Print Violation: 00108534-AP-083268

Provider Information

Gilman Grove Assisted Living

2205 GILMAN DRIVE
Oregon City, OR 97045

Date: 10/22/2020
Report number: 00108534-AP-083268
Type: Abuse: Neglect
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to follow care plan
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: 411-054-0036(2)(g)
Findings: On or about October 22, 2020, the Alleged Victim (AV) was found to have a laceration/ skin breakdown around his/her supra pubic catheter site. AV was care planned to have this/her catheter sponge replaced daily, which alleviates the pressure of the catheter. Facility staff was not replacing the sponge daily, leading to skin breakdown for AV, causing unreasonable discomfort. The facility failed to follow the care plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction: ALFCP21-03175 $500.00 fine assessed