV needs help going to the bathroom but can’t get ahold of us due to not being able to see how to push pendant due to being blind. On or about January 20, 2024 at approximately 0200 AV was found sitting on the edge of h/h bed when s/he urinated on the floor and began slipping off the edge of the bed, landing on h/h bottom with h/h legs straight out. AV experienced redness and pain in h/h lower back when staff assessed AV, EMS was called to assess AV and assisted AV back into bed. Again on January 20, 2024 at approximately 0740 AV was found sitting on the floor on the right side of h/h bed, with h/h back against the bed and legs stretched out. There was urine on the floor under AV’s body, AV reported that s/he was attempting to get to the restroom at the time of the fall. The incident report indicates service plan was not being followed. AV did not have brief on . Prior shift did not put a brief on AV. The facility failed to follow the care plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) has a poor gait, decreased ROM, weakness, poor balance and decreased mobility. AV has a history of falls with a broken hip. AV is blind and has [progressive eye disease]. AV is only able to see shadows. AV utilizes a wheelchair and a walker for assistance with ambulation and transfers. AV can't remember to press the button [on the call light]. Staff report AV has never been able to use the call light themself to ask for help. On or about January 13, 2024, documentation indicates AV has been having issues with pendant, AV can’t feel the button to call CP when needing assistance. AV needs help going to the bathroom but can’t get ahold of us due to not being able to see how to push pendant due to being blind. On or about January 17,2024 AV was found on the floor between the end of h/h bed and the dresser. AV’s left foot was on one side of the dresser while h/h right foot was on the other side of the dresser and stuck underneath arch of the dresser at the bottom. AV reported that s/he fell trying to get to the restroom. AV had redness and pain to the top of h/h right foot and back. The interventions put into place to reduce AV’s risk of falls that witnesses were able to recall included completing frequent checks on AV, ensuring AV was in a common area, and toileting AV frequently. The facility failed to properly plan care, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about July 23, 2026, the facility failed to monitor each resident consistent with his/her evaluated needs and service plan which is a violation of Oregon Administrative Rules.

On or about May 26, 2026, the facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules.

On or about May 19, 2026, the facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules.

On or about May 18, 2026, the facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules.

On or about May 13, 2026, the facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules.

On or about May 8, 2026, the facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules.

On or about February 16, 2026, the facility failed to provide a safe medication administration system to ensure The Alleged Victim’s (AV) medications were administered as ordered. The failure is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during a site visit on 03/31/25, the facility’s failure to ensure the implementation of services was substantiated for 1 of 1 sampled resident (#1). Findings include, but are not limited to: Resident 1's service plan dated 03/06/25 indicated the following: Resident needs staff encouragement to shower twice weekly in the mornings on Sundays and Thursdays. Routine weekly housekeeping services. Staff to assist with brushing Resident 1’s hair daily. Housekeeping schedule indicated Resident 1 was to receive services on Mondays. Housekeeping checkoff list dated 08/22/24 through 03/25/25 indicated Resident 1 had not been receiving weekly housekeeping services. Resident 1's shower sheets from 01/10/25 through 03/30/35 indicated the following: There were seven occurrences within the timeframe during which no shower was documented as provided or refused. On 03/07/25, stated, "hair was severely matted, difficult to shampoo, and condition". On 03/09/25, stated, "to start de-matting hair tomorrow". On 03/10/25, stated, "hair detangled" An interview with Staff 1 (Executive Director) and Staff 4 (Resident Care Coordinator) indicated Resident 1 had a history of refusing services, including showers. Staff 1 indicated the facility had found a pattern that had been working for the last couple of weeks. Compliance Specialist had attempted to interview and observe Resident 1, however, s/he had been sleeping. The facility’s failure to ensure the implementation of services was substantiated.

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