- Date
- 11/20/2025
- Report number
- CALMS - 00095935
- Type
- Licensing Violation
- Level
- 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
- Allegation
- Failed to intervene when resident's condition changed
- Result
- Substantiated
- Findings
- Based on observation, interview and record review, the facility failed to communicate to staff on each shift what actions or interventions were needed for short-term changes of condition following hospital visits. Smoking interventions were not communicated to staff upon a residents return from the hospital after suffering second and third degree burns due to smoking in the facility with oxygen on. Staff were unaware a resident had returned, and a critical medication was not administered as prescribed. The facility’s failure is a violation of Oregon Administrative Rules.