Stoneybrook Assisted Living

Witness #1 (W1) was documented to display sexual behaviors towards opposite gender residents and staff. The Alleged Victim (AV) had kissed another resident, and it was documented that resident had touched AV on his/her behind. This interaction was considered consensual, because AV had initiated contact. The facility failed to ensure that AV had the capacity to consent. On or about September 30, 2023, W1 was sitting very close to AV with his/her hand between AV's upper thighs, AV has reported that W1 makes him/her uncomfortable. After this incident, minimal instruction was provided to staff regarding the incident. W1 continued to have contact with AV, pinning AV in their seat in the dining area, touching and hovering over AV, The facility failed to properly care plan for W1 and AV, causing AV unreasonable discomfort and a loss of personal dignity. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

• Alleged Victim (AV) relies on the facility for h/h care. On or about September 11, 2023, it was discovered AV was not provided incontinence care overnight, leaving AV and his/her bed soaking wet from urine. AV experienced itching, odor, and serious loss of personal dignity. The Alleged Perpetrator (AP2) had previously been formally reprimanded on two occasions for not providing care to residents, without improvement. AP2 and the facility failed to provide care is a violation of resident rights, is neglect of care and constitutes abuse.

The Alleged Victim (AV) is care planned for needing assistance for all activities of daily living. The facility failed to provide services according to AV’s needs, relating to incontinence needs, showers, and responding to call lights. According to an investigation, between March 2022, and September 2022, AV was left in soiled briefs for long periods of time, received eight out of twenty-two showers on his/her scheduled days, and had 109 documented wait times that exceeded 15 minutes, due to lack of staff. As a result, AV sustained multiple urinary tract infections, experiencing repeated unreasonable discomfort and a loss of personal dignity. 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 care plan related to the Alleged Victim’s (AV) change of condition. On or about November 3, 2022, AV was complaining of abdominal pain and was sent to the hospital, which revealed that AV had a large bruise on his/her right side and internal bleeding. The bruise was directly in line with the straps from the lift that was used to get AV out of bed. The facility indicated they were using a lift that was no longer appropriate for the resident in their weakened state. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility for care. AV’s care plan states facility staff will assist AV with dressing, catheter care, bringing resident to meals, and providing safety checks. The facility was short staffed on October 10, 2022, which resulted in AV being left in their room all day, still wearing their night clothes, not receiving breakfast or lunch, as well as AV not receiving catheter care. The facility failed to follow AV’s care plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Between October 4, 2022, and October 9, 2022, the Alleged Victim (AV) missed multiple doses of his/her behavioral medication, due to the facility running out. On approximately October 8, 2022, AV felt anxiety and that they were “dying” and was sent to the hospital. The facility failed to provide a safe medication administration system, which is violation of resident’s rights, is considered neglect of care and constitutes abuse.

The facility failed to provide appropriate services according to the Alleged Victim (AV)'s needs, relating to lack of care planning and instruction. According to an investigation, on or about October 1, 2022, AV experienced a fall that resulted in AV being sent to the hospital where he/she was diagnosed with multiple rib fractures, a left wrist sprain, and bruising to both the forehead and eye socket. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to provide appropriate services according to the Alleged Victim’s (AV) needs. Dating back to August 20, 2022, the Alleged Victim (AV) had multiple falls, some resulting in injury, and there are multiple instances that it appears the care plan was not being followed, and / or care changes were not relayed to staff timely. On or about September 13, 2022, AV was noted to have approximately four (4) pressure sores, on AV’s back and heels. The facility failed to provide appropriate services to respond to AV’s change of conditions, which caused unreasonable discomfort, is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about August 10, 2022, the facility ran out of the Alleged Victim’s (AV) metabolic medication. There was one (1) dose of medication that was missed, putting AV at risk for harm. The facility failed to provide a safe medication administration system, which is violation of resident’s rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility for his/her care and has a history of a skin condition that facility staff regularly monitor. On or about June 21, 2022, AV was found to have a bruise of unknown origin on his/her left leg and be in pain. Over approximately the next 5 days, multiple facility staff charted that AV’s skin condition and pain was worsening. On or about June 27, 2022, AV was sent to the hospital. The facilities failure to assess AV and provide timely medical treatment caused AV repeated unreasonable discomfort, is a violation or resident rights, is considered neglect of care and constitutes abuse.

On or about May 11, 2022, the facility ran out of the Alleged Victim’s (AV) metabolic medication. The AV missed approximately seven (7) doses of medication, which resulted in AV “not feeling well” and high metabolic marker readings and placing AV at risk for serious harm. The facility failed to provide a safe medication administration system, which is violation of resident’s rights, is considered neglect of care and constitutes abuse.

On or about May 6, 2022, the facility ran out of the Alleged Victim’s (AV) metabolic medication. There were approximately four (4) doses of medication that were missed, putting AV at risk for harm. The facility failed to provide a safe medication administration system, which is violation of resident’s rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) was not given multiple doses of their antibiotic medication between approximately January 1, 2022, and January 4, 2022, which led to AV exhibiting multiple symptoms, unnecessary discomfort, and to be transported to the hospital for treatment. AV was diagnosed with encephalopathy due to him/her not receiving ordered medications and remained hospitalized for approximately 7 days. The facility failed to provide a safe medication administration system to ensure Alleged Victim’s (AV) physician orders were followed. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately care plan regarding Alleged Victim’s (AV) known fall risk. On or about January 2, 2022, AV fell out of his/her power recliner after lifting it to a standing position, causing injury and resulting in unreasonable discomfort. The facility failed to implement interventions to mitigate AV’s fall risk, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility ran out of the Alleged Victim’s (AV) metabolic medication on or around December 11, 2021, which led to AV exhibiting multiple symptoms, causing him/her unnecessary discomfort, and to be transported to the hospital for treatment. The facility failed to provide a safe medication administration system to ensure Alleged Victim’s (AV) physician orders were followed and medications were reordered timely. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) has a history of falls. On or about November 2, 2021, AV sustained two falls in which one of these two falls caused a fractured ankle bone. An investigation determined that facility failed to provide AV care, services, and a safe environment by not mitigating AV's fall history with an adequate safety plan, interventions, and updating AV Service Plan to ensure AV's care needs are met. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions to mitigate the risk of Alleged Victim's (AV) change of condition. An investigation determined that AV showed signs of confusion, increased health needs, and an inability to complete Activities of Daily Living as previously capable and facility failed to provide appropriate health assessment, oversight and monitoring when AV's condition changed. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

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 the interior free from unpleasant odors. An investigation determined this 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 from March 1, 2023 to March 31, 2023, for a total of 30 days.

The facility failed to carry out medication and treatment orders as prescribed. An investigation determined a licensing violation or abuse occurred.

According to the documentation, the Alleged Perpetrator (AP2) did not follow the Alleged Victim’s (AV) care plan by transferring the AV by themselves. The failure caused the AV to experience anxiety for fear of falling causing unreasonable discomfort, which is a violation of resident rights and considered emotional abuse. The facility failed to ensure care plan was being followed which is a violation of Oregon Administrative Rules.

The facility failed to provide direct care staff sufficient in number to meet the scheduled and unscheduled needs of the residents. An investigation determined a licensing violation or abuse occurred.

The facility failed to fully implement and update an Acuity Based Staffing Tool. An investigation determined a licensing violation or abuse occurred.

The facility failed to provide assistance with bathing and washing hair. An investigation determined a licensing violation or abuse occurred.

Based on interview, observation, and record review, it was confirmed that the facility failed to fully implement and update an acuity-based staffing tool (ABST). Corrective Action being issued under CC-OR00036923.

Based on interview, observation, and record review, it was confirmed that the facility failed to fully implement and update an acuity-based staffing tool (ABST). Corrective Action being issued under CC-OR00036923.

The facility allegedly failed to provide safe environment for the Alleged Victim (AV) by failing to train the Alleged Perpetrator 2 (AP2). An investigation determined no abuse occurred by either the facility or AP2. The facility is substantiated for a licensing violation.

Compliance Specialist (CS) reviewed Resident #4 (R4) medication administration records (MARs) for June 2022 progress notes from 6/7/2022- 6/15/2022 and the facilities policy and procedures for medication errors. CS identified on 6/6/2022 R4 returned from the hospital and the medication orders were sent to the pharmacy. The medication was not imputed into the medication administration records (MARs) until the afternoon of 6/7/2022. This resulted in R4 to have missed two doses of the proscribed medication X.

The allegation that the facility failed to have sufficient staff to meet the scheduled and unscheduled needs of the residents in accordance with OAR 411-054-0070(1) per complaint that it takes up to 3 hours for staff to respond to call lights was verified.

The allegation that the facility failed to have sufficient staff to meet the scheduled and unscheduled needs of the residents in accordance with OAR 411-054-0070(1) per complaint that there is not enough staff to answer call lights during meal times and not enough staff to assist residents with changing oxygen tank was verified.

An unknown Alleged Perpetrator 2 (AP2) wrongfully took $140.00 from Alleged Victim (AV) which resulted in financial loss to AV. AP2's actions is considered Financial Exploitation which constitutes abuse. The facility failed to provide a safe environment for Alleged Victim (AV) which is a violation of Oregon Administrative Rules.