Print Violation: 00393804-AP-344486

Provider Information

Gilman Grove Assisted Living

2205 GILMAN DRIVE
Oregon City, OR 97045

Date: 4/5/2025
Report number: 00393804-AP-344486
Type: Licensing Violation
Level: 3 - Moderate harm or potential for serious harm
Allegation: Failed to provide a safe medication administration system
Result: Substantiated
Rule(s) Violated: External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0055(1)(a) and (f)
Findings: Alleged Perpetrator 2 (AP2) failed to ensure The Alleged Victim’s (AV) medications were administered as ordered. Based on facility documentation and interviews, AP2 failed to administer correct medication to AV, on or about April 5, 2025. As a result of AP2's error, AV experienced adverse reactions to taking the wrong medication which resulted in AV being hospitalized. AP2's actions is considered neglect of care which constitutes abuse. The facility failed to provide a safe medication administration system for AV which is a violation of Oregon Administrative Rules.