Aging and People with Disabilities
Safety, Oversight and Quality
Print Violation: CALMS - 00118673
Provider Information
Stephanie Gardens Residential Care
19751 SE STARK ST
Portland, OR 97233
- Provider ID
- 50R503
- Administrator
- Jason Wart
- Phone
- (971) 292-2265
- ed@stephanieresidential.com
Violation Details
- Date
- 6/11/2026
- Report number
- CALMS - 00118673
- Type
- Licensing Violation
- Level
- 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Rule(s) Violated
-
411-054-0025(1)(a) and (b)
411-054-0036(2)(g)
- Findings
- Based on observations, interviews, and record reviews conducted during the 6/6/2026, site visit, the facility failed to implement required services for Resident 1, the sole sampled resident. Resident 1 was injured when staff did not follow the Service Plan and failed to intervene when Resident 1’s smoking created an immediate safety risk. Findings include: Service Plan dated 06/10/26: • Resident 1 admitted on 06/11/26. • Staff were required to intervene when smoking or vaping posed an immediate safety risk. • Staff were required to assist Resident 1 in preparing smoking materials. Incident Report – 06/11/26: • At approximately 12:15 p.m., a caregiver escorted Resident 1 to the smoking area. • Resident 1 did not have a lighter and grabbed one from another resident. • Resident 1 lit a cigarette while still wearing oxygen, resulting in Resident 1 catching on fire. • Staff extinguished the fire and provided care. Staff 10 Interview: • Resident 1 had moved in only 15 minutes earlier and wanted to smoke. • Staff 11 left to retrieve Resident 1’s cigarettes, leaving Staff 10 with Resident 1. • Staff 10 had not yet been oriented to Resident 1 or the Service Plan and was unaware of Resident 1’s impulsive behaviors. • Resident 1 quickly took another resident’s lighter and cigarette and ignited it before staff could intervene. • Resident 1’s oxygen was still on, causing the fire. • Staff 10 assisted and extinguished the fire. Staff 1 Interview: • Reported that all direct care staff received orientation on Resident 1’s Service Plan and smoking the day before move-in. Staff Interviews: • All reported they were not oriented to Resident 1’s Service Plan and were unaware of Resident 1’s smoking needs prior to move-in. Documentation Review: • No evidence was found that Staff 10 was oriented to Resident 1 or the Service Plan before providing care. Observation – 06/25/26 at 1:05 p.m.: • Multiple staff were observed yelling “stop” and running to the smoking area. • Resident 1 held an unlit cigarette. • Staff intervened before it was lit. • Staff 1 was seen walking inside with Resident 1’s oxygen tubing. Incident Report – 06/25/26 at 1:05 p.m.: • Resident 1 asked another resident for a cigarette in the smoking area. • No staff were present at the time. • Staff intervened and found Resident 1 with a cigarette and lighter. • Resident 1 had a cannula around the neck but no oxygen tank in place. • A caregiver arrived, provided supervision, and Resident 1 was allowed to smoke. Staff 1 Interview – 06/25/26: • Resident 1 went to the smoking area without staff knowledge or escort. • Resident 1 should have been escorted and supervised. • Resident 1 obtained a lighter and cigarette from another resident. • Staff intervened before the cigarette was lit. • Resident 1 had a cannula on but no oxygen connected, and Staff 1 stated Resident 1 was not in danger. • Staff 1 returned the oxygen tubing to Resident 1’s apartment. Service Plan dated 06/12/26: • Staff must assist Resident 1 in getting to the smoking area. • Staff must monitor Resident 1 at all times during smoking due to impulsive behaviors that pose safety risks. • Resident 1 has a history of lighting their face on fire while smoking with oxygen. • Staff must ensure oxygen is off and tubing removed before Resident 1 lights a cigarette. At 1:47 p.m. on 06/25/26, the LCU team requested an immediate plan of correction. The facility submitted an acceptable plan at 3:34 p.m. The immediate risk was addressed; however, the facility must evaluate broader systemic failures related to these licensing violations. The investigation determined staff failed to follow Resident 1’s Service Plan regarding smoking safety. On 06/11/26, staff did not intervene when smoking posed an immediate risk, resulting in Resident 1 catching fire. On 06/25/26, Resident 1 accessed the smoking area unsupervised, obtained smoking materials from another resident, and attempted to smoke with oxygen tubing around the neck. Documentation confirmed no staff were present, despite the requirement for staff escort and monitoring. The facility's failuire to ensure the implementation of services for Resident 1, caused serious harm to Resident 1 which is a violation of Oregon Administrative Rules.