Curry Manor

According to the documentation, the facility failed to properly care plan appropriate interventions for Witness 1 (W1) to prevent physical altercations with the Alleged Victim (AV). On or about December 23, 2024, the AV and W1 were involved in a physical altercation and were quickly separated. The facility failed to care plan appropriate interventions to prevent further incidents from occurring. On or about December 31, 2024, W1 and the AV were involved in another physical altercation where W1 punched the AV in the face causing pain and unreasonable discomfort. the facility failure to appropriately care plan interventions to prevent physical altercations between W1 and the AV is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about November 5, 2024, Alleged Victim (AV) was found unresponsive in bed during morning rounds and confirmed deceased by emergency responders. Based on facility documentation and interviews, AV was admitted to the facility on November 4, 2024, at approximately 2:30pm. No prescribed medications or physician orders had been received for AV at time of admissions. Alleged Perpetrator 2 (AP2) administered a non-narcotic pain medication to AV without a physician's order. The evidence of the investigation supports that the facility failed to ensure safe medication administration practices at the time of AV's admission. AV had a documented allergy to acetaminophen, and no physician orders had been received. Despite AP2's medication technician competency checklist for not having required signatures ensuring AP2 was competent to administrator medication, AP2 was allowed to work in a position administering medications. The facility failed to confirm AP2 was authorized to perform administration or ensure that critical medical information was accessible, placing AV at serious risk of harm. Although AP2 had not received training on how to respond when MAR information was unavailable, AP2 proceeded without confirming AV's orders or allergy status. AP2's actions is considered a serious 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/her employment duties. The facility's failure to provide adequate and professional oversight of its medication administration system for a newly admitted residents is a serious violation of AV's resident rights which resulted in serious neglect of care outcome because no medications or physician orders were available at time of admissions. The facility's failure is a serious violation of AV's resident rights, is considered neglect of care which constitutes abuse.

According to the service plan, the facility failed to follow the care plan for the Alleged Victim (AV) by ensuring the same gender caregiver aids with showers. On the September 10, 2024, service plan, the AV was to have the same gender care giver provide shower assistance as there were accusations made in the past about sexual comments being made towards the AV. On or about October 22, 2024, the AV reported to staff of an unknown staff member of a different gender who made sexual comments towards them while assisting the AV while they bathed. The failure to ensure the facility followed the care plan to have same gender staff provide bathing assistance to the AV caused emotional distress, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to properly care plan appropriate interventions for Witness 1 (W1) to prevent physical altercations with the Alleged Victim (AV). The AV and W1 have a history of physical and verbal altercations. W1 waits outside their room and waits for the AV to walk by so they can yell at them for walking too loudly. On or about October 04, 2024, the AV was walking by W1 room and W1 attacked them with a fly swatter, hitting them with it and causing a physical altercation. The facility’s failure to appropriately care plan interventions to prevent physical altercations between W1 and the AV is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately care plan related to the Alleged Victim's (AV) fall history. The failure resulted in AV experiencing an unwitnessed fall with a fracture after tripping in his/her room, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care needs. Witness 1 (W1) self- reported that Alleged Perpetrator 2 (AP2) had approached W1 and explained that AP2 gave the AV a short acting metabolic blood disorder medication when it was supposed to be a long acting/ slow-release metabolic blood disorder medication. W1 stated that AP2 told W1 that it was accidental and that AP2 became “distracted” while conversing with another staff member. W1 stated that due to the medication that was given, it could have put the AV’s levels in a dangerous position and the AV “could have” died as a result. AP2 failed to provide a safe medication administration system for AV, which is neglect of care and constitutes abuse. The facility failed to assure AV received a safe medication administration system, which is a violation of Oregon Administrative Rules.

Based on interview and record review, the facility’s failure to provide records to the Department upon request. The facility’s failure is a violation of Oregon Administrative Rules.

Based on interview and record review, the facility failed to fully implement and update the Acuity Based Staffing Tool (ABST). The facility’s failure is a violation of Oregon Administrative Rules.

Based on interview and record review, the facility failed to fully implement and update the Acuity Based Staffing Tool (ABST). The facility’s failure is a violation of Oregon Administrative Rules.

Based on interview and record review, the facility failed to fully implement and update the Acuity Based Staffing Tool (ABST). 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 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.

Based on interview and record review, the facility failed to fully implement and update the Acuity Based Staffing Tool (ABST). 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.

Based on interview and record review, the facility failed to fully implement and update the Acuity Based Staffing Tool (ABST). 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 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 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 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 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 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 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 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 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 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 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 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) is care planned to be assisted during toileting and is not to be left alone at any time during toileting. On or about September 8, 2024, AV was being assisted to the toilet by two staff members, including the Alleged Perpetrator #2 (AP2). According to investigation and video evidence, one staff left AV's room while AP2 was still in the room with AV. AP2 then left the room, leaving AV on the toilet by themselves. Another staff went into AV's room and found him/her on the floor in the bathroom by the sink. No staff were in the room with AV when found. AP2's failure to follow the care plan is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility's failure to ensure the care plan is being followed 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 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 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 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 facility failed to keep interiors free from unpleasant odors. Based on observation and interview, conducted during a site visit on 04/02/24, it was confirmed the facility failed to keep interiors free from unpleasant odors. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to ensure the implementation of services. Based on observation, interview, and record review, conducted during a site visit on 04/02/24, it was confirmed the facility failed to ensure the implementation of services for 1 of 1 sampled resident (#1). An investigation determined no licensing violation or abuse occurred.

The facility failed to ensure the implementation of services in accordance with the service plan. An investigation determined this 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 leading long call light wait times. An investigation determined this is a violation of Oregon Administrative Rules.

On March 20, 2024, Alleged Perpetrator 2 (AP2) and another staff member were assisting Alleged Victim (AV) with his/her Activities of Daily Living. While care was being administered to AV, AV became agitated and combative, resulting in AP2 pushing AV. AP2 became upset with AV's behavior and grabbed AV by the arms, shoved AV backwards, and then pushed AV into the wall with railing. AP2 was observed threatening AV as a result of AV's combative behavior. AP2 was observed by the facility camera to interlock his/her hands with AV, moving AV forcefully into wall with railing. AP2 could be seen screaming in AV's face. AP2 physically abused AV by grabbing AV and shoving him/her into a wall. AP2's action constitutes physical abuse. AP2 verbally/emotionally abused AV causing emotional harm. AP2's action constitutes verbal abuse. The facility failed to provide a safe environment for AV which is a violation of Oregon Administrative Rules.

On or about April 1, 2023, the Oregon Health Authority reported to the Department that Respondent failed to comply with weekly reporting requirements of vaccinated individuals, residents and staff, to the proper authority as required by law. This failure has been ongoing for a total of 30 days.

On or about April 11, 2023, Alleged Victim (AV) left the locked memory care facility without assistance and without injury. Based on facility documentation and interviews, AV has a history of exit seeking. The facility's failure to provide a safe environment for AV is a violation of Oregon Administrative Rules.

On or about first day of the month February 1, 2023, the Oregon Health Authority reported to the Department that Respondent failed to comply with weekly reporting requirements of vaccinated individuals, residents and staff, to the proper authority as required by law. This failure has been ongoing for a total of 30 days.

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 facility failed to have an Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their 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. Condition abated based on violation being resolved.

Based on observation, record review, and interview, it was confirmed that the facility failed to provide direct care staff sufficient enough in number to meet the needs of the residents. Findings include: During an unannounced site visit on 10/3/2022, the Compliance Specialist (CS) observed full laundry baskets in resident ' s rooms in memory care. CS observed 4 direct care staff in Memory Care and 2 in Assisted Living. A review of the facility's posted staffing plan indicated there are to be 7 care partners and 2 med-techs on day and evening shifts for Memory Care (MC) and Assisted Living (AL). A review of the staffing schedules dated September 2022 indicated 6 care partners and 2 med-techs scheduled, 1 less than they require. Review of service plans for residents#1-4 indicate assistance with activities of daily living. In separate interviews on 10/3/2022, Staff #1-6 (S1-6) S1-6 reported the following: The facility is staffing 6 care partners and 2 med-techs on day and evening shift for the MC and AL, a care partner called out for day shift in MC today, Day shift often runs short staffed, and residents needs get missed because there isn't enough time, laundry often gets missed and the care partner in AL often has to help in MC due to being short staffed.

The facility allegedly failed to update resident service plans at least quarterly, to correspond with the quarterly service plan updates, reviewed and make needed updates to residents ' care needs. An investigation determined this is a violation of Oregon Administrative Rules.

The facility alleged failed to maintain infection prevention and control protocols to provide a safe, sanitary, comfortable environment and, comply with masking requirements. An investigation determined this is a violation of Oregon Administrative Rules.

On or about September 1, 2022, the Oregon Health Authority reported to the Department that Respondent failed to comply with weekly reporting requirements of vaccinated individuals, residents and staff, to the proper authority as required by law. This failure has been ongoing from August 1, 2022 to August 31, 2022, for a total of 30 days.

The facility failed to exercise reasonable precautions against any condition that may threaten the health, safety, or welfare of residents. The facility's failure is a violation of Oregon Administrative Rules.

Alleged Perpetrator 2 (AP2) failed to administer basic care to Alleged Victim (AV) as ordered when he/she failed to toilet/change AV during the swing shift on or about May 12, 2022. Based on interviews and facility documentation, AP2 was informed by facility staff several times during the swing shift that AV, who was on hospice at time of incident, needed attention due to AV being soaked and caked in bodily fluids. AP2's failure to follow AV's care plan is neglect of care which constitutes abuse. The facility failed to provide a safe environment for AV which is a violation of Oregon Administrative Rules. Alleged Perpetrator 3 (AP3) allegedly neglected AV. An investigation determined no wrongdoing/abuse occurred.

Alleged Perpetrator 2 (AP2) financially exploited Alleged Victim (AV) by wrongfully taking medications belonging to AV which resulted in financial loss to AV. AP2's actions in considered financial exploitation which constitutes abuse. The facility failed to provide a safe environment for AV which is a violation of Oregon Administrative Rules.

The allegation that the facility failed to carry out medication orders as prescribed in accordance with OAR 411-054-0055(1)(f) per complaint that the facility did not administer resident's medication as ordered was verified.

On or about December 12, 2021, Alleged Perpetrator 2 (AP2) stuffed rubber or latex gloves into Alleged Victim's (AV) mouth while assisting AV with his/her Activities of Daily Living. AP2's actions is considered physical abuse. The facility failed to provide a safe environment for AV which is a violation of Oregon Administrative Rules.