Dorian Place Assisted Living Facility

Alleged Victim (AV) relies on the facility to administer his/her medications. On or about May 5, 2023, it was indicated that the facility did not order AV’s psychotropic medication and so AV went without it between April 24th through 30th, 2023. As a result of the missed medication AV had unreasonable discomfort. The facility failed to provide a safe medication administration system for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility to administer his/her medications. On or about July 26, 2022, AV ran out of his/her pain medication and went to the ER due to extreme pain. On or about August 18, 2022, AV was not given his/her 12am pain management medication. The facility failed to provide a safe medication administration system, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility to administer his/her medications. On or about August 11, 2022, AV did not receive PM dose of schedule pain medication. On August 12, 2022, AV did not receive AM or PM dose and on August 13, 2022, AV did not receive schedule AM dose of schedule pain medication. As a result, AV experienced pain due to not having schedule pain medication. The facility failed to provide a safe medication administration system, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility to administer his/her medications. On or about May 30, 2022, AV went without scheduled pain medication three (3) time at 12am, 6am and 12 pm. AV stated they suffered pain as a result of not having pain medication and suffered undue stress. The facility failed to provide a safe medication administration system, which is a violation of resident rights, is neglect of care and constitutes abuse.

On or about March 31, 2022, the Alleged Victim (AV) came back from the hospital and was prescribed cough medication. There was some confusion as to when AV was to receive the medication, if it was every 3 hours or every 8 hours. On April 2, 2022, AV was given the medication at 7:51 am and again at 11:31 am, which caused AV dizziness and unreasonable discomfort. On April 3, 2022, AV refused the additional medication at noon, citing it was not the correct time for the medication. After that, the medication was given correctly. The facility failed to provide a safe medication administration system, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility to administer his/her medications. On or about February 27, 2022, AV went without one (1) scheduled dose of pain medication. On or about February 28, 2022, AV went without three (3) doses of scheduled pain medication. AV indicated he/she felt sick and suffered pain as a result of not having his/her pain medication. The facility failed to reorder AV’s pain medication in time for the medication to be made available to AV when scheduled. The facility failed to provide a safe medication administration system for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

The facility failed to provide assistance with eating. An investigation determined a licensing violation or abuse occurred.

The facility failed to provide documents to the Department upon request. An investigation determined a licensing violation or abuse occurred.

The facility failed to provide modified special diets . An investigation determined a licensing violation or abuse occurred.

The facility failed to have a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated, or discontinued medications administered by the facility. An investigation determined a licensing violation or abuse occurred.

The licensee failed to be responsible for the operation of the facility and the quality of services rendered in the facility. An investigation determined a licensing violation or abuse occurred.

The facility failed to evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed for a significant change of condition. An investigation determined a licensing violation or abuse occurred.

The facility failed to have a training program that includes methods to determine competency of direct care staff. An investigation determined a licensing violation or abuse occurred.

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.

The facility failed to have a training program that includes methods to determined competency of direct care staff. 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 delegation and teaching by a RN. 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.

Facility failure to ensure all medications administered by the facility must be stored in locked containers in a secured environment such as a medication room or medication cart. An investigation determined a licensing violation or abuse occurred.

Facility failure to ensure medications must be kept secure between set-up and administration of medications. An investigation determined a licensing violation or abuse occurred.

Facility failure to arrange or provide transportation for medical purposes per complaint that the facility refuses to assist with transportation for residents discharged from the hospital. the facility failure is a violation of Oregon Administrative Rules.

According to the documentation, the Alleged Perpetrator 2 (AP2) and Alleged Perpetrator 3 (AP3) failed to provide a safe medication administration system for the Alleged Victim (AV). On or about October 24, 2024, AP2 was training the AP3 on medication pass. AP2 handed AP3 a cup of meds to administer to the AV. AP3 did not double check the medication’s handed to them by AP2 were in fact the medications of the AV. AP3 administered the medication to the AV. After the wrong medications were administered, AP3 realized the medications were not correct but it was too late. Administrative staff were immediately notified and the AV was sent to the ER for monitoring in case the AV experienced serious side effects. The failure to provide a safe medication administration system to the AV placed them at a risk of harm, 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.

According to the documentation, the Unknown Alleged Perpetrator (AP2) failed to provide a safe medication administration system. On or about October 24, 2024, a cup of three different medications was found in the AV’s room by the kitchen area. It is unable to be determined who or when the medications were left on the counter. Leaving medications on the counter leaves residents at risk of harm and 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.

The facility failed to fully implement and update an acuity-based staffing tool. An investigation determined no 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 qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. An investigation determined a licensing violation or abuse occurred.

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

Violation 1: Staffing for scheduled and unscheduled needs. STATEMENT OF FACTS: 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. The facility must staff above ABST time. CONCLUSION OF LAW: The facility’s failure to provide qualified awake care staff is a violation of the following OARs: 411-054-0070(1) Violation 2: Acuity-based staffing tool. STATEMENT OF FACTS: Facilities must select and implement an acuity-based staffing tool (ABST) that is technology-based for determining appropriate staffing levels. Individual resident needs and care elements must be the primary consideration when developing and maintaining an ABST. CONCLUSION OF LAW: The facility’s failure to fully implement and update an ABST is a violation of the following OARs: 411-054-0037(1) Violation 3: Staffing training and competencies. STATEMENT OF FACTS: The facility failed to have a training program that includes methods to determine competency of direct care staff. 1 of 12 caregivers whose documentation was reviewed, had documentation of demonstration of competencies in areas of caregiving. CONCLUSION OF LAW: The facility’s failure to properly train and determine competencies is a violation of the following OARs: 411-054-0070(2)(a) Violation 4: Resident services. STATEMENT OF FACTS: Based on observation and record review, a resident who had orders for a mechanical soft diet due to a diagnosis of aspiration, was observed to be given an uncut porkchop for lunch, which put the resident at risk for aspiration. CONCLUSION OF LAW: The facility’s failure to provide modified special diets is a violation of the following OARs: 411-054-0030(1)(a)(A) Violation 5: Facility operation. STATEMENT OF FACTS: The licensee failed to be responsible for the operation of the facility and the quality of the services rendered in the facility as demonstrated during the licensing investigation.

According to the documentation, the Alleged Perpetrator 2 (AP2) failed to provide a safe medication administration system to the Alleged Victim (AV). AP2 admitted to giving medications more than what was prescribed by the primary care provider, sometimes up to double the amount. The AV suffered nausea, pain and tingling in their fingers, which is a violation of resident rights and is considered abuse. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.

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

Alleged Victim (AV) relies on the facility for his/her care. AV has a PRN nebulizer. Alleged Perpetrator 2 (AP2) stated he/she recalls AV asking for the PRN nebulizer treatment; AP2 responded to AV by explaining he/she would bring it to AV when he/she was free, but he/she wasn’t going to drop everything and needed to finish setting up scheduled medication pass before he/she would be able to give AV his/her requested PRN nebulizer treatment. As a result, AP2 deviated from policy for medication administration there fore the allegation that AP2 neglected AV is substantiated. AP2 failed to provide a safe medication administration system for AV, which is a 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.

Alleged Victim (AV) relies on the facility to administer his/her medication. On or about February 7, 2023, Alleged Perpetrator 2 (AP2) did not give AV his/her schedule medication, but AP2 entered in the MAR as given which was not true. AP2 knowingly and falsely omitted and entered in the MAR as giving the medication. 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, which is a violation of Oregon Administrative Rules.

Alleged Victim (AV) relies on the facility to administer his/her medication. On or about January 23, 2023, AV went without his/her evening medication. AV’s medication in the med cart had run out. The facility had re-ordered the medication in a timely manner and it had already been delivered to the facility. Alleged Perpetrator 2 (AP2) failed to obtain the delivered medication refill and add it to the medication cart. 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, which is a violation of Oregon Administrative Rules.

Alleged Victim (AV) relies on the facility to administer his/her medication. On or about December 3, 2022, AV went to the med cart and requested his/her PRN medication for nausea. Alleged Perpetrator 2 (AP2) made an error by administering a medication for antipsychotic/antiemetic that was not prescribed to AV. AP2 stated that the med error was his/her fault; AP2 deviated from protocol and did not check AV’s MAR for available PRN medications first. As a result of the medication error, AV complained of a headache. 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.

On or about August 18, 2022, Alleged Perpetrator #2 (AP2) failed to ensure that the Alleged Victim (AV) took his/her medication as ordered. AV’s medications were found at AV’s bedside by a family member. AP2's actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility failure is a violation of Oregon Administrative Rules.

Alleged Victim (AV) relies on the facility for his/her care. AV had five hundred dollars in their possession from selling furniture items. AV has a locked drawer and key in his/her room but prefers it not to be locked and worries about misplacing the key therefore AV keeps it on his/her table in the room. It is believed that an unknown Alleged Perpetrator 2 (AP2) may have taken the money. AP2’s action constitutes financial exploitation, which is neglect of care and constitutes abuse. The facility failed to protect AV from financial exploitation, which is a violation of Oregon Administrative Rules.