- Date
- 3/20/2025
- Report number
- CALMS - 00089168
- 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 09/12/25, the facility's failure to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident was substantiated for 1 of 4 sampled residents (# 2). Findings include, but are not limited to: A review of the posted staffing plan indicated the following:
· Day shift: eight direct care staff;
· Swing shift: eight direct care staff; and
· Night shift: three direct care staff.
A review of staffing schedules dated 03/13/25 through 03/20/25 indicated the following:
· Schedules unavailable or not provided for 03/17/25-03/18/25.
· Facility was short-staffed by one direct care staff on 03/13/25.
Call light response times for Resident 2 on 03/20/25 indicated three calls between 20 and 45 minutes.
In an interview, Resident 2 stated the following:
· There was not enough staff;
· Call lights took 30-45 minutes;
· Sometimes medications were late;
· Laundry was not getting done weekly; and
· “Sometimes I'll sit on the toilet for over 20 minutes waiting for them”.
In separate interviews, Staff 1 (Executive Director), Staff 2 (Wellness Director, Staff 3 (Med Tech), Staff 4 (Med Tech), and Staff 5 (MT) stated the following:
· Not enough staff to do two-hour checks;
· Call lights could take 45 minutes to an hour;
· Laundry and dishes were not getting done;
· Staffing was off because the ABST (Acuity-Based Staffing Tool) was off;
· Call lights were not being monitored in the past unless residents brought up a concern; and
· Showers were not getting done.
The facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules. Corrective Action taken on related allegation.