Print Violation: OR0004839101

Provider Information

Pacific Grove Senior Living Community

2112 OAK ST
Forest Grove, OR 97116

Date: 2/14/2024
Report number: OR0004839101
Type: Licensing Violation
Level: 3 - Moderate harm or potential for serious harm
Allegation: Failed to provide oversight and monitoring of change of condition
Result: Substantiated
Rule(s) Violated: External site: 411-054-0040 (1-2)
Findings: Based on observation, interview, and record review, conducted during a site visit on February 07, 2024, through February 15, 2024, it was confirmed the facility failed to evaluate, determine interventions, update the service plan, and refer to the facility nurse for significant change of condition and ensure resident monitoring consistent with his/her evaluated needs and service plans for 2 of 2 sampled residents (#s 1 and 2). Resident 1 ' s blood sugar and insulin administration were not monitored, and s/he was hospitalized on February 10, 2024, for high blood sugar. Resident 2 was not receiving meals and experienced severe weight loss. Resident 2 had lost 9.7% of his/her body weight in a three-month period, constituting a significant change of condition. It was determined the facility failed to provide Resident 2 with his/her meals and assistance if needed. The Facility’s non-compliance places residents in immediate jeopardy. Facility failed to provide service and failed to provide oversight and monitoring of change of condition.