**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of facility documentation, review of facility policy and interviews for one sampled resident (Resident #236) reviewed for pain, the facility failed to administer pain medication for a resident whose pain level was assessed at a severe level of pain. The findings include: Resident #236's diagnoses included cellulitis of left leg, cellulitis of right leg, Type 2 diabetes mellitus with diabetic chronic kidney disease. The care plan dated 3/9/24 identified Resident #236 was at risk for pain/discomfort and noted that pain may impact mobility, mood (anxiety, depression), behaviors, sleep, ADL functioning, and relationships with others. Care plan interventions directed medication(s) as ordered, skilled assessment of pain symptoms: location, type, duration, frequency, intensity, factors that exacerbate and relieve pain. admission physician's orders dated 3/9/24 directed to assess pain every shift using the pain of scale 010 0: no pain 1-2: mild pain 3-4: minimal pain 5-6: moderate pain 7-8: strong pain 9-10: severe pain, and administer Oxycodone HCl oral tablet 15 mg, give 1 tablet by mouth every 3 hours as needed for severe pain. The admission history and physical progress note dated 3/10/24 authored by MD#1 identified Resident #236 was admitted to the facility on [DATE] status post peritoneal dialysis catheter placement, lower extremity cellulitis with chronic wounds with a plan to continue Oxycodone (narcotic) and return to the pain clinic when stable where previously on Suboxone (opioid). Observation on 3/10/24 at 11:30 AM identified Resident #236 lying in bed crying, interview with Resident #236 at the time of the observation identified he/she had been administered a dose of Oxycodone early that morning. He/she further identified that he/she had been admitted to the facility around 9 or 9:30 PM on 3/9/24. In addition, Resident #236 identified he/she was in severe pain at the present time and noted that the nurse was aware that he/she was experiencing severe pain. Interview with LPN #1 on 3/10/24 at 11:40 AM identified she was aware that Resident #236 was in pain, and noted she was waiting for the resident's pain medication to be delivered from the pharmacy. The nurse's note dated 3/10/24 at 3:12 PM written by LPN #1 identified Resident #236 was in a lot of pain and non-compliant with care. When attempts made to re-approach, resident identified that she needed Oxycodone and a Nicotine patch. The note further identified that when the resident was administered Tylenol, the cup was crumpled and thrown to the floor. Further review of the nurse's note failed to identify the resident was administered Oxycodone by LPN #1 at any time during the shift. The Nurse Practitioner's (#1) progress note dated 3/11/24 identified Resident #236 had undergone multiple vascular procedures in the most recent hospital stay including lower extremity angioplasties with stent placements and peritoneal dialysis catheter placement on 3/1/24. The note further identified that the resident's hospital stay was complicated by uncontrolled pain which required intravenous (IV) opioids. A second interview with LPN #1 on 3/12/24 at 11:24 AM identified she entered Resident #236's room around 10:00 AM to administer morning medications, and Resident #236 complained of pain and rated it as a level 10 on the pain scale. She noted that she did not administer Oxycodone for the resident's complaint of severe pain because the medication had not been delivered by the pharmacy. She further identified that she did not think to check the automated medication dispensing system because she thought that it contained back up medications for residents that already had their medications in house. Additionally, LPN#1 identified that medication was retrieved from the automated medication dispensing system for Resident #236 because the therapist went into the room to see the resident and identified that the medication could be obtained from the automated medication dispensing system. She further noted that she and the Therapist went to the Nursing Supervisor, who was able to obtain the Oxycodone HCL 15mg dose from the automated medication dispensing system, but LPN #1 could not recall administering the medication to the resident, and identified that her shift ended shortly after 3:00 PM Review of the medication administration record (MAR) for 3/10/24 identified Resident #236 had been administered Oxycodone HCL 15mg at 5:25 AM and then at approximately 5:00 PM but failed to reflect documentation that Oxycodone HCl was administered between 7:00 AM and 3:00 PM (1st shift). Further review of the MAR identified Resident #236's pain level was assessed at a level 10 (severe) on the 1st shift. Interview with the Nursing Supervisor (RN#5) on 3/12/24 at 11:48 AM with LPN #1 present, identified she was notified by the MDS Coordinator (RN #3) on 3/10/24 in the afternoon that Resident #236 was in pain and needed to be medicated with medication from the automated medication dispensing system (emergency medication storage). RN#5 further noted that she obtained the medication from the automated medication dispensing system and handed it to LPN #1. Review of the automated medication dispensing system's detail report with the DNS on 3/12/24 at 11:58 AM identified RN #5 retrieved Oxycodone 10mg at 2:08 PM and Oxycodone 5mg at 2:09 PM on 3/10/24 from the automated medication dispensing system (emergency medication supply). Interview with the MDS Coordinator (RN #3) on 3/12/24 at 12:12 PM identified that she went to Resident #236's room to convey the date of the care plan meeting, and while in the room she identified the resident was in severe pain and notified LPN #1. RN #3 further noted that LPN#1 told her that the resident did not have any available Oxycodone because the resident's medications had not yet been delivered by the pharmacy. RN #3 noted that she told LPN #1 that she could obtain the Oxycodone from the automated medication dispensing system and went with LPN #1 to speak with RN #5. Further, RN #3 identified that she accompanied RN #5 to the automated medication dispensing system to obtain the medication and then watched RN #5 hand the medication to LPN #1. RN #3 further identified that the medication should have been documented in the electronic MAR, which would indicate the time the medication was administered. After reviewing the MAR for 3/10/24, RN #3 identified that she did not see documentation to indicate the resident was medicated with Oxycodone on first shift. A third interview with LPN #1 on 3/12/24 at 12:20 PM identified she could not locate documentation of the administration of Oxycodone on 3/10/24, however she indicated that it was a crazy day, and she may have forgotten to document. LPN#1 indicated that she may have thought she did not have to document administration due to the fact the medication was not from her cart and that it was obtained from the automated medication dispensing system and indicated that she thought the administration may have been documented already through the automated medication dispensing system. LPN#1 indicated she did not notify the Nursing Supervisor when the medication was unavailable and the resident's pain level was at a level 10. A second interview with Resident #236 on 3/12/24 at 2:45 PM identified that on 3/10/24 she was in pain all day and she needed a Nicotine patch that he/she had his/her significant other on standby waiting for him/her to say the word for him/her to come pick him/her up. Resident #236 further noted that she was not medicated for pain until sometime on the second shift and identified that they wanted to change the dressings on his/her legs immediately after administering the medication but he/she told the nurse that he/she needed to wait until the pain medication kicked in first. He/she did not know the exact time he/she was medicated but referred to a text message that had been sent to his/her significant other at 5:02 PM that identified that they'd just given him/her medication. Resident #236 indicated that it was around that time that he/she had finally received the medication. Further, he/she noted that she had not received pain medication on the first shift on 3/10/24. Interview with MD #1 on 3/14/24 at 11:45 AM identified she saw Resident #236 on 3/10/24 around 8:00 AM and the resident did not complain of pain at that time. and noted was not notified the resident was in pain on 3/10/24 following her visit to the facility. MD #1 further identified that she would expect to be notified if a resident is in pain and a pain medication is unavailable or ineffective at controlling the pain. Interview with the Staff Development nurse (RN #6) on 3/12/24 at 2:40 PM identified training materials regarding medication administration are done via video as well as verbal information about various topics. She further identified LPN #1 was walked through the automated medication dispensing system area during the orientation tour and also received 120 hours of mentoring for orientation. Review of the Receipt of Interim/Stat/Emergency delivered medications policy identified that the facility should not borrow medication from another resident. The facility should immediately notify the pharmacy when the facility receives from a physician/prescriber a medication order that may require an interim/stat/emergency delivery and if a necessary medication is not contained within a facility's interim/stat/emergency supply, and the facility determines that an interim/stat/emergency supply is necessary, the facility should make arrangements with the pharmacy to obtain the medication. Based on review of the facility's policy, interviews and record review, the facility failed to comply with their policy for obtaining a necessary medication in a timely manner. The facility failed to ensure that a resident who was assessed to be in severe pain and had pain medication ordered for severe pain that could be administered every three hours was medicated as ordered. The resident waited for a period of approximately 9 to be medicated for complaints of severe pain.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records, facility documentation, observations, interviews, and policy reviews, the facility failed to ensure adequsate staffing levels to protect the residents' right to be free from neglect for thirty (31) residents who required assistance with turning, repositioning, transfers and incontinent care, (Resident #1, 2, 3,4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, and 31). The findings include: a. Resident #1 had diagnoses that included mild cognitive impairment and brain cancer. A quarterly Minimum Data Set assessment (MDS) dated [DATE] identified that the resident had severe cognitive impairment, required total dependence with Activities of Daily Living (ADSL's), including bed mobility, was at risk for pressure ulcers, and was always incontinent of bowel and bladder. A care plan dated 7/10/23 identified that the resident needed staff assistance with ADL's with an intervention to receive incontinent care per facility policy. A physician's order dated 9/23/21 directed Hoyer lift assist of two staff for transfers. b. Resident #2 had diagnoses that included dementia and schizocarp disorder. A care plan dated 3/8/23 identified that the resident had a total self-care deficit related to a progressive neurological disorder with interventions that included to provide AM/PM care as per facility protocol. It further identified the resident was at risk for skin breakdown with interventions that included incontinent care per facility policy. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required total dependence with ADL's, including eating and bed mobility, was at risk for pressure ulcers, and was always incontinent of bowel and bladder. c. Resident #3 had diagnoses that included dementia, a pressure ulcer on the coccyx and dysphasia. A MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required total dependence with ADL's, including bed mobility, was at risk for pressure ulcers and was always incontinent of bowel and bladder. A care plan dated 7/12/23 identified that the resident was at risk for skin breakdown with interventions that included incontinent care per policy and turn and reposition per standards of nursing practice. d. Resident #4 had diagnoses that included psychotic disturbance and dysphasia. A MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility, was at risk for pressure ulcers and was occasionally incontinent of bladder. A care plan dated 6/12/23 identified that the resident was incontinent of bowel and bladder with interventions that included to check the resident for incontinence per his/her needs and provide him/her with care if he/she was incontinent. e. Resident #5 had diagnoses that included dementia and dysphasia. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility, was at risk for pressure ulcers, and was always incontinent of bowel and bladder. A care plan dated 5/1/23 identified that the resident needed assistance with self-care tasks with interventions that included to provide the resident with complete management of his/her incontinence care needs. A physician's order dated 7/18/22 directed a Hoyer lift transfer with assist of two. f. Resident #6 had diagnoses that included Alzheimer's dementia and major depressive disorder. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, was totally dependent with ADL's, including bed mobility, was at risk for pressure ulcers, was always incontinent of bowel and was frequently incontinent of bladder. A care plan dated 7/6/23 identified that the resident was incontinent of bowel with the inability to identify urges with interventions that included to check for incontinence at typical defecation times. A physician's order dated 4/29/22 directed Hoyer lift to custom wheelchair. g. Resident #7 had diagnoses that included Alzheimer's dementia and major depressive disorder. A MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required total dependence with ADL's, including bed mobility, was at risk for pressure ulcers, and was always incontinent of bowel and bladder. A care plan dated 6/5/23 identified that the resident was at risk for skin breakdown with interventions that included incontinent care per policy and to turn and reposition per standards of nursing practice. A physician's order dated 12/5/22 directed a Hoyer lift with assist of two. h. Resident #8 had diagnoses that included dementia, psychotic disturbance, and dysphagia. A MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required total dependence with ADL's, required extensive assistance with bed mobility, was at risk for pressure ulcers, and was always incontinent of bowel and bladder. A care plan dated 6/6/23 identified that the resident was at risk for skin breakdown with interventions that included incontinent care per policy and to turn and reposition per standards of nursing. i. Resident #9 had diagnoses that included dementia, dysphagia, and a pressure ulcer of the sacral region. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required total dependence with ADL's, including bed mobility, was at risk for pressure ulcers and was always incontinent of bowel and bladder. A care plan dated 7/27/23 identified that the resident was at risk for skin breakdown with interventions that included incontinent care per policy and turn and reposition per standards of nursing practice. j. Resident #10 had diagnoses that included Alzheimer's disease and dysphagia. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility, was at risk for pressure ulcers and was always incontinent of bowel and bladder. A care plan dated 6/29/23 identified that the resident needed assistance with self-care tasks with interventions that included to provide the resident with complete management of his/her incontinence care needs. A physician's order dated 9/23/21 directed mechanical lift with assist of two for transfers. k. Resident #11 had diagnoses that included dementia, major depressive disorder, and dysphagia. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility, was at risk for pressure ulcers and was always incontinent of bladder. A care plan dated 6/14/23 identified that the resident was at risk for skin breakdown with interventions that included incontinent care per policy and turn and reposition per standards of nursing practice. A physician's order dated 9/24/21 directed a stand mechanical lift with assist of two for transfers. l. Resident #12 had diagnoses that included dementia, stroke, and failure to thrive. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's including bed mobility, was at risk for pressure ulcers, and was always incontinent of bowel and bladder. A care plan dated 7/6/23 identified that the resident needed staff assistance with ADLs with interventions that included to assist as needed to meet toileting needs and incontinent care per policy. m. Resident #13 had diagnoses that included Alzheimer's dementia, severe protein-calorie malnutrition, and dysphagia. A quarterly MDS assessment dated [DATE] identified that the resident had moderately impaired cognition, required extensive assistance with ADL's, including bed mobility, was at risk for pressure ulcers and was always incontinent of bowel and bladder. A care plan dated 5/9/23 identified that the resident needed staff assistance with ADLs with interventions that included to assist as needed to meet toileting needs and incontinent care per policy. A physician order dated 7/25/23 directed an assist of two for transfers. n. Resident #14 had diagnoses that included neurocognitive disorder with Lewy bodies, dysphagia, and major depressive disorder. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility and eating, was at risk for pressure ulcers and was frequently incontinent of bowel and bladder. A care plan dated 6/14/23 identified that the resident was incontinent of bowel and bladder related to diminished sensation with interventions that included to check the resident for incontinence per his/her needs, provide incontinence care when the resident has been incontinent and provide the resident with assistance with toileting. A physician order dated 9/28/21 directed assist of two via hydraulic lift to wheelchair. o. Resident #15 had diagnoses that included Alzheimer's dementia. A MDS dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility, was at risk for pressure ulcers and was frequently incontinent of bowel and bladder. A care plan dated 6/6/23 identified that the resident needed staff assistance with ADLs with interventions that included incontinent care per policy and assist the resident as needed to meet toileting needs. p. Resident #16 had diagnoses that included macular degeneration and mild cognitive impairment. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, was at risk for pressure ulcers and was frequently incontinent of bladder. A care plan dated 7/19/23 identified that the resident was incontinent of bladder with interventions that included to check the resident for dryness frequently during waking hours and use incontinent garments to contain urine. It further identified the resident was at risk for skin breakdown due to incontinence with interventions that included incontinent care per policy and turn and reposition per standards of nursing practice. A physician's order dated 7/30/22 directed assist of two for transfers. q. Resident #17 had diagnoses that included Alzheimer's dementia, pressure ulcer of sacral region and severe protein-calorie malnutrition. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility and eating, was at risk for pressure ulcers and was always incontinent of bowel and bladder. A care plan dated 6/5/23 identified that the resident had a pressure injury to coccyx with interventions that included incontinence care per policy and to turn and reposition per nursing standards of care and policy. r. Resident #18 had diagnoses that included dementia, expressive language disorder and adult failure to thrive. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required total dependence with ADL's, including bed mobility and eating, was at risk for pressure ulcers and was always incontinent of bowel and bladder. A care plan dated 6/5/23 identified the resident was dependent on staff for all ADLs with interventions that included to assist as needed to meet toileting needs and incontinent care per policy. A physician's order dated 1/28/22 directed to transfer the resident with the mechanical lift. s. Resident #19 had diagnoses that included metabolic encephalopathy, Alzheimer's dementia, and palliative care. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's and eating, including bed mobility, was at risk for pressure ulcers and was frequently incontinent of bowel and always incontinent of bladder. A care plan dated 7/21/23 identified that the resident was at risk for skin breakdown due to incontinence with interventions that included incontinent care per policy. A physician's order dated 1/30/23 directed assist of two for bed to chair transfers. t. Resident #20 had diagnoses of Alzheimer's dementia, expressive language disorder and syncope. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility, was at risk for pressure ulcers and was always incontinent of bowel and bladder. A care plan dated 6/6/23 identified that the resident was at risk for skin breakdown due to incontinence with interventions that included incontinent care per policy and to turn and reposition per standards of nursing practice. u. Resident #21 had diagnoses of dementia, cerebral infarction, and dysphagia. A MDS dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility, was at risk for pressure ulcers, and was always incontinent of bowel and bladder. A care plan dated 4/19/23 identified that the resident was at risk for skin breakdown due to incontinence with interventions that included incontinent care per policy. v. Resident #22 had diagnoses that included dementia and schizoaffective disorder. A MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility, was at risk for pressure ulcers and was always incontinent of bladder and frequently incontinent of bowel. A care plan dated 6/6/23 identified that the resident needed staff assistance with ADLs with interventions that included to assist as needed to meet toileting needs and incontinent care per policy. w. Resident #23 had diagnoses that included frontotemporal neurocognitive disorder. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility and eating, was at risk for pressure ulcers and was always incontinent of bladder and frequently incontinent of bowel. A care plan dated 6/29/23 identified that the resident was at risk for skin breakdown due to incontinence with interventions that included incontinent care per policy and to turn and reposition per standards of nursing practice. A physician's order dated 2/22/23 directed to transfer the resident with a mechanical lift with assist of two. x. Resident #24 had diagnoses that included epilepsy and schizophrenia. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility, was at risk for pressure ulcers and was frequently incontinent of bladder. A care plan dated 6/29/23 identified that the resident was incontinent of bowel with interventions that included to check for incontinence at typical defecation times, and further identified the resident was incontinent of bladder with interventions that included to use incontinence garment to contain urine and check for dryness frequently during waking hours. y. Resident #25 had diagnoses that included dementia, adult failure to thrive, dysphagia and pressure ulcer of sacral region. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility, was at risk for pressure ulcers and was always incontinent of bladder and frequently incontinent of bowel. A care plan dated 6/6/23 identified that the resident was incontinent of bowel with interventions that included to check for incontinence at typical defecation times. The care plan further identified that the resident was incontinent of bladder with interventions that included to use incontinence garment to contain urine and check for dryness frequently during waking hours. A physician's order dated 12/10/21 directed a Hoyer lift for transfers. z. Resident #26 had diagnoses that included dementia and muscle weakness. A MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility, was at risk for pressure ulcers and was occasionally incontinent of bladder. A care plan dated 7/21/23 identified that the resident was at risk for skin breakdown due to incontinence with interventions that included incontinent care per policy. aa. Resident #27 had diagnoses that included Alzheimer's dementia and severe protein-calorie malnutrition. A care plan dated 2/24/23 identified that the resident was at risk for skin breakdown due to incontinence with interventions that included incontinent care per policy, and to turn and reposition per standards of nursing practice. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility, was at risk for pressure ulcers and was frequently incontinent of bladder and always incontinent of bowel. bb. Resident #28 had diagnoses that included dementia and schizoaffective disorder. A MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility, was at risk for pressure ulcers and was always incontinent of bladder and bowel. A care plan dated 5/11/23 identified that the resident was at risk for skin breakdown due to incontinence with interventions that included incontinent care per policy and to turn and reposition per standards of nursing practice. cc. Resident #29 had diagnoses that included dementia and bipolar disorder. A MDS assessment dated [DATE] identified that the resident had moderately impaired cognition, required extensive assistance with ADL's, including bed mobility, was at risk for pressure ulcers and was occasionally incontinent of bladder and bowel. A care plan dated 5/2/23 identified that the resident needed staff assistance with ADLs with interventions including incontinence care per policy. dd. Resident #30 had diagnoses that included Alzheimer's dementia and weakness. An admission MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility, was at risk for pressure ulcers and was frequently incontinent of bladder and bowel. A care plan dated 7/21/23 identified that the resident was at risk for skin breakdown due to incontinence with interventions that included incontinent care per policy and to turn and reposition per standards of nursing practice. ee. Resident #31 had diagnoses that included epilepsy, cognitive communication deficit and encephalopathy. A MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility and eating, was at risk for pressure ulcers and was always incontinent of bladder and bowel. A care plan dated 5/11/23 identified that the resident was at risk for skin breakdown due to incontinence with interventions that included incontinent care per policy. A physician's order dated 5/31/23 directed Sara lift with assist of two for transfers. Review of the facility assessment dated [DATE] identified that the average census in the building is 85 to 95 residents and the staffing plan identified that there will be seven (7) NAs on the 3:00 PM to 11:00 PM shift, a ratio of one (1) NA to 12 residents. Review of clinical records and facility documentation identified on 6/13/23 thirty-one (31) residents were at risk for pressure ulcers, twenty-nine (29) residents had severly impaired conginition, two (2) residents had moderately impaired cognition, thirteen (13) residents required Hoyer lifts or assist of two staff for transfers, four (4) residents were scheduled for showers, ten (10) residents required total feeding assist and twenty-nine (29) residents were incontinent of bowel and/or bladder and required incontinent care and turning and repositioning. Review of clinical records and facility documentation on 7/10/23 identified that thirty-one (31) residents were at risk for pressure ulcers, thirteen (13) residents required Hoyer lift assistance for transfers and/or assist of two staff for transfers, four (4) residents were scheduled for showers, ten (10) residents required total feeding assist, and thirty (30) residents were incontinent of bowel and/or bladder. Review of the facility schedule of Tuesday 6/13/23 identified the facility census was 92. The staffing for the 3:00 PM to 11:00 PM shift included one (1) NA (NA #1) and one (1) licensed staff (LPN #1) on the lower unit and one (1) NA (NA #2) and one (1) registered nurse (RN #1) on the upper unit. NA #1 was the only NA on the lower unit, responsible for forty-six (46) residents and NA #2 was the only NA on the upper unit, responsible for 46 residents. According to the 3.0 staffing required by the state agency in accordance with the Public Health Code (PHC) for 7:00 AM to 9:00 PM on 6/13/23 the facility had 64 NA hours and were required to have 144 NA hours to be in compliance with the staffing requirements of the state agency (a shortage of 80 NA hours for 6/13/23). Review of the facility schedule of Monday 7/10/23 identified the facility census was 88. The staffing for the 3:00 PM to 11:00 PM shift included two (1) NA (NA #1) and one (1) licensed staff on the lower unit for forty-six (46) residents and one (2) NA's (NA #3), two (2) NA students and (2) licensed staff on the upper unit for forty-one (41) residents. According to the 3.0 staffing required by the state agency in accordance with the Public Health Code (PHC) for 7:00 AM to 9:00 PM on 7/10/23 the facility had 58 NA hours and required 144 NA hours to be in compliance with the staffing requirements of the state agency (a shortage of 86 NA hours for 7/10/23). Interview with NA #1 on 7/27/23 at 10:15 AM identified she was the only NA who worked from 3:00 PM to 11:00 PM on the lower level on 6/13/23 (responsible for 46 residents). She identified Resident's #4, #11, #15 and #29 did not receive any care, except for being served meals during the entire 3:00 PM to 11:00 PM shift (bathing, incontinent care and turning and repositioning). NA#1 further identified that she barely had time to look at resident #4, #11, #15, and #29. She identified Resident's #1, #3, #5, #6, #7, #8, #9, #10, #12, #13, #14, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, and #31 had one incontinent change and one reposition and Resident #2 had two incontinent changes and two repositions because he/she was known to void large amounts when incontinent. She identified that she was aware that these residents required incontinent care and repositioning every two (2) hours, however, she could not accomplish this task by herself, additionally, the incontinent care she was able to give was not thorough. She identified she did not give any residents showers during her shift. She further identified that she Hoyered residents without a second staff member, although she was aware two (2) staff were required per policy, she did not have a second NA on the floor to assist. (NA#1 could not identify the number of residents she Hoyered without assistance of another staff member, as she could not remember) She identified for the residents who were totally dependent for eating (10 residents), she fed one at a time in their rooms (either in their bed if they were in bed or in their chair) because it would have been impossible to get all the resident's out of their room by herself. Furthermore, she had no help on the floor from any staff on 6/13/23. She identified she did not tell the charge nurse or DNS that she was the only NA on 6/13/23 because she would expect them to know because they create the staffing schedules. Further interview with NA #1 on 7/27/23 at 10:35 AM identified she had also worked from 3:00 PM - 11:00 PM on the lower level on 7/10/23, along with NA #3. She identified the floor was split between her and NA #3 and she cared for the Residents in rooms 100 - 113 and 130-134 (a total of twenty (25) residents). She identified Residents' #1, #3, #5, #6, #7, #8, 10, #12 and #30, had incontinent care and repositioning twice during that shift. Residents' #9, #11 #28 had incontinent care once during the shift. Residents' # 9 and #11 had one incontinent change because they were in their wheelchairs, and she changed them when they were placed into bed for the night (around 9:00 PM). She identified she did not give any residents showers during her shift as even with two NA's, it is impossible to provide showers. NA #2 identified that although she was aware to give incontinent care every (2) hours this could not be accomplished while caring for 25 residents. Interview with NA #2 on 7/27/23 at 2:40 PM identified she worked from 3:00 PM - 11:00 PM on 6/13/23 on the upper level. She identified sometimes she works as the only NA but the nurse on the floor would help, and they would work as a team. She further identified that she did not have time to assist NA#1 on the lower level and further identified that management does not usually help when needed on the floor because they leave by 5:00 PM. Interview with LPN #1 on 8/7/23 at 12:37 PM identified she was the nurse who worked 3:00 PM - 11:00 PM on 6/13/23 on the lower level. She identified it was just her and NA #1 who were on the floor. She identified she helped feed at dinner time and put 3 or 4 residents to bed after dinner. She identified she did not provide any showers incontinent care or turn and reposition residents. She identified she had to tend to two medication carts. She further identified NA #1 did not tell her there was care that she did not get done. Interview with Person #1 (facilities previous scheduler) on 8/7/23 at 1:21 PM identified her last day was 6/14/23. She identified if the schedule was not meeting the minimum requirements, she would tell HR #1, who trained Person #1. She identified they would have a daily meeting at 1:00 PM to discuss the schedule. She further identified she could not recall the schedule on 6/13/23. Interview with the DNS on 7/27/23 at 1:00 PM identified he was not aware of the schedule on 6/13/23. He identified it could not be accurate and the scheduler confirmed it was. He further identified he was not aware that residents did not receive appropriate care and had he known, he would have checked on the residents. He identified on 7/10/23, NA #3 was moved from the upper-level unit to the lower-level unit to help NA #1. He further identified he does not notify corporate of staffing issues, as he was not told to do so. The DNS stated that residents who are scheduled for shower, should receive showers on their scheduled day, residents who are incontinent and require repositioning should be given incontinent care and repositioned every 2 hours, and there should be two (2) staff assists with Hoyer lift transfers. Interview with the Administrator on 7/20/23 at 11:30 AM identified their goal for staffing NA's is 12 NAs on 7:00 AM - 3:00 PM shift and 9 NAs on 3:00 PM - 11:00 PM shift and if the census is greater than 90 then 11 NAs on 3:00 PM - 11:00 PM shift. She identified they are currently staffing with the staff they have available. She identified the hardest shift to find new staff for is the 3:00 PM - 11:00 PM shift. She identified there are currently five (5) NA students who will be independent upon completion of the class in August. She identified when there are call outs, all staff are reached out to, and the rehab staff is asked to assist on the floor. The facility is active in job fairs and provides bonus'. The administrator further identified that one or two NAs on a unit is not acceptable. After surveyor inquiry, the facility has begun an investigation of neglect regarding the care concerns identified on 6/13/23. The facility submitted a report for Residents' #4, #11, #15 and #29 to the reportable event website on 7/27/23 for investigation of neglect. Although attempted, an interview with RN #1 (RN for 3:00 PM - 11:00 PM on 6/13/23) was not obtained. The facility administrator identified that there was no staffing policy, the facility follows the state public health code. Review of the Administrator job description identified an essential job function to ensure all written policies, procedures and manuals are maintained, updated, and followed. Review of the incontinent care policy directed that incontinent care is performed by nursing staff on all residents following an episode of incontinence, every two hours and as needed. Review of the bathing/shower policy directed that each resident will be offered a full bath/shower at least weekly. Review of the positioning policy directed residents who are unable to turn themselves will be repositioned at least every two hours and/or as needed. Review of the abuse policy identified that neglect means a deprivation of an individual, including a caretaker, of good and services that are necessary to attain or maintain physical mental or psychological well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records, facility documentation, observations, interviews, and policy reviews, for thirty (31) residents who required assistance with turning, repositioning, transfers and incontinent care, (Resident #1, 2, 3,4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, and 31), the facility failed to ensure adequate staffing levels to meet the needs of the residents. The findings include: a. Resident #1 had diagnoses that included mild cognitive impairment and brain cancer. A quarterly Minimum Data Set assessment (MDS) dated [DATE] identified that the resident had severe cognitive impairment, required total dependence with Activities of Daily Living (ADSL's), including bed mobility, was at risk for pressure ulcers, and was always incontinent of bowel and bladder. A care plan dated 7/10/23 identified that the resident needed staff assistance with ADL's with an intervention to receive incontinent care per facility policy. A physician's order dated 9/23/21 directed Hoyer lift assist of two staff for transfers. b. Resident #2 had diagnoses that included dementia and schizocarp disorder. A care plan dated 3/8/23 identified that the resident had a total self-care deficit related to a progressive neurological disorder with interventions that included to provide AM/PM care as per facility protocol. It further identified the resident was at risk for skin breakdown with interventions that included incontinent care per facility policy. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required total dependence with ADL's, including eating and bed mobility, was at risk for pressure ulcers, and was always incontinent of bowel and bladder. c. Resident #3 had diagnoses that included dementia, a pressure ulcer on the coccyx and dysphasia. A MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required total dependence with ADL's, including bed mobility, was at risk for pressure ulcers and was always incontinent of bowel and bladder. A care plan dated 7/12/23 identified that the resident was at risk for skin breakdown with interventions that included incontinent care per policy and turn and reposition per standards of nursing practice. d. Resident #4 had diagnoses that included psychotic disturbance and dysphasia. A MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility, was at risk for pressure ulcers and was occasionally incontinent of bladder. A care plan dated 6/12/23 identified that the resident was incontinent of bowel and bladder with interventions that included to check the resident for incontinence per his/her needs and provide him/her with care if he/she was incontinent. e. Resident #5 had diagnoses that included dementia and dysphasia. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility, was at risk for pressure ulcers, and was always incontinent of bowel and bladder. A care plan dated 5/1/23 identified that the resident needed assistance with self-care tasks with interventions that included to provide the resident with complete management of his/her incontinence care needs. A physician's order dated 7/18/22 directed a Hoyer lift transfer with assist of two. f. Resident #6 had diagnoses that included Alzheimer's dementia and major depressive disorder. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, was totally dependent with ADL's, including bed mobility, was at risk for pressure ulcers, was always incontinent of bowel and was frequently incontinent of bladder. A care plan dated 7/6/23 identified that the resident was incontinent of bowel with the inability to identify urges with interventions that included to check for incontinence at typical defecation times. A physician's order dated 4/29/22 directed Hoyer lift to custom wheelchair. g. Resident #7 had diagnoses that included Alzheimer's dementia and major depressive disorder. A MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required total dependence with ADL's, including bed mobility, was at risk for pressure ulcers, and was always incontinent of bowel and bladder. A care plan dated 6/5/23 identified that the resident was at risk for skin breakdown with interventions that included incontinent care per policy and to turn and reposition per standards of nursing practice. A physician's order dated 12/5/22 directed a Hoyer lift with assist of two. h. Resident #8 had diagnoses that included dementia, psychotic disturbance, and dysphagia. A MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required total dependence with ADL's, required extensive assistance with bed mobility, was at risk for pressure ulcers, and was always incontinent of bowel and bladder. A care plan dated 6/6/23 identified that the resident was at risk for skin breakdown with interventions that included incontinent care per policy and to turn and reposition per standards of nursing. i. Resident #9 had diagnoses that included dementia, dysphagia, and a pressure ulcer of the sacral region. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required total dependence with ADL's, including bed mobility, was at risk for pressure ulcers and was always incontinent of bowel and bladder. A care plan dated 7/27/23 identified that the resident was at risk for skin breakdown with interventions that included incontinent care per policy and turn and reposition per standards of nursing practice. j. Resident #10 had diagnoses that included Alzheimer's disease and dysphagia. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility, was at risk for pressure ulcers and was always incontinent of bowel and bladder. A care plan dated 6/29/23 identified that the resident needed assistance with self-care tasks with interventions that included to provide the resident with complete management of his/her incontinence care needs. A physician's order dated 9/23/21 directed mechanical lift with assist of two for transfers. k. Resident #11 had diagnoses that included dementia, major depressive disorder, and dysphagia. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility, was at risk for pressure ulcers and was always incontinent of bladder. A care plan dated 6/14/23 identified that the resident was at risk for skin breakdown with interventions that included incontinent care per policy and turn and reposition per standards of nursing practice. A physician's order dated 9/24/21 directed a stand mechanical lift with assist of two for transfers. l. Resident #12 had diagnoses that included dementia, stroke, and failure to thrive. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's including bed mobility, was at risk for pressure ulcers, and was always incontinent of bowel and bladder. A care plan dated 7/6/23 identified that the resident needed staff assistance with ADLs with interventions that included to assist as needed to meet toileting needs and incontinent care per policy. m. Resident #13 had diagnoses that included Alzheimer's dementia, severe protein-calorie malnutrition, and dysphagia. A quarterly MDS assessment dated [DATE] identified that the resident had moderately impaired cognition, required extensive assistance with ADL's, including bed mobility, was at risk for pressure ulcers and was always incontinent of bowel and bladder. A care plan dated 5/9/23 identified that the resident needed staff assistance with ADLs with interventions that included to assist as needed to meet toileting needs and incontinent care per policy. A physician order dated 7/25/23 directed an assist of two for transfers. n. Resident #14 had diagnoses that included neurocognitive disorder with Lewy bodies, dysphagia, and major depressive disorder. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility and eating, was at risk for pressure ulcers and was frequently incontinent of bowel and bladder. A care plan dated 6/14/23 identified that the resident was incontinent of bowel and bladder related to diminished sensation with interventions that included to check the resident for incontinence per his/her needs, provide incontinence care when the resident has been incontinent and provide the resident with assistance with toileting. A physician order dated 9/28/21 directed assist of two via hydraulic lift to wheelchair. o. Resident #15 had diagnoses that included Alzheimer's dementia. A MDS dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility, was at risk for pressure ulcers and was frequently incontinent of bowel and bladder. A care plan dated 6/6/23 identified that the resident needed staff assistance with ADLs with interventions that included incontinent care per policy and assist the resident as needed to meet toileting needs. p. Resident #16 had diagnoses that included macular degeneration and mild cognitive impairment. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, was at risk for pressure ulcers and was frequently incontinent of bladder. A care plan dated 7/19/23 identified that the resident was incontinent of bladder with interventions that included to check the resident for dryness frequently during waking hours and use incontinent garments to contain urine. It further identified the resident was at risk for skin breakdown due to incontinence with interventions that included incontinent care per policy and turn and reposition per standards of nursing practice. A physician's order dated 7/30/22 directed assist of two for transfers. q. Resident #17 had diagnoses that included Alzheimer's dementia, pressure ulcer of sacral region and severe protein-calorie malnutrition. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility and eating, was at risk for pressure ulcers and was always incontinent of bowel and bladder. A care plan dated 6/5/23 identified that the resident had a pressure injury to coccyx with interventions that included incontinence care per policy and to turn and reposition per nursing standards of care and policy. r. Resident #18 had diagnoses that included dementia, expressive language disorder and adult failure to thrive. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required total dependence with ADL's, including bed mobility and eating, was at risk for pressure ulcers and was always incontinent of bowel and bladder. A care plan dated 6/5/23 identified the resident was dependent on staff for all ADLs with interventions that included to assist as needed to meet toileting needs and incontinent care per policy. A physician's order dated 1/28/22 directed to transfer the resident with the mechanical lift. s. Resident #19 had diagnoses that included metabolic encephalopathy, Alzheimer's dementia, and palliative care. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's and eating, including bed mobility, was at risk for pressure ulcers and was frequently incontinent of bowel and always incontinent of bladder. A care plan dated 7/21/23 identified that the resident was at risk for skin breakdown due to incontinence with interventions that included incontinent care per policy. A physician's order dated 1/30/23 directed assist of two for bed to chair transfers. t. Resident #20 had diagnoses of Alzheimer's dementia, expressive language disorder and syncope. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility, was at risk for pressure ulcers and was always incontinent of bowel and bladder. A care plan dated 6/6/23 identified that the resident was at risk for skin breakdown due to incontinence with interventions that included incontinent care per policy and to turn and reposition per standards of nursing practice. u. Resident #21 had diagnoses of dementia, cerebral infarction, and dysphagia. A MDS dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility, was at risk for pressure ulcers, and was always incontinent of bowel and bladder. A care plan dated 4/19/23 identified that the resident was at risk for skin breakdown due to incontinence with interventions that included incontinent care per policy. v. Resident #22 had diagnoses that included dementia and schizoaffective disorder. A MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility, was at risk for pressure ulcers and was always incontinent of bladder and frequently incontinent of bowel. A care plan dated 6/6/23 identified that the resident needed staff assistance with ADLs with interventions that included to assist as needed to meet toileting needs and incontinent care per policy. w. Resident #23 had diagnoses that included frontotemporal neurocognitive disorder. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility and eating, was at risk for pressure ulcers and was always incontinent of bladder and frequently incontinent of bowel. A care plan dated 6/29/23 identified that the resident was at risk for skin breakdown due to incontinence with interventions that included incontinent care per policy and to turn and reposition per standards of nursing practice. A physician's order dated 2/22/23 directed to transfer the resident with a mechanical lift with assist of two. x. Resident #24 had diagnoses that included epilepsy and schizophrenia. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility, was at risk for pressure ulcers and was frequently incontinent of bladder. A care plan dated 6/29/23 identified that the resident was incontinent of bowel with interventions that included to check for incontinence at typical defecation times, and further identified the resident was incontinent of bladder with interventions that included to use incontinence garment to contain urine and check for dryness frequently during waking hours. y. Resident #25 had diagnoses that included dementia, adult failure to thrive, dysphagia and pressure ulcer of sacral region. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility, was at risk for pressure ulcers and was always incontinent of bladder and frequently incontinent of bowel. A care plan dated 6/6/23 identified that the resident was incontinent of bowel with interventions that included to check for incontinence at typical defecation times. The care plan further identified that the resident was incontinent of bladder with interventions that included to use incontinence garment to contain urine and check for dryness frequently during waking hours. A physician's order dated 12/10/21 directed a Hoyer lift for transfers. z. Resident #26 had diagnoses that included dementia and muscle weakness. A MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility, was at risk for pressure ulcers and was occasionally incontinent of bladder. A care plan dated 7/21/23 identified that the resident was at risk for skin breakdown due to incontinence with interventions that included incontinent care per policy. aa. Resident #27 had diagnoses that included Alzheimer's dementia and severe protein-calorie malnutrition. A care plan dated 2/24/23 identified that the resident was at risk for skin breakdown due to incontinence with interventions that included incontinent care per policy, and to turn and reposition per standards of nursing practice. A quarterly MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility, was at risk for pressure ulcers and was frequently incontinent of bladder and always incontinent of bowel. bb. Resident #28 had diagnoses that included dementia and schizoaffective disorder. A MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility, was at risk for pressure ulcers and was always incontinent of bladder and bowel. A care plan dated 5/11/23 identified that the resident was at risk for skin breakdown due to incontinence with interventions that included incontinent care per policy and to turn and reposition per standards of nursing practice. cc. Resident #29 had diagnoses that included dementia and bipolar disorder. A MDS assessment dated [DATE] identified that the resident had moderately impaired cognition, required extensive assistance with ADL's, including bed mobility, was at risk for pressure ulcers and was occasionally incontinent of bladder and bowel. A care plan dated 5/2/23 identified that the resident needed staff assistance with ADLs with interventions including incontinence care per policy. dd. Resident #30 had diagnoses that included Alzheimer's dementia and weakness. An admission MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility, was at risk for pressure ulcers and was frequently incontinent of bladder and bowel. A care plan dated 7/21/23 identified that the resident was at risk for skin breakdown due to incontinence with interventions that included incontinent care per policy and to turn and reposition per standards of nursing practice. ee. Resident #31 had diagnoses that included epilepsy, cognitive communication deficit and encephalopathy. A MDS assessment dated [DATE] identified that the resident had severely impaired cognition, required extensive assistance with ADL's, including bed mobility and eating, was at risk for pressure ulcers and was always incontinent of bladder and bowel. A care plan dated 5/11/23 identified that the resident was at risk for skin breakdown due to incontinence with interventions that included incontinent care per policy. A physician's order dated 5/31/23 directed Sara lift with assist of two for transfers. Review of the facility assessment dated [DATE] identified that the average census in the building is 85 to 95 residents and the staffing plan identified that there will be seven (7) NAs on the 3:00 PM to 11:00 PM shift, a ratio of one (1) NA to 12 residents. Review of clinical records and facility documentation identified on 6/13/23 thirty-one (31) residents were at risk for pressure ulcers, twenty-nine (29) residents had severly impaired conginition, two (2) residents had moderately impaired cognition, thirteen (13) residents required Hoyer lifts or assist of two staff for transfers, four (4) residents were scheduled for showers, ten (10) residents required total feeding assist and twenty-nine (29) residents were incontinent of bowel and/or bladder and required incontinent care and turning and repositioning. Review of clinical records and facility documentation on 7/10/23 identified that thirty-one (31) residents were at risk for pressure ulcers, thirteen (13) residents required Hoyer lift assistance for transfers and/or assist of two staff for transfers, four (4) residents were scheduled for showers, ten (10) residents required total feeding assist, and thirty (30) residents were incontinent of bowel and/or bladder. Review of the facility schedule of Tuesday 6/13/23 identified the facility census was 92. The staffing for the 3:00 PM to 11:00 PM shift included one (1) NA (NA #1) and one (1) licensed staff (LPN #1) on the lower unit and one (1) NA (NA #2) and one (1) registered nurse (RN #1) on the upper unit. NA #1 was the only NA on the lower unit, responsible for forty-six (46) residents and NA #2 was the only NA on the upper unit, responsible for 46 residents. According to the 3.0 staffing required by the state agency in accordance with the Public Health Code (PHC) for 7:00 AM to 9:00 PM on 6/13/23 the facility had 64 NA hours and were required to have 144 NA hours to be in compliance with the staffing requirements of the state agency (a shortage of 80 NA hours for 6/13/23). Review of the facility schedule of Monday 7/10/23 identified the facility census was 88. The staffing for the 3:00 PM to 11:00 PM shift included two (1) NA (NA #1) and one (1) licensed staff on the lower unit for forty-six (46) residents and one (2) NA's (NA #3), two (2) NA students and (2) licensed staff on the upper unit for forty-one (41) residents. According to the 3.0 staffing required by the state agency in accordance with the Public Health Code (PHC) for 7:00 AM to 9:00 PM on 7/10/23 the facility had 58 NA hours and required 144 NA hours to be in compliance with the staffing requirements of the state agency (a shortage of 86 NA hours for 7/10/23). Interview with NA #1 on 7/27/23 at 10:15 AM identified she was the only NA who worked from 3:00 PM to 11:00 PM on the lower level on 6/13/23 (responsible for 46 residents). She identified Resident's #4, #11, #15 and #29 did not receive any care, except for being served meals during the entire 3:00 PM to 11:00 PM shift (bathing, incontinent care and turning and repositioning). NA#1 further identified that she barely had time to look at resident #4, #11, #15, and #29. She identified Resident's #1, #3, #5, #6, #7, #8, #9, #10, #12, #13, #14, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, and #31 had one incontinent change and one reposition and Resident #2 had two incontinent changes and two repositions because he/she was known to void large amounts when incontinent. She identified that she was aware that these residents required incontinent care and repositioning every two (2) hours, however, she could not accomplish this task by herself, additionally, the incontinent care she was able to give was not thorough. She identified she did not give any residents showers during her shift. She further identified that she Hoyered residents without a second staff member, although she was aware two (2) staff were required per policy, she did not have a second NA on the floor to assist. (NA#1 could not identify the number of residents she Hoyered without assistance of another staff member, as she could not remember) She identified for the residents who were totally dependent for eating (10 residents), she fed one at a time in their rooms (either in their bed if they were in bed or in their chair) because it would have been impossible to get all the resident's out of their room by herself. Furthermore, she had no help on the floor from any staff on 6/13/23. She identified she did not tell the charge nurse or DNS that she was the only NA on 6/13/23 because she would expect them to know because they create the staffing schedules. Further interview with NA #1 on 7/27/23 at 10:35 AM identified she had also worked from 3:00 PM - 11:00 PM on the lower level on 7/10/23, along with NA #3. She identified the floor was split between her and NA #3 and she cared for the Residents in rooms 100 - 113 and 130-134 (a total of twenty (25) residents). She identified Residents' #1, #3, #5, #6, #7, #8, 10, #12 and #30, had incontinent care and repositioning twice during that shift. Residents' #9, #11 #28 had incontinent care once during the shift. Residents' # 9 and #11 had one incontinent change because they were in their wheelchairs, and she changed them when they were placed into bed for the night (around 9:00 PM). She identified she did not give any residents showers during her shift as even with two NA's, it is impossible to provide showers. NA #2 identified that although she was aware to give incontinent care every (2) hours this could not be accomplished while caring for 25 residents. Interview with NA #2 on 7/27/23 at 2:40 PM identified she worked from 3:00 PM - 11:00 PM on 6/13/23 on the upper level. She identified sometimes she works as the only NA but the nurse on the floor would help, and they would work as a team. She further identified that she did not have time to assist NA#1 on the lower level and further identified that management does not usually help when needed on the floor because they leave by 5:00 PM. Interview with LPN #1 on 8/7/23 at 12:37 PM identified she was the nurse who worked 3:00 PM - 11:00 PM on 6/13/23 on the lower level. She identified it was just her and NA #1 who were on the floor. She identified she helped feed at dinner time and put 3 or 4 residents to bed after dinner. She identified she did not provide any showers incontinent care or turn and reposition residents. She identified she had to tend to two medication carts. She further identified NA #1 did not tell her there was care that she did not get done. Interview with Person #1 (facilities previous scheduler) on 8/7/23 at 1:21 PM identified her last day was 6/14/23. She identified if the schedule was not meeting the minimum requirements, she would tell HR #1, who trained Person #1. She identified they would have a daily meeting at 1:00 PM to discuss the schedule. She further identified she could not recall the schedule on 6/13/23. Interview with the DNS on 7/27/23 at 1:00 PM identified he was not aware of the schedule on 6/13/23. He identified it could not be accurate and the scheduler confirmed it was. He further identified he was not aware that residents did not receive appropriate care and had he known, he would have checked on the residents. He identified on 7/10/23, NA #3 was moved from the upper-level unit to the lower-level unit to help NA #1. He further identified he does not notify corporate of staffing issues, as he was not told to do so. The DNS stated that residents who are scheduled for shower, should receive showers on their scheduled day, residents who are incontinent and require repositioning should be given incontinent care and repositioned every 2 hours, and there should be two (2) staff assists with Hoyer lift transfers. Interview with the Administrator on 7/20/23 at 11:30 AM identified their goal for staffing NA's is 12 NAs on 7:00 AM - 3:00 PM shift and 9 NAs on 3:00 PM - 11:00 PM shift and if the census is greater than 90 then 11 NAs on 3:00 PM - 11:00 PM shift. She identified they are currently staffing with the staff they have available. She identified the hardest shift to find new staff for is the 3:00 PM - 11:00 PM shift. She identified there are currently five (5) NA students who will be independent upon completion of the class in August. She identified when there are call outs, all staff are reached out to, and the rehab staff is asked to assist on the floor. The facility is active in job fairs and provides bonus'. The administrator further identified that one or two NAs on a unit is not acceptable. After surveyor inquiry, the facility has begun an investigation of neglect regarding the care concerns identified on 6/13/23. The facility submitted a report for Residents' #4, #11, #15 and #29 to the reportable event website on 7/27/23 for investigation of neglect. Although attempted, an interview with RN #1 (RN for 3:00 PM - 11:00 PM on 6/13/23) was not obtained. The facility administrator identified that there was no staffing policy, the facility follows the state public health code. Review of the Administrator job description identified an essential job function to ensure all written policies, procedures and manuals are maintained, updated, and followed. Review of the incontinent care policy directed that incontinent care is performed by nursing staff on all residents following an episode of incontinence, every two hours and as needed. Review of the bathing/shower policy directed that each resident will be offered a full bath/shower at least weekly. Review of the positioning policy directed residents who are unable to turn themselves will be repositioned at least every two hours and/or as needed. Review of the abuse policy identified that neglect means a deprivation of an individual, including a caretaker, of good and services that are necessary to attain or maintain physical mental or psychological well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, review of facility documentation, review of facility policy, and interviews for 1 of 2 sampled residents reviewed for falls (Resident #107), the facility failed to ensure two staff were utilized during a transfer that resulted in an injury, and/or for 1 resident reviewed for smoking (Resident #53), the facility failed to properly complete a quarterly and/or yearly smoking assessment per facility policy and/or for 1 of 1 sampled resident with behaviors of opening the medication cart (Resident #409), the facility failed to ensure medication was secured. The findings include: 1. Resident #107's diagnoses included transient cerebral ischemic attack, cerebrovascular disease and left sided hemiparesis and hemiplegia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #107 was without cognitive impairment and required the extensive assistance of two staff with transfers. a. The Resident Care Plan (RCP) dated 10/15/18 identified a risk for falls with interventions that included to utilize the assistance of two staff with all transfers. A physician's order dated 12/19/18 directed to provide the assistance of two staff with transfers. The Reportable Event (RE) form dated 12/27/18 at 9:45 PM identified Resident #107 was lying on the floor at the bedside and was assessed prior to being assisted off the floor with assist of two staff and a gait belt. The fall scene investigation (FSI) dated 12/27/18 identified that the root cause of Resident #107's fall was that Resident #107 required the assistance of two staff, only one staff transferred the resident, and that the facility had failed to update the Nurse Aide (NA) care card to reflect the need for two staff for transfers. A new intervention to update the NA care card was implemented. The nurse's note dated 12/27/18 at 10:58 PM identified that Resident #107 was lying on the floor at the bedside. The NA stated he/she helped the resident to the floor during the transfer. The resident stated I bumped my head on the bed but not hard, denies pain of discomfort with range of motion. b. A physician's order dated 3/30/19 directed to use the assistance of two staff and a stand [NAME] (orbit [NAME]) for transfers. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #107 was cognitively intact and required extensive assistance of two for bed mobility, transfers, dressing, toilet use and personal hygiene. The Resident Care Plan (RCP) dated 4/8/19 identified a risk for falls with interventions that included to provide the assistance of two staff with transfers. A Reportable Event form dated 4/12/19 at 9:00 PM identified that Resident #107 lost his/her balance during a transfer from the wheelchair to the bed using a pivot disc. The facility investigation dated 4/12/19 identified that Resident #107 was not assisted with two staff. Additionally, disciplinary action was issued to the Nurse Aide (NA). The care plan was updated on 4/12/19 to include that staff was reminded of the need for the assistance of two staff with transfers for Resident #107. The nurse's note dated 4/12/19 at 9:56 PM identified the resident was being transferred from the wheelchair to the bed with the assistance of one staff and a pivot board when the resident fell to the floor landing on his/her buttocks. The NA and Resident #107 both lost their balance. There were no marks present, Resident #107 denied pain and range of motion was at baseline. c. The Resident Care Plan (RCP) dated 7/1/19 identified a risk for falls with interventions that included to provide the assistance of two staff with transfers and remind the staff of the need for the assistance of two staff with transfers. A physician's order dated 7/2/19 directed to use the assistance of two staff and a stand [NAME] (orbit [NAME]) for transfers. The Reportable Event form dated 7/2/19 at 7:15 AM identified that NA #4 transferred Resident #107 from the bed to the wheelchair, the resident became weak, and was assisted to the floor. Facility investigation identified that Resident #107 was alert and oriented and that NA #4 was not using a gait belt, was not using an orbit [NAME], and was transferring Resident #107 independently, without the assistance of a second NA. Additionally, NA #4 did not transfer Resident #107 per the care plan, per the care card and/or per the physician's order. The nurse's note dated 7/2/19 at 11:19 AM identified the resident had a witnessed fall during a transfer. Resident #107 reported pain with the movement of his/her left upper extremity. Resident #107 was lowered to the floor during transfer from the bed to the chair. Resident #107 complained of left shoulder pain radiating down the left arm at an intensity pain level of 10 where 10/10 was the worst pain and he/she was moaning and grimacing. Resident #107 was transferred to the Emergency Department for evaluation. Nurse's notes dated 7/2/19 at 5:07 PM identified Resident #107 returned from the hospital with the left arm in a sling and a diagnoses of a left shoulder fracture. Interview with Resident #107 on 7/22/19 at 10:58 AM identified that about a month ago there were supposed to be two staff helping with his/her transfer, there was only one and the chair went back. He/she wasn't sure if the brake was off but the wheelchair rolled back. Additionally, Resident #107 stated that when he/she was on the floor, the Supervisor came over, went in back of him/her, grabbed his/her arm and pulled. That was when Resident #107 identified that he/she heard a snap and said my arm, my arm. Resident #107 identified that the Supervisor was trying to lift him/her up. Resident #107 identified that he/she could not see the Supervisor and was not sure who the staff member was. Interview and review of facility documentation with Registered Nurse (RN) #2 on 7/24/19 at 1:08 PM identified that he/she had worked the prior 11:00 PM to 7:00 AM shift on 7/2/19 and was giving report to the on-coming 7:00 AM to 3:00 PM shift Licensed Practical Nurse (LPN) #7, when NA #4 reported that Resident #107 was on the floor. On arrival, Resident #107 was noted to be on the door side of the bed, facing the headboard wall, leaning back at a 45 degree angle, holding onto the left side rail with his/her right arm across his/her body with the left side of his/her body pressed against the bed frame and mattress. RN #2 identified that Resident #107 initially denied pain. RN #2 identified that he/she was kneeling behind Resident #107 and was trying to slip his/her hand under the resident's armpit edging him/her away from the bed. RN #2 identified that he/she could not lay Resident #107 down because he/she would have hit his/her head, could have moved the bed, but wanted to support Resident #107. RN #2 identified that he/she was not sure if the resident broke his/her arm on the fall and/or if when the pressure was relieved the bone displaced. Interview and review of facility documentation with LPN #7 on 7/24/19 at 2:34 PM identified that after being told Resident #107 was on the floor, he/she and RN #2 went to assess the resident. LPN #7 identified that he/she had been looking at Resident #107's legs when he/she had heard a pop noise. LPN #7 identified that Resident #107 was uncomfortable prior to the pop noise. Interview and review of facility documentation with NA #4 on 7/25/19 at 11:20 AM identified that there was supposed to be five NA's on the upper level but there were only four at the time Resident #107 fell. He/she was the only NA assigned to the entire hall of 32 residents on the 7:00 AM to 3:00 PM shift and had transferred Resident #107 alone without the benefit of the orbit [NAME]. Additionally, NA #4 identified when Resident #107 was placed in the wheelchair, the wheelchair slipped out and he/she had lowered Resident #107 to the floor. NA #4 identified that he/she had not looked at the care card, was not aware that Resident #107 required the assistance of two NA's to transfer, had not used a gait belt and was not aware that Resident #107 required the orbit [NAME] to transfer from the bed to the wheelchair. NA #4 identified that he/she could not recall what position Resident #107 was in when he/she returned from reporting the fall to the nurses but identified that Resident #107 was on his/her back with a pillow under his/her head when both RN #2 and LPN #7 attempted to pull Resident #107 up from his/her arms. NA #4 identified that was when a pop noise was heard. On demonstration with the surveyor, NA #4 identified that he/she had swung Resident #107's legs over so that his/her feet and part of the calves were off the bed. NA #4 then demonstrated that he/she had hooked his/her left arm under Resident #107's left arm (the affected side) and pulled Resident #107 to a sitting position on the bed. NA #4 identified that he/she then swung Resident #107, still holding the left affected arm and the back of the resident's clothing into the wheelchair. NA #4 was unsure if the wheelchair brake gave way or if he/she had hit the brake with his/her leg when the chair started to roll away. While trying to boost Resident #107 back in the chair, NA #4 identified that he/she lowered the resident to the floor. Interview and review of facility documentation with the DNS on 7/25/19 at 9:21 AM identified that the facility determined Resident #107 was difficult to move because of his/her position close to the bed. RN #2 was closest to the bed on the resident's affected left and weakened side, and because he/she was so close to the bed and leaning at a 45 degree angle, RN #2 felt the need to move the resident to get to a safer position. When RN #2 gently moved Resident #107, a pop was heard RN #2 and just let him/her go and called 911. Interview and review of facility documentation with MD #1 on 7/25/19 at 10:00 AM identified that per the X-ray report Resident #107 had a displaced transverse humeral neck fracture. The shaft fragment was anteriorly located relative to the humeral head. Humeral head remains located relative to the glenoid. The details of the resident's fall as discussed with the DNS were reviewed; the resident was transferred using the assistance of one NA landing on the left side with the resident's body against the bed and when a range of motion was performed by the RN#2 a pop was heard. MD #1 identified that pops and cracks that are heard, are usually the result of tendons and the noise may have been from an air bubble in the joint fluid. MD #1 identified that the fracture, most likely, resulted from the fall. Review of facility Gait Belt Policy identified the use of gait belts is mandatory for transferring or ambulating a resident. 2. Resident #53 was admitted to the facility on [DATE] with diagnoses that included paranoid schizophrenia, dementia with behavioral disturbance. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #53's cognition could not be determined, was always continent of bowel and bladder and was independent with activities of daily living. The Resident Care Plan dated 6/17/19 identified a problem with smoking with interventions to complete a quarterly smoking assessment, do not allow smoking materials on person, and escort Resident #53 out to the smoking area. Resident #53 individualized resident assignment identified Resident liked to smoke, must go with staff and wear an apron, staff must light cigarette for resident and should stay with resident and bring lighter back to nurse. A Smoking assessment dated [DATE] identified was a current smoker, resident did not have a potential to violate the smoking policy, and could not demonstrate the ability to light and smoke a cigarette, but did have safe technique for putting out lighter, hold a cigarette, and verbalize understanding of smoking in designated areas Observations on 7/23/19 at 9:45 AM identified Resident #53 was brought to the designated smoking area, wore an apron, and was supervised smoking per the 12/4/18 smoking assessment. Interview and review of the smoking assessments with the DNS on 7/25/19 at 1:12pm failed to identify that a quarterly smoking assessment had been completed since 12/4/18. Additionally, the DNS identified that it is the nurses responsibility to complete the smoking assessment and that the MDS coordinator may also complete the assessment. DNS further identified that he/she does not know the reason a quarterly smoking assessment was not completed per policy. Review of facility smoking policy identified a smoking assessment was to be completed annually, quarterly, and with a significant change in condition. 3. Resident #409's diagnoses included dementia, alcohol induced disorder and depression. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #409 was severely cognitively impaired, had delusions and physical/verbal behaviors directed to others and walked unassisted with supervision in the corridor. A nurse's note dated 6/19/19 at 12:40 PM identified Resident #409 attempted to remove anything appealing to him/her from the nurse's cart and was continually in search of vanilla milkshakes. A nurse's note dated 6/20/19 at 10:31 PM identified Resident #409 attempted to snatch medication off the nurse's medication cart. The Resident Care Plan (RCP) dated 7/21/19 identified Resident #409 likes to try to open medication cart. Interventions included to modify the enviornment to prevent situations that trigger inappropriate behaviors, to provide consistent caregivers, and to gently redirect Resident #409 when inappropriate behaviors are exhibited. Observation on 7/22/19 at 10:45 AM on the Gardenview unit identified Registered Nurse (RN) #4 at a medication cart preparing medications for administration while Licensed Practical Nurse (LPN) #4 prepared transfer paperwork for another resident (Resident #46). RN #4 left the medication cart unattended, approached the nurse's station and reviewed Resident #46's paperwork with LPN #4. Additionally, Resident #409 was heard approaching the unattended medication cart, make the statement this is a milkshake, I can take it. Resident #409 was then observed to pick up a cup from the unattended medication cart (the cup contained a white liquid), walk away from the medication cart towards the dining room carrying the cup of white liquid. Further observation identified a medication cup that contained 2 pills was on top of the unattended medication with an unidentified resident seated alongside the medication cart. This surveyor immediately notified RN #4 who was reviewing paperwork facing away from the medication cart that Resident #409 had taken a cup with white liquid from. RN #4 identified that he/she was not concerned with Resident #409 taking a cup with white liquid because it was milkshake and did not contain medication (although there was a cup with 2 pills located on top of the medication cart when Resident #409 was at the unattended cart). Interview on 7/22/19 at that time with RN #4 identified he/she had left the medication cart unattended because he/she was helping LPN #4 with paperwork. A review of the medication administration policy identified facility staff should not leave medications unattended.