Aging and People with Disabilities
Safety, Oversight and Quality
Print Violation: 00372055-AP-322399
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
- 12/15/2024
- Report number
- 00372055-AP-322399
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious 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) is a resident of the facility and the facility has a responsibility to provide a safe environment. AV care plan indicates, AV is to receive moderate care and support for medication and monitoring. AV has a seizure disorder that requires medication and monitoring from the facility. On or about December 12, 2024, AV's seizure medication ran out. Verbal reports were made by Witness 2 (W2) that AV’s provider’s office was notified of AV's medication being out on December 13, 2024, there is no documentation showing this occurred. AV’s provider’s office does not have record of communication from the facility regarding AV's medication being out of stock until December 16, 2024. AV was not placed on alert charting until December 15, 2024, regarding the missed medication. AV missed three days of h/h seizure medication starting December 13, 2024, to December 15, 2024, which resulted in AV having a seizure on December 15, 2024, that required hospitalization. The facility failed to provide a safe and homelike environment, failed to ensure a safe medication administration system, and failed to ensure AV's seizure medication was refilled prior to AV running out. The facility failed to administer AV's medication as prescribed, which resulted in AV missing h/h seizure medication for three days and resulted in AV having a seizure requiring emergency services and hospitalization.
- Sanction
- ALFCP25-00439 $1125.00 fine assessed