Wiley Creek Senior Living

Alleged Victim (AV) is alert to person, place, time, and situation and is able to make h/h needs known. AV relies on facility staff to administer h/h medications as prescribed by h/h provider(s). AV is prescribed a psychological medication once daily. AV missed the doses of the medication on approximately December 31, 2023, January 1, 2024 and January 2, 2024. The medication is marked as being unavailable. AV experienced increased agitation and irritability as a result of missing the prescribed psychological medication. On approximately December 31, 2023, Witness 6 (W6) left a message with the pharmacy regarding AV's medication, however, at this point AV was already out of the psychological medication. AP1 failed to administer AV h/h psychological medication as prescribed, resulting in AV experiencing increased agitation and irritability The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) is alert to person, place, time, situation and is able to make h/h needs known. AV relies on facility staff to administer h/h medications as prescribed by h/h provider(s). In approximately October of 2023, AV had an order written by h/h PCP for doses of scheduled narcotic pain medication to be given at 8:00 am and 8:00 pm, and had an order written by h/h PCP for doses of PRN narcotic pain medication to be given as needed in addition to the two scheduled doses, not to exceed four tablets in one day. AV had been taking this narcotic pain medication for at least the past year prior to November 4, 2023. On or about November 4, 2023, Witness 2 (W2) asked Alleged Perpetrator 2 (AP2) for clarification regarding AV’s medication orders and the timing of the doses of narcotic pain medication as W2 was unsure if the doses could be given close together. A fax was sent to AV’s PCP requesting clarification and additional parameters for the narcotic pain medication orders. The fax was sent on a Friday, and the order clarifications from the PCP were not received by the facility until the following Monday. AP2 directed the med-techs that there had to be at least 4 hours between when the scheduled dose of narcotic pain medication and the PRN dose of narcotic pain medication were given. AP2 stated that this decision was put into place by h/h based on “normal spacing” as s/he knew them from h/h education. The facility was unable to produce a policy or guidelines that stated what the required parameters for narcotic prescriptions are. AV received no doses of PRN narcotic pain medication between November 4, 2023 and November 6, 2023. While awaiting the order clarification AV experienced trouble sleeping due to increased pain, experienced more shaking than normal and needed additional staff assistance while transferring. AP1 and AP2 failed to administer AV PRN pain medication as prescribed, resulting in pain and unreasonable discomfort The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about June 18, 2023, the Alleged Victim (AV) was transported to the hospital due to signs of unreasonable discomfort associated with shortness of breath. While hospitalized, AV was treated with an increased dosage of his/her prescribed diuretic medication to alleviate symptoms, as AV was found to have approximately 32 pounds of excess fluid, which was subsequently removed. AV returned to the facility on July 3, 2023, under hospice care. Based on facility documentation and interviews, AV had moved into the facility on June 10, 2023, approximately eight days prior to the hospitalization event. The Hospital After Visit Summary, specifically on page 5, directed that AV should continue taking the diuretic medication, 40 mg tablet daily. Following AV’s return, Alleged Perpetrator 3 (AP3) completed medication adjustments on AV’s Medication Administration Record (MAR); however, AV's prescribed diuretic medication was not entered. The facility utilizes a 3-Step Check stamp on documentation related to resident care to ensure that any changes to the resident’s care are accurately updated in the facility’s system. AP3’s signature appears as the third and final staff member confirming that the document had been reviewed and confirmed correct. AV continued to experience unreasonable discomfort after returning to the facility on July 3, 2023, due to AP3’s failure to ensure AV’s MAR accurately reflected all of AV's physician ordered medications as stated in AV’s Hospital After Visit Summary. On July 17, 2023, AV's showed signs of swelling. It was at this time that hospice and facility staff discovered the error on AV's MAR, after AV's July 3, 2023, hospital discharge. AV is diagnosed with a significant heart disease and not receiving his/her diuretic medication placed AV at risk of harm. AP3's actions caused AV to suffer from increased swelling and hospitalization which is considered neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system for AV, which resulted in AV not receiving his/her prescribed diuretic medication and subsequent hospitalization after the June 18, 2023, hospitalization. The facility's failure is a violation of resident rights, is considered neglect of care which constitutes abuse. As the new owner of this facility, you are responsible for correcting any deficiencies which pre-date your ownership. You must correct violations which occurred under previous ownership, as directed by the Department. You will not be responsible for paying civil penalties incurred by previous owner(s). However, if you fail to correct identified deficiencies within the specified time you may be subject to aggravated civil penalties.

On or about June 18, 2023, the Alleged Victim (AV) was transported to the hospital due to signs of unreasonable discomfort associated with shortness of breath. While hospitalized, AV was treated with an increased dosage of his/her prescribed diuretic medication to alleviate symptoms, as AV was found to have approximately 32 pounds of excess fluid, which was subsequently removed. AV returned to the facility on July 3, 2023, under hospice care. Based on facility documentation and interviews, AV had moved into the facility on June 10, 2023, approximately eight days prior to the hospitalization event. Based on facility documentation and interviews, Alleged Perpetrator 2 (AP2) failed to enter AV's diuretic medication into AV's MAR, which resulted in AV experiencing increased swelling and hospitalization shortly after AV admissions to the facility. AP2 was still in training when AP2 entered AV's medication into AV's MAR. AP2 was hired to work at the facility on April 18, 2023. The facility's new hire policy states new employees are considered in training while in their 90-day probationary period. There is sufficient evidence to indicate that AP2 failed to accurately transcribe AV's medication orders into their MAR, which resulted in AV not receiving his/her diuretic medication as ordered, which resulted in AV being hospitalized. However, as AP2 was still in their training/probationary period when the error occurred, the facility is ultimately responsible for AP2's actions. The facility failed to provide a safe medication administration system which caused AV unreasonable discomfort resulting in hospitalization. The facility's failure is a violation of resident rights is considered neglect of care which constitutes abuse. As the new owner of this facility, you are responsible for correcting any deficiencies which pre-date your ownership. You must correct violations which occurred under previous ownership, as directed by the Department. You will not be responsible for paying civil penalties incurred by previous owner(s). However, if you fail to correct identified deficiencies within the specified time you may be subject to aggravated civil penalties. Allegation Notes

The facility failed to appropriately care plan and implement reasonable interventions to address AV’s increasing and ongoing falls and provide appropriate services according to the Alleged Victim (AV) needs, relating h/h change of condition. AV experienced a fall on or about January 08, 2023, where AV experienced a head injury and is noted as being weak, dizzy and/or lightheaded on multiple occasions in January and February 2023. AV experienced and unwitnessed fall on or about February 17, 2023, resulted in a lumbar fracture, and unreasonable discomfort. AV had an additional unwitnessed fall after tripping over a stool in h/h room on February 21, 2023 and was transported to the emergency room. The facility failure is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) has a history of falls. On or about September 28, 2022, AV fell resulting in a fractured femur. AV returned to the facility on or about November 23, 2022, with discharge instructions for additional assistance with h/h care needs. AV required one person assistance for dressing, grooming, mobility, and toileting. On or about November 24, 2022, AV experience a fall in h/h room and was found on the floor and in a lot of pain. AV was sent to the hospital where it was determined that AV broke h/h left femur again, requiring surgery. The facility failed to update AVs service plan and did not provide staff with necessary information and instructions regarding AV current care needs, which led to AV having an additional fall. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to appropriately care plan and implement reasonable interventions to address Alleged Victim (AV) need for additional supervision when leaving the facility.

AV has a known history of unsafely smoking in his/her room. The facility failed to provide a safe environment and implement appropriate interventions to mitigate the risk of serious harm to AV when unsafely smoking in his/her room. The facility failure is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) is care planned as independent mobility with the use of h/h walker or wheelchair. AV has history of non-compliance with community rules. AV has history of balance issues, has a diagnosis, and takes medications that affect balance and contribute to falls. On or about April 02, 2022, AV had an unwitnessed fall out of h/h wheelchair that resulted in a fracture injury. The facility failed to properly plan care around AV’s needs and provided interventions appropriate to mitigate AV falls which is a violation of resident rights, is neglect of care and constitutes abuse.

From November 2025 through the end of December 2025, Alleged Victim (AV) experienced persistent delusions and hallucinations, resulting in unpredictable and unsafe behaviors, including episodes of physical aggression toward others. During this time, the facility failed to protect AV from ongoing verbal mistreatment by other residents. Although the incident did not rise to the level of verbal abuse, the facility violated AV’s resident rights which is a violation of Oregon Administrative Rules.

On or about December 10, 2025, the facility failed to have an Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population, their needs, and all required Activities of Daily Living (ADL). Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. Facility was not staffing to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

On or about September 24, 2025, Alleged Perpetrator 2 (AP2) failed to provide a safe environment for Alleged Victim (AV) when AP2 forcefully grabbed AV’s arm while assisting AV with transferring. AP continued to treat AV roughly despite AV stating that AP2’s actions were causing pain, resulting in unreasonable physical discomfort. AV is a resident of the facility and relies on facility staff to provide safe and adequate care. AP2 had received all required training necessary to work at facility in a caregiver position. After incident, AV was observed with visible skin discoloration on both the right and left arms and reported that AP2 caused pain during the transfer on the date of the incident. AP2’s actions constitute neglect of care, which meets the definition of abuse. The facility’s failure to ensure a safe environment for AV represents a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during a site visit on 07/23/25, the facility’s failure to ensure that delegation and teaching must be provided and documented by an RN was substantiated for 2 of 2 sampled residents (#'s 1 and 2). Findings include, but are not limited to: An interview with Staff 1 (Executive Director) indicated that Staff 2 (MT) had provided insulin without having been delegated on five separate occasions to two residents. The facility self-reported the incident, and Staff 2 was now delegated. Staff 2 had been training with Staff 3 (RSS) on 06/23/25 and 06/24/25, where Staff 3 incorrectly told Staff 2 that s/he was delegated. Staff 3 had received corrective action on 07/09/25. A review of Resident 1's records indicated the following: Service plan dated 06/04/25, indicated resident was type 2 diabetic and was insulin-dependent, staff were to administer insulin. Physicians’ orders dated 05/05/25 and 05/19/25 indicated the following medications for type 2 diabetes: Aspart pen injector 100 unit/ml, inject six units under the skin three times daily before meals, hold if blood sugars are less than 90; and Glargine-YFGN pen injector 100 units, inject 38 units under the skin daily at bedtime. Medication administration records (MARs) from 06/01/25 through 07/23/25 indicated Staff 2 administered Aspart at 5:00 pm and Glargine-YFGN at 8:00 pm on 06/23/25, 06/24/25, 07/02/25, 07/05/25, and 07/07/25. A review of Resident 2's records indicated the following: Service plan dated 06/13/25, indicated resident was type 2 diabetic and was insulin-dependent, staff were to administer insulin. Physicians’ orders dated 05/01/25 indicated the following medications for type 2 diabetes: Humalog pen injector 100 unit/ml, inject 15 units under the skin twice daily with breakfast and dinner; and Toujeo Solostar pen injector 300 unit/ml, inject 68 units under skin daily. MARs from 06/01/25 through 07/23/25 indicated Staff 2 administered Humalog at 5:00 pm and Toujeo at 8:00 pm on 06/23/25, 06/24/25, 07/02/25, 07/05/25, and 07/07/25. A review of Staff 2's training and delegation records indicated that s/he had been delegated to administer insulin for Resident 1 and Resident 2 on 07/08/25. The facility’s failure to ensure that delegation and teaching must be provided and documented by an RN was substantiated. An investigation determined that a licensing violation occurred.

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

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

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

On or about January 22, 2024, it was discovered that there was a discrepancy in the Alleged Victim's (AV) liquid pain medication. Alleged Perpetrator #2 (AP2) had administered AV's liquid pain medication with a cup rather than the appropriate syringe for the medication on January 19, 2024. AP2 was not trained properly on administering liquid medication by the facility. AV did not suffer any adverse reaction to receiving more medication than prescribed. The facility's failure to ensure proper training of staff is a violation of Oregon Administrative Rules.

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

On or about November 09, 2022, Alleged Perpetrator #2 (AP2) was assisting the Alleged Victim (AV) with changing h/h clothes. AV wallet, containing $60.00 cash went missing from his/her room. The items were taken by 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 protect AV from financial exploitation which is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) cloth pouch, containing $100.00 cash, went missing from his/her room. The money was 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 protect AV from financial exploitation which is a violation of Oregon Administrative Rules.

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

The facility allegedly failed to visually observe residents take medication. An investigation determined this is a violation of Oregon Administrative Rules.

The allegation that the facility failed to provide housekeeping services as required by 411-054-0030(1)(g). Per the complainant the facility staff is not cleaning the residents apartment was verified.

The allegation that the facility failed to provide three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables in accordance with OAR 411-054-0030(1)(a), per complaint the food is served cold was verified.

The allegation that the facility failed to provide a daily program of social and recreational activities in accordance with OAR 411-054-0030(1)(c) per complaint that there are not activities for residents was verified.