- Date
- 6/13/2025
- Report number
- CALMS - 00109745
- 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 04/21/26 and 04/22/26, the facilities failure to ensure the implementation of services through evaluation and resident preference was substantiated for 1 of 1 sampled resident (# 1). Findings include, but are not limited to:
A record review of Resident 1’s service plan dated 09/23/25 indicated:
· Resident 1 required two-person assistance for transferring in and out for bathing;
· Required two-person assistance for commode both during the day and at night;
· For mobility and ambulation Resident 1 required two-person with bed mobility and repositioning; and
· Resident 1 required two staff members to move in recliner.
A record review of Resident 1’s service plan dated 09/23/25 indicated:
· Resident 1 fall intervention stated two person assistance using a gait belt for transfers;
· Resident 1 required two-person assistance for transferring in and out for bathing;
· Required two-person assistance for commode both during the day and at night;
· For mobility and ambulation Resident 1 required two-person with bed mobility and repositioning; and
· Resident 1 required two staff members to move in recliner.
A record review of Resident 1’s incident report dated 06/13/25 indicated:
· One care staff transferred Resident 1 into the wheelchair from the recliner. Resident 1 feet slipped and the wheelchair moved back and Resident 1 had a fall.
In an interview with Staff 9 and Resident 1. Resident 1 is a two-person transfer. The facility failed to ensure the implementation of services through evaluation and resident preference which is a violation of Oregon Administrative Rules.