Print Violation: 00389687-AP-340234

Provider Information

Springs at Clackamas Woods ALF

14404 SE WEBSTER RD
Milwaukie, OR 97267

Date: 3/11/2025
Report number: 00389687-AP-340234
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)
External site: 411-054-0027(1)(g) and (s)
Findings: According to the documentation, the Alleged Perpetrator 2 (AP2) failed to provide a safe medication administration system for the Alleged Victim (AV). On or about March 11, 2025, AP2 did not follow protocol to ensure the AV received the correct medication and gave the AV their roommates medication. AP2 then administered the AV their correct medication in addition to their roommates medication without consulting AV’s primary care physician. The failure to provide a safe medication administration systems caused the AV to experience dizziness, abnormal blood pressure shakiness and other symptoms, placing them at risk of harm, which is a violation of resident rights, 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.