Skylark Assisted Living

The Alleged Victim (AV) had a CPAP machine when he/she moved into the facility. Former facility staff placed AV's CPAP in the closet and told AV he/she did not need it any longer. AV is having episodes of hypoxemia and still needs to use his/her CPAP. AV needed a physician order to use his/her CPAP. The facility failed to get a physician order for AV to use his/her CPAP, placing AV at risk for harm. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is a known fall risk. AV had multiple falls between January 2024 and July 1, 2024. AV was considered a fall risk beginning March 11, 2024, however, AV's care plan was not updated to reflect this or interventions to reduce the risk of falls. AV suffered a fractured toe, requiring skilled nursing and a two person assist. The facility's failure to properly care plan caused AV unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitute abuse.

The Alleged Victim (AV) has blindness and needs facility assistance. On or about April 2, 2024, AV fell while trying to retrieve his/her food tray from outside his/her door. AV's food tray is to be delivered inside his/her room. AV tripped and dropped his/her tray while trying to bring it inside, where AV suffered and injury to his/her head and knees. AV called for assistance but no one came to assist AV. AV wasn't notified that the call system hadn't been working since March 31, 2024 and staff should have been completing 15 minute checks on all residents during the outage of the call system, which were not being completed. The facility's failure to ensure resident safety is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is care planned to have his/her brief changed every two hours. On or about January 31, 2024, it was discovered that AV hadn't been changed and his/her sheets and bedding were soaked through to the mattress. It was discovered that night shift staff were not checking or changing AV every two hours as stated in the care plan. Staff didn't want to wake AV to change him/her. Staff were told they needed to wake AV to change him/her if necessary. The facility's failure to follow the care plan placed AV at risk for harm and placed AV in unreasonable discomfort. The facility's failure is a violation of resident rights, are considered neglect of care and constitute abuse.

The Alleged Victim (AV) has a diagnosis of major depression disorder and is prescribed medication for depression and mood stabilization. AV went without these medications number days over a 90 day period, as the facility failed to order the medication timely, resulting in AV not receiving the medication. This lack of medication made AV have suicidal behaviors. The facility's failure to ensure AV's medications were ordered and given timely is a violation of resident rights, is considered neglect of care and constitute abuse.

Alleged Perpetrator #2 (AP2) had worked as a med tech in the past, however, AP2 was not trained on the med cart once beginning work at the facility. On or about July 5, 2023, it was discovered that the Alleged Victim (AV) had denied his/her medication. It was unusual for AV to deny this medication. AP2 was passing medication to AV, to which AP2 stated AV denied the medication, so AP2 destroyed the medication. There is no record of the destroyed medication, nor did any other staff observe or sign off on the destruction of medication. AV did not have any negative reaction to missing the medication. AP2's actions were investigated and it was determined inconclusive to the outcome of abuse. The facility's failure to provide a safe medication administration system and properly train AP2 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 (AV)'s needs. The AV has a medical diagnosis which can cause AV to suffer from SOB and impact AV’s ability breathe. AV had approximately two separate occasions when AV asked for emergency medical services to be called so s/he could go to the hospital and was denied h/her request. AV was admitted to the hospital on the second incident with vitals significant for hypoxia, and AV oxygen saturation were low. The facility failure is a violation or resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) has his/her medications managed by the facility. AV did not receive his/her pain medication multiple times during February, April and March of 2023. The facility did not order AV's medication timely, leaving AV at risk for pain. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) had approximately six (6) falls from November 08, 2022, January 17, 2023. Some of the falls involved AV hitting h/h head, sustaining skin tears, and required emergency services. The facility failed to appropriately care plan and implement reasonable interventions to address AV’s increasing and ongoing falls, which 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 (AV)’s needs, resulting in AV experiencing unreasonable discomfort and loss of dignity. Documentation provided to the department shows AV has history of laying in soiled clothing for extended periods. AV service plan indicates AV requires staff to conduct daily incontinence checks, assist with cleaning and replacing, linens, bedding, and clothing when AV has an episode of incontinence. Staff to also assist in removing incontinence trash. On or about January 19, 2023, AV was lying in soiled bedding , AVs room smelled strongly of urine and had a pile of urine-soaked clothes on the floor. AV call light was pushed for assistance and staff did not respond to the call for over approximately thirty (30) minutes. 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)s medications were administered as prescribed. On multiple occasions, on or about October 2022 through November 2022 it was discovered, AV did not receive h/h narcotic pain, and other medications 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.

Alleged Victim (AV) relies on the facility for his/her care. AV is care planned to be assisted with incontinence care at least twice per shift and as needed. On or about November 19, 2022, AV called staff to assist with brief change. AV fell asleep in his/her wheelchair and was not assisted until the next day when he/she was found sitting in soiled briefs that had seeped out of his/her pants and through an incontinence pad onto his/her wheelchair, causing a loss of dignity and unreasonable discomfort. The facility failed to follow the care plan which is a violation of resident’s rights is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for h/h care. The facility failed to provide a safe medication administration system to ensure AV medications were given per physician orders. On or about November 10, 2022, and again on or about November 13, 2022, AV was not given his/her metabolic medication because there were no delegated staff onsite. AV not receiving metabolic medication places AV at risk of 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.

The facility failed to provide a safe medication administration system to ensure the Alleged Victims (AV)s medication orders were administered as prescribed and documented in the Medication Administration Record (MAR). Documentation provided to the Department shows on multiple occasions on or around November 2022 through December 2022 AV had several missed doses of insulin, and/or medication administered but not documented. Documentation shows AVs blood glucose readings to be high and as a result AV was admitted to the hospital with Diabetic Ketoacidosis (DKA) on two separate occasions. 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 given per physician orders. AV was not given his/her blood pressure medication for approximately 2 weeks starting October 2, 2022, and then was also not given the medication multiple times over the next month. On or about November 5, 2022, AV went to the ER with chest wall pain and was noted to be hypertensive. The facility failed to provide a safe medication administration system placing AV at risk for serious harm, which is violation of resident’s rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for h/h care. On or about September 3, 2022 it was discovered that the facility had ran out of the AV’s diabetic medication. The AV missed at least 3 doses while waiting for the medication to arrive from the pharmacy. The facility failed to provide a safe medication administration system to ensure AV medications were ordered and administered per physician orders which placed AV at risk of harm. The failure is a violation of resident’s rights, is considered neglect of care and constitutes abuse.

On or about August 30, 2022, it was discovered that approximately 70 narcotic medication pills were unaccounted for belonging to the Alleged Victim (AV). The Alleged Perpetrator (AP2) did not return to work after the medication was noticed to be missing. The allegation that AP2 stole AV’s medications was investigated and wrongdoing was unable to be determined. The facility failed to have a safe medication administration system that prevents theft or misuse of medications. The failure is a violation of resident rights, is considered neglect of care resulting in financial exploitation which constitutes abuse.

The Alleged Victim was known to need a higher level of care than what the facility could provide. The facility started the move out process for AV, but did not follow up with required documentation so the move out notice was denied. On or about August 2, 2022, AV fell at the facility and broke both of his/her legs. The facility failed to provide a safe environment for AV, 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. From approximately May 2022 through July 2022, there are multiple documented instances where AV’s medications were not onsite and available for administration to AV. The facility failed to provide a safe medication administration system to ensure medications were ordered and administered according to physician orders, causing AV unreasonable discomfort. The facility failed to provide necessary care, which is a violation of resident rights, is neglect of care and constitutes abuse.

On or about July 15, 2022, Alleged Perpetrator #3 (AP3) was training the Alleged Perpetrator #2 (AP2) in medication administration. AP2 was in their second day of training and was not yet deemed competent to pass medications alone. AP3 stepped away to assist another resident and AP2 administered another resident’s medications to the Alleged Victim (AV). AP3 failed to ensure the Alleged Victim’s (AV) medications were administered as ordered. The failure resulted in desaturation of AV’s oxygen levels and AV was sent to the hospital for overnight observation. AP3’s actions are 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 resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. AV recent needs had changed, including increased urinary incontinence, increased assistance with brief changes, AV refusing to have sheets changed and refusing showers. AV was also found numerous times to be laying on a soiled bed pad or mattress and in soiled briefs. The facility did not have documentation that the notifications occurred or that the facility responded to the refusal of showers or resistance to care. No additional interventions were put in place and on or about May 27, 2022, AV was diagnosed with a pressure ulcer. The facility failed to assist AV with his/her hygiene and failed to care plan in accordance with AV's capabilities which is a violation of resident rights is neglect of care and constitutes abuse.

The Alleged Victim (AV) missed multiple doses of pain medication between approximately April 28, 2022, and April 29, 2022, and also missed at least two additional medications between approximately May 16, 2022, and May 24, 2022. Missing multiple medication doses placed AV at a risk for serious harm. The facility failed to provide a safe medication administration system to ensure AV’s medications were given, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) missed all ordered medications from approximately April 29, 2022, to May 2, 2022, causing AV to be anxious, shaky, and suffer repeated unreasonable discomfort. The facility failed to provide a safe medication administration system to ensure AV’s medications were given, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about April 27, 2022, the Alleged Victim (AV) experienced a medical emergency and facility response was delayed. AV was ultimately sent to the hospital for treatment. The facility failed to provide a safe environment, which caused AV unreasonable discomfort, is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) was given the wrong dose and/or also missed multiple doses of scheduled pain medication between approximately March 29, 2022, and April 6, 2022, causing AV unnecessary discomfort. The facility failed to provide a safe medication administration system to ensure AV’s physician orders were followed, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) has orders for his/her blood sugar checked every morning. AV had at least three instances where his/her blood sugar was not checked by staff, placing AV at risk for harm. On or about November 8 and 9, 2021, AV missed 3 doses of ordered medication, placing AV at risk for harm. The facility's failure to provide a safe medication administration system is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is to receive his/her medication two times per day. AV's medication was sent in for only a two week supply, rather than a one month supply. The facility ran out of AV's medication and AV missed his/her medication at two different intervals due to the facility not re-ordering AV's medication timely. The facility's failure to re-order medication is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) had product that he/she makes tea from to assist with pain. Alleged Perpetrator #2 (AP2) was offered some of the product from AV. AP2 took home the product and used the product which belonged to AV. AP2's actions are a violation of resident rights, are considered neglect of care and constitute financial abuse. The facility failed to protect AV from financial abuse, which is a violation of Oregon Administrative Rules.

On or about June 19, 2023, the Alleged Victim (AV) pushed his/her call light for staff assistance to the bathroom. No staff answered AV's call light, so he/she took him/herself to the bathroom. When AV was done, he/she pushed the call light again. No staff answered the call light for almost two hours, leaving AV in the bathroom, unable to get him/herself up. Alleged Perpetrator #2 (AP2) and Alleged Perpetrator #3 (AP3) were both working that shift, and neither responded to AV's call light, leaving AV at risk for harm. AP2 and AP3's failure is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility's failure to ensure the call lights are answered timely 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 allegation that the facility failed to evaluate resident to assure ability to safely self-administer medications in accordance with OAR 411-054-0055(5)(a) per complaint that resident was self administering their medications and took too many pills was verified.

The facility failed to provide direct care staff sufficient in number to meet the scheduled and unscheduled needs of the residents in accordance with OAR 411-054-0070(1) per complainant that the facilities only have one med tech and one caregiver covering all three floors. It took one hour before staff answered their call light.

The facility failed to include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation. An investigation determined a licensing violation or abuse occurred.

The facility failed to document that they have observed and evaluated the individual ' s ability to perform safe medication and treatment administration unsupervised. An investigation determined a licensing violation or abuse occurred.

The facility failed to contact resident's emergency contact. An investigation determined a licensing violation or abuse occurred.

The facility failed to provide direct care staff sufficient in number 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 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. Facility is not currently staffing to the levels as indicated by the ABST. Corrective Action taken on related allegation.

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

The facility failed to implement a training program that includes methods to determine competency of direct care staff. 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. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to ensure an adequate professional oversight of the medication administration system. An investigation determined this 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 this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

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. Facility is not currently staffing to the levels as indicated by the ABST. Corrective Action taken on related allegation.

The facility allegedly failed to assist with ambulation or mobility. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to care plan in accordance with assessment. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide household services essential for the health and comfort of the resident. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to provide personal and other laundry services. An investigation determined this 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 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. Corrective Action taken on related allegation.

The facility failed to provide direct care staff sufficient in number to meet the scheduled and unscheduled needs of the residents in accordance with OAR 411-054-0070(1) per complainant that it is extremely difficult to get ahold of facility staff to discharge medical stable residents back to the facility.

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 provide assistance with toileting and bowel and bladder management. An investigation determined a licensing violation or abuse occurred.

The allegation that the facility failed complete resident service plan before resident moves in as required by OAR 411-054-0036(2)(a)(A) per complaint that the facility did not have a service plan for resident for a couple of weeks after resident moved in is substantiated.

The allegation that the facility allegedly failed to administer medication as ordered for the Alleged Victim. An investigation determined no licensing violation or abuse occurred was verified.

The allegation that the facility allegedly failed to administer medication as ordered for the Alleged Victim was verified.