- Date
- 9/11/2025
- Report number
- CALMS - 00094262
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- Based on interview and record review, conducted during a site visit on 11/04/25, the facility’s failure to ensure the service plan must reflect the resident’s needs was substantiated for 1 of 1 sampled resident (#1). Findings include, but are not limited to: A progress note dated 08/15/25 at 11:16 am, indicated the following:
· Resident 1 is yelling out over and over, wanting to exit the community in her car; and
· Resident 1 is un-redirectable.
A progress note dated 08/17/25 at 07:08 pm, indicated the following:
· Resident 1 is yelling and screaming; and
· Resident 1 was given water and toileted, and resident continued yelling.
An incident report dated 09/11/25, indicated resident was struggling with behaviors yelling and screaming. Resident 1’s service plan dated 06/17/25, indicated the following for behaviors:
· Care staff are to report any and all behaviors to MT on duty so they can get it into the chart; and
· Exhibits normal, functional behavior patterns.
Staff 1 stated:
· Staff 2 takes Resident 1 on walks as an intervention for behaviors;
· S/he was aware Resident 1’s service plan did not document interventions for behaviors. The investigation determined the facility failed to ensure the service plan must reflect the resident’s needs which is a violation of Oregon Administrative Rules.