- Date
- 7/4/2026
- Report number
- CALMS - 00121421
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to staff as indicated by ABST
- Result
- Substantiated
- Findings
- Based on interview and record review, conducted during a site visit on 07/28/26, the facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and/or unscheduled needs of each resident. Findings include, but are not limited to:
The facility’s posted staffing plan indicated:
For Day shift, 5 direct care staff;
For Swing shift, 4 direct care staff; and
For Night shift, 3 direct care staff.
The facility’s staffing schedule dated 06/28/26-07/04/26, indicated the facility was not staffing to its posted staffing plan for 3 of 21 shifts reviewed. Interview with Staff 5 (Caregiver) stated Resident 1 (R1) was often up all night and had damaged cupboards as she/he is looking for snacks. R1 had been able to plug the microwave back in and she/he had put things in that are not appropriate for the appliance. Staff 5 believed this was due to R1 being up all night and she/he was unsupervised. ?The facility's failure to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident is a violation of Oregon Administrative Rules.