Avamere Living at Newberg

The facility failed to implement new and progressive fall interventions and failed to provide appropriate supervision related to the Alleged Victim’s (AV) known history of falls. On May 24, 2025, AV suffered an unwitnessed fall which resulted in a fracture to his/her small toe. During the month of May 2025, AV suffered 4 falls prior to fall on May 24, 2025. The facility's failure to properly care plan for AV's fall risk resulted in AV experiencing several falls, causing AV unreasonable discomfort, which is a moderate violation of resident rights, is considered neglect of care and constitutes abuse.

During a shift change on or about April 28, 2025, Alleged Victim (AV) requested assistance with his/her Activities of Daily Living (ADLs). Alleged Perpetrator 2 (AP2), an employee of the facility, responded to AV's request for assistance. Shortly after AP2 began to assist AV with toileting, AP2 stated to AV that he/she needed to check on another resident. AP2 had partially taken AV's clothes off when he/she left AV unattended during toileting. Based on facility documentation and interviews, no other resident had pressed their call pendant during the time that AP2 was with AV. AV is a fall risk and requires assistance with all care relating to toileting, bathing, and dressing. The investigation concluded that AP2 abandoned AV by leaving AV in the restroom while in the middle of providing care to AV, resulting in AV being left alone for approximately 10 to 15 minutes, placing AV in a situation in which AV was exposed to a potential for serious risk of harm due to AV's known fall risk. AP2's actions is considered abandonment of care which is considered abuse. The facility is responsible for the supervision, training, and overall conduct of AP2 when AP2 is acting within the scope of his or her employment duties. Based on facility documentation and interviews, AP2 received a performance improvement notification on February 20, 2025, due to AP2 not providing care to another resident of the facility when this resident requested assistance. AP2 did not receive any additional training or guidance after receiving his/her first Non-Compliance Notice nor did AP2 receive training after the 2 Performance Improvement Notifications. The facility failed to provide adequate oversight and training to AP2, resulting in AP2 abandoning AV in the restroom when he/she was in the middle of providing care to AV which caused AV emotional harm, unreasonable discomfort, and placed AV at risk for a serious fall with injury. The facility's failure is a moderate violation of resident rights, is considered neglect of care which constitutes abuse.

On or about April 18, 2025, at approximately 11:15 PM, Alleged Victim (AV) fell in his/her room and was not found until 7:45 AM the following day. AV is care planned to have one safety check each shift due to AV's risk for falls. AV was able to keep track of the time as he/she has a clock that sits near his/her television. Based on facility documentation and interviews, AV was documented to have received his/her safety check on April 19, 2025, at 2:12AM by Alleged Perpetrator 2 (AP2). Facility documentation shows AP2 did not complete AV's safety check as documented due to AP2 being on his/her meal break at time of incident and was not in the facility. AP2 failed to follow AV's care plan for scheduled safety checks, resulting in AV laying on the floor in his/her room after a fall from 11:15 PM to 7:15 AM causing AV to have pain on the right side of his/her body. AP2's actions is considered neglect of care which constitutes abuse. The facility failed to provide adequate oversight of AP2, resulting in AV laying on the floor of h/h room from 11:15 PM to 7:45 AM causing AV to have pain on the right side of h/h body. The facility's failure to provide a safe environment is a moderate violation of resident rights, is considered neglect of care which constitutes abuse.

The facility failed to provide a safe medication administration system to ensure The Alleged Victim’s (AV) medications were administered as ordered. Based on facility documentation and interviews, AV went without blood pressure medication for two months. On September 27, 2024, AV was sent to the emergency room due to elevated blood pressure and another health issue after going to a scheduled appointment. The facility's failure resulted in unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and provide appropriate supervision related to the Alleged Victim’s (AV) known history of falls. The failure resulted in AV experiencing several falls (3 injury falls and 13 non injury falls) between February 10, 2022 through April 21, 2022, causing unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and provide appropriate supervision related to the Alleged Victim’s (AV) known history of falls. The failure resulted in AV experiencing a fall on May 9, 2022 in which AV sustained an abrasion to his/her forehead. Based on facility documentation and interviews, the facility failed to implement new interventions after AV's last fall on April 21, 2022. The facility's failure caused AV unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and provide appropriate supervision related to the Alleged Victim’s (AV) known history of falls. The failure resulted in AV experiencing several falls with injury between March 8, 2021 and May 18, 2021, causing AV unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

AP1 neglected AV as defined in OAR 4110200002(1)(b)(A)(ii) by failing to ensure AP2 was properly trained and supervised while giving medications, resulting in AV being put in serious risk of harm.

The facility has an established triple check policy that calls for the medication technician who receives the order to update the medication administration record and verify it has been entered in correctly. A second verification is completed by a medication technician on the next shift. The third verification is completed by the facility nurse on there next shift. There is no time-frame outlined for the third check. On or about October 8, 2019, Alleged Victim's (AV's) blood thinning medication was lowered as a results of his/her lab work. Alleged Perpetrator 6 (AP6) was providing step-by-step training to a new medication technician on updating the medication administration record with the new order. The update failed due to the trainee's processing, and AP6 did not catch the error, resulting in the MAR not being updated with the new order. AP6 conducted the second part of the facility's established triple-check process. AP6 did not visually confirm that the MAR had been updated and so did not catch the error. As a result, AV was given a higher dose of blood thinner three time putting AV at risk for serious harm. The error wasn't caught until the third check was completed on October 11, 2019. AP4 and the facility failed to provide a safe medication administration system, which is a violation of resident rights, is neglect of care and constitutes abuse.

AP neglected AV as defined in OAR 4110200002 (1) (b) (A)(i) by failing to provide Basic Medical Care and Supervision by not ensuring AV received h/h Buprenorphine, resulting in AV not receiving h/h medication on 09/10 and 09/11.

AP1 neglected AV as defined in OAR 4110200002 (1) (b) (A)(ii) by failing to ensure a safe medication administration system was implemented creating a risk of serious harm to AV.

AP neglected AV as defined in OAR 4110200002 (1) (b)(A)(i) by failing to provide AV's scheduled medication, placing AV at risk of harm due to untreated UTI.

The facility failed to secure a refill of RVs pain medication, causing RV to suffer increased pain for over 24 hours.

The facility failed to protect RV from theft of money.

The facility failed to follow care plan for RV.

The facility failed to protect RV from theft.

The facility failed to provide a secure environment.

The facility failed to maintain an adequate medication system.

The facility failed to provide an adequate medication system for RV.

Facility failed to prevent aresidenttoresident contact between RV1 and RV2.

Facility failed toprevent a residenttoresident contactbetween RV1 and RV2.

Facility failed to prevent aresidenttoresident contactbetween RV1 and RV2.

Facility failed to prevent a residenttoresident contact between RV1 and RV2.

The facility failed to maintain an adequate medication system.

The facility failed to provide an adequate medication system.

The facility failed to protect RV from inappropriate verbal comments.

The facility failed to provide a safe environment.

The facility failed to maintain an adequate medication system.

Requesting cp for survey deficiencies.

The facility failed to provide a safe medication system.

The facility failed to provide a safe environment.

Based on observation and record review conducted during a site visit on 08/18/25 and 08/20/25, the facility's failure to implement a written policy that prohibits the falsification of records in accordance with OAR 411-054-0025 (8) (a) for 1 of 1 sampled Resident (# 1) was substantiated. Findings include, but are not limited to, the following: On 08/18/25, the facility provided to the Department an original incident report for Resident 1. The incident report consisted of two parts: The facility's system generated Incident Report 08/15/25; and a separate multipage investigation document that was not signed or dated. On 08/18/25, Staff 2 stated there was not enough room in the chart incident report form to include all the information, so a separate document had to be generated. On 08/19/25, the Department received from the facility an identical incident report and additional investigation document via email. The investigation document was signed by Staff 2 and dated 08/15/25. The facility's failure to implement a written policy that prohibits the falsification of records is violation of Oregon Administrative Rules.

On or about August 14, 2025, the Oregon Department of Human Services (ODHS) Adult Protective Services (APS) initiated Investigation #00420205 following a serious safety concern at a licensed care facility. The APS investigation triggered The ODHS Licensing Complaint Unit (LCU) to conduct a follow-up investigation, which led to the issuance of Condition ALFCD25-00400. The investigation determined the facility failed to provide a safe environment for residents by not ensuring that second-floor windows were equipped with operable safety mechanisms to prevent accidental falls which is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during a site visit on 08/18/25 and 08/20/25, the facility failed to evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed, and failed to provide written communication of a resident's change of condition, including any required interventions, to caregivers on each shift in accordance with OAR 411-054-0040 (1-2) was substantiated for 1 of 1 sampled resident. (# 1). Resident 1’s mental health and medication changes were not evaluated, and interventions were not communicated to caregivers on each shift. Resident 1 suffered a fall from a second story window resulting in serious injury. Findings include but are not limited to: Resident 1 moved into the facility on 03/2024 with a diagnosis of major depressive disorder. S/He was admitted to hospice on 06/13/25. Resident 1’s service plan, dated 06/17/25, indicated “Staff should be aware of actions that may indicate increased mental health struggles and/or the need for support such as self-isolation or showing a lack of interest such as: refusing to eat, refusing to take medications or see family.” And noted Resident 1 had a history of hallucinations and delusions and had demonstrated “anxious/paranoid or suspicious behavior.” Staff were instructed to “reassure [him/her] [s/he] was safe and give [him/her] time to vent and express [his/herself].” On 06/13/25, Staff 5 completed a form titled Significant Change of Condition Comprehensive Assessment. There was no documented evidence interventions were made as a result of the assessment or communicated to staff. There was no documented evidence of interventions for staff on each shift to take or monitor in the event Resident 1 was experiencing suicidal ideations or hallucinations. Progress notes for Resident 1, dated 07/17/25 through 08/13/25, indicated: - On 08/06/25, Resident 1 was suffering hallucinations, seeing children in his/her room; - On 08/10/25, Resident 1 was experiencing hallucinations, thinking s/he was a fictional character; - On 08/11/25, Resident was found on the floor of his/her apartment, confused, with unidentified pills in his/her hand, again experiencing hallucinations, that there was a man in his/her bathroom; - On 08/12/25, Resident 1 “appears agitated, restless, and [sic] hallucinations;” and - On 08/13/25, Resident 1 had hit a family member in the face with a metal water bottle, made comments about wanting “to be taken out of this world,” and staff had administered PRN Haloperidol and Olazepam. The 08/13/25 progress note also indicated on 08/11/25 Resident 1 had been combative with staff, hallucinating, and telling staff “everyone was trying to kill [him/her].” - The progress note entries on 08/06/25, 08/10/25, 08/11/25, and 08/12/25 were documented as “outside provider notes.” Resident 1’s physician orders, dated 07/17/25 through 08/12/25, indicated: - On 07/17/25, Resident one was prescribed Haloperidol 5mg scheduled once a day, one hour before bedtime, for nighttime hallucinations; - On 08/05/25, Haloperidol 2mg (hallucinations and agitation) every six hours PRN discontinued, Lorazepam 0.5mg (agitation and restlessness) every four hours as needed discontinued and Haloperidol 2mg every four hours PRN started, Lorazepam 1mg every four hours as needed started. - On 08/11/25, the following medications were discontinued: Lantus SoloStar 100 units/mL (insulin) once daily at bedtime, Risperidone 1mg (hallucinations) twice daily, Carvedilol 6.25mg (hypertension) two times daily, Duloxetine 20mg (depression) two capsules twice a day, Furosemide 40mg (edema) once daily, and Gabapentin 100mg (neuropathy) twice a day; - On 08/11/25 Resident 1 was prescribed Lorazepam 1 mg (sleep/hallucinations) once a day; - On 08/12/25, the following medications were discontinued: Lorazepam 1mg every four hrs PRN, Lorazepam 1mg once a day, Dilaudid 2mg (pain management) every 0.5 tablet every two hours as needed, Dilaudid 2mg three times a day; - On 08/12/25, the following medications were prescribed: Methadone Hydrochloride 0.25mL (pain management) every 12 hours as scheduled, Olanzapine 5mg 0.5 tablet. Notes indicated staff to use Haloperidol if Olanzapine was ineffective. - There was no documented evidence Resident 1’s ongoing hallucinations or multiple medication changes were monitored, previous interventions for hallucinations had been used and/or were effective, or new actions or interventions were developed or communicated to staff. An incident report, dated 08/15/25, indicated: - Resident 1 had been administered PRN medication for hallucinations at 02:38 pm with ineffective results; - Staff had noted the medications administered had been ineffective; - At 05:08 pm Resident 1 had fallen from a second story window; and - At the time s/he fell from the window s/he was hallucinating and stating someone was after her. On 08/13/25 at approximately 5:08 pm, Staff 1 heard someone yelling for help. S/He found Resident 1 beneath an open second story window. Resident 1 was sent to the hospital and diagnosed with “multiple fractures.” Resident 1 died at the hospital on 08/14/25. On 08/18/25 at 12:35 pm, Staff 5 stated "I did a Change of Condition on 06/13/25 when [s/he] went on Hospice. I reviewed the Change of Condition on 06/18/25 and determined monthly reviews of the Change of Condition were appropriate." There was no documented evidence the RN had reviewed the change of condition since 06/18/25. The facility’s failure to evaluate the resident, refer to the facility nurse, document the change, update the service plan as needed, and provide written communication of required actions or interventions for caregivers on each shift was substantiated. On 08/20/25 at 5:10 pm, the LCU team requested an immediate plan of correction. An acceptable plan of correction was received from the facility on 08/20/25 at 6:38 pm. The immediate risk was addressed; however, the facility will need to evaluate the overall system failures associated with the licensing violation. The facility failed to assess, monitor, and intervene when Resident 1 experienced a significant change of condition. The facility's failure is a serious violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

Based on interview and record review, conducted during site visits on 08/18/25 and 08/20/25, the facility's failure to accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan in the facility’s Acuity-Based Staffing Tool (ABST) was substantiated for 1 of 1 sampled resident (# 1). Findings include, but are not limited to: Resident 1's service plan, dated 06/17/25, indicated: Resident 1 does have off days where she is confused about where she is and what day it is; S/He required staff assistance with orientation and redirection within the community weekly, sometimes multiple times a week; Resident 1 will forget what floor she is on; and non-pharmacological behavioral interventions included spending time with family and sitting one-on-one with staff. Resident 1's ABST, last updated on 07/18/25, indicated zero minutes were allocated for ensuring non-drug interventions for behaviors and cueing or redirecting due to a cognitive impairment. Resident 1's ABST was not reflective of care needs outlined in his/her service plan. The facility's failure to accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan in the facility’s Acuity-Based Staffing Tool was substantiated. The facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

Based on interview and record review, conducted during site visits on 08/18/25 and 08/20/25, the facility’s failure to ensure service plans reflect the resident's needs as identified in the evaluation and provide clear direction to staff regarding the delivery of services was substantiated for 1 of 1 sampled resident (# 1). Findings include but are not limited to: Resident 1 was admitted to the facility 03/2024 with a diagnosis of major depressive disorder, recurrent and other specified depressive episodes. Resident 1's service plan, dated 06/17/25, in the section titled personality/behaviors, indicated Resident 1 “Has been identified as experiencing hallucinations or delusions. [Resident 1] will make comments about seeing people who are not that [sic], usually happens in the evening or at night.” On 08/20/25 Staff 2 stated there were “no other interventions other than her oral pharmacological intervention meds.” There was no documented evidence staff had been provided instructions on what to do for Resident 1 when s/he was experiencing hallucinations. The facility’s failure to ensure service plans reflect the resident's needs as identified in the evaluation and provide clear direction to staff regarding the delivery of services is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during site visits on 08/18/25 and 08/20/25, the facility's failure to have a Registered Nurse assess all residents with a significant change of condition was substantiated for 1 of 1 sampled resident (# 1). Findings include but are not limited to: Resident 1's service plan, dated 06/17/25, in the section titled personality/behaviors, indicated Resident 1 “Has been identified as experiencing hallucinations or delusions. [Resident 1] will make comments about seeing people who are not that [sic], usually happens in the evening or at night.” Progress notes for Resident 1, dated 07/17/25 through 08/13/25, indicated: - On 08/06/25, Resident 1 was suffering hallucinations, seeing children in his/her room; - On 08/10/25, Resident 1 was experiencing hallucinations, thinking s/he was a fictional character; - On 08/11/25, Resident was found on the floor of his/her apartment, confused, with unidentified pills in his/her hand, again experiencing hallucinations, that there was a man in his/her bathroom; - On 08/12/25, Resident 1 “appears agitated, restless, and [sic] hallucinations;” and - On 08/13/25, Resident 1 had hit a family member in the face with a metal water bottle, made comments about wanting “to be taken out of this world,” and staff had administered PRN Haloperidol and Olazepam. The 08/13/25 progress note also indicated on 08/11/25 Resident 1 had been combative with staff, hallucinating, and telling staff “everyone was trying to kill [him/her].” - The progress note entries on 08/06/25, 08/10/25, 08/11/25, and 08/12/25 were documented as “outside provider notes.” On 08/20/25 Staff 2 stated there were “no other interventions other than her oral pharmacological intervention meds.” On 06/13/25, Staff 5 completed a form titled Significant Change of Condition Comprehensive Assessment. There was no documented evidence interventions were made as a result of the assessment or communicated to staff. There was no documented evidence of interventions for staff on each shift to take or monitor in the event Resident 1 was experiencing suicidal ideations or hallucinations. On 06/18/25, Staff 5 completed a form titled Significant Change of Condition update. There was no documented evidence of interventions for staff on each shift to take or monitor in the event Resident 1 was experiencing suicidal ideations or hallucinations. On 08/18/25 at 12:35 PM, Staff 5 stated the last review of Resident 1's change of condition was 06/18/25, and “I don’t know if there was any changes of condition in [Resident 1].” The facility's failure to have a Registered Nurse assess all residents with a significant change of condition is a serious violation of Oregon Administrative Rules.

Based on interview and record review, conducted during site visits on 08/18/25 and 08/20/25, the facility’s failure to carry out medication and treatment orders as prescribed in accordance with OAR 411-054-0055 (1) (f) was substantiated for 1 of 1 sampled resident(s). Findings include, but are not limited to: An unsigned physician order for Resident 1, faxed to the facility on 08/12/25, indicated to discontinue the following medications: - Lorazepam 1 mg tablet every four hours as needed (anxiety, shortness of breath); - Lorazepam 1 mg once daily (sleep, hallucinations); - Dilaudid 2 mg tab as needed every two hours (pain management); and - Dilaudid 2 mg tab three times daily for pain management. The discontinue order was not signed by a Physician or prescriber. Resident 1’s MAR, dated 08/01/25 through 08/13/25, indicated the facility stopped administering the above medications at 4:00 am on 08/12/25. An incident report, dated 08/09/25, indicated “Resident received 2 doses of 5mg haloperidol one at approx. 1854 signed out at1959 and one at approx. 2103 due to duplicate orders at separate times.” In an interview on 08/18/25, Staff 5, stated "On 08/09/25, Resident 1 received two, 5 milligram doses of haloperidol, s/he was sedated due to the extra dose.” The facility’s failure to carry out medication and treatment orders as prescribed is a violation of Oregon Administrative Rules.

Based on observation and interview, the facility’s failure to have operable windows designed to prevent accidental falls when sill heights are lower than 36 inches and above the first floor was substantiated for 1 of 1 sampled resident (# 1). Windows on the second floor of the facility were not secured and were able to open freely. Resident 1 suffered a fall from a second story window resulting in serious injury. This constituted an immediate jeopardy situation which put the health and safety of residents at risk. Findings include, but are not limited to: An incident report, dated 08/15/25, indicated on 08/13/25 at 05:08 pm Resident 1 had fallen from a second story window. On 08/13/25 at approximately 5:08 pm, Staff 1 heard someone yelling for help. S/He found Resident 1 beneath an open second story window. Resident 1 was sent to the hospital and diagnosed with “multiple fractures.” Resident 1 died at the hospital on 08/14/25. A safety plan obtained by the Department from the facility on 08/18/25 indicated the “All top floor windows have window locks not exceeding 4 inches for the opening. This was audited and verified by Executive Director and Maintenance director on 8/13/25.” On 08/18/25, at approximately 10:00 am, Staff 1 stated the facility had ensured all second story windows had locks on them. An observation, on 08/18/25 at approximately 12:00 pm, of a second story window in the same room Resident 1 had fallen from, revealed: - The windowsill was 25 inches in height; - The window did not have a lock; and - The window was able to be fully opened. When shown the window by the on-site investigator, Staff 1 acknowledged the window did not meet requirements for resident units. The facility’s failure to have operable windows designed to prevent accidental falls when sill heights are lower than 36 inches and above the first floor was substantiated. On 08/18/25, at 3:08 pm, the Licensing Complaint Unit requested an immediate plan of correction. The on-site investigator and Staff 1 audited every second-floor window and found four additional windows were not secured to prevent accidental falls. At approximately 5:46 pm, windows in the facility were observed to be properly secured. An acceptable written plan of correction was received from the facility on 08/19/25 at 10:23 am. The immediate risk was addressed; however, the facility will need to evaluate the overall system failures associated with the licensing violation. The facility's failure is a serious violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

Based on observation and interview, the facility’s failure to have operable windows designed to prevent accidental falls when sill heights are lower than 36 inches and above the first floor was substantiated for 1 of 1 sampled resident (# 1). Windows on the second floor of the facility were not secured and were able to open freely. Resident 1 suffered a fall from a second story window resulting in serious injury. This constituted an immediate jeopardy situation which put the health and safety of residents at risk. Findings include, but are not limited to: An incident report, dated 08/15/25, indicated on 08/13/25 at 05:08 pm Resident 1 had fallen from a second story window. On 08/13/25 at approximately 5:08 pm, Staff 1 heard someone yelling for help. S/He found Resident 1 beneath an open second story window. Resident 1 was sent to the hospital and diagnosed with “multiple fractures.” Resident 1 died at the hospital on 08/14/25. A safety plan obtained by the Department from the facility on 08/18/25 indicated the “All top floor windows have window locks not exceeding 4 inches for the opening. This was audited and verified by Executive Director and Maintenance director on 8/13/25.” On 08/18/25, at approximately 10:00 am, Staff 1 stated the facility had ensured all second story windows had locks on them. An observation, on 08/18/25 at approximately 12:00 pm, of a second story window in the same room Resident 1 had fallen from, revealed: - The windowsill was 25 inches in height; - The window did not have a lock; and - The window was able to be fully opened. When shown the window by the on-site investigator, Staff 1 acknowledged the window did not meet requirements for resident units. The facility’s failure to have operable windows designed to prevent accidental falls when sill heights are lower than 36 inches and above the first floor was substantiated. On 08/18/25, at 3:08 pm, the Licensing Complaint Unit requested an immediate plan of correction. The on-site investigator and Staff 1 audited every second-floor window and found four additional windows were not secured to prevent accidental falls. At approximately 5:46 pm, windows in the facility were observed to be properly secured. An acceptable written plan of correction was received from the facility on 08/19/25 at 10:23 am. The immediate risk was addressed; however, the facility will need to Amended Notice & Order Imposing License Condition evaluate the overall system failures associated with the licensing violation. The facility's failure is a serious violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

On or about August 12, 2025, Alleged Victim (AV) discovered $50.00 was missing from his/her wallet. Based on witness statements, investigator observations, and documentary evidence collected during Adult Protective Services (APS) Investigation #00422069, the APS Investigator determined that AV's money was taken by an unknown individual, and this person is responsible for theft of property which is considered financial exploitation and constitutes abuse. The facility failed to protect AV's property from theft which is a violation of Oregon Administrative Rules.

Based on interview and record review, conducted during a site visit on 03/18/25, the facility’s failure to carry out medication and treatment orders as prescribed was substantiated for 1 of 1 sampled resident (# 1). Findings include, but are not limited to: - A medication error report for Resident 1, dated 01/29/25, indicated the facility had been notified by Resident 1’s physician of an issue with his/her medication beginning on 01/22/25. - Staff 3 stated Resident 1’s Torsemide 20mg (diuretic) had been prescribed to be administered for 14 days beginning on 01/21/25, and the med tech had entered the order into the facility’s system to be administered every 14 days. - Resident 1’s MAR, dated 01/01/25 through 01/31/25, indicated his/her Torsemide 20mg had been entered multiple times into the MAR. S/he had received his/her Torsemide 20mg on 01/23/25 and did not receive it again until 01/28/25. - The facility was unable to produce physician orders for Resident 1’s Torsemide. Based on facility reports and interviews, it was determined the facility failed to carry out medication and treatment orders as prescribed which is a violation of Oregon Administrative Rules.

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) per complaint that call lights can take 40 minutes.

On or about April 16, 2024, Alleged Victim (AV) requested his/her pain medication. AV has a PRN for a narcotic pain medication. Instead of giving AV his/her requested pain medication, Alleged Perpetrator 2 (AP2) gave AV a different than routine dose of AV's anxiety medication and told AV it was his/her pain medication. Based on facility documentation and interviews, AV's routine dose of bedtime anxiety medication was not given. As a result of AP2's actions, AV experienced increased tremors, increased confusion, was very tired, and was worried about medication errors causing AV to feel scared about taking his/her medication. AP2's action is considered neglect of care which constitutes abuse and is considered neglect of care. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.

The facility failed to have 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) per complainant, caregivers are scheduled alone on shift to care for 80 residents, which is a violation of Oregon Administrative Rules.

The facility failed to provide fall prevention/interventions resulting in Alleged Victim (AV) sustaining multiple falls. Based on facility documentation and interviews, between June 29, 2023, and October 8, 2023, AV fell a total of 20 times transferring himself/herself in his/her room. Facility records noted the only fall prevention interventions made during this time period was to check on AV and remind him/her to use the call light for assistance with transfers. It was documented on February 22, 2022, that AV does not have the cognitive ability to understand the need to call for assistance. AV had no documented injuries or pain related to any falls during this time period. The facility's failure to properly care for AV's care needs is a violation of Oregon Administrative Rules.

On or about September 13, 2023, the facility failed to provide a safe medication administration system which resulted in Alleged Victim (AV) missing one dose of his/her insulin due to the insulin not being available. The facility's failure 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.

The allegation that the facility failed to exercise reasonable precautions against any condition that may threaten the health, safety, or welfare of the residents was investigated and findings were verified.

The allegation that the facility failed to coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers per complaint that resident is not able to go to dining room because they are out of portable oxygen was verified.

The allegation that the facility failed to exercise reasonable precautions against any condition that may threaten the health, safety, or welfare of the residents per complaint that staff are not wearing their masks appropriately or not at all was verified.

The allegation that the facility failed to ensure that reasonable precautions must be exercised against any condition that may threaten the health, safety, or welfare of residents was investigated and findings were verified.

The allegation that the facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident was investigated and findings were verified

The allegation that the facility failed to provide assistance with toileting and bowel and bladder management was investigated and findings were verified.

The allegation that the facility failed to provide qualified awake caregivers, sufficient in number, to meet the 24-hour scheduled and unscheduled needs of each resident pursuant to OAR 411-054-0070(1) was confirmed.

Alleged Victim (AV) had money go missing from his/her room. Alleged Perpetrator 2 (AP2) admitted to taking money from AV. AP2's actions are considered theft and constitutes abuse by means of financial exploitation. The facility failed to provide a safe environment which is a violation of Oregon Administrative Rules.

Alleged Victim (AV) is a known fall risk and requires supervision when in the common areas. On or about November 20, 2019, Alleged Perpetrator 2 (AP2) reportedly left the common area unattended. In AP2's absence AV ambulated without assistance and fell resulting in a fractured clavicle. After further investigation, due to the filing of a Petition for Reconsideration, the allegation that AP2 failed to provide a safe environment was unable to be determined. The facility failed to ensure a qualified caregiver was present which is a violation of Oregon Administrative Rules.

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The facility failed to comply with safe medication administration or treatment practices as required by OAR 4110540055(1)(f), per complaint that scheduled medications are being administered late.

The facility failed to preventinappropriate contact between RV1 and RV2.

The facility failed to provide a safe environment, resulting in RV1 being shoved.

The facility failed to maintain an adequate medication management system.

The facility failed to provide an adequate medication system.

The facility failed to maintain an adequate medication system.

The facility failed to protect RV from inappropriate verbal comments.

The facility failed to maintain an adequate medication system.

The facility failed to provide a safe medication system.

The facility failed to have operable windows designed to prevent accidental falls when sill heights are lower than 36 inches and above the first floor in accordance with OAR 411-054-0300(5)(c)(D).

Facility failed to provide a safe environment