**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, observation, nursing staff schedule review, facility assessment review, and policy review, the facility failed to maintain sufficient levels of state tested nursing staff and licensed nursing staff to meet the total care needs of all facility residents. This resulted in Immediate Jeopardy when on 08/26/24 at 7:00 A.M., there were three licensed practical nurses (LPN) and two state tested nurse aides (STNA) on duty to provide for the routine care, monitoring, medication administration, assessments, response to urgent resident needs and/or treatments for all 105 residents residing in the facility. The lack of nursing staff in the facility to provide nursing care and services resulted in actual and/or the potential for serious harm, injuries and/or negative health outcomes for residents related to the lack of care and services, activities of daily living (ADL), supervision of common areas, smoking areas and assistance with meal intake. This had the potential to affect all 105 residents. On 08/27/24 at 2:55 P.M. Regional Director of Operations (RDO) #224, Regional Clinical Nurse (RCN) #222, and the Administrator were notified that the Immediate Jeopardy began on 08/26/24 at 7:00 A.M. when the facility failed to ensure an sufficient nursing staff was on duty and present in the facility to provide for the routine care, monitoring, response to urgent resident needs and meal assistance for all 105 residents residing in the facility. The Immediate Jeopardy was removed on 08/28/24 when the facility implemented the following corrective actions: • By 08/28/24, staffing levels will be increased to five nurses on day shift and four nurses on night shift, STNA ' s staffing levels will be increased to eight STNA ' s on first shift and six nursing assistants on night shift. Staffing levels will be increased by increasing hours for current staff, reassigning staff from sister facilities and signing contracts with two temporary staffing agencies. The shift charge nurse will authorize the use of the agency staff. • By 08/28/24, the charge nurses will be provided with the agencies phone numbers and will be educated to call agency when there are call offs and our staff will not pick up open shifts. • By 08/28/24, RDO #224 will develop a bonus structure for new hires. • By 08/28/24, the RDO #224 will develop a bonus structure for staff that will pick up extra shifts. • By 08/28/24, RDO #224 will develop a bonus structure for staff who refer new candidates. • By 08/28/24, Human Resource (HR) Director #6 will call all applicants for the last 60 days to re-offer interviews. • By 08/28/24, the Director of Nursing (DON) or designee will conduct resident assessments to identify those with pressure ulcers and extensive assist from two staff members with ADL to prioritize their care and ensure immediate needs are addressed. • By 08/28/24, RDO #224 or designee will notify residents and their representatives about the staffing situation, the steps that are being taken to address the issue and what they can expect in terms of care. • By 08/28/24, an ad hoc quality assurance (QA) committee meeting will be held to review the plan. • By 08/28/24, [NAME] President of Human Resources (VPHR) #800 or designee will develop and implement a long-term plan to recruit and retain qualified staff including offering competitive wages, benefits and professional development opportunities. • Beginning 08/28/24, RDO #224 or designee will review staffing levels daily and adjust as necessary depending on new admissions/discharges and significant changes. This may involve hiring additional permanent staff or adjusting the staff to resident ratio based on acuity levels. • By 08/28/24, RDO #224 will educate the administrator, the DON and HR Director #6 on the appropriate staffing levels to meet the residents needs and to adjust the staffing levels depending on new admissions/discharges and significant changes. • Weekly for four weeks, RDO #224 or designee will interview four residents and four direct care members to ensure appropriate staffing levels and quality of care. • The data collected from the above audits and feedback will be used to make ongoing adjustments to the staffing plan and care protocols, ensuring compliance and that residents receive high-quality care. The audits will be submitted weekly to the QA committee for trending, tracking and recommendations. Although the Immediate Jeopardy was removed on 08/28/24, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. 1. Medical record review for Resident #41 revealed an admission on [DATE] with diagnoses including but not limited to traumatic hemorrhage of cerebrum, hemiplegia on right and left side, epilepsy, respiratory failure, coma, persistent vegetative state, acute cystitis without hematuria, hypertension, anxiety disorder, tracheostomy status and gastrostomy status. Review of the annual Minimum Data Set (MDS) assessment for Resident #41 revealed resident was in a persistent coma state. Resident #41 has physical impairments on both sides affecting arms and legs. Resident #41 is dependent for all care. Resident #41 has a gastrostomy (feeding tube) and receives 51 percent of calories through parenteral feedings. Resident #41 has a tracheostomy in place and receives oxygen via compressor at 20 pounds per square inch (PSI). Review of the plan of care for Resident #41 dated 03/19/22 revealed resident has an ADL self-care performance deficit related to motor vehicle accident (MVA) with brain injury resulting in comatose state. Interventions include assisting with activities of daily living requiring two staff members for the completion of bed mobility, transfers with a mechanical lift, and toileting. Resident #41 was dependent for eating with one staff member required for task involving enteral feedings. Review of the active physician orders for Resident #41 revealed an order for nothing by mouth dated 03/20/24, head support cushion under head as tolerated dated 03/20/24, Hoyer lift for all transfers dated 03/20/24, incontinence care every two hours and as needed, with house barrier cream after each incontinent episode dated 03/20/24 and keep head of bed elevated as tolerated dated 07/24/24. During an observation on 08/22/24 at 9:50 A.M., Resident #41 was lying in bed on her back, head of bed elevated to approximately 30 degrees, neck appeared to be in a contracted state leaning to the resident ' s right shoulder, tracheostomy in anterior neck and secured appropriately, linens clean and resident without odor. On 08/22/24 at 11:30 A.M., STNA #12 was observed to enter the room of Resident #41 and shut the door. At 11:51 A.M. STNA #12 was observed to exit the room. During an interview on 08/22/24 at 11:53 A.M. with STNA #12 verified Resident #41 was checked for incontinence and repositioned. STNA #12 stated she completed ADL and incontinent care for Resident #41. STNA #12 stated she had not had the time to provide care for Resident #41 since she arrived at the facility and clocked in at 7:00 A.M. STNA #12 stated she has 20 residents on her assignment at that time. STNA #12 received report and then started passing breakfast trays. STNA #12 stated she has had three total bed changes due to incontinence and changed eight resident incontinent garments before providing care for Resident #41. STNA #12 stated sometimes the nurses were able to help but the other STNA ' s were in the same situation that she was in and were not able to help at times either. 2. Medical record review for Resident #4 revealed an admission date of 08/31/22 with diagnoses including but not limited to psychosis, dementia, major depressive disorder, and schizoaffective disorder. Resident #4 resided on the memory care unit. Review of the quarterly MDS assessment dated [DATE] revealed Resident #4 was not able to complete a Brief Interview for Mental Status (BIMS) because she was rarely/never understood. Resident #4 was dependent with eating, toileting, bathing, dressing, and transfers. Resident #4 required two staff members for toileting, transfers and bed mobility. Review of the plan of care for Resident #4 revealed resident has an ADL self-care performance deficit related to dementia with behaviors, cerebral palsy, seizures, schizophrenia, psychosis, major depressive disorder, cerebrovascular accident with right hemiparesis and hemiplegia. Interventions include assist with activities of daily living, two-staff member assistance is required with bed mobility, toileting and transfers. Resident #4 resides on a secured unit. Review of the care plan dated 07/26/24 revealed Resident #4 had impaired skin integrity as evidenced by pressure to coccyx. Interventions included assist with turning and repositioning as needed, complete skin inspection every seven to 10 days and as needed, complete wound evaluation to monitor the progress of skin condition, enhanced barrier precautions, medications per orders, and good nutrition and hydration. Review of the task log for Resident #4 revealed the resident has not gotten out of bed in the last three months. During an observation on 08/22/24 at 12:05 P.M., Resident #4 was sleeping in bed. Her lunch tray was in the room, but there were no staff available to feed her. Resident #4 was lying on her right side. At 12:22 P.M., no one had been in the room to feed Resident #4 her lunch. During an interview on 08/22/24 at 12:24 P.M., STNA #46 stated there are at least five residents that require assistance with meals and typically only one STNA assigned to the memory care unit. One STNA cannot feed five residents at the same time. STNA #46 stated at 12:30 P.M. Resident #4 ' s lunch tray was still sitting unattended due to not having staff available. STNA #46 stated there was no wound dressing on Resident #4 ' s coccyx, but dried gauze from a previous time. STNA #46 stated there has not been a dressing on the wound since she started training on this unit on 08/12/24. Resident #4 had a foul-smelling odor with two flies near the coccyx wound. During an observation on 08/22/24 at 12:42 P.M., Resident #4 was sleeping in bed and the lunch tray was still in the room. Resident #4 had not been fed her lunch meal. During an interview on 08/22/24 at 12:49 P.M., STNA #172 stated the wound dressing for Resident #4 was not in place this morning. STNA #172 stated they used to get residents up with the Hoyer lift because they had two staff members on this unit. STNA #172 stated now it's just one STNA on the memory care unit and the unit does not have Hoyer lift pads to get residents up with. STNA #172 stated the last time Resident #4 was out of bed was at least a month ago. STNA #172 stated she had six residents to feed on the memory care unit, and she was the only staff back there at the time of meal tray delivery. STNA #172 stated she fed the residents in the dining room first, and then she assisted with the residents in their room after the dining room residents were finished. On 08/22/24 at 12:55 P.M., STNA #172 entered Resident #4 ' s room to assist her with eating her lunch, which was 50 minutes after the lunch tray was observed in the resident ' s room at 12:05 P.M. 3. Medical record review for Resident #50 revealed an admission date of 08/20/18 with diagnoses including but not limited to vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the comprehensive MDS assessment dated [DATE] for Resident #50 revealed staff assessment for memory indicated severe cognitive impairment. Resident #50 was not coded with any behaviors during the assessment period. Resident #50 requires set up for eating. Resident #50 was coded as dependent on staff for toileting, bed mobility and transfers. Resident #50 is incontinent for both bladder and bowel. Review of the plan of care for Resident #50 dated 03/18/22 and revised on 06/29/22 revealed resident has an ADL self-care performance deficit related to schizoaffective disorder and hemiparesis. Interventions include assist with ADL as needed, eating requires one staff member assistance, transfers with Hoyer lift with two staff members, toileting and bed mobility requires two staff members. During an observation on 08/26/24 at 9:48 A.M., Resident #50 was in bed and noted with dried food on his upper chest area. Resident #50 had a soaked incontinent brief, and the bed linen had a yellow wet circular area around the resident. During an observation on 08/26/24 at 9:48 A.M., there were two STNAs present working the floor at the current time. STNA #148 was covering all of 200 and 300 halls except the memory care unit and one covering the mental health unit. There were 40 residents on 200 hall, 10 residents on the 300 hall, and 25 residents on the mental health unit. During an interview on 08/26/24 at 9:55 A.M., STNA #148 stated she had not been in Resident #50 ' s room since 7:00 A.M., the start of the shift due to not enough staff this morning. There were only two STNA in the whole building at that time and since the start of the shift, one STNA covering mental health and one covering the rest of the building. STNA #148 confirmed Resident #50 had old, dried food on his chest, not the same food as breakfast that was served. She also confirmed Resident #50 was wet with urine and the bed linens were wet with a yellow ring surrounding the resident. 4. Review of the Facility Assessment for the year 2023-2024, dated 05/31/24, identified staffing and staffing assignments would be determined using various reports to analyze the number of patients, velocity of expected admission and discharges, diagnoses and the total number and types of tasks and services required of nursing, nursing assistants and ancillary personnel. The facility assessment did not address the staffing needs required for the specialized units, the memory care unit and mental health unit. During an interview on 08/26/24 at 8:24 A.M., the Administrator stated she was unaware of any other reports identified in the facility assessment that would be used to determine staffing. She ensures the facility meets the state licensure requirements of 2.5 hours of care per resident per day and used the punch detail to collect the data for that report. The facility does not use agency staff as they do not have a budget for it. The Administrator referred questions related to how staffing levels impact the residents to the Interim Director of Nursing (IDON). The Administrator stated she has not received any complaints from any residents in the last three months. They offer a bonus for shifts that are picked up and if they are not filled, they will pull facility staff that are STNAs to fill the open shifts. The Administrator stated the facility has a Registered Nurse (RN) in the facility to meet the eight-hour requirement daily. Review of the facility ' s Nursing Staff Daily Schedule dated June 2024 through August 2024 revealed the facility scheduled five STNA ' s consistently to care for up to 105 residents residing in the facility. Review of the facility ' s Nursing Staff Daily Schedule dated 08/26/24 for the day shift revealed STNAs #54, #102, #148, #34 and #46 were scheduled to work from 7:00 A.M. to 7:00 P.M. and LPNs #18, #32, #162, and #148 were scheduled to work from 7:00 A.M. to 7:00 P.M. Review of the facility ' s Punch Details for 08/26/24 from 7:00 A.M. to 7:00 P.M. revealed two STNA were in the facility for the day shift starting at 7:00 A.M. Additional STNA ' s clocked in at 7:33 A.M., 9:02 A.M., 10:53 A.M. and 11:58 A.M. Review of the day shift STNA schedule dated August 2024 revealed two STNA ' s were scheduled for 08/26/24. During an interview on 08/26/24 at 8:56 A.M., RCN #222, the acting Director of Nursing, stated she was not involved in the staffing determination. RCN #222 stated she has been in the DON position since the survey started and does not have extensive history of the facility. She stated the facility has had a staff scheduler in place for about three weeks. During an interview on 08/26/24 at 9:22 A.M., STNA #46 verified she was on the schedule for today and not called in for staff coverage. STNA #46 verified she was not present at 7:00 A.M. and arrived at the facility late. STNA #46 stated she was the only STNA on the assigned unit. STNA #46 stated she was looking through the Kardex for resident instructions as she had not worked in the area before. STNA #46 verified the nurse assigned to the area also had rooms on the outside of the locked memory care unit and was not available to confirm care and services required by the STNA. During an interview on 08/26/24 at 1:01 P.M., Certified Nurse Practitioner (CNP) #218 stated staffing is an issue in the facility, and it is possible that the in house acquired pressure ulcers occurred and worsened due to the facility staffing levels. The facility has always had a staffing concern which affects the care. Just like today, there is a staffing concern. During an interview on 08/27/24 at 8:50 A.M., STNA #10 stated she has twenty-five residents assigned to her today. STNA #10 stated she did not work yesterday and no one from the facility contacted her to see if she was able to come in. STNA #10 verified the facility has four STNA ' s at this time with three nurses for 105 residents. STNA #10 stated there have been times that she is unable to complete her assigned showers and will report it to the oncoming staff. STNA #10 stated it is very hard to supervise all the residents and provide care to them as well. Nurses will assist but they have forty residents sometimes and do not have time to help either. The nurses that are assigned the specialized units have residents in the other outside hallways as well. STNA #10 stated there have been times when the residents have complained about the length of time, they had to wait for help but nothing formal like a grievance that she is aware of. STNA #10 stated the residents here do not have family members looking after them or advocate for them. During an interview on 08/27/24 at 10:10 A.M., Facility Staffing Coordinator (FSC) #78 verified she has been in the current position for three weeks and is still learning the new position. FSC #78 states she was given the Nursing Staff Daily Schedule template and has been using that to schedule staff. FSC #78 stated the goal is to have all positions filled but they do not have the staff to reach that at the time but have been hiring additional staff recently. FSC #78 states she has not been given any other guidelines for staffing only the daily schedule template. FSC #78 stated the schedule template has seven positions for the STNAs and four positions for nurses for both twelve-hour shifts in a twenty-four-hour day. FSC #78 verified there were staff running late and one call off on 08/26/24, but she would have to check her paper to make sure she had her staffing numbers correct. During an observation on 08/27/24 at 2:10 P.M., STNA #210 took a meal tray out of the food cart and was walking down the South Hall. STNA #210 stated she had to help in the dining room for all meals to assist with resident meal selection, meal tray delivery and supervision. STNA #210 stated when the resident ' s trays are passed, she must stay in the dining area for supervision until they are finished. STNA #210 states then she can return to her assignment. STNA #210 stated the nurse realized what was going on today and started to help with tray delivery on the hall. STNA #210 stated the tray she is delivering is the last one. STNA #210 stated the resident requires assistance with all meals and she was not able to feed the resident until now. STNA #210 stated she has not completed all the baths scheduled for today and is not sure she will be able to get them all done before she goes home. STNA # 210 verified the lunch tray had to be heated up prior to serving. During an interview on 08/27/24 at 4:30 P.M., Unit Manager LPN #50 stated she assists with the facility nursing schedule but has not received any other training regarding staffing, how to assess for staffing needs or determine if more staffing is needed. LPN #50 stated she uses the daily template that allows us to have seven STNAs and four nurses for both twelve-hour shifts. LPN #50 verified the staffing has been very low at times on day shift with all the staff slots going unfilled. During an interview on 08/28/24 at 8:40 A.M., the Administrator stated she does not have any access to reports regarding staff or staffing level requirements. She has a budget that allows staffing levels from 2.5 hours to 2.75 hours per resident per day. A staffing report is run by the Administrator daily to ensure compliance with the staffing levels. She stated they have struggled to meet the state minimum staffing level at times in the last few weeks. She has requested a budget for agency staff and has been denied each time. If the facility is staffed over the 2.5 hours per resident per day, it is brought up in the operational meeting with staff from the corporate level staff. The Administrator said she was asked not to attend the daily staffing meetings approximately two to three months ago. She is only to attend on Mondays and Fridays and does not understand why she was asked to step away. During an interview on 08/28/24 at 9:00 A.M., Chief Executive Officer (CEO) #240 and [NAME] President of Clinical Operations (VPCO) #230 stated the facility has meetings with staff regarding concerns related to the facility. Corporate staff have meetings with the facility management to talk about the acuity of the residents and meeting the PDPM requirements. CEO #240 stated the corporate has a standard level of 2.75 hours per resident per day daily for the facilities. VPCO #230 stated the staffing numbers are run globally and not individually as that is the responsibility of the Administrator. Both CEO #240 and VPCO #230 stated they are adding staff to the schedule by utilizing agency and will have the signed contract in place soon. During an interview on 08/28/24 at 2:10 P.M., STNA #210 stated she did not work on 08/24/24 or 08/25/24 and no one from the facility contacted her to see if she was willing to come in to work on either day. STNA #210 stated the facility works with four STNAs a lot of the time. They will have a staff member that comes in at 11:00 A.M. and that is helpful, but they need more staff. STNA #210 stated the biggest problem is when she is helping another resident in a room, she cannot be in the common areas supervising the residents. Care is completed but it is not always timely or as thorough as it should be. During an interview on 08/28/24 at 3:30 P.M., LPN #50 stated she was not on call 08/24/24 through 08/25/24 but did see that requests came through on the WhatsApp( WhatsApp is a messaging app that uses the internet to send messages, images, audio or video) saying the facility needed help. The request was sent out to the Administrator, the MDS nurse and herself, along with a unit manager who no longer works for the facility. The facility staff in the building did not receive any contact from the Administrator, or MDS Nurse to come in and assist due to low staffing levels. LPN #50 verified the staff member identified as being on call is not employed by the facility at the time of the assignment. During an interview on 08/29/24 at 6:48 A.M., STNA #52 stated she is unable to get showers done because there is no one else to watch the residents when she is in the shower room for extended periods of time. They give bed baths, but the residents want showers at times, and they cannot provide them. STNA #52 stated she gave four showers last night because they had two staff members scheduled. STNA #52 stated there was only one nurse working in the memory care unit adding that she also had resident rooms in the rehabilitation area. STNA #52 stated it was difficult to provide good care, complete incontinence care and showers with only one staff member. STNA #52 has approached the management staff regarding concerns but there has been such staff turnover that issues do not get addressed. During an interview on 08/29/24 at 7:00 A.M., STNA #34 stated the facility does not have enough linen to provide care to the residents at times. STNA #34 stated the staff at night must do laundry to be able to provide care adding that the facility has three dryers, but only one is operational. STNA #34 stated she worked on 08/26/24 and heard the facility started out with only two STNA ' s during report from the nurse assigned to the hall. STNA #34 stated when she left at 7:00 P.M. there had been five aides to care for 105 residents in the facility. During an observation on 08/29/24 at 7:10 A.M, the linen room for the locked mental health unit contained no washcloths, no bath towels, no draw sheets, and only two blankets, and six bed sheets. During an interview on 08/29/24 at 7:45 A.M., the Administrator verified there was no linen available for use to provide care in the mental health unit. During an interview on 08/29/24 at 8:00 A.M., VPCO #230 verified the linen closet lacked sufficient linen supplies to complete care and services on the unit. During an observation on 08/29/24 at 9:21 A.M., the linen room for the locked mental health unit still had no linen. During an interview on 08/29/24 at 9:22 A.M., STNA #34 stated some of the residents had supplies in their room for incontinent care (disposable wipes), but they still had residents that were waiting for linens to be delivered to the unit for care. During an interview on 08/29/24 at 10:27 A.M., STNA #34 stated some of the residents were still waiting for clean linen to complete A.M. care. STNA #34 verified they borrowed linen from other units but if they took anymore the staff on those units would be waiting for linens as well. During a telephone interview on 08/29/24 at 11:25 A.M., Physician #232 stated there had been several people in the role of Director of Nursing in the last few months. Physician #232 stated he would follow-up with facility management but had mostly been engaging with the Administrator lately due to the changes with nursing management. He was aware of staffing challenges to a certain degree but had not been advised of any significant negative resident outcomes. During an interview on 08/29/24 at 3:27 P.M., Registered Nurse (RN) #166, the MDS nurse, stated the Administrator asked if she would fill in for the DON. RN #166 stated she never ended up taking any duties for the position, the last DON was only at the facility for a week before resigning. The facility couldn ' t keep a consistent DON or unit managers, and it affected the continuity of care. Things were being missed. She did not attend the morning meetings or QAPI (Quality Assurance and Performance Improvement) meetings, was not present for nutrition at risk meetings and was told MDS did not need to be involved. During an interview on 09/03/24 at 12:21 P.M., LPN #212 verified on 08/26/24 at 7:00 A.M., there were only two STNAs present to care for 105 residents residing in the facility. The nurse let management, and the staff scheduler know scheduled staff were not present at the start of the shift. LPN #212 stated the nurses present just started getting the residents awakened for breakfast, assisting with tray delivery and answering call lights as needed. LPN #212 verified that there were three nurses in the facility and that her current assignment consisted of 28 rooms, and she was not sure how many residents there were on that day. LPN #212 stated the facility uses an electronic application that has specific groups of management and staff. Staff send messages to the management group when there is a call off. The scheduler also receives the messages and works Monday through Friday. The scheduler is a trained STNA and will help when there is a call off as well. During an interview on 09/03/24 at 12:30 P.M., LPN #38 verified on 08/26/24 at 7:00 AM, there were only two STNAs present to care for 105 residents residing in the facility. LPN #38 stated there were more staff on the schedule, but she was unable to recall what had happened to each one that was not there. LPN #38 stated there were some managers in the facility because the surveyors were returning to the facility, and they were advised on the missing staff. LPN #38 stated there was only one nurse assigned to the mental health unit at the beginning of the shift and was there by herself until the staffing was figured out. LPN #38 stated the scheduler came out and covered a unit but was not sure what area she was assigned. LPN #38 stated it was very chaotic when the shift started. LPN #38 stated the assigned workload is heavy and it does not help when staffing is challenged to start with. LPN #38 stated the office staff that are STNAs will come to the floor and assist but they do not take a unit, they just get the bare minimum done. LPN #38 stated the recent staffing shortage occurred when the management left the facility, and they took their staffing with them. LPN #38 was unable to state if anything specific was not being completed for the residents just a lot of short cuts to get the basic care completed. LPN #38 stated she had 21 residents, or 14 rooms assigned to her on 08/26/24 with one STNA assigned to her unit. During an interview on 09/03/24 at 2:00 P.M. with FSC #78 stated she was only able to confirm staffing that was on the Daily Staff Schedules. FSC #78 stated she does not have access to the facility punches and does not keep track of what staff is working, where they are working and when there are changes made to the schedule. Initially she stated she was not working on the day in question (08/26/24), then recanted her statement stating she couldn ' t remember what happened every day. FSC #78 stated there were six STNAs scheduled for 08/26/24, there was one call off, and two staff members were running late. The sixth staff member was schedule for 11:00 A.M. to 7:00 P.M. FSC #78 stated she covered the memory care unit until the scheduled staff arrived at the facility at noon but was not sure of the exact time. FSC #78 verified the LPN scheduled for the mental health unit was the only staff member present until the STNA arrived at the facility at an unknown time. FSC #78 verified she was working in the memory care unit until the scheduled staff member showed up around noon. FSC #78 stated she was helping in both specialty units. When the nurse was passing medications in the memory care unit, she went to the mental health unit and assisted with breakfast trays and answered call lights. FSC #78 stated staff did not always call her when there was a call off initially, they were calling several different people and that is when errors were made. FSC #78 was unable to identify who staff was calling to notify when there was a call off, but they now use the mobile application called What ' s app. FSC #78 stated the facility uses the app to notify groups of management related to staffing needs. FSC #78 verified the nurses ha[TRUNCATED]