Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 02/01/22.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified:

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

cc:cubic centimeter

CG:caregiver

cm:centimeter

F:Fahrenheit

HH:Home Health

HS or hs:hour of sleep

LPN:Licensed Practical Nurse

MA:Medication Aide

MAR:Medication Administration

Record

MCCMemory Care Community

mg:milligram

ml:milliliter

O2 sats:oxygen saturation in the

blood

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

RN:Registered Nurse

SP:service plan

TAR:Treatment Administration

Record

tid:three times a day

Based on observation, interview, and record review, conducted during a site visit on 06/05/24 and 06/07/24, and interviews on 06/06/24, it was confirmed the facility failed to implement a policy for the referral of residents who may be victims of acute sexual assault to the nearest trained sexual assault examiner within 86 hours. Resident 1 was not referred to the nearest trained sexual assault examiner within 86 hours following a possible sexual assault. Findings include, but are not limited to:

An incident report, dated 05/30/24, indicated Resident 1 was found in Resident 2's room undressed, and Resident 2 was in the process of undressing. It further indicated sexual abuse had been ruled out.

An email from Staff 2 (LPN) to the Department, dated 06/05/24, indicated "There were no signs of sexual abuse or sexual activity. I performed an assessment on the female resident and found no signs of abuse such as bruising, bleeding, or tearing."

During an interview on 06/05/24, Staff 2 (LPN) stated the following:

-S/he had performed an evaluation and ruled out sexual abuse;

-Staff 2 was not a trained sexual assault examiner;

-S/he was unaware of the requirement to refer residents who may be victims of sexual assault the nearest trained sexual assault examiner within 86 hours; and

-Resident 1 had not been referred to the nearest sexual assault examiner.

An incident report, dated 05/31/24, indicated the following:

-Resident 1 had been found in Resident 2's room;

-Resident 1 and Resident 2 were unclothed;

-Resident 2 was attempting to penetrate Resident 1 sexually;

-An assessment had been conducted on Resident 1 and there were "no signs of sexual abuse noted;" and

-Resident 1 had "small yellowing bruises on [his/her] right buttock that appeared to be days old."

During an interview on 06/05/24, Staff 2 stated s/he had conducted the assessment of Resident 1 on 05/31/24. S/he again stated s/he was not a trained sexual assault examiner.

An incident report, dated 06/02/24, indicated that at approximately 5:00 am Resident 1 had been found by a staff member on Resident 3's bed. Resident 1 was fully clothed, while Resident 3 was partially undressed and touching himself sexually over Resident 1. It further indicated "no signs of sexual abuse were noted."

In an interview Staff 2 again stated s/he had performed the assessment of Resident 1 on 06/02/24.

The facility's "Intimacy/Sexual Intimacy/Sexual Assault" policy indicated "Initial Interventions:  ... Call 911. Report suspicion of acute sexual assault and request transportation via ambulance to the E.R. for examination by a trained Sexual Assault Examiner (SAE)."

Resident 1 was observed to be transported by ambulance at approximately 10:22 pm on 06/05/24, approximately 89 hours after the incident on 06/02/24. Staff 2 stated Resident 1 was being transported for a sexual assault assessment.

During an interview on 06/06/24, Witness 1 (Hospice RN) stated "No, [Resident 1] can't consent to anything." S/he further stated Resident 1 was incapable of undressing his/herself.

Resident 1's service plan, dated 03/12/24, indicated s/he required "care staff to assist [Resident 1] with all undressing and dressing needs," "demonstrates inappropriate judgment, behavior, and ability to function in social settings," and "has severe memory loss."

The facility failed to refer Resident 1 to the nearest trained sexual assault examiner within 86 hours, resulting in possible degradation of evidence.

LCU requested a safety plan for Residents 1, 2, and 3 on 06/05/24 at approximately 8:30 pm.

Safety plans for Residents 1, 2, and 3, were provided by the facility and accepted by LCU at approximately 10:25 pm.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Regional Administrator), Staff 2, Staff 3 (Lead Med Tech), Staff 8 (Assisted Living Administrator), and Staff 9 (Vice President).

The Department placed a condition on the facility on 06/07/24.

Based on observation, interview, and record review, conducted during a site visit on 06/05/24 and 06/07/24, and interviews on 06/06/24, it was confirmed the facility failed to monitor a resident consistent with his or her evaluated needs and service plan. The facility was to provide one-on-one supervision for the safety of Resident 1 and failed to do so. Findings include, but are not limited to:

An incident report, dated 05/30/24, indicated Resident 1 was found in Resident 2's room undressed, and Resident 2 was in the process of undressing. It further indicated sexual abuse had been "ruled out."

During an interview on 06/05/24, Staff 2 (LPN) stated Resident 1 had moved rooms.

An incident report, dated 05/31/24, indicated the following:

-Resident 1 had been found in Resident 2's room;

-Resident 1 and Resident 2 were unclothed;

-Resident 2 was attempting to penetrate Resident 1 sexually;

-An assessment had been conducted on Resident 1 and there were "no signs of sexual abuse noted;" and

-Resident 1 had "small yellowing bruises on [his/her] right buttock that appeared to be days old."

During an interview on 06/05/24, Staff 2 (LPN) stated Resident 1 had been placed on 15-minute checks on 05/31/24 and placed under 1-on-1 supervision on 06/01/24. S/he further stated the facility RN had not been notified of the incidents on 05/30/24, 05/31/24, 06/02/24, or 06/04/24 as of approximately 6:35 pm on 06/05/24.

Fifteen-minute safety check logs for Resident 1 obtained on 06/05/24 were dated 06/02/24 through 06/05/24. There was no prior documented evidence 15-minute safety checks had been implemented for Resident 1.

A temporary service plan, dated 06/01/24, indicated Resident 1 "needs to be 1-on-1 with a care staff at all times to ensure [his/her] safety."

Staff training documentation for Resident 1's 1-on-1 requirement indicated staff signed the document on 06/05/24.

An incident report, dated 06/02/24, indicated that at approximately 5:00 am Resident 1 had been found by staff on Resident 3's bed. Resident 1 was fully clothed, while Resident 3 was partially undressed and touching his/herself sexually over Resident 1. It further indicated "no signs of sexual abuse were noted."

In an interview on 06/05/24, Staff 3 (Lead Med Tech) stated the employee that was supposed to be doing the 1-on-1 had been suspended. S/he further stated the 15-minute safety check log had been started on 06/02/24 and the 1-on-1 supervision had been in place before 06/02/24.

An incident report, dated 06/04/24, indicated Resident 1 had been found cornered by Resident 3, in Resident 3's shower, with his/her back up against the wall.

During an interview on 06/05/24, Staff 6 (Med Tech) stated the following:

-"Shortly after the first incident" 15 minute checks and 1-on-1 put in place;

-"There's been a few things I believe [since the first incident]  ... at least two additional [incidents];"

-"I was here last night, I saw that [the incident with Residents 1 and 3 in the shower] with my own eyes;" and

-"The person that was supposed to be 1-on-1 [with Resident 1] had laid [him/her] down and was doing hall room checks."

During an interview on 06/06/24, Witness 1 (Hospice RN) stated "No, [Resident 1] can't consent to anything." S/he further stated Resident 1 was incapable of undressing his/herself.

Resident 1's service plan, dated 03/12/24, indicated s/he required "care staff to assist [Resident 1] with all undressing and dressing needs," "demonstrates inappropriate judgment, behavior, and ability to function in social settings," and "has severe memory loss."

The facility's failure to monitor Resident 1 consistent with his/her evaluated needs, by providing one-on-one supervision, placed Resident 1 at repeated risk of further harm.

LCU requested a safety plan for Residents 1, 2, and 3 on 06/05/24 at approximately 8:30 pm.

Safety plans for Residents 1, 2, and 3, were provided by the facility and accepted by LCU at approximately 10:25 pm.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Regional Administrator), Staff 2, Staff 3, Staff 8 (Assisted Living Administrator), and Staff 9 (Vice President).

The Department placed a condition on the facility on 06/07/24.

Based on interview and record review, conducted during a site visit on 06/05/24 and 06/07/24, and interviews on 06/06/24, it was confirmed the facility failed to ensure the facility RN is notified of nursing needs for 1 of 1 sampled resident (# 1). Findings include, but are not limited to:

The facility's "Intimacy/Sexual Intimacy/Sexual Assault" policy indicated "When residents express a desire to have an intimate/sexual relationship, the facility administrator and the facility RN will be notified and immediate steps taken to determine interventions related to the residents' intimacy and sexual needs ... If abuse is alleged or suspected, follow the processes described in the Abuse Policies and / or the sexual assault process above."

During an interview on 06/05/24, Staff 2 (LPN) stated s/he had not notified the facility RN of multiple incidents of possible sexual assault occurring on 05/30/24, 05/31/24, and 06/02/24 involving Residents 1, 2, and 3 as of 06/05/24.

During an interview on 06/07/24, Staff 10 (RN) stated s/he had not been notified of multiple incidents involving Resident 1 until 06/07/24.

There was no documented evidence the facility RN had been notified of the incidents involving Resident 1 by 06/05/24.

LCU requested a safety plan for Resident 1 on 06/05/24 at approximately 8:30 pm.

A safety plan for Resident 1 was provided by the facility and accepted by LCU at approximately 10:25 pm.

It was determined the facility failed to ensure the facility RN was notified of nursing needs for a resident.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Regional Administrator), Staff 2 (LPN), Staff 3 (Lead Med Tech), Staff 8 (Assisted Living Administrator), and Staff 9 (Vice President).

The Department placed a condition on the facility on 06/07/24.

Based on observation, interview, and record review, conducted during a site visit on 06/05/24 and 06/07/24, and interviews on 06/06/24, it was confirmed the facility failed to provide effective administrative oversight over the operation of the Memory Care Community (MCC). Findings include, but are not limited to:

The licensee is responsible for the operation of the MCC and the provision of person-directed care that promotes each resident's dignity, independence, and comfort. This includes the supervision and overall conduct of the staff.

During the LCU investigation, conducted 06/05/24 through 06/07/24, administrative oversight to ensure adequate resident care and services was found to be ineffective based on the severity of citations in the following areas:

OAR 411-054-0025(7)(f) Facility Adminstration;

OAR 411-054-0040(2)(a) Change of Condition and Monitoring; and

OAR 411-054-0045(1)(d) Resident Health Services.

LCU requested a safety plan for Residents 1, 2, and 3 on 06/05/24 at approximately 8:30 pm.

Safety plans for Residents 1, 2, and 3, were provided by the facility and accepted by LCU at approximately 10:25 pm.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Regional Administrator), Staff 2 (LPN), Staff 3 (Lead Med Tech), Staff 8 (Assisted Living Administrator), and Staff 9 (Vice President).

The Department placed a condition on the facility on 06/07/24.