Aging and People with Disabilities
Safety, Oversight and Quality
Print Violation: 00130314-AP-101873
Provider Information
Bonaventure of Gresham Assisted Living
22514 SE STARK
Gresham, OR 97030
- Provider ID
- 70A327
- Administrator
- Alexandra Whittlesey
- Phone
- (503) 328-0010
- executivedirectorgre@livebsl.com
Violation Details
- Date
- 2/18/2021
- Report number
- 00130314-AP-101873
- Type
- Abuse: Neglect
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide a safe medication administration system
- Result
- Substantiated
- Rule(s) Violated
-
External site: 411-054-0027(1)(f) and (r)
External site: 411-054-0028(2)
External site: 411-054-0055(1)(a) and (f)
- Findings
- Alleged Victim (AV) relies on the facility to administer his/her medications. AV had orders for 18 units of blood sugar medication every morning starting on or about January 27, 2021. The dose increased to 22 units every morning on February 12, 2021. AV was getting blood checks every morning and evening. On or about February 18, 2021, the facility stated they had not received the new order to increase AV’s blood sugar medication from 18 to 22 units. The facility was to notified AV’s doctor if his/her sugar was less than 70 and greater than 400. AV’s blood sugar was documented as 514 by the facility on February 18, 2021 and AV was transported to the hospital. The facility did not notify AV’s doctor about AV’s blood sugar reading over 400 on February 4th, 6th, 7th, 11th, and 13th, 2021. AV did not consistently receive his/her medication, including blood sugar medication and testing, in a timely manner. The facility failed to provide a safe medication administration system, which is a violation of resident rights, is neglect of care and constitutes abuse.
- Sanction
- ALFCP22-00374 $250.00 fine assessed