- Date
- 12/23/2025
- Report number
- CALMS - 00097234
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- Based on observation, record review, and interview, the facility failed to ensure Resident #1’s service plan reflected the resident’s needs and preferences and provided clear direction to staff during a high-activity event. On or about December 23, 2025, the facility hosted a Christmas party from 2:00 p.m. to 3:30 p.m., resulting in increased visitor traffic. During the event, a contractor performing kitchen repairs propped open a service door to move hoses and cords, creating an unsecured exit point. At approximately 3:00 p.m. to 3:15 p.m., Resident #1 was observed walking around the unit. At about 3:30 p.m., law enforcement notified the facility that Resident #1 had been found outside the facility at a nearby restaurant. Review of Resident #1’s service plan revealed it did not address elopement risk or provide specific monitoring instructions for special events. The unsecured door and lack of event-specific supervision contributed to the resident’s exit from the facility. The facility's failure resulted in AV eloping the secured building, without staff knowledge which is a violation of Oregon Administrative Rules.