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Ashland Memory Care Center Found in Non-Compliance; 'Residents at Risk for Harm'

ONLY ON: In March of 2018, NewsWatch 12 discovered a local memory care facility was no longer allowed to accept new patients after an investigation into neglect and the improper use of medication.

ASHLAND, Ore. -- An investigation by NewsWatch 12 reveals that state health officials are stepping in to make sure dementia patients are safe at an Ashland facility.

The Village at Valley View opened on July 26, 2017, and the Oregon Department of Human Services (DHS) opened an investigation in December. They started interviewing current and former staff about neglect and the off-label use of medication that sedated patients.

By February 2018, adult protective services brought in a consultant to evaluate and review the facility.

NewsWatch12's Sionan Barrett submitted a public records request to DHS on February 8. On March 5, Barrett received the documents detailing the investigation.

DHS found 24 serious violations of residents’ rights in the investigation, and concluded that the facility's, "non-compliance places residents at harm or risk for harm."

READ: Description of Violations (PDF)

The Village at Valley View was ordered to post a “restriction of admissions” sign inside and outside the facility entrances and exits.

The state also ordered the facility not to accept any new residents while violations are being corrected. DHS officials said that only 5 percent of the facilities the agency oversees per year receive restrictions as severe as those leveled against Valley View.

A former employee told NewsWatch 12: “I saw residents that would write that they were scared to be alone on their whiteboard because they couldn’t communicate any other way.”

The former employee wants to stay anonymous but spoke to NewsWatch 12 because she said families need to know what’s happening inside the facility.

Former employee: “The medication errors, I feel they were serious to the point where it led to complications in some of the residents.”

During a regular inspection, DHS investigators found major concerns about the use of PLO Gel, an antipsychotic cream gel that has not been approved by the Food and Drug Administration for use on dementia patients.

DHS Spokesperson Ann McQueen: "We found instances during our survey or inspection process of residents who had significant weight loss who should’ve had a registered nurse assessment who didn’t have those things and those things either did or have the potential to cause serious harm to a resident.”

PLO Gel in its cream form is usually found in Hospice settings to make people comfortable toward the end of their life.

McQueen: “It’s a non-approved use, and antipsychotics in this vein are also considered 'black boxed.' Really they are not recommended for people with dementia-related behaviors, for this use. And there’s a lot of research out there that indicates that’s not the proper use for that.”

MORE: Read the Notice Of Violations (PDF)

One of the owners of Village Valley View is John Chmelir; he does not have a direct role in patient care, but said his employees have not misused PLO Gel.

Chmelir: “The PLO Gel is only to be used on residents that have been prescribed its use. It’s a pharmaceutical. It’s a prescription drug, so you can’t just get a tube of it and use it on other people. We have missed some of the documentation. There’s no question about that. And to the extent that if you don’t have documentation saying you did this, then the only conclusion is that it wasn’t done. Then that’s how DHS has to interpret that. I get that they have a very hard job because they’re protecting some very vulnerable people so we’re just working hard to make their standard."

When asked if residents at Valley View are being abused, Chmelir said, "I don’t think so. Absolutely not. I will say that absolutely not. I think our care staff really does care about the residents, and I think we do the very best we can.”

Ashland Care Associates was fined $500 for neglect of care due to the inappropriate use of chemical restraint. Chmelir said the facility and staffers are taking DHS' concerns seriously and are taking the suggested steps to correct its actions. The DHS Aging and People with Disabilities Licensing division has an agreement with Village at Valley View that requires a Department-approved Registered Nurse (RN) consultant, not affiliated with the licensee, to be on-site for a minimum of two times each month a minimum of 16 hours per visit. That RN will submit a written report every two weeks to DHS to provide an evaluation of systems, procedures and practices reviewed, recommendations provided, staff training, and any other areas to note.

READ: Order Imposing License Condition (PDF)

DHS told NewsWatch12 that investigators are confident the facility will take the steps necessary to keep patients safe and comfortable.

Anyone who is concerned about the care of their loved one(s) in any healthcare facility can contact DHS here.

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