- Date
- 4/30/2025
- Report number
- CALMS - 00089171
- 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 (# 1). Findings include, but are not limited to: A review of the posted staffing plan indicated the following:
· Day shift: nine direct care staff;
· Swing shift: nine direct care staff; and
· Night shift: three direct care staff.
A review of staffing schedules dated 04/24/25 through 04/30/25 indicated the following:
· Schedules unavailable or not provided for 04/26/25-04/27/25.
· Facility was short-staffed by one direct care staff on the swing shift for 04/24/25, 04/25/25, 04/28/25, and 04/30/25.
A review of Resident 1’s service plan dated 01/02/25 and shower sheets for April 2025 indicated the following:
· Resident to receive standby assistance once per week with showering.
· Shower sheets dated 04/06/25 (completed), 04/22/25 (completed), and 04/26/25 (Refusal).
· Resident 1 was not getting weekly showers.
· Note on 4/22/25 shower sheet indicated “Rescheduled Saturday 4/19 shower due to low staff."
In an interview, Resident 1 stated the following:
· There was not enough staff;
· Call lights took 30-45 minutes;
· Not getting showers;
· Sheets/bedding wasn’t getting changed; and
· “They forget about me”.
In separate interviews, Staff 1, Staff 2, Staff 3, Staff 4, and Staff 5 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 Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population, their needs, and all required Activities of Daily Living (ADL). Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. Facility was not staffing to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules.
Corrective Action taken on related allegation.