Cornell Estates Retirement And Assisted Living Residence

Alleged Victim (AV) relies on the facility to administer his/her medications. AV’s service plan indicates staff to perform CBG and to perform insulin injections, staff to reorder medications as needed, facility will assist AV in taking all routine and PRN medications according to doctor’s orders. On or about November 07, 2022, AV CBG was checked before dinner, and it was severely high with a reading of (597). It was discovered AV insulin was discontinued on the MAR on or about October 20, 2022. AV had not received their daily insulin for approximately eighteen (18) days. The facility failed to administer medication as ordered, which 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 Victims (AV) medication orders were administered as prescribed. It was discovered AV did not receive pain medication as scheduled, causing unreasonable pain and discomfort. 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 Victims (AV) medication orders were administered as prescribed. On or about 08/21/2022 AV was found on the ground. It was discovered that AV was administered the incorrect dose of medication, causing AV to fall. 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 Victims (AV) medication orders were administered as prescribed. On or about April 03, 2022, AVs provider decreased the dosage to h/h medication. AV did not receive his h/h medication of the new dosage until on or about April 08, 2022. 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 his/her care. AV was not administered his/her medications for approximately ten (10) days. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.

Alleged Victim (AV) has a history of falls with injuries and injuries from unknown causes. AV had approximately four (4) falls from November 14, 2021, thru January 22, 2022, which resulted in trips to the emergency room and an admission to hospice. The facility failed to plan care implement interventions to mitigate, the risk of falls with injury and injuries due to unknown cause, which is a violation of resident’s rights, is neglect of care and constitutes abuse.

Based on observation and interview conducted during a site visit on 09/23/24, it was confirmed that the facility failed to keep all exterior equipment and all equipment necessary for the health, safety and comfort of the residents, in good repair. Findings include, but not limited to the following: - On 09/23/24, Compliance Specialist observed the trash compacter to have a rusted hole approximately 8 to 10 inches wide and approximately 8 inches high on the same side as the compactor door rendering an unsanitary and safe situation. - On 09/23/24, Staff 1 stated the trash compactor had been like that since she/he arrived over a month ago. It was confirmed the facility failed to keep all equipment in good repair. Facility failure to keep all exterior equipment and all equipment necessary for the health, safety, and comfort of the residents, in good repair is a violation of Oregon Administrative Rules.

According to documentation, the Alleged Perpetrator 2 (AP2) failed to ensure AV's medication was administered as ordered. The failure resulted in AV going without his/her medication, causing unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system, which is a violation of Oregon Administrative Rules

Alleged Victim (AV) did not require facility assistance with shopping and the care plan was being followed at the time of the incident. On or about March 4, 2024, AV’s family called facility to make them aware of AV’s credit card, debit card and cash being stolen. On or about February 28, 2024, was the last time AV used h/h card. The card was laying on the counter and debit card along with cash was in AV's Wallet. Per LEA report on or about March 05, 2024, LEA received an email from Costco. Costco was able to locate the transaction on video and captured the vehicle the suspect had been driving as well. They included many photos of the suspect while in the store, a printed transaction of the items purchased and the membership information for the suspect. The member account used to make the transaction was under the name of Alleged Perpetrator 2 (AP2). LEA completed an Oregon DMV check on AP2 and found that the DMV photo in file on or about June 10, 2022, matches AP2 in Costco. The physical descriptors in the DMV entry shows AP2 which matches with the suspect. The complete name in the entry is AP2. LEA also received video and photographs of a suspect who fraudulently used AV’s card at the Target. The suspect on the video was also AP2. Per LEA report AP2 told LEA he/she was the one who took the credit cards. AP2 said s/he used the cards for purchasing things for his/her children. AP2 said s/he was the only one who used the cards. LEA asked AP2 how many cards s/he took from AV and AP2 reported s/he took only two cards. AV's credit card had 11 fraudulent charges, $1,745.81 in total and AV’s debit card had 5 fraudulent charges, $1,094.48 in total loss, $2,840.29. Based upon the review of documentary observations, court charges and proceedings, confirmation of AP2 identity through multiple sources, and AP2's own admission AP2 is responsible for financial exploitation and constitutes abuse. The facility failed to protect AV from financial exploitation which is a violation of Oregon Administrative Rules.

Resident 1 had an order to receive 1 tab of hydrocodone daily. A review of an incident report dated December 21, 2023, revealed that on December 20, 2023,at 5:00 am, Staff 2 gave Resident 1, a half hydrocodone, instead of 1 full tab. The incident report indicated that no side effects or reaction occurred due to the error. On January 5, 2024, Staff 1, confirmed that the medication error occurred. Staff 1 stated in the interview that three care staff will be advanced to the Med Tech position and are receiving training on the cart. Based on interview and record review conducted during a desk review, on January 5, 2024, it was confirmed the facility failed to carry out medication orders as prescribed for 1 of 1 sampled residents (#1).

On January 5, 2024, with Staff 1, confirmed that the medication error occurred. Staff 1 stated in the interview that three care staff will be advanced to the Med Tech position and are receiving training on the cart. Those same individuals are being delegated for residents who require delegated administration. A review of APS Referral Form Screening dated December 14, 2023, and the facility self report of the dated December 13, 2023, it was indicated that Resident 1 received medication for high blood pressure despite being outside parameters for administration. Medication was to be held if Resident 1's Systolic Blood Pressure (SBP) was below 120, or heart rate was below 60. Resident 1 received high blood pressure medication when their SBP was 116 and heart rate was 56. On January 3, 2024, it was confirmed the facility failed to carry out medication orders as prescribed for 1 of 1 residents (#1) who received medications.

The facility failed to ensure a safe medication administration system by failing to reorder a resident's medication timely. An investigation determined this is a violation of Oregon Administrative Rules.

Alleged Victim (AV) relies on the facility for h/h care. AV has parameters for a certain medication. AV’s parameters state if AV’s [medical parameters are higher than an established number], medication should be administered. On or about December 04, 2023, AV’s [medical parameters were higher than that established number] and medication should have been administered. AP2 did not administered AV medication, there was no negative outcome to AV as a result of the lack of medication administration. AP2’s, and the Facility actions failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.

Alleged Victim (AV) relies on the facility for h/h care. AV has parameters for a certain medication. The medication should be held if under a certain number. On or about November 22, 2023, AV’s [parameter] was under that certain number, meeting the criteria for holding medication. AP2 administered AV medication, there was no negative outcome to AV as a result of the medication administration. AP2’s, and the Facility actions failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.

On January 11, 2023, Staff 2 stated the facility sometimes had delays refilling "cycle fills" and reordering narcotics for Resident 1. Resident 1's MAR, dated November 1, 2023, through November 30, 2023, revealed the following medications were not administered: On November 2, 2023, Oxycodone 5mg twice a day; On November 21, 2023, Cetirizine 10mg, Atorvastatin 40 mg, Prednisone 5mg once a day; and On November 22, 2023, Pantoprazole 40 mg once a day. The MAR noted the facility was waiting on medication to arrive from the pharmacy. Based on interview and record review, conducted during a site visit on January 11, 2023, it was confirmed the facility failed to carry out medication orders as prescribed for 1 of 1 sampled resident (# 1).

On or about November 02, 2023, it was discovered Alleged Victim's (AV’s) medication was not being administered as ordered. AV was receiving medication every day instead of every two (2) days, placing him/her at risk of serious harm. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.

The facility failed to provide a safe medication administration system for the Alleged Victim (AV). An investigation determined on or about September 24, 2023, AV was administered a full tab of medication, when order written for half-tab. AV received medication at 11:00am instead of 4:00pm. The facility failure is a violation of Oregon Administrative Rules.

On 01/03/24, Witness 1 (APS Investigator) stated Staff 1 (Caregiver) administered insulin to Resident 1, without having been delegated. A record review of an email exchange between Witness 1 and Staff 3 (Administrator) on 09/19/23, Staff 1 was not delegated to administer insulin to resident 1. Staff 2 (LPN) responded via email, that Staff 1 was not delegated to administer insulin to Resident 1. Based on interview and record review, conducted through a desk review on 01/03/24, it was confirmed the facility failed to document that they had observed and evaluated the individual's ability to perform safe medication and treatment administration unsupervised for 1 of 1 sampled residents (#1) who received insulin, by a staff member who was not delegated.

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

The facility failed to implement a safe medication administration system. An investigation determined this is a violation of Oregon Administrative Rules.

On or about December 01, 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 for a total of 30 days

The facility failed to fully implement and update an Acuity Based Staffing Tool (ABST). An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action not taken due to violation being abated.

On or about November 01, 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 for a total of 30 days.

The facility failed to have an Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their needs. An investigation determined this is a violation of Oregon Administrative Rules.Corrective Action not taken due to violation being abated.

According to documentation Alleged Perpetrator 2 (AP2) financially exploited the Alleged Victim (AV) by borrowing items belonging to AV and brought different items back to AV instead of the items borrowed.. The failure resulted in AV not getting their property returned, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to provide a safe environment which is a violation of Oregon Administrative Rules.

On or about October 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 September 1, 2022 to September 30, 2022, for a total of 30 days.

On or about August 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 July 1, 2022 to July 31, 2022, for a total of 30 days.

The allegation that the facility failed to provide household services to assist the resident in accordance with OAR 411-054-0030(1)(g) Per a complaint the resident's apartment smelled horribly was verified.

The allegation that the facility failed to keep the interior of the facility free from unpleasant odors in accordance with OAR 411-054-0300(4)(h) Per a complaint the resident's apartment smelled like pet urine and smoke was verified.

The allegation that the facility failure to provide reasonable precautions against any condition that may threaten the health, safety, or welfare of residents per OAR 411-054-0025(4) was verified.

The allegation that the facility failure to have medical and other records kept confidential except as otherwise provided by law per OAR 411-054-0027(1)(i) was verified.

On or about May 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 April 1, 2022 to April 30, 2022, for a total of 30 days.

On or about March 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 February 1, 2022 to February 28, 2022, for a total of 27 days.