Aging and People with Disabilities
Safety, Oversight and Quality
Print Violation: 00348248-AP-298730
Provider Information
Pacific Grove Senior Living Community
2112 OAK ST
Forest Grove, OR 97116
- Provider ID
- 70M035
- Administrator
- Lisa Vincent
- Phone
- (503) 359-1002
- aled@pacificgroveslc.com
Violation Details
- Date
- 8/12/2024
- Report number
- 00348248-AP-298730
- Type
- Abuse: Neglect
- 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(2)
External site: 411-054-0036(2)(g)
External site: 411-054-0055(5)(a), and (b)
- Findings
- Alleged Victim (AV) moved to into facility on or about August 5, 2024, from a sister facility. AV's service plan dated August 6, 2024, indicates AV self-administers medications, keeps all medications in h/h room, MT to order all medication through pharmacy as needed, self-medication evaluation will be done quarterly or as needed to make sure AV continues to safely self-administer h/h medications, and to see MAR. On or about August 7, 2024, AV requested help ordering medication that is almost out. AV was not sent with any backstock of medications from prior facility. On August 8 and 9, 2024, AV voiced concerns about h/h medications. On August 10, 2024, AV reported missing h/h blood pressure medication and reports experiencing headache and high blood pressure. AV continued to report missing blood pressure medication and experiencing headache and on August 12, 2024, AV reported pain in left shoulder and requested vitals be taken. AV blood pressure 203/97 EMTs were called, and AV was transported to the Emergency Department due to elevated blood pressure. AV returned to facility on August 13, 2024, with a new order for blood pressure medication. The facility failed to have a safe medication administration system in place, to evaluate AV upon move-in, to assure AVs ability to safely self-administer medications, and have all medications available for AV to take as ordered, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
- Sanction
- ALFCP25-00116 $188.00 fine assessed