- Date
- 8/18/2025
- Report number
- CALMS - 00086799
- Type
- Licensing Violation
- Level
- 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- Based on observation, interview, and record review, conducted during a site visit on 08/18/25, the facility’s failure to carry out medication and treatment orders as prescribed was substantiated for 1 of 1 sampled resident (# 1). Resident 1, who had a signed physician’s order for a mechanical soft diet, was served a regularly textured meal. This put Resident 1 at risk of choking and constituted an immediate jeopardy situation. Findings include but are not limited to: Resident 1’s physician orders, dated 05/16/25, indicated Resident 1 was to receive a mechanical soft diet. On 08/18/25, at approximately 11:45 am, Resident 1 was observed to have been served a firm sausage cut in approximately two to three-inch slices. This meal was inconsistent with a mechanical soft diet. On 08/18/25, at approximately 12:00 pm, Resident 1 stated s/he could not eat the food, and staff were supposed to have cut up his/her food, but they had not. On 08/18/25, at approximately 12:30 pm, Resident 1 was served a hamburger cut into quarters. Resident 1 stated s/he was unable to pick up and eat the hamburger. This meal was inconsistent with a mechanical soft diet. The facility’s failure to carry out medication and treatment orders as prescribed was substantiated. On 08/18/25 at 2:45pm, the LCU team requested an immediate plan of correction. An acceptable plan of correction was received from the facility on 08/18/25 at 5:03 pm. The immediate risk was addressed; however, the facility will need to evaluate the overall system failures associated with the licensing violation. The facility's failure is a serious violation of resident rights, which is a violation of Oregon Administrative Rules. Additional corrective action was taken concerning this case. ODHS issued condition, ALFCD25-00399, effective August 19, 2025.