- Date
- 4/29/2025
- Report number
- CALMS - 00080701
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to use an ABST
- Result
- Substantiated
- Findings
- Based on interview and record review, conducted during a site visit on 05/07/25, the facility's failure to maintain an accurate Acuity-Based Staffing Tool (ABST) was substantiated for 1 of 1 sampled resident (#1). Findings include, but are not limited to:
During a Compliance Specialist's (CS) onsite visit on 05/07/25, Resident 1 was out of the facility at the local hospital. The CS was unable to interview Resident 1 or make observations during the site visit. Resident 1’s service plan, dated 02/05/25, indicated the following: The resident used his/her call light pendant for assistance; and Staff to assist the resident with soaking the right foot for 10 minutes twice daily. Interviews with Staff 1 (Executive Director) and Staff 5 (Med Tech) were conducted. Staff 1 and Staff 5 indicated Resident 1 used his/her call pendant when s/he needed assistance. Staff 5 indicated that providing treatment for wound care took more than 6 minutes to complete. Resident 1’s ABST evaluation indicated the following:
There was no time allotted for responding to call lights; and the time allotted for treatments (e.g., skin care, wound care, and antibiotic treatment) was only 6 minutes twice daily. The facility’s ABST evaluation for Resident 1 did not accurately capture care time for needs reflected in the service plan.
The facility failed to fully implement an Acuity-Based Staffing Tool (ABST). Time and frequency were unable to be determined by the facility's current internal assessment tool for all required 22 ADLs with staff time required to complete the care needs. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action was taken on related allegation.