Aging and People with Disabilities
Safety, Oversight and Quality
Print Violation: 00391784-AP-342352
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
- 3/10/2025
- Report number
- 00391784-AP-342352
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- 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(1)(f)
External site: 411-054-0036(2)(g)
External site: 411-054-0055(1)(a) and (f)
- Findings
- Alleged Victim's (AV's) Service Plan requires facility staff to administer, store and reorder all medication for AV according to physician's orders. On or about March 10, 2025, Alleged Perpetrator #2 (AP2) received a medication order for a new strength of Metoprolol. AV's medication order changed, AV was receiving two 25 mg Metoprolol, the order changed to one 50 mg Metoprolol instead. AP2 changed the medication record incorrectly by discontinuing the current order and not registering the new order. As a result, AV was not receiving their medication from March 10, 2025, until March 27, 2025. During that period AV complained of edema in their lower extremities, shortness of breath while ambulating and fatigue. AP2 received all required training to administer medications and to make entries into MAR and participated in follow up meetings monthly. AP2 acknowledged completing the Medication Technician Training and receiving a training manual on July 15, 2024. AP2 failed to update AV medication order, and administer AP2 medication as order, AP2's actions are a violation of resident rights, considered neglect of care and constitutes abuse. The facility failed to provide an oversight, and a safe medication administration system which violates Oregon Administrative Rules.