Aging and People with Disabilities
Safety, Oversight and Quality
Print Violation: OR0004713601
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
- 12/25/2023
- Report number
- OR0004713601
- 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)(f)
- Findings
- Based on interview and record review, conducted during a site visit on 02/07/24 through 02/15/24, it was confirmed the facility failed to carry out medication orders as prescribed for 2 of 2 sampled residents (#s 5 and 12). During an interview on 02/13/24, It was confirmed there had been no med tech the morning of 12/25/23, and there were only two caregivers on shift. Resident 5 was in pain and had not received his/her pain medication; and Resident 12 had a "panic attack" due to missing medications. Resident 12's MAR, dated 12/25/23, indicated Resident 12's 6:00 am Oxycodone-Acetaminophen 7.5-325mg (pain medication) was "Refused - administered as prescribed" by Staff 12. Staff 12 was found to have falsified a MAR and Narcotics Logs during the course of the investigation. During an interview on 02/09/24, Resident 5 stated s/he had been taken to the emergency room on 12/25/23 for foot pain. Resident 5's MAR, dated 12/25/23, indicated his/her 8:00 am Morphine Sulfate ER 30mg (pain medication) was not administered as s/he was out of the facility. There were no med techs in the facility to administer the 8:00 am dose. Resident 5 was sent to the emergency department at approximately 9:23 am. It was confirmed the facility failed to carry out medication orders as prescribed