Based on interview and record review, conducted during a site visit on 08/22/25, the facility's failure to update an Acuity-Based Staffing Tool (ABST) was substantiated. Findings include, but are not limited to:

A review of the facility's posted staffing plan indicated the following:

·Side A:

oDay shift: Two caregivers and one shared med tech;

oSwing shift: Two caregivers and one shared med tech; and

oNight shift: One caregiver and one shared med tech.

·Side B:

oDay shift: Two caregivers and one shared med tech;

oSwing shift: Two caregivers and one shared med tech; and

oNight shift: One caregiver and one shared med tech.

A review of the facility's staff schedule from 08/16/25 through 08/22/25 indicated the facility had not scheduled two direct care staff at all times for residents who required the assistance of two direct care staff for scheduled and unscheduled needs.

An interview with Staff 1 (Executive Director) indicated both segregated sides had residents who required multiple-person transfers. There were four residents on side A and two on side B of the facility.

The findings of the investigation were reviewed and acknowledged by Staff 1.

The facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident; and the facility failed to incorporate the staffing requirements outlined in OAR 411-054-0070(1) in the posted staffing plan.