The findings of the on-site investigation, conducted 08/08/23, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities.

Based on interview and record review, conducted during a site visit on 08/08/23, it was confirmed the facility failed to immediately notify the local APD office, or the local AAA, of any incident of abuse or suspected abuse for 1 of 1 sampled resident (#8). Findings include, but are not limited to:

A review of Resident 8's progress notes revealed on 04/03/23, s/he was on alert for a resident-to-resident altercation resulting in a "possible head injury" from another resident headbutting him/her. There was no other documentation provided regarding the incident or evidence of an internal investigation.

A review of an email sent to the Licensing Complaint Unit on 07/05/23 by APS confirmed the incident had not been reported.  

In an interview on 08/08/23 Staff 1 (Business Office Manager) stated anytime a resident puts hands on another resident, there should have been an incident report filled out and an internal investigation done. Staff 3 (Resident Care Coordinator) stated it had been reported to the ED.

The above information was shared with Staff 1 (Business Office Manager) on 08/08/23. S/he acknowledged the findings.

It was determined the facility failed to immediately notify the local APD office, or the local AAA, of any incident of abuse or suspected abuse.

Verbal pan of correction: Re-training for RCCs and Nurses on Abuse reporting will be done within 30 days. The ED and Business office manager will be responsible for auditing incidents to ensure that resident to resident altercations and any suspected abuse/neglect is being reported to APS.