Aging and People with Disabilities
Safety, Oversight and Quality
Print Violation: OR0004897900
Provider Information
Pacific Grove Memory Care
3334 22ND AVE
Forest Grove, OR 97116
- Provider ID
- 5MA242
- Administrator
- Amanda Hatcher
- Phone
- (503) 359-1002
- mced@pacificgroveslc.com
Violation Details
- Date
- 3/6/2024
- Report number
- OR0004897900
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to administer medication as ordered
- Result
- Substantiated
- Rule(s) Violated
-
411-054-0055(1)(f)
- Findings
- It was confirmed the facility failed to carry out medication orders as prescribed for 15 of 15 sampled residents (#s 2, 3, 4, 7, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, and 19). In an interview on 04/16/24 at 10:42 am, Staff 7 (Med Tech) stated there were issues with the prior nurse where s/he wasn't passing medications. A review of residents' Medication Administration Records (MARs), dated 03/01/24-03/31/24, and progress notes, dated 03/06/24-03/20/24, indicated the following medications were missed on 03/06/24: a. Resident 2: one missed dose of Cefpodoxime used to treat infection and one dose of Melatonin used to treat delayed sleep. b. Resident 3: one missed dose of Trazodone used to treat insomnia; one dose of Preparation H cream used to treat rectal itching and pain; and one dose of Salicylic Acid patch used to treat skin disorder. c. Resident 4: one missed dose of Depakote used to treat seizure disorder and one dose of Quetiapine used to treat Alzheimer's. d. Resident 7: one missed dose of Metformin used to treat diabetes; one dose of Olanzapine used to treat agitation; one dose of Senna used to treat constipation; and one dose of Trazodone used to treat insomnia. e. Resident 9: one missed dose of Atorvastatin used to treat cholesterol. f. Resident 10: one missed dose of Quetiapine used to treat Alzheimer's. g. Resident 11: one missed dose of Refresh Optive Ophthalmic Gel used to treat eye irritation. h. Resident 12: one missed dose of Clopidogrel used to treat stroke prevention; one dose of Donepezil used to treat Alzheimer's; one dose of Melatonin used to treat delayed sleep; one dose of Namenda used to treat dementia; and one dose of Hydraguard Silicone cream used to treat skin breakdown. i. Resident 13: one missed dose of Enulose Solution used to treat constipation. j. Resident 14: one missed dose of Tamsulosin used to treat enlarged prostate. k. Resident 15: one missed dose of Donepezil used to treat Alzheimer's. l. Resident 16: one missed dose of Acetaminophen used to treat pain. m. Resident 17: one missed doses of Cosopt Ophthalmic used to treat glaucoma; one dose of Melatonin used to treat delayed sleep; one dose of Memantine used to treat dementia; and one dose of Methylphenidate used to treat depression. n. Resident 18: one missed dose of Memantine used to treat dementia; one dose of Mirtazapine used to treat major depressive disorder; and one dose of Trazodone used to treat delayed sleep. o. Resident 19: one missed dose of bedtime skin cleanse treatment used to treat candidiasis of skin.