- Date
- 3/20/2025
- Report number
- CALMS - 00129300
- 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 08/21/26, 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, complete or update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly as required, and use the results of an ABST to develop and routinely update the facility's posted staffing plan was substantiated. Findings include, but are not limited to: The facility’s census was 45. A review of the facility’s last ABST evaluation update per resident indicated 4 of 45 residents had not been updated quarterly as required as of 03/20/25.
A review of the facility’s ABST care times as of 03/20/25 indicated:
· For Day shift, 47.66 hours, or a minimum of 6.5 direct care staff;
· For Swing shift, 40.02 hours, or a minimum of 5.5 direct care staff; and
· For Night shift, 13.82 hours, or a minimum of 2 direct care staff.
The facility’s posted staffing plan indicated:
· For Day shift, 7 direct care staff;
· For Swing shift, 5 direct care staff; and
· For Night shift, 3 direct care staff.
The facility's posted staffing plan did not meet/exceed the ABST minimum hours required. The facility’s staffing schedule, dated 03/20/25, indicated the facility was not staffing to its posted staffing plan for 1 of 3 shifts reviewed. The findings were reviewed with and acknowledged by Staff 1 on 08/21/26. 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, complete or update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly as required and use the results of an ABST to develop and routinely update the facility's posted staffing plan is a violation of Oregon Administrative Rules.