- Date
- 10/11/2025
- Report number
- CALMS - 00129090
- 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 08/18/2026, the facility’s failure to use the results of an ABST to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident was substantiated. Findings include, but are not limited to:
A review of the facility’s ABST care times as of 10/15/2025 indicated:
For Day shift, 4.04, or a minimum of 4.5 direct care staff;
For Swing shift, 3.40, or a minimum of 3.5 direct care staff; and
For Night shift, 0.99 hours, or a minimum of 1 direct care staff.
The facility’s posted staffing plan indicated:
For Day shift, 4-4.5 direct care staff;
For Swing shift, 4-4.5 direct care staff; and
For Night shift, 2 direct care staff.
The facility’s direct care staffing schedule, dated 10/11/2025, indicated:
For Day shift, 4 direct care staff;
For Swing shift, 4 direct care staff; and
For Night shift, 2 direct care staff.
According to the facility’s direct care staffing schedule, the facility was not staffing to the ABST care times to account for the scheduled and unscheduled needs of the residents for 1 of 3 shifts reviewed. 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 was substantiated. The findings were reviewed with and acknowledged by Staff 1 on 08/20/2026. An investigation determined this is a violation of Oregon Administrative Rules.