Print Violation: 00153913-AP-121928

Provider Information

Gilman Grove Assisted Living

2205 GILMAN DRIVE
Oregon City, OR 97045

Date: 6/28/2021
Report number: 00153913-AP-121928
Type: Licensing Violation
Level: 3 - Moderate harm or potential for serious harm
Allegation: Failure to provide a system that prevents theft or misuse of medication
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: 411-054-0055(1)(a) and (f)
Findings: On or about June 28, 2021, it was discovered that the morphine for the Alleged Victim (AV) had been diluted. Staff noticed it changed from a hot pink color to a pale pink color. Also, AV had been complaining that his/her pain had not been alleviated by the normal dose of pain medication. On or about June 29, 2021, all Medication Technicians at the facility were drug tested, and all were negative except Alleged Perpetrator #2 (AP2). AP2's actions caused unreasonable discomfort for AV. AP2 is responsible for theft of medication, which is a violation of resident rights, is considered neglect of care and constitutes financial abuse. The facility failed to ensure AV's medication was safe, which is a violation of Oregon Administrative Rules.