Print Violation: 00214434-AP-173722

Provider Information

Cedar Crest Alzheimer Special Care Center

18325 SW PACIFIC HWY
Tualatin, OR 97062

Date: 8/3/2022
Report number: 00214434-AP-173722
Type: Licensing Violation
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to provide a safe medication administration system
Result: Substantiated
Rule(s) Violated: External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0027(1)(f) and (r)
External site: 411-054-0028(2)
External site: 411-054-0055(1)(a) and (f)
Findings: Alleged Perpetrator 2 (AP2) failed to ensure the Alleged Victim’s (AV) medications were administered as ordered, placing AV at risk for harm. On or about August 3, 2022, AP2 did not administer AV their medications, which included multiple medications that would help AV sleep, resulting in AV staying awake, having an unwitnessed fall, and being sent to the hospital. AP2’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 Oregon Administrative Rules.