- Effective date
- 12/26/2025
- End date
- 1/9/2026
- Reference number
- CALMS - 00096321
- Allegation
- Failed to provide safe environment
- Description
- Violation 1: The facility failed to provide a safe environment,STATEMENT OF FACTS: On or about December 22, 2025, the Alleged Victim (AV) had eloped from the facility unnoticed. At approximately 2:00 pm, the AV was found outside of the facility sitting in the grass with bruising and skin tears on their face. AVs family requested they be sent to the hospital for assessment and it was diagnosed with a fracture to their neck. On December 24, 2025, the AV passed away.CONCLUSION OF LAW: The facilitys failure is a violation of the following OARs:OAR 411-054-0027(1)(g) and (s)Violation 2: The facility failed to ensure working exit door alarms were in place at time of incident,STATEMENT OF FACTS: On or about December 22, 2025, the Alleged Victim (AV) had eloped from the facility unnoticed. At the time of the incident there was not a working exit door alarms in place on the door the AV eloped from.CONCLUSION OF LAW: The facilitys failure is a violation of the following OARs:OAR 411-054-0200(11)(b)
- Findings
- Facility failed to provide a safe environment
- Sanction
- RCFCD25-01492