- Date
- 4/1/2025
- Report number
- CALMS - 00079845
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide service
- Result
- Substantiated
- Findings
- The findings contained in this report are in response to Condition No. RCFCD24-00266, following the facility's assertion of compliance on 04/01/25.
Based on observation, interview, and record review, conducted during a site visit on 04/17/25, the facility’s failure to ensure the service plan reflected the residents’ needs and to ensure the implementation of services was substantiated for 3 of 4 sampled residents (#s 2, 3, and 4). Findings include, but are not limited to:
1. Resident 2’s physician orders, dated 03/04/25, indicated s/he required a pureed diet. Resident 2’s service plan, dated 02/28/25, indicated s/he was to receive a mechanical soft diet.
2. Resident 3’s service plan, dated 02/07/25, indicated s/he used a wheelchair as an assistive device and was to be evacuated in a wheelchair in case of emergency. Resident 3 was not observed to have a wheelchair. Staff 3 stated Resident 3 did not have a wheelchair.
3. Resident 4’s service plan, dated 01/27/25, indicated s/he required two staff members to assist him/her with transferring. At approximately 11:00 am, Staff 16 requested assistance toileting Resident 4 over the radio. At approximately 11:03 am, Staff 16 stated Resident 4 needed his/her briefs changed. A second staff member did not assist Staff 16 with Resident 4’s needs until approximately 11:39 am.
It was determined the facility’s failure to ensure the service plan reflected the residents’ needs and ensure the implementation of services was substantiated. The findings of the investigation were reviewed with and acknowledged by Staff 1, Staff 2, Staff 3, Staff 4, Staff 5, and Staff 6. An investigation determined this is a violation of Oregon Administrative Rules.