Print Violation: 00290669-AP-244669

Provider Information

Avamere at Sherwood Assisted Living Facility

16500 SW CENTURY DRIVE
Sherwood, OR 97140

Date: 9/12/2023
Report number: 00290669-AP-244669
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)
Findings: On or about September 12, 2023, Alleged Perpetrator 2 (AP2) administered the wrong medication to Alleged Victim (AV). Based on facility documentation and interviews, AV was observed to be completely drowsy as a result of the medication error and was taken the hospital for monitoring. AP2's actions caused AV unreasonable discomfort, 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.