Print Violation: 00468948-AP-421285

Provider Information

Redwood Terrace

3111 CANAL AVENUE
Grants Pass, OR 97527

Date: 4/8/2026
Report number: 00468948-AP-421285
Type: Licensing Violation
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to follow care plan
Result: Substantiated
Rule(s) Violated: 411-054-0025(1)(a) and (b)
411-054-0027(1)(g) and (s)
411-054-0028(2)
Findings: The Alleged Victim (AV) relies on the facility for their care. The AV had an order to have dressing changed by facility staff on Saturday. According to an investigation, Alleged Perpetrator 2 (AP2) did not change AV’s dressing, but marked that they did. As a result, AV went for approximately four days without their dressing being changed causing AV’s wound to smell and increase in size. AV was transported to urgent care and prescribed two different types of antibiotics for the infected wound. AP2’s action is considered neglect of care, which constitutes abuse as defined in OAR 411-020-0002(1)(b)(A)(i). The facility failed to ensure the care plan was followed, which is a violation of Oregon Administrative Rules.