Print Violation: 00350498-AP-300914

Provider Information

Bonaventure of Gresham Assisted Living

22514 SE STARK
Gresham, OR 97030

Date: 8/15/2024
Report number: 00350498-AP-300914
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)(g) and (s)
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. On or about August 15, 2024, AV was admitted to hospice. Hospice sent the facility orders for a medication change on August 16, 2024, for (pain medication) which was to be administered 30 minutes prior to all cares, including transfer and any bedbound care. Hospice visited AV on or about August 21, 2024, and noticed the facility was not giving AV the (pain medication) prior to repositioning, which was causing AV pain. On or about August 23, 2024, hospice continued to see inconsistent (pain medication) administration and provided the facility with a medication order change. The facility failed to provide a safe medication administration system for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.
Sanction: ALFCP24-01139 $500.00 fine assessed