- Date
- 6/14/2026
- Report number
- CALMS - 00128541
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- Based on record review and interview, conducted during a site visit on 08/11/26, 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: Review of Resident 1’s service plan dated 06/17/26, physician’s report dated 08/12/25, charting notes dated 05/07/26 through 08/11/26, and incident investigation report dated 06/23/26 indicated the following:
Resident 1 was diagnosed with major neurocognitive disorder;
Resident 1 was diagnosed as confused/disoriented;
Resident 1 had cognitive impairments;
Resident 1 was not able to leave the facility unassisted;
Resident 1 left the facility unassisted on 6/13/26;
Resident 1 fell asleep at a bus stop and could not find their way home; and
Resident 1 was returned to the facility by a public transportation employee on 06/14/26.
Resident 1 stated in an interview that they were new to the facility, it was a new neighborhood, they got disoriented and the bus driver had to bring them back to the facility.
In separate interviews, Staff 2, Staff 3, Staff 4, Staff 5, and Staff 6 each stated Resident 1 leaves the facility unassisted on a regular basis; they also stated there was an incident in 06/2026 where resident 1 left the facility unassisted, got disoriented, and the resident needed assistance from a community member to get back to the facility. In an interview, Staff 2 and Staff 3 acknowledged the physician’s report dated 08/12/25 and Resident 1’s service plan dated 06/17/26 indicated the resident was not able to leave the facility unassisted. Because Resident 1’s service plan stated they were not able to leave the facility unassisted and the Resident left the facility unassisted on 06/13/26, the facility’s failure to ensure the implementation of services is a violation of Oregon Administrative Rules.