Print Violation: 00314791-AP-267102

Provider Information

Waterhouse Ridge Memory Care Community

1115 NW 158TH AVENUE
Beaverton, OR 97006

Date: 2/22/2024
Report number: 00314791-AP-267102
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)(g) and (s)
External site: 411-054-0028(1)(a) and (b)
External site: 411-054-0030(f)
External site: 411-054-0036(2)(g)
External site: 411-054-0055(1)(a) and (f)
Findings: Alleged Victim (AV) resides in a secure facility that has a responsibility to provide care and a safe environment. AV is prescribed multiple scheduled and as needed medications and a trained med tech is responsible for ordering, storing, and administering all of AV's medications per physician orders. On or about February 21, 2024, a medication cart audit was completed, and narcotic discrepancies was found. These discrepancies involved inaccurate counts as well as missing/tampered with bottles of morphine. AV's morphine was determined to be watered down. AP1 failed to ensure a safe, adequate medication administration system, which resulted in AV's prescribed morphine being diverted by an unknown Alleged Perpetrator (AP2). AP2’s actions are a violation of resident rights, are considered neglect of care and constitutes abuse. The facility failure is a violation or Oregon Administrative rules.