Print Violation: 00065845-AP-047562

Provider Information

Gilman Grove Assisted Living

2205 GILMAN DRIVE
Oregon City, OR 97045

Date: 1/11/2020
Report number: 00065845-AP-047562
Type: Abuse: Neglect
Level: 3 - Moderate harm or potential for serious harm
Allegation: Failed to provide safe environment
Result: Substantiated
Rule(s) Violated: External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0027(1)(f) and (r)
External site: 411-054-0028(2)
External site: 411-054-0030(1)(e)(I)
External site: 411-054-0036(2)(g)
Findings: The facility failed to provide a safe environment and follow the care plan for the Alleged Victim (AV). The AV was care planned to be checked on every hour and to be escorted to dinner at 4:30 pm each day. On or about January 11, 2020, AV eloped from the facility campus, fell and sustained a fractured sacrum. The last time that staff saw AV was at 4:00 pm and did not know that AV was not at the facility when they were contacted by AV's family after 6:00 pm, advising that AV had been found approximately .8 miles away from the facility. The facility failed to follow the care plan and failed to provide a safe environment. The facility failures are a violation of resident rights, are considered neglect of care and constitute abuse.
Sanction: ALFCP20-00331 $338.00 fine assessed