- Date
- 3/14/2025
- Report number
- CALMS - 00085041
- 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 04/08/25, the facility’s failure to consistently have qualified direct care staff, sufficient in number to meet the 24-hour scheduled an unscheduled need of each resident was substantiated. Findings include but are not limited to: Staff 1 stated the facility utilized the ODHS ABST, and the census was 38. There were two residents who were not updated quarterly in the ABST. The facility's specific needs contract, dated 06/07/24, indicated when the facility was at full capacity for specific needs contract residents, which was 36 residents, the facility was required to staff a minimum of 12 direct care staff on day and swing shifts, and a minimum of seven direct care staff on night shift.
The facility’s posted staffing plan indicated there were two med techs and six caregivers scheduled for day and swing shifts, and one med tech and four caregivers for night shift. The posted staffing plan did not account for the facility's specific needs contract. A review of the facility’s staff schedule, dated 03/08/25 through 03/14/25, indicated the facility was not staffing according to their posted staffing plan for 12 of 21 reviewed shifts, or 57.14% of the shifts reviewed. Of the 21 reviewed shifts, the facility was not staffing to their specific needs contract 100% of the time. The facility’s failure to consistently have qualified direct care staff, sufficient in number to meet the 24-hour scheduled an unscheduled need of each resident was substantiated.
?The findings of the investigation were reviewed with and acknowledged by Staff 1, Staff 2, and Staff 3 via phone. The facility's failure is a violation of Oregon Administrative Rules. Corrective Action has been taken.