- Date
- 6/2/2026
- Report number
- CALMS - 00128529
- 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 an investigation on 08/11/26, 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 and use the results of an ABST to develop and routinely update the facility’s posted staffing plan, and complete or update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly, as required, was substantiated. Findings include, but are not limited to:
The ABST was reviewed for the alleged event date of 06/02/26.
The facility’s posted staffing plan indicated:
Day shift: 7 direct care staff;
Swing shift: 6 direct care staff; and
Night shift: 3 direct care staff.
A review of the facility's ABST "minimum time needed based on acuity" indicated:
Day shift: 7.2 direct care staff;
Swing shift: 6.2 direct care staff; and
Night shift: 1.7 direct care staff.
The facility staffing plan was below the ABST required minimum hours based on acuity for day and swing shift.
The facility direct care staff schedule for 05/27/26 through 06/02/26 indicated:
The facility was not staffing to its posted staffing plan for 06/21 shifts reviewed; and
The facility was staffed below the ABST minimum time needed based on acuity for 12/21 shifts reviewed.
The facilities census was 75.
A review of the facility’s last ABST evaluation update per resident indicated 5 of 75 residents had not been updated quarterly as required. The facility’s failure to use the results of an ABST to develop and routinely update the facility’s posted staffing plan and have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident, and complete or update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly, as required, is a violation of Oregon Administrative Rules.