Gilman Grove Assisted Living

On or about August 25, 2023, the Alleged Victim (AV) noticed $300.00 missing from his/her room. AV's room did not have a lock box in his/her room. The facility failed to protect AV from financial exploitation, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) and Witness #1 (W1) are known to not get along with each other, have verbal altercations and W1 is known to be aggressive towards AV. On or about August 7, 2023, AV and W1 collided wheelchairs outside. W1 grabbed AV's arm and twisted it, leaving a red mark. The facility failed to provide a safe environment, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) reported to staff on March 26, 2023 that the Alleged Perpetrator #2 (AP2) requested massages and back scratches from the AV. AP2 admitted to receiving this physical contact from AV. AP2 had previously been disciplined by the facility for inappropriate behavior, however, the facility allowed AP2 to continue working at the facility, placing AV at risk for harm. AP2's actions are a violation of resident rights, are considered neglect of care and constitutes sexual harassment The facility's failure to provide a safe environment is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about March 21, 2023, the Alleged Victim's (AV) room flooded due to an overflowing toilet from above his/her room. AV's room and the items in it were very wet, including his/her bed. AV had to sleep in his/her bed, with the room and contents wet and smelling of sewage. Alleged Perpetrator #2 (AP2) was made aware of the situation by staff and told staff to change AV's sheets and have AV sleep in his/her room. AV was very distraught over this situation, felt dirty, experienced unreasonable discomfort and humiliation. AP2 and the facility failed to provide a safe environment for AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about March 12, 2023, the Alleged Victim (AV) was having his/her compression sock placed by staff. AV states that staff scratched his/her legs with staff's long fingernails while putting on compression socks. AV received a skin tear, which needed to be bandaged. Staff provided wound care to AV, however, AV's wound worsened and his/her leg began to swell, causing AV pain and unreasonable discomfort. AV was sent out to the hospital and diagnosed with an infected wound on his/her leg. The facility's failure to provide proper wound care is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) has a history of past sexual trauma. AV was to receive care from same gender staff only. Between February 2023 and March 2023, Alleged Perpetrator #2 (AP2), on at least three separate occasions, made requests for AV to have physical contact with him/her, which resulted in AV performing oral sex on AP2. AP2's actions are a violation of resident rights, are considered neglect of care and constitutes sexual abuse. The facility had reprimanded and suspended AP2 for inappropriate conduct and sexual harassment, however, AP2 was allowed to return to work. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is bed-bound, diabetic and is care planned for external toenail care. AV's nails are very thick and overgrown. The facility failed to ensure AV's nails were trimmed in a timely manner. The facility failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #1 (W1) is known to have aggressive behaviors and enter other residents rooms. On or about June 20, 2022, W1 entered the Alleged Victim's (AV) room when a caregiver unlocked AV's door. W1 yelled at AV who had been sleeping, and placed his/her hands around AV's neck attempting to strangle him/her. AV received an injury to his/her lip. The facility failed to provide a safe environment, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about May 9, 2022, the Alleged Victim (AV) engaged in an altercation with Witness #1 (W1) and Witness #2 (W2). The facility failed to provide a safe environment, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about November 23, 2021, the Alleged Victim (AV) pressed the call button as he/she needed to use the restroom. AV is known to have constipation and take medication to alleviate constipation. AV waited over an hour for staff to answer the call light, resulting in AV soiling him/herself, causing unreasonable discomfort. The facility's failure to answer the call light timely is a violation of resident rights, is considered neglect of care and constitutes abuse.

Based on interview and record review conducted during an investigation on 07/20/26, the facility’s failure to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each was substantiated. Findings include, but are not limited to: The facility’s posted staffing plan indicated: • For Day shift, 9 direct care staff; • For Swing shift, 8 direct care staff; and • For Night shift, 4 direct care staff. The facility’s staffing schedule dated 04/14/26 indicated the facility was not staffing to its posted staffing plan for 1 of 3 shifts reviewed. The facility’s failure to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident is a violation of Oregon Administrative Rules.

Based on interview and record review conducted during an investigation on 07/20/26, the facility’s failure to accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan in the Acuity-Based Staffing Tool (ABST) and complete or update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly as required was substantiated (for 1 of 1 sampled resident (# 1). Findings include, but are not limited to: Resident 1’s service plan, dated 03/27/26, indicated: • Requires hands on assistance for dressing dependent on current needs and pain status. • Staff performs scheduled treatments. • Requires assistance with cleaning and filing nails and applying lotion on shower days. • Requires limited assistance with toileting 1-2 times daily. In an interview, Staff 3 indicated s/he assists Resident 1 with help getting ready for bed. Resident 1’s ABST profile, last updated on 03/16/26, indicated: Zero minutes were assigned to resident’s ABST profile for: - Dressing and undressing; - Providing treatments; - Personal hygiene; and - Help with bowel and bladder management. The facility’s census was 99. A review of the facility’s last ABST evaluation update per resident indicated 11 of 99 residents had not been updated quarterly as required as of 04/05/26. The facility’s failure to accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan in the Acuity-Based Staffing Tool (ABST) and complete or update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly as required is a violation of Oregon Administrative Rules.

Based on interview and record review conducted during an investigation on 07/20/26, the facility’s failure to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident was substantiated. Findings include, but are not limited to: The facility’s posted staffing plan indicated: • For Day shift, 9 direct care staff; • For Swing shift, 8 direct care staff; and • For Night shift, 4 direct care staff. The facility’s staffing schedule dated 03/30/26 – 04/05/26 indicated the facility was not staffing to its posted staffing plan for 15 of 21 shifts reviewed. The facility’s failure to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident is a violation of Oregon Administrative Rules.

Based on interview and record review conducted during an investigation on 07/20/26, the facility’s failure to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each was substantiated. Findings include, but are not limited to: The facility’s posted staffing plan indicated: • For Day shift, 9 direct care staff; • For Swing shift, 8 direct care staff; and • For Night shift, 4 direct care staff. The facility’s staffing schedule dated 04/01/26 indicated the facility was not staffing to its posted staffing plan for 1 of 3 shifts reviewed. The facility’s failure to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident is a violation of Oregon Administrative Rules.

Based on interview and record review conducted during an investigation on 07/20/26, the facility’s failure to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each was substantiated. Findings include, but are not limited to: The facility’s posted staffing plan indicated: • For Day shift, 9 direct care staff; • For Swing shift, 8 direct care staff; and • For Night shift, 4 direct care staff. The facility’s staffing schedule dated 03/28/26 indicated the facility was not staffing to its posted staffing plan for 1 of 3 shifts reviewed. The facility’s failure to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident is a violation of Oregon Administrative Rules.

The facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

On or about July 4, 2025, the facility failed to have an Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population, their needs, and all required Activities of Daily Living (ADL). Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. Facility was not staffing to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

On or about July 4, 2025, the facility failed to have an Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population, their needs, and all required Activities of Daily Living (ADL). Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. Facility was not staffing to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.

On or about May 2, 2025, the Alleged Victim (AV) suffered from redness and pain and swelling to the left side of his/her neck from an Unknown Alleged Perpetrator #2 (AP2) who was assisting AV with taking off his/her shirt. AP2's actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility's failure to protect AV from physical abuse is a violation of Oregon Administrative Rules.

On or about May 2, 2025, the facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. A Licensing Complaint Unit (LCU) investigation determined this is a violation of Oregon Administrative Rules.

On or about April 23, 2025, the facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. A Licensing Complaint Unit (LCU) investigation determined this is a violation of Oregon Administrative Rules.

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.

On or about April 5, 2025, the facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. A Licensing Complaint Unit (LCU) investigation determined this is a violation of Oregon Administrative Rules.

On or about April 3, 2025, the facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. A Licensing Complaint Unit (LCU) investigation determined this is a violation of Oregon Administrative Rules.

On or about April 1, 2025, the facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. A Licensing Complaint Unit (LCU) investigation determined this is a violation of Oregon Administrative Rules.

On March 20, 2025, the facility discovered that staff failed to give Alleged Victim's (AV) anti-depressant medication to AV for 14 days. The facility is responsible for managing and administering AV's medications. AV did not have any side effects from missing the medication; however, the facility failed to provide a safe medication administration system for AV which is a violation of Oregon Administrative Rules.

The Alleged Victim (AV) requires assistance to and from the bathroom and also requires stand by assist while toileting. On or about September 29, 2024, Alleged Perpetrator #2 (AP2) was assisting AV in the bathroom and left AV alone. While alone, AV attempted to stand by him/herself and fell backwards onto the toilet. When AV fell backwards, the tank to the toilet broke. When staff were checking AV for injury, they found a skin tear on AV's arm. AP2's failure to follow the care plan is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility's failure is a violation of Oregon Administrative Rules.

On or about July 27, 2023, staff became aware that the Alleged Victim's (AV) bank card was being used for unauthorized withdrawals. On or about July 28, 2023, Alleged Perpetrator #2 (AP2) admitted to taking AV's debit card without AV's knowledge, used it for shopping and withdrew money from an ATM totaling over $5,000.00 over a 9 month period. AP2's actions are a violation of resident rights, are considered neglect of care and constitute financial abuse. The facility's failure is a violation of Oregon Administrative Rules.

On or about June 15, 2023, the Alleged Victim (AV) reported to staff that his/her wallet was missing. Alleged Perpetrator #2 (AP2, Unknown) took AV's wallet. AP2's actions are a violation of resident rights, are considered neglect of care and constitute financial exploitation. The facility failed to protect AV from financial exploitation, which is a violation of Oregon Administrative Rules.

On or about March 17, 2023, Alleged Perpetrator 2 (AP2) administered another resident's medication to Alleged Victim (AV) due to AP2 being distracted. AV experienced light headiness and increased urination, causing AV unreasonable discomfort. 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.

The Alleged Victim (AV) had three rings go missing between February 1, 2023 and February 4, 2023. AP4 (Unknown) took the rings from AV. AP4's actions are a violation of resident rights, are considered neglect of care and constitute financial abuse. The facility's failure to protect AV from financial abuse is a violation of Oregon Administrative Rules.

According to documentation, Alleged Perpetrator 2 (AP2) failed to provide a safe medication administration system. The failure resulted in the Alleged Victim (AV) receiving another resident’s medication, experienced a fall when ambulating and went to the hospital for evaluation, which is a violation of resident rights and considered neglect. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.

On or about November 1, 2022, the Oregon Health Authority reported to the Department that Respondent failed to comply with weekly reporting requirements of vaccinated individuals, residents and staff, to the proper authority as required by law. This failure has been ongoing from October 1, 2022 to October 31, 2022, for a total of 30 days.

The facility failed to provide direct care staff sufficient in number to meet the scheduled and unscheduled needs of the residents, which is a violation of Oregon Administrative Rules.

The facility failed to carry out medication and treatment orders as prescribed, which is a violation of Oregon Administrative Rules.

On or about October 1, 2022, the Oregon Health Authority reported to the Department that Respondent failed to comply with weekly reporting requirements of vaccinated individuals, residents and staff, to the proper authority as required by law. This failure has been ongoing from September 1, 2022 to September 30, 2022, for a total of 30 days.

On or about September 4, 2022, the Alleged Victim (AV) was in his/her room and his/her call pendant was not within reach. AV could not call for assistance and waited for a while for any staff to find AV. AV is care planned to have his/her pendant near him/her at all times. Alleged Perpetrator #2 (AP2) failed to place AV's pendant near him/her. AP2's actions are a violation of resident rights, are considered neglect of care and constitute involuntary seclusion. The facility failed to protect AV from involuntary seclusion, which is a violation of Oregon Administrative Rules.

The facility failed to verify direct care staff have demonstrated satisfactory performance in any duty they are assigned, which is a violation of Oregon Administrative Rules.

The facility failed to keep the interior free from unpleasant odors and all interior surfaces clean, which is a violation of Oregon Administrative Rules.

The facility failed to implement effective methods to responding to and resolving resident complaints, which is a violation of Oregon Administrative Rules.

The facility failed to maintain all interior and exterior materials and surfaces (e.g. floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident must be kept clean and in good repair in accordance with OAR 411-054-0300(4)(i) Per a complaint that the resident's ceiling has black mold growing and an unrepaired hole.

The facility failed to develop and implement effective methods of responding to and resolving resident complaints in accordance with OAR 411-054-0025(7)(c) Per a complaint that the resident's request to repair damage has been ignored.

The facility allegedly failed to communicate necessary information, which is a violation of Oregon Administrative Rules.

The facility failed to have enough staff to meet the scheduled and unscheduled needs of the residents, which is a violation of Oregon Administrative Rules.

The facility failed to have sufficient staff to meet the scheduled and unscheduled needs of the residents, which is a violation of Oregon Administrative Rules.

The facility failed to carry out medication orders as prescribed which is a violation of Oregon Administrative Rules.

The facility failed to exercise reasonable precautions against any condition that may threaten the health, safety, or welfare of residents, which is a violation of Oregon Administrative Rules.

The facility failed to develop and implement effective methods of responding to and resolving resident complaints, which is a violation of Oregon Administrative Rules.

The facility failed to ensure all interior and exterior materials and surfaces (eg floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of residents must be kept clean and in good repair, which is a violation of Oregon Administrative Rules

The facility failed to keep an accurate Medication Administration Record. Medication administration records were signed by a staff member other than the one that administered the medications, which is a violation of Oregon Administrative Rules.

The facility failed to complete service plans quarterly, which is a violation of Oregon Administrative Rules.

On or about February 4, 2022, it was discovered that the Alleged Victim's (AV) Wedding Ring was missing from his/her hand. Hospice, Staff and Family all deny removing AV's ring from his/her hand, and all state that it could not have fallen from AV's hand, due to his/her knuckles being large, it would have had to be removed. An investigation determined the ring was taken by an unknown individual, Alleged Perpetrator #2 (AP2). AP2's actions are considered neglect of care and constitutes Financial abuse. The facility failed to protect AV from financial abuse, which is a violation of Oregon Administrative Rules.

The facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. The failure is a violation of Oregon Administrative Rules.

The facility failed to exercise reasonable against any condition that may threaten the health, safety, or welfare of residents, The failure is a violation of Oregon Administrative Rules.