- Date
- 5/21/2026
- Report number
- CALMS - 00114248
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- Based on observation, interview, and record review, conducted during an investigation on 06/08/26, the facility’s failure to have service plans available to staff and provide clear direction regarding delivery of services was substantiated. Findings include, but are not limited to: During the investigation, the Temporary Service Plan (TSP) binder was observed not to have contained Resident 1’s service plan dated 05/22/26 or a TSP following Resident 1’s elopement on 05/21/26. In an interview, Staff 3 and Staff 4 stated they were not present during Resident 1’s elopement on 05/21/26 and did not recall seeing a TSP regarding Resident 1’s elopement in the TSP binder. And they did not know about the elopement on 05/21/26 until the Department investigation on 06/08/26.
In an interview, Staff 1 and Staff 5 stated they suspected Resident 1’s service plan, and the TSP was in the locked office of a staff member who was not at the facility during the investigation. On 06/09/26 an electronic communication from Staff 1 was received by the Department. Staff 1 confirmed Resident 1’s Service Plan had been locked in the staff member’s office and provided Resident 1’s Service Plan dated 05/22/26 and Resident 1’s TSP dated 05/21/26 regarding the elopement. The TSP had not been signed by Staff 3 or Staff 4. And the Service Plan had not been signed by Staff 4. The facility's failure to have service plans available to staff and provide clear direction regarding delivery of services is a violation of Oregon Administrative Rules.