Print Violation: 00380540-AP-331055

Provider Information

Cedar Crest Alzheimer Special Care Center

18325 SW PACIFIC HWY
Tualatin, OR 97062

Date: 1/27/2025
Report number: 00380540-AP-331055
Type: Licensing Violation
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to administer medication as ordered
Result: Substantiated
Rule(s) Violated: External site: 411-054-0055(1)(a) and (f)
Findings: The Alleged Victim (AV) was prescribed medication for wrist pain following a fall. The Alleged Perpetrator 2 (AP2) did not process and input the new physician order, therefore the AV was not given the medication. There was no observable or documented evidence of a negative outcome. The facility failed to provide a safe medication administration system to ensure the Alleged Victim’s (AV) medications were administered as ordered, which is a violation of Oregon Administrative Rules.