- Date
- 4/29/2025
- Report number
- CALMS - 00085047
- 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 05/05/25, the facility's failure to fully implement and maintain an acuity-based staffing tool (ABST) was substantiated for 1 of 1 resident (# 2). Findings include but are not limited to: A review of Resident 2's service plan, dated 02/26/25, and progress notes, dated 04/04/25 – 05/05/25, indicated resident had been placed on two-hour checks. A review of resident’s ABST profile did not indicate any time allotted to resident safety checks. In an interview on 04/08/25, Staff 1 stated Resident 2 had been placed on safety/wellness checks recently for suicidal ideations and the passing of a friend. The facility’s posted staffing plan and ABST were reviewed and compared with the facility’s staff schedule from 04/28/25 – 05/04/25 which indicated the facility was not consistently staffed to the posted staffing plan by at least one care staff for seven of 42 shifts reviewed.
A review of facility’s ODHS ABST indicated six residents' evaluations had not been updated quarterly, as required. The facility failed to fully update the residents' ABST evaluations no less than quarterly, failed to accurately capture care time and care elements that staff are providing to each resident; and failed to provide direct care staff sufficient in number to meet the unscheduled needs of each resident. Findings were reviewed with and acknowledged by Staff 1, and Staff 4. The facility failure is a violation of Oregon Administrative Rules. Corrective Action has been taken.