- Date
- 8/7/2026
- Report number
- CALMS - 00128984
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- Based on interview and record review, conducted during a site on 08/24/26, the facility’s failure to ensure the implementation of services was substantiated for 1 of 1 sampled resident. Findings include, but are not limited to:
Staff 2 stated the following:
· Facility video was reviewed and it showed Resident 1 (R1), not only exit seeking prior to elopement, but able to open the side door without using keypad code;
· R1 walked out into the side yard and out into the parking lot where care staff eventually saw R1 outside of the dining room window, before helping R1 back into facility; and
· There was no record of when care staff had eyes on R1 prior to R1’s exit-seeking and elopement.
Witness 1, in a phone interview on 08/24/26, stated the following:
· The door had possibly malfunctioned because of a power surge or glitch but W1 does not know for sure; and
· After W1 was notified about the elopement, the door was then upgraded to be equipped with a super magnetic lock which made the door more secure.
Staff 1, stated the following:
· All doors are checked when staff pass doors, at a minimum, hourly, on all shifts; and
· Staff 1 explained the procedure, when fire alarm or power failure occur, what care staff are to do to ensure residents’ health and safety.
A record review of R1’s Service Plan, dated 05/19/26, indicated the following:
· R1 has a history of exit-seeking during the day and night;
· R1 has a history of wandering throughout the building and into other residents’ rooms;
· Care staff are to be attentive to R1’s whereabouts, as R1 has attempted to exit the facility in the past; and
· Use interventions and redirection, as needed, to ensure R1’s health and safety.
A record review of a document titled "Doors, Locks and Alarms: Test Operation of Doors and Locks" indicated staff checked the following doors on 08/07/26:
· Front Entrance - 6:00 am, 11:00 am, 4:00 pm, 9:00 pm and 1:00 am;
· Interior Entrance - 6:00 am, 11:00 am, 4:00 pm, 9:00 pm and 1:00 am;
· Door by Room 2 - 6:00 am, 11:00 am, 4:00 pm, 9:00 pm and 1:00 am;
· Pass Through Door - 6:00 am, 11:00 am, 4:00 pm, 9:00 pm and 1:00 am;
· Exterior Pass-Through Door - 6:00 am, 11:00 am, 4:00 pm, 9:00 pm and 1:00 am; and
· Kitchen Exterior Door - 6:00 am, 11:00 am, 4:00 pm, 9:00 pm and 1:00 am.
The findings were reviewed with and acknowledged by Staff 2 on 08/24/26. The facility failure to ensure the implementation of services is a violation of Oregon Administrative Rules.