OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING (b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average. (c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. (d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1). (e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule. (f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. (g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to complete an acuity-based staffing tool (ABST) that accurately captured care time and care elements that staff were providing to each resident as outlined in each individual service plan for 3 of 4 sampled residents (#s 1, 2, and 3) whose ABST records were reviewed. Findings include, but are not limited to: Resident 1, 2, and 3’s service plans, Interim Service Plans (ISPs), and corresponding ABST individual minutes were reviewed. The residents were observed, and interviews were conducted with staff. The residents’ ABST evaluated care times and care elements were found to not be reflective in one or more of the following areas: * Bowel and bladder management; * Dressing; * Personal hygiene; * Grooming; * Safety checks; * Ambulation; * Repositioning; * Assisting with leisure activities; * Communication; * Transfers; and * Call lights. The need to ensure the facility ABST accurately captured care time and care elements that staff were providing was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (LPN), Staff 26 (Regional RN), and Staff 27 (Regional RN) on 11/13/25. They acknowledged the findings.

ABST was reviewed and updated for Resident #1, #2, and #3 at the time of the survey to correct noted discrepancies. ABST has been assigned to the LPN for review, as the LPN has more direct knowledge of the residents’ needs, which will help increase the accuracy of information in the ABST tool. ABST reviews are completed as part of service plan and evaluation updates, as well as whenever there are significant changes in a resident’s condition. Executive Director will audit the ABST tool weekly for the first 30 days and every two weeks thereafter. A sample of residents will be reviewed to ensure that the care being provided on the floor aligns with what is documented in the service plan and ABST. Executive Director is responsible for ensuring that all corrections are completed and monitored.