The company that operates the Gresham facility where a mental health aide worker was stabbed to death July 16 has been fined $7,250 by the Oregon Occupational Safety and Health Division for failing to protect employees from workplace violence.

A recent several-hundred-page inspection report revealed that a number of safety violations had taken place at the duplex-style independent living facility known as McCarthy Place, which is run by Cascadia Health.

Mental health aide Haley Rogers, 26, was working alone on an overnight shift when she was attacked by 59-year-old James Calvin Smith. Smith was a resident of the facility who been deemed “dangerous and psychotic” as far back as the late 1980s and had a history of violent attacks, including an assault charge that involved the use of a weapon in 2001.

The young woman’s family, who said she was not warned of Smith’s violent past and forced to work alone, believes the citation represents a small degree of accountability.

Smith faces charges of second-degree murder, unlawful use of a weapon and evidence tampering.

Rogers was one of two caregiver deaths covered by the Rogue Valley Times last year. Medford caregiver Bobbie Kolada was fatally injured while caring for a developmentally disabled man who had attacked her several times before.

State leaders have called for a response to the deaths of Rogers and Kolada, both of whom were working alone when attacked.

Rogers’ mother, Meshell Rogers, who is pursuing a civil case against Cascadia, said the result of OSHA’s inspection was validation that the company put her daughter and others at risk.

The inspection determined the nonprofit “did not provide the health hazard control measures necessary to protect the employees’ health from harmful or hazardous conditions,” and specifically “did not implement feasible measures to prevent or mitigate workplace violence in the form of employee assaults.”

Data included in the report provides insight into Rogers’ final shift.

Working alone in a two-part facility with capacity for up to 10 residents, Rogers was found by a shift change the morning of July 16 with dozens of stab and cut wounds. Rogers was found in the north wing, but blood was tracked to the south wing, where Smith lived.

A diagnosed schizophrenic, Smith experienced varying levels of paranoia and auditory hallucinations. Prior to living at the Cascadia facility, he had been remanded to the Oregon State Hospital, under jurisdiction of the Psychiatric Security Review Board. His 2001 weapons charge related to stabbing a stranger. Pleading unable to aid and assist, he was supervised by the board and released in 2011.

Over the following years, reports indicated an “increase in (Smith’s) psychiatric symptoms.” He had at least one stint in a crisis residential treatment facility.

In the weeks prior to attacking Rogers, Smith had been refusing medication and isolating. Staff reported Smith “not doing too good” on or around July 5. A site manager emailed Smith’s treatment team on July 12 to “initiate safety evaluation,” which resulted in a July 13 decision to wait and see. A case supervisor noted that Smith had “a tendency to decompensate at times and then come back to baseline.”

The day before Rogers was killed, staff noted Smith “glaring in an uncharacteristic and angry manner at staff.”

Factors that could have contributed to Rogers’ inability to escape her attacker included an inside door handle that had to be turned instead of pushed (a bar-style exit) to open, and single entry and exit points for the facility kitchen, meaning a client “could obstruct someone’s exit,” the report concluded.

A wooden “sharps” drawer, which contained knives and sharp kitchen utensils, had a gap between the top of the drawer and countertop. A large, sharp BBQ-style spatula was available to clients and used to pry the drawer open. Smith obtained from the drawer a knife that he used to stab Rogers.

Cascadia representatives, in an email to the Times, said they have implemented changes since Rogers’ death.

Stephanie Tripp, director of communications for Cascadia, said the company has budgeted $1 million toward “investing in safety-specific measures” over the next year and that the company hired an outside consultant to provide a safety assessment.

“Since July 17, 2023, all overnight shifts within Cascadia staffed housing have two staff,” Tripp said in an email.

To ensure staffing levels can be maintained, Cascadia is hiring for additional overnight positions and plans to hire a director of security. A full-time safety administrator was hired in recent months, and camera systems were installed in some of Cascadia’s facilities, with plans for potentially arming security staff as well as providing staff with personal alarms, intercoms and access control systems.

Meshell Rogers said the changes are a step in the right direction, although more is needed at the state level.

“I am disappointed that the death of my daughter wasn’t enough to make our state leaders do something, anything. … Out of nowhere, this man came and destroyed her, took her from all of us. She was a truly innocent victim. And the really sh***y part is that the people responsible for making sure that an individual could safely live in that ‘hands-off’ non-secure environment, they knowingly sent her there, alone, with no support, no backup, no emergency panic button, nothing,” Rogers said.

“No one with the capacity to aid heard her screaming or fighting for her life, because she was working alone.”

Rogers said she plans to attend a bail hearing March 22 and a jury trial, set to begin May 5, 2025.

Rogers said the union to which her daughter belonged — the American Federation of State, County and Municipal Employees — is lobbying for improved laws for caregivers.

“A friend from the union called me about doing a bill or a law or something. They wanted to know if it was OK to name it after Haley … a law to hold nonprofits accountability for staff safety,” Rogers said.

“I don’t think anybody should be allowed to forget or sweep it under the rug. Nobody should ever have to go to work and feel like it’s a possibility that, ‘I might be assaulted today,’ or, ‘I could be murdered today.””