Print Violation: CALMS - 00119377

Provider Information

Gilman Grove Assisted Living

2205 GILMAN DRIVE
Oregon City, OR 97045

Date: 7/6/2026
Report number: CALMS - 00119377
Type: Licensing Violation
Level: 2 - Minor harm or potential for moderate harm
Allegation: Failed to provide a safe medication administration system
Result: Substantiated
Rule(s) Violated: 411-054-0055(1)(f)
Findings: Based on interview and record review, conducted during an investigation on 07/20/26, the facility’s failure to ensure medication and treatment orders must be carried out as prescribed was substantiated for 1 of 1 (#1) sampled resident. Findings include, but are not limited to: The following documents were reviewed: • Resident 1’s Service Plan dated 06/05/26; • Resident 1’s Hospital After Visit Summary dated 07/07/26; • Resident 1’s Progress Notes dated 07/01/26 – 07/20/26; and • Resident 1’s MAR dated 07/01/26 – 07/31/26. A review of Resident 1’s progress notes indicated s/he was given the wrong dose of h/h pain medication. On one occasion Resident 1 was given h/h morning dose of pain medication instead of the PRN dose as requested. On the second occasion Resident 1 was given h/h bedtime dose of pain medication instead of the PRN dose as requested. The facility’s failure to ensure medication and treatment orders are carried out as prescribed is a violation of Oregon Administrative Rules.