- Date
- 7/11/2026
- Report number
- CALMS - 00119110
- 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 07/20/26, the facility’s failure to ensure the implementation of services was substantiated for 1 of 1 sampled resident (#1). Findings include, but are not limited to: During a facility walkthrough and window audit, on 07/20/26, all resident apartment windows had window locks installed. Resident 1 was observed resting in a chair in the common area. A record review of Resident 1's Service Plan dated 06/30/26, indicated Safety Checks twice a shift. A review of the Safety Check record for 07/11/26 indicated safety checks had occurred according to the Service Plan. The Service Plan was updated on 07/20/26 to indicate increased safety checks every 2 to 3 hours. A review of Resident 1's Progress Notes dated 07/11/26, indicated an Interim Service Plan (ISP) was initiated for the functional area to monitor for behaviors. The ISP Note indicated the change was frequent safety checks, which was concurrent with existing service plan instructions. There was not an Interim Service Plan generated for staff to review new interventions for the incident. Staff 2 indicated that s/he will retrain staff on how to correctly implement an Interim Service Plan. Staff 2 stated when s/he went to check Resident 1's apartment, the window locks had been removed, and both windows were all the way up and the screen in the window on the left-hand side was torn. Staff 2 indicated that s/he conducted an audit of all windows after the incident and found no other windows that were missing locks. The facility's failure to ensure the implementation of services is a violation of Oregon Administrative Rules.