- Date
- 6/25/2026
- Report number
- CALMS - 00118675
- Type
- Licensing Violation
- Level
- 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- Based on observation, interview, and record review conducted during a site visit on 06/25/26 the facility’s failure to exercise reasonable precautions against any condition that may threaten the health, safety, or welfare of Residents was substantiated for 1 of 1 sampled Resident (#2). Resident 2 was smoking in his/her room. This posed an immediate jeopardy situation that could threaten the health safety and welfare of Residents. Findings include but are not limited to:
On 06/25/26 at approximately 11:30 am, the following was observed inside Resident 2’s room:
· A strong odor of cigarette smoke;
· Two packs of cigarettes in his/her bedside nightstand; and
· A lighter, two cigarette butts and ash residue on his/her tray table.
Resident 2’s smoking agreement dated 10/09/25 stated Residents may not smoke in their apartment in any manner or inside the community.
Resident 2’s service plan dated 04/06/26 stated the following:
· Resident 2 had been provided the smoking policy and had signed the agreement;
· Resident 2 had a history of forgetting not to smoke in his/her room;
· Staff were to remind the Resident to smoke outside; and
· If staff happened to see or smell Resident 2 smoking, they were to ensure the cigarette was put out and re-direct Resident 2 outside; and
· Ensure all findings are documented in the progress notes.
Progress note dated 05/24/26 at 02:11pm indicated Resident 2’s room smelled like smoke.
Progress note dated 05/25/26 at 10:27 pm indicated Resident 2’s room had strong cigarette odor.
Progress note 05/26/26 at 09:51 pm indicated the following:
· Resident 2’s room had extremely strong smell of cigarette smoke;
· The entire hallway smelled of cigarette smoke; and
· Resident was not observed going outside to smoke.
Progress note dated 05/27/26 at 06:15 am indicated Resident 2’s room smelled like smoke.
Staff 2, Staff 3, Staff 4, and Staff 5 were interviewed and all stated Resident 2 smoked in his/her room every day and nothing had been done about it since the resident had moved in. There was no documented evidence that staff had re-directed Resident 2 to smoke outside or documented all Resident’s occurrences of smoking as specified in the Service Plan. Prior to completing the investigation, the facility had implemented a risk management agreement with Resident 1. On 06/25/26 at 01:47 pm the LCU team requested an immediate plan of correction. An acceptable plan of correction was received from the facility on 06/25/26 at 03:34 pm. The immediate risk was addressed; however, the facility will need to evaluate the overall system failures associated with the licensing violations. The facility’s failure to ensure reasonable precautions that threaten the health, safety, or welfare of residents is a violation of Oregon Administrative Rules.