Print Violation: OR0004756900

Provider Information

Pacific Grove Memory Care

3334 22ND AVE
Forest Grove, OR 97116

Date: 12/22/2023
Report number: OR0004756900
Type: Licensing Violation
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to report potential or suspected abuse
Result: Substantiated
Rule(s) Violated: External site: 411-054-0028(2)(b)
Findings: Based on interview and record review, conducted during a site visits 02/07/24 through 02/13/24, it was confirmed the facility failed to immediately notify the local Seniors and People with Disabilities (SPD) or the local AAA of an incident of abuse or suspected abuse for 1 of 1 sampled resident (# 30). A Suspected Abuse or Unexplained Injury Reporting Form for Resident 30 was signed and dated 12/29/23, for an incident that occurred on 12/22/23. It was confirmed the facility failed to immediately notify the local SPD office or the local AAA of an incident of abuse or suspected abuse.