Avamere at St Helens

On June 6, 2024, Alleged Victim (AV) suffered an unwitnessed fall in his/her room around 2:30am resulting in a head injury. Based on facility documentation and interviews, at time of incident AV appeared disoriented, and AV's pain level was reported to be a 4 out of 10. AV was not initially taken to the hospital due to AV's family being informed that AV had fallen, resulting in a small bruise. After incident, AV continued to remain at the facility. Facility staff later observed that AV was slurring his/her words, showing a drop in his/her cognitive baseline, and AV would not eat or drink. AV was then sent to the hospital in the afternoon of June 6, 2024. Hospital medical staff stated that AV should have been sent to the hospital when the incident initially occurred due to AV possibly having a brain bleed that could cause a hemorrhagic stroke which can be potentially fatal. Based on facility documentation, AV has a known history of falls and experienced several falls in a short period of time. AV suffered eleven falls between April 10, 2024, and May 28, 2024. The facility failed to implement appropriate interventions and provide appropriate supervision related to AV's known history of falls. As a result, AV experienced several unwitnessed falls, causing unreasonable discomfort, and a hospitalization. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide appropriate oversight and monitoring when the Alleged Victim's (AV) condition changed which resulted in AV's condition worsening, causing AV being sent to the hospital for treatment. Based on facility documentation and interviews, the facility failed to provide the basic care of nutrition and fluids to AV which caused AV to suffer dramatic weight loss, confusion, and weakness. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) has documented acts of inappropriate behaviors after moving into the facility on February 27, 2024. On or about March 18, 2024, AV was observed throwing items out a window by Witness 1 (W1) and W1 told AV not to do that and then W1 put his/her hands on AV and grabbed AV by the hair for continuing to throw items out the window. W1's actions caused AV unreasonable discomfort. Based on facility documentation and interviews, AV exhibited behaviors prior to the incident on March 18, 2024, and behaviors continue for several days following the incident on March 18, 2024. The facility failed to properly plan care, implement behavioral interventions, and provide person centered interventions appropriate to mitigate AV's behaviors which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide appropriate supervision to the Alleged Victim (AV) according to his/her needs. The failure resulted in AV eloping the secured building, without staff knowledge, placing him/her at risk of harm. Based on facility documentation and interviews, AV eloped from the facility on or about February 2, 2024, by following another resident and their family member who were walking out the front entrance of the facility at time of incident. Facility staff from the adjoining facility (Assisted Living Facility) brought AV back into the facility (Residential Care Facility) when the facility staff found AV standing alone with bare feet. AV complained that their feet were cold. The facility's failure to provide a safe environment for AV is a violation of resident rights is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately monitor Witness 1 (W1) according to his/her known behavior and prior altercations. On or about January 30, 2024, W1 was observed in Alleged Victim's (AV) room in which AV later reported that W1 assaulted them by holding AV's upper appendage down and began kissing and slobbering on AV's head. The facility's failure caused unreasonable discomfort to the AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to follow safety interventions and appropriately monitor the Alleged Victim’s (AV) known behaviors and recent increase of altercations. The failure resulted in a physical altercation with Witness 1 (W1) on or about January 27, 2024, in which AV pushed W1 to the floor, causing unreasonable discomfort. Based on facility documentation and interviews, AV's behavior escalated and affected other resident(s) between January 11, 2024, and January 24, 2024. The facility's failure to provide a safe environment is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to ensure staff have access to Alleged Victim's (AV) behavioral support plan as well as staff were not trained on AV's behavioral care needs in order to appropriately monitor AV which resulted in an altercation with Witness 1 (W1) on or about January 27, 2024, causing unreasonable discomfort to the Alleged Victim, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately monitor Witness 1 (W1) according to his/her known behavior and prior altercations. On or about January 11, 2024, W1 and Alleged Victim (AV) had a physical altercation and causing unreasonable discomfort to the AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to appropriately monitor Alleged Victim (AV) according to his/her known behavior and prior altercations. On or about January 11, 2024, AV grabbed Witness 1's (W1) right arm and started punching W1, causing W1 unreasonable discomfort. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately monitor Witness 1 (W1) according to his/her known behavior and prior altercations. The facility's failure resulted in a physical altercation between W1 and Alleged Victim (AV) in which AV became upset when he/she found W1 wandering in his/her room. W1 responded to AV by kicking his/her legs, hitting AV, causing AV to lose his/her balance. The facility's failure to provide a safe environment caused unreasonable discomfort to the AV which is a violation of resident rights, is considered neglect of care and constitutes abuse.

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 staffed 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.

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 Alleged Victim (AV) displays physical behaviors during incontinent care. AV is care planned regarding this and staff are to give AV space, re approach or have another staff member try to provide cares. On or about December 16, 2024 at approximately 7:00 am, Alleged Perpetrator #2 (AP2) heard another staff member state that they needed assistance with AV. AP2 assisted the other staff member to get AV upright to put on medicated cream and pull their pants up. AV was being aggressive and began to squeeze the caregivers hands when AP2 became upset and yelled at AV, antagonizing him/her. AP2 was yelling at AV to "hit them" multiple times, causing AV further agitation. AV hit another staff member due to heightened agitation. AP2's actions are a violation of resident rights, are considered neglect of care and constitute verbal abuse. The facility's failure to protect AV from verbal abuse is a violation of Oregon Administrative Rules.

Alleged Victim (AV) has a condition requiring facility care and assistance. On or about August 20, 2024, on duty staff at the facility witnessed Alleged Perpetrator 2 (AP2) berating and being rude to Alleged Victim (AV) during NOC shift. AP2 was observed refusing to assist AV with his/her care needs and AP2 also failed to address AV's concerns. Based on facility documentation and interviews, at time of incident, AV reported to have hip pain and AV was emotional due to the pain. AP2 refused to give AV pain medication and spoke to AV in a rude, demeaning manner which caused AV emotional harm. AP2's actions is considered neglect of care which constitutes abuse. The facility is responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of his or her employment duties. The facility failed to provide a safe environment for AV which is a violation of Oregon Administrative Rules.

On or about August 5, 2024, Alleged Victim (AV) was sitting in a community chair in the facility common area when Witness 1 (W1) became upset and tried to physically remove AV from the chair due to W1 believing the chair belongs to W1. W1 was not showing signs of aggression prior to this incident, and facility documentation stated incident between AV and W1 happened quickly. W1 is known to have possessive behaviors over this specific chair that AV was sitting in at time of incident, and W1 is known to take this specific chair into his/her room at night. Based on facility documentation and interviews, it was determined the facility failed to implement appropriate behavior interventions regarding W1's impulsive possessive behaviors towards the facility's community chair which is a violation of Oregon Administrative Rules.

The facility's failure to have a full-time administrator onsite at least 40-hours per week and the facility's failure to post the name of the designee in charge was confirmed on June 11, 2024, and June 12, 2024, by the Department's Licensing Compliant Unit (LCU). The facility's failure placed its' residents at risk of serious harm. LCU's investigative findings include, but are not limited to: On June 11, 2024, at 4:43pm and on June 12, 2024, at 9:04am, the LCU's Compliance Specialist entered the facility and did not observe a licensed administrator to be onsite. Facility staff were interviewed and made the following statements: At 4:45pm: - "there is no administrator for the memory care". - "The previous administrator stepped down two weeks ago". - "If he/she doesn't know who the manager on duty is, he/she will go to the med tech". At 5:00pm: - "Staff is available via phone and not scheduled to be onsite this week". At 5:30pm: - "The Administrator is (Staff 3)". - "There was no information provided on who was to fill-in when former MCC Administrator stepped down". At 5:45pm: - "Since the former MCC Administrator stepped down, he/she can't say there's been a licensed administrator onsite for 40 hours". On June 11, 2024, the Regional Director of Operations was unable to provide a clear plan as to what steps/actions were taken to inform facility staff who was in charge for Facility Operational Oversight when the former MCC Administrator stepped down. On June 11, 2024, there were no waivers or exceptions granted or provided that allowed the facility to operate without an administrator. On June 11, 2024, at approximately 4:45pm, it was observed that the facility's required Designated Person in Charge signage stated "Health Care Coordinator" but lacked the name of the staff member in charge. By 7:35pm, the signage was updated with a name. However, on June 12, 2024, at 9:16am, it was observed there was no administrator onsite and the facility's required Designated Person in Charge signage was blank. In separate interviews on June 12, 2024, staff identified the nurses and RCC's as being the person in charge, that the RCC was in charge since the former MCC Administrator stepped down, and there was no communication to care staff who was filling in as interim Administrator. In an interview on June 12, 2024, at 10:38am, Witnesses (visitors and/or community partners) were interviewed and stated that a manager had not been seen in the MCC during their visits. The Witnesses stated that if they had concerns, they would go to the front desk for help but did not know who was in charge. The facility's failure to provide administrative oversight is a violation of Oregon Administrative Rules and placed residents at risk of serious harm. The facility's failure necessitated ODHS to issue license condition, RCFCD24-00603, on facility effective June 14, 2024, at 5pm.

The facility failed to ensure it's Acuity-Based Staffing Tool (ABST) was updated to accurately reflect residents' care needs and the facility failed to ensure it was staffing at appropriate staffing levels to meet the residents' scheduled and unscheduled care needs. The facility's failure to provide a safe environment is a violation of Oregon Administrative Rules and placed residents at risk of serious harm. The facility's failure necessitated ODHS to issue license condition, RCFCD24-00603, on facility effective June 14, 2024, at 5pm.

On or about, June 12, 2024, the Licensing Compliant Unit (LCU) confirmed that facility failed to individually identify resident's rooms to assist residents in recognizing their room. The LCU Compliance Specialist observed Resident 2's apartment lacked any identifiable information that would assist Resident 2 with recognizing his/her apartment. The facility's failure 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. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to ensure each residential care and assisted living facility must be licensed, maintained, and operated as a separate and distinct facility. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to have a training program that includes methods to determine competency of direct care staff through evaluation, observation, or written testing. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to comply with masking requirements in which facility staff were observed not wearing masks or they were not wearing masks correctly. The facility's failure is a violation of Oregon Administrative Rules.

The facility failed to employ a full-time administrator, scheduled to be on-site in the facility at least 40 hours per week with an administrator's license. The facility's failure is a violation of Oregon Administrator Rules.