Sheridan Assisted Living

Alleged Victim (AV) has a PRN medication for nausea/vomiting that can be taken every 4-6 hours. On or about November 23, 2023, AV had to be transported to the hospital. He/she had been vomiting for hours and had vomited a black bile like substance. AV had hemorrhagic shock and an acute GI bleed. AV was not offered medication for his/her illness. AV’s illness and hospitalization were never documented, Alleged Perpetrator 2 (AP2) and Alleged Perpetrator 3 (AP3) where aware AV had been vomiting and had not documented it. AP2 and AP3 put AV in risk of harm by failing to report his/her illness and delaying medical care. The facility failed to provide service to AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care needs. On or about September 4, 2023, AV injured his/her ankle and AV had requested medical care from staff. AV had also asked for bandages for his injury, but AV was never given bandages. AV did not get any medical treatment for his/her injury when it occurred. The facility failed to provide service to AV when requested by AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. Witness 2 (W2) and Witness 3 (W3) have a history of resident-to-resident altercations with AV. On or about July 15, 2023, AV was entering the facility when W2 and W3 blocked AV form entering, they begun to yell at AV and swore at AV, they also threatened AV and called AV names causing AV to feel afraid. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. On or about June 15, 2023, AV was left in the bathroom unattended or checked for over an hour because the call light was not working, and AV did not have a working pendant. AV had to shout and pound on his/her wall until another resident used his/her call light to get staff’s attention to assist AV back to bed. The call lights were only randomly being checked by the facility to ensure they were operational, and there was no schedule to ensure call lights were checked on a regular basis. The facility failed to maintain functional call systems, which is a violation of resident rights is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. On or about December 7, 2022, AV was sent to the ER. AV did not return to the ER and was transfer to another facility. During the time when AV was out of the facility Witness 2 (W2) and facility administrator entered AV’s room, collected $430 cash that was scattered in AV’s room and placed the money in a labeled envelope. W2 did not witness the administrator actually placing the envelope in the facility safe. Alleged Perpetrator 2 (AP2) stated he/she found the envelope on his/her desk when he/she started working at the facility on or about February 2023. AP2 stated he/she placed the envelope in the safe at that time. When AV’s family approached the facility in March 2023, to retrieve AV’s money, W2 and Witness 4 (W4) opened the safe and discovered the envelope and AV’s cash were gone. The facility failed to protect AV from financial exploitation, which is a violation of resident rights, is neglect of care and constitutes abuse.

The Alleged Victim (AV) is care planned for assistance on an off the toilet, is a high fall risk, and has a history of falls. According to an investigation, on or about January 21, 2023, the AV was assisted to the toilet and left unattended. The AV used their call pendent and the bathroom call cord to request assistance off the toilet. There was no response to the call light or pendent for in excess of an hour. The AV attempted to transfer independently and fell, causing unreasonable discomfort and placing the AV at a risk of harm. The facility failed to provide appropriate services according to AV’s needs, which is a violation of resident rights, is neglect of care, and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. AV frequently smokes outdoors at the facility “smoke shack” which is an area set up as a 2-sided outdoor canopy with a roof. On or about January 17, 2023, a resident told staff (after midnight) they thought someone was at the smoke shack, but staff did not check on the identity of the person. Staff had seen AV at the smoke shack around 11:30PM, but there is no indication they went to check on AV and to make sure he came back inside. AV was noted to be outside in the smoke shack at around 5:30AM when staff went to give AV his/her morning medication. When AV was found, he/she was shivering and had a blank stare. AV’s sugars were 538, so 911 was called and AV was transported to the hospital where he/she was diagnosed with hypothermia. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Perpetrator (AV) relies on the facility for his/her care. Between May 29th, through October 18, 2022, it was documented that AV fell eight (8) times, including one time when AV felt unstable. As a result of the falls during that time, AV experienced pain and injuries, and was sent to the hospital at least once. AV’s care plan dated January 24, 2023, has no mention of AV falling and no interventions to prevent falls. The facility failed to care plan and mitigate AV’s risk of falls, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. On or about August 28, 2022, AV was found in the shower by staff after being left alone for about four (4) hours and was found to be “purple” in color. EMTs were called and reported initial O2 in the 60%-70% range. It was reported that AV suffered a seizure while being left alone in the shower and as a result was admitted to the ICU with acute respiratory failure. The facility failed to provide service to AV by leaving AV of about four (4) hours alone in the shower, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) has a history of having wounds on his/her buttocks. AV was left in souled depends overnight resulting in his/her bottom being super red. AV has also been found with dried feces on his/her body and his/her beds and their room has been found dirty with garbage and food stains. AV has refused housekeeping service and he/she has also refused staff assistance. AV’s service plan does not address AV’s refusal or provide interventions for staff if AV refuses care, putting AV in risk of harm. The facility failed to care plan around AV’s refusal, which is a violation of resident rights, is neglect of care and constitutes abuse.

On or about June 25 - 27, 2022, the Alleged Victim (AV) did not receive his/her prescribed medication as ordered. The facility was out of the medications and could not provide the medication as ordered. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement appropriate interventions to address AV's behaviors and reduce altercations. The failure resulted in AV and W1 having multiple altercations, causing unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to appropriately care plan and provide care for the Alleged Victim (AV). AV was found to have decubitus ulcers on h/h buttock that required medication. Staff were not monitoring these wounds and the condition worsened causing pain and unreasonable discomfort. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) receives his/her medication from the facility. On multiple occasions, the facility has no record of AV receiving his/her medication. AV's primary care physician changed, however, the facility didn't update their records, resulting in AV being sent to the wrong physician's office more than once. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide a safe medication administration system to ensure The Alleged Victim’s (AV) medications were available to administered as ordered. The failure resulted in unreasonable discomfort and putting the AV at risk of serious harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Perpetrator 2 (AP2) neglected Alleged Victim (AV) by failing to provide assistance with medication administration which resulted in emotional harm to AV. On or about March 10, 2022 and March 11, 2022, AP2 withheld AV's hallucination medication without signed doctor's order. AP2's actions is considered neglect of care which constitutes abuse. The facility failed to provide a safe medication administration system which caused AV unreasonable discomfort. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to appropriately care plan according to AV’s needs and comfort during transfers. The failure resulted in AV experiencing skin injury and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Based on observation, interview and record review, the facility failed to communicate to staff on each shift what actions or interventions were needed for short-term changes of condition following hospital visits. Smoking interventions were not communicated to staff upon a residents return from the hospital after suffering second and third degree burns due to smoking in the facility with oxygen on. Staff were unaware a resident had returned, and a critical medication was not administered as prescribed. The facility’s failure is a violation of Oregon Administrative Rules.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and maintained in good repair, kitchen staff followed infection control practices, and proper food handling procedures were followed in accordance with the Food Sanitation Rules. The facility’s failure is a violation of Oregon Administrative Rules.

Based on observation, interview, and record review, the facility failed to ensure medication and treatment orders were carried out as prescribed. The facility’s failure is a violation of Oregon Administrative Rules.

Based on observation, interview and record review, the facility failed to ensure medication and treatment orders were carried out as prescribed was substantiated for modified diet textures. This placed residents at risk of aspiration. The facility’s failure is a violation of Oregon Administrative Rules.

Based on observation, interview and record review, the licensee failed to be responsible for the operation of the facility and the quality of services rendered in the facility. The facility’s failure is a violation of Oregon Administrative Rules.

Based on observation, interview, and record review, the facility failed to take reasonable precautions to ensure the health, safety, and welfare of residents related to smoking in the building while using oxygen and catching fire and not positioning properly during meals resulting in choking. This constituted an immediate threat to resident’s health and safety. The facility’s failure is a violation of Oregon Administrative Rules.

Based on interview and record review, the facility failed to complete, update, review, and document ABST evaluations. The facility’s failure is a violation of Oregon Administrative Rules.

Based on observation, interview, the facility failed to ensure service plans were readily available to staff and provided clear direction regarding the delivery of services. The facility’s failure is a violation of Oregon Administrative Rules.

Based on interview and record view, the facility’s failure to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each specific needs contract resident. The facility’s failure is a violation of Oregon Administrative Rules.

Based on observation, interview, and record review, the facility failed to implement a smoking policy and procedure. The facility’s failure is a violation of Oregon Administrative Rules.

Based on interview and record review, the facility's failure to update the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly. The facility’s failure is a violation of Oregon Administrative Rules

Based on observation, interview, and record review, the facility failed to ensure the implementation of services. The facility’s failure is a violation of Oregon Administrative Rules.

Based on interview and record review, the facility's failure to update the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to develop, maintain, and implement an Acuity Based Staffing Tool. The facility’s failure is a violation of Oregon Administrative Rules

The facility failed to establish and maintain infection prevention and control protocols in accordance with OAR 411-054-0050(1); per complaint facility is out of wipes, which is a violation of Oregon Administrative Rules.

The facility failed to conduct and record fire drills every other month in accordance with OAR 411-054-0090(1)(a); per complaint the facility had not conducted a fire drill in greater than six months, which is a violation of Oregon Administrative Rules.

The facility failed to treat residents with dignity and respect in accordance with OAR 411-054-0027(1)(a) per complaint residents are served meals in their rooms on paper plates, which is a violation of Oregon Administrative Rules.

The licensee failed to be responsible for the facility and the quality of services rendered in accordance with OAR 411-054-0025; per complaint the residents records were removed from the facility, Medication Techs did not have documentation demonstrating competency, specific needs staffing contract was not followed, resident records were not preserved for the required three years, a resident was smoking in their room, and administration was aware of the situation, which is a violation of Oregon Administrative Rules.

The facility failed to develop and implement a smoking policy in accordance with OAR 411-054-0025(7)(e); per complainant, there are residents smoking methamphetamines in their rooms, which is a violation of Oregon Administrative Rules.

The facility failed to provide delegation and teaching documented by an RN in accordance with OAR 411-054-0045(1)(f)(B); per complainant, the nurse delegated staff to all residents by observing them administering insulin to one resident and the nurse walked staff through administration verbally, but did not actually see staff administer the medications, which 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 in accordance with OAR 411-054-0070(2)(a); per complainant, there are no documentation or competencies for newly hired staff, which is a violation or 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 sufficient staff to meet the scheduled and unscheduled needs of the residents. It was determined the lack of staff is leading to needs not being met or taking extended periods of time to be met. Facility is not currently staffing 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 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 is not currently staffing 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 facility failed to have sufficient staff to meet the scheduled and unscheduled needs of the residents. It was determined the lack of staff is leading to needs not being met or taking extended periods of time to be met. Facility is not currently staffing 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 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 is not currently staffing 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 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 is not currently staffing 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 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 is not currently staffing 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 carry out medication and treatment orders as prescribed in accordance with OAR 411-054-0055(1)(f); per complaint resident's medications are being given 2-3 hours late, which is a violation of Oregon Administrative Rules.

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 is not currently staffing 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 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 is not currently staffing 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 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 is not currently staffing 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 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 is not currently staffing 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 cooperate with complaint investigations and make records available to the department upon request in accordance with OAR 411-054-0105(1)(a) per complaint the facility did not respond to Department requests for ABST information nor allow the Department access to the facility’s video and audio systems, which is a violation of Oregon Administrative Rules.

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 is not currently staffing 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 provide a health system that ensures delegation and teaching must be provided and documented by a RN. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

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 provide and document delegation and teaching by a RN. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide direct care staff sufficient in numbers to meet the scheduled and unscheduled needs of each resident. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to provide pre-service Fire safety and emergency procedure training to employees. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to immediately notify the local Department office, or the local AAA, of any incident of abuse or suspected abuse. The facility’s failure is a violation of Oregon Administrative Rules.

The facility failed to fully implement and update an acuity-based staffing tool. The facility’s failure is a violation of Oregon Administrative Rules.

On or about 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 from January 1, 2023, to January 31, 2023, for a total of 30 days.

The facility failed to employ a full-time administrator scheduled to be on-site in the facility at least 40 hours per week. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to exercise reasonable precautions against any condition that may threaten the health, safety, or welfare of the resident, which 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, it was determined the facility failed to adopt an acuity-based staffing tool (ABST) tool to determine appropriate staffing levels for the facility. Findings include During onsite visit on 08/18/2022 Staff #1 (S1) stated they have adopted the ODHS ABST tool, however the facility has not updated all 51 residents into the tool yet. S1 stated they are working on this and currently have 30 residents' records updated and accurate. On 08/18/2022 Compliance Specialist (CS) reviewed ODHS ABST tool which showed 30 residents' acuity input into the tool.

The facility failed to keep all equipment in good repair. An investigation determined this is a violation of Oregon Administrative Rules.

The facility allegedly failed to provide service for the Alleged Victim. An investigation determined this is a violation of Oregon Administrative Rules.

Based on interview, observation and record review, it was confirmed the facility failed to provide enough staff to meet resident needs. Findings include: Compliance Specialist (CS) review of facility posted staffing plan, direct care staff schedules for 08/2022, and resident acuity reveal multiple discrepancies. CS observed two caregivers (CG) and one Medication Assistant (MA) to be on duty during site visit on 08/18/2022, which is less staff than the facility indicated was needed. During separate interviews with Staff #1 and Staff #2 (S1 and S2) and Residents #1-2 (R1-2) all stated that resident assistance and service plan needs are not being met. S2 stated it is difficult to get all residents' showers completed as well as toileting assistance.

Based on interview and record review, it was determined the facility failed to adopt an ABST tool to determine appropriate staffing levels for the facility. Findings include: During onsite visit on 08/18/2022 Staff #1 (S1) states they have adopted the ODHS ABST tool, however the facility has not updated all 51 residents into the tool yet. S1 states they are working on this and currently have 30 residents' records updated and accurate. On 08/18/2022 Compliance Specialist (CS) reviewed ODHS ABST tool which showed 30 residents acuity inputted into the tool.

Based on interview, observation and record review, it was confirmed the facility failed to provide assistance with bathing. Findings include: During onsite visit on 08/18/2022, Compliance Specialist (CS) reviewed Resident #1 (R1) and Resident #4 (R4) service plans and resident shower schedules for day and swing shift, which reveal multiple discrepancies. CS observed R4 to be ungroomed and odiferous. During separate interviews with Staff #2 and Staff #3 both stated that showers don't always get done due to the facility being short staffed.

The facility failed to develop and implement a policy on smoking, which is a violation of Oregon Administrative Rules.

The facility failed to have sufficient staff to meet the scheduled and unscheduled needs of the residents. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to keep all interior materials and surfaces clean. An investigation determined this is a violation of Oregon Administrative Rules.

Based on interview and record review, it was determined the facility failed to adopt an Acuity-Based Staffing Tool (ABST) tool to determine appropriate staffing levels for the facility. The ABST was unable to produce staff time required to building a staffing schedule. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

Alleged Victim (AV) relies on the facility to administer his/her medication. On or about December 22, 2021, Alleged Perpetrator 2 (AP2) decided to withhold AV’s narcotic pain medication because AV was intoxicated. As a result, AV experienced severe pain and was taken to the emergency room. Facility med techs are only allowed to withhold medications if there is a signed doctor’s order in place, which AV did not have. AP2 failed to provide a safe medication administration system, which is neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system for AV, which is a violation of Oregon Administrative Rules.