- Date
- 10/15/2025
- Report number
- CALMS - 00093141
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to investigate injury of unknown origin to rule out abuse
- Result
- Substantiated
- Findings
- On 08/15/25, Resident 1 had been found on the floor lethargic, confused, his/her eyes were non-reactive, and s/he could not keep her eyes open. The facility’s investigation was dated 08/24/25, with administrator review dated 08/27/25;
On 08/16/25, Resident 1 was noted as having a bruise on his/her left thigh, with notes that s/he had received from the fall the day prior. The facility’s investigation was dated 08/24/25, with administrator review dated 08/27/25;
On 08/17/25, Resident 1 had suffered a fall with injury. The facility’s investigation was dated 08/24/25, with administrator review dated 08/27/25;
An incident report, dated 08/19/25, indicated Resident 1 had not received medication from 08/06/25 through 08/14/25. The facility’s investigation was dated 08/24/25, with administrator review dated 08/27/25;
On 09/03/25, Resident 1 was found on the floor of his/her room unresponsive, with the electrical cord from his/her oxygen concentrator wrapped around his/her neck. There was no documented evidence the facility had investigated the incident, nor was their administrator review of
the incident as of the site visit on 09/08/25.
The facility failed to promptly investigate all reports of abuse and suspected abuse with administrator review was substantiated, an investigation determined this is a violation of Oregon Administrative Rules.