- Date
- 7/4/2026
- Report number
- CALMS - 00121419
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- Based on observations, interviews, and record reviews conducted during a site visit on 07/28/26, the facility failed to ensure implementation of services for 1 of 1 resident (#1) sampled. Findings include, but are not limited to:
Observations:
Resident 1 (R1) she/he was observed by compliance specialist exiting another resident’s room unsupervised, carrying a pair of shoes that were not her/his. R1 had put the shoes in a basket outside her/his room. R1 went into her/his room and closed the door. A staff member returned the shoes to the other resident’s room.
Record review:
- ALF/RCF Facility Safety Plan dated 07/13/26 indicated the facility would increase supervision and safety checks.
- R1's service plan last completed 06/04/26 and 07/13/26 under safety indicated she/he would have safety checks of 2-3 hours. Safety checks were not increased on 07/13/26 R1's her/his service plan but was indicated the facility would increase per safety plan.
- Incident report #3653 Elopement dated 07/04/26 indicated R1 eloped from the secured memory care facility, and she/he was an active exit seeker.
Interview(s):
- Staff 6 (Caregiver) stated R1 she/he was on two-hour checks but should have increased frequency as she/he was a very active exit seeker who frequently entered other residents’ rooms and removed their personal belongings and this could have caused conflict with other residents. Staff 6 believed that R1's care plan should be updated to help she/he with tasks for redirection. Staff 6 stated she/he think R1’s service plan should be updated for her/his anxiety.
- Staff 5 (Caregiver) stated R1 was on 2–3-hour safety checks and that was not enough for she/he as R1 was an active exit seeker. Staff 5 indicated R1 was often up most nights and she/he slept a lot of the day. Staff 5 indicated R1 was looking for snacks in the kitchen area, and she/he pulled very hard on locked cupboards causing damage. Staff 5 stated R1 had put things in the microwave that are not appropriate when she/he was unsupervised.
- R1 was not available for interview.
The facility’s failure to ensure implementation of services to meet resident’s needs is a violation of Oregon Administrative Rules.