- Date
- 7/28/2026
- Report number
- CALMS - 00121424
- 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 review conducted during a site visit on 07/28/26, the facility failed to maintain reasonable precautions against conditions that could threaten the health, safety, or welfare of residents. This issue was substantiated for 1 of 1 sampled residents (#1). Findings include, but are not limited to the following:
A review of Incident Report #3653 dated 07/04/26 regarding the elopement of Resident 1 (R1) indicated that she/he exited the secured unit by following a visitor out of the main door unnoticed by Staff. Staff became aware of the elopement after a visitor outside the building notified staff inside the building, Additinal information indicated in the report, R1 is continuously and actively trying to leave the community and she/he wanders, roams and looks for people/things that are not there.
Observations:
The door alarm for the main entrance to the Memory Care unit was observed plugged into a hallway outlet. Staff 2 (Med Tech) reported that when residents unplugged the alarm and staff reconnected it, the alarm volume would reset to the lowest level unless manually adjusted. At the lowest level the alarm could not be heard if not in the immediate area where the alarm was placed.
The south door was observed to have an 8-second delay before locking after closing and did not have a functioning audible alarm. This door led to a hallway connecting to an elevator on the east side and a hallway on the west side that exited outside near the dumpster and parking lot. R1 was known as an active exit seeker, and she/he would often try to open doors.
Maintenance staff adjusted the timing of the south door to lock within 3 seconds after the code was entered. This adjustment appeared reasonable to ensure the door locked promptly after staff or visitors exited and could not be opened again without the code.
Staff Interviews:
Staff 1 (Regional Director) stated she/he was unaware that the south Memory Care door had an extended delay before locking after code entry. Staff 1 indicated she/he would work with maintenance to put covers over the alarms in the hallway and have batteries checked frequently to prevent alarm failure.
Staff 2 (Med Tech) stated that the door R1 exited to where she/he was found in the parking lot was typically locked without delay but acknowledged that there had been occasions when it did not. Staff 2 reported that residents sometimes unpluged the door alarms and that, when reconnected, the alarms reset to a low volume unless staff adjusted them.
Staff 3 (Life Enrichment Coordinator) stated that the main door had a delay before locking after someone entered or exited. Staff 3 believed that the south door alarm battery needed replacement.
Staff 5 (Caregiver) stated that the door where R1 exited when she/he had eloped did not lock immediately upon closing on the day of the elopement. Staff 5 reported that door the alarms sometimes failed due to battery issues. Staff 5 notified management, and maintenance subsequently adjusted the door lock timing and replaced the alarm battery.
The facility failed to ensure reasonable precautions were taken to protect the resident from conditions when a resident eloped from the facility by providing secure doors that locked timely to prevent resident from following visitors out of the facility and having functioning door alarms is a violation of Oregon Administrative Rules.