- Date
- 8/3/2026
- Report number
- CALMS - 00129104
- 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 08/13/2026, 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. Findings include, but are not limited to:
A review of the facility's ABST care times as of 08/03/2026:
- For Day shift, 4.11, or a minimum of 4.5 direct care staff;
- For Swing shift, 3.51, or a minimum of 4 direct care staff; and
- For Night shift,1.16, or a minimum of 1.5 direct care staff.
- The facility’s posted staffing plan indicated:
- For Day shift, 4 to 4.5 direct care staff;
- For Swing shift, 4 to 4.5 direct care staff; and
- For Night shift, 2 direct care staff.
- The facility’s staffing schedule, dated 08/03/2026, indicated the facility was not staffing to its posted staffing plan for 1 of 3 shifts reviewed and not staffing at or above the ABST care times for 1 of 3 shifts.
The findings were reviewed with and acknowledged by Staff 1 on 08/13/2026. 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.