Based on interview and record review it was determined the facility failed to protect the resident's right to be free from abuse by staff for 1 of 3 residents (#40) reviewed for abuse. This resulted in skin tears, increased anxiety and post-traumatic stress disorder (PTSD) for Resident 40. Findings Include: Resident 40 was admitted to the facility in 2019 with diagnoses including depression. Resident 40's 9/27/22 cognitive assessment indicated normal cognitive function. An incident report dated 12/6/22 indicated Resident 40 was upset regarding the noise early in the morning and asked Staff 27 (Agency LPN) and Staff 29 (Agency CNA) to be quiet while looking through the curtain to her/his roommate's side. Staff 29 told Resident 40 to stay on her side of the room and pushed Resident 40 back into her/his section using the armrests of Resident 40's wheelchair which Resident 40's arms were resting on. This resulted in a 2.75 cm x .72 cm skin tear on her/his left outer forearm and a 3.56 cm x 2.1 cm skin tear on the back of her/his right hand. A 12/7/22 at 11:52 AM Progress Note indicated the resident became distressed and tearful stating 'I feel like I'm getting worse emotionally. I'm going to have a breakdown. I'll take whatever you want to give' regarding medications. A 12/8/22 at 9:33 AM Progress Note indicated Resident 40 was reported to have experienced night terrors and was unable to sleep. Staff 26 reported Resident 40 was in distress when the 12/6/22 abuse incident was discussed. A 12/15/22 Progress Note indicated on 12/13/22 Resident 40 was prescribed prazosin (a medication used to reduce nightmares and general symptoms of PTSD) due to new onset of nightmares and diagnosis of PTSD. On 10/30/23 at 2:38 PM Resident 40 recalled the incident consistent with the incident report and stated she never wanted to see Staff 29 ever again. Resident 40 stated she/he experienced increased anxiety after the incident. On 11/2/23 at 3:51 PM Staff 27 (Agency LPN) stated she witnessed the 12/6/22 incident. Staff 27 stated Staff 29 forcefully pushed Resident 40 backwards into her/his room using the wheelchair armrest while her/his arms were on the armrests. Resident 40 reacted after the incident by yelling, look at what he did . I'm bleeding. Staff 27 stated Resident 40's skin was torn back on both arms and required immediate wound cleaning and bandaging. Staff 27 stated Resident 40 was very vocal and very upset after the incident. Staff 27 stated Resident 40's stress and anxiety continued for two to three weeks after the incident repeatedly saying, make sure he never comes back. Look what he did. Attempts to contact Staff 29 (Agency CNA) were unsuccessful. On 11/1/23 3:51 PM Staff 28 (LPN) confirmed Resident 40 was abused by Staff 29 which resulted in skin tears and triggered the resident's PTSD.

Based on observation, interview and record review it was determined the facility failed to follow care plan interventions, assess for care plan effectiveness, identify and implement new fall interventions and provide adequate supervision needed to prevent falls for 1 of 1 sampled resident (#57) reviewed for falls. This failure resulted in the resident having eight falls in ten months, one with serious injury, which resulted in the resident sustaining a fractured hip requiring surgery. Findings include: Resident 57 was admitted to the facility in 2020 with diagnoses including anxiety, depressive disorder and schizo-affective disorder (a mental health disorder). Resident 57's 7/3/23 Quarterly MDS indicated the resident had no cognitive impairments. Resident 57 required supervision for walking in her/his room, the hallway and for toilet transfers. Resident 57 was not on a toileting program. Resident 57's 8/27/23 5 Day MDS indicated the resident had severe cognitive impairment and required extensive assistance of two people for toileting and transfers. The resident was not steady moving from a seated to standing position, walking was unsteady and she/he was only able to stabilize herself/himself with staff assistance. Resident 57 was not on a toileting program. Resident 57's 10/3/23 Quarterly MDS indicated the resident had no cognitive impairment. The resident required supervision to touch assistance when moving from a sitting to standing position and during toilet transfers. Resident 57 was not on a toileting program. From 1/13/23 through 10/31/23, 11 fall risk evaluations were completed. Resident 57 was typically identified to be at a moderate to high fall risk. Resident 57's current Care Plan indicated the resident was at risk for falls related to cognitive problems, deconditioning, gait/balance problems, history of falls, history of self-transferring and self-ambulating. The following fall preventions were in place: -Ensure call light was within reach. Initiated 12/23/20. Revised 1/29/21. -Encourage resident to wear non-skid footwear at all times. Initiated 2/5/21. -Encourage resident to use a front wheeled walker (FWW) when ambulating for safe mobility per therapy. The resident self-ambulated despite reminders to ask for assistance without walker. Initiated 12/24/20. Revised 8/21/23. -One person assistance with transfers with FWW. Initiated 12/24/20. Revised 10/11/23. -The resident required one person supervision with FWW for toilet transfers; however, [she/he] self toileted and did not ask for assistance. If already in the bathroom provide frequent checks. Initiated 12/24/20. Revised 11/1/23. -The resident was sensitive to bright lights and often closed [her/his] eyes while trying to ambulate down the hallway. The resident had sunglasses. Encourage [her/him] to wear the sunglasses when up ambulating. Provide frequent reminders of this and to call for assistance. Initiated 4/5/21. -Review and update fall risk assessments quarterly, post any falls and PRN. Initiated 4/5/21. -Rule out potential causes of fall such as infection, medication side effects, diagnoses related and environmental. Initiated 4/5/21. -Do not leave [the resident] unsupervised in the bathroom or on the beside commode. Initiated 9/27/23. On 11/1/23 this intervention was discontinued and the level of supervision was decreased to frequent checks when in the bathroom. -Keep bed in the lowest position except during care. Initiated 9/27/23. -Mobility bars/bed cane. Initiated 9/27/23. -PT/OT evaluation and/or treatment if indicated. Initiated 9/27/23. -The resident required two person assistance with transfers. Initiated 9/27/23. -FWW for all ambulation. Initiated 9/27/23. -Use gait belt with all transfers. Initiated 9/27/23. From 1/10/23 through 10/28/23, Resident 57 experienced eight falls in the facility, one with serious injury which resulted in a fractured hip requiring surgical intervention. Fall investigations revealed the following: -1/10/23 at 6:35 PM Fall Investigation revealed Resident 57 fell in her/his room and sustained a 2 cm X 15 cm scratch on the left forearm and a skin tear on the fourth left finger. Resident stated she/he was going to the bathroom to take a shower. Summary: Resident continued with limited safety awareness and obsessive behaviors regarding taking showers. The resident continued to be at risk for falling. Falls may not be preventable. No new fall care plan interventions were put in place. -1/21/23 at 1:30 PM Fall Investigation revealed Resident 57 fell in her/his room while going to the sink to wash her/his hands. Resident 57 reported her/his legs became weak which contributed to the fall. The resident was ambulating without assistance. Summary: The resident had another fall. The resident has photosensitivity. Dark sunglasses were recommended but the resident no longer chose to wear them. Falls may be unavoidable. No new fall care plan interventions were put in place. -1/23/23 at 11:42 PM Fall Investigation revealed Resident 57 was found on the floor by her/his door in a sitting position. The nurse was called to come to the unit from the third floor to assess Resident 57. The resident reported she/he was trying to go to the bathroom and bumped into something. Summary: Resident 57 has had multiple falls to and from the bathroom. As per previous documentation, falls may be unavoidable due to resident's choices and mental health issues. -8/19/23 at 3:08 PM Fall Investigation revealed Resident 57 walked from the dining room unassisted and without a walker. Resident 57 was observed by a CNA down the hallway, zig-zagging across the hallway. The resident fell onto her/his right side. Resident 57 was known to have a gait imbalance and ambulated without assistance. Resident 57 was unable to walk after the fall and was sent to the hospital for an evaluation. Resident 57 sustained a hip fracture which required surgical intervention. Summary: Resident 57 self-ambulated from her/his room, to the dining room and on the way back to her/his room the resident fell. Resident 57 was supposed to be ambulating with SBA (stand by assistance) of 1 person with a FWW. Resident 57's care plan was not followed as she/he was supposed to have SBA with a FWW in order to ambulate in the hallway. No new fall care plan interventions were put in place. -9/18/23 at 11:01 AM Fall Investigation revealed Resident 57 was found down on the bathroom floor. Resident 57 stated she/he lost her/his balance. Resident 57 was assisted to the toilet and then back to her/his chair. Summary: Resident 57 had a history of falls. Her/his last fall resulted in a right hip fracture. The resident's medications increased her/his risk of falls. Resident 57 frequently covered her/his eyes due to light sensitivity and self-toileted. The resident had dark sunglasses; the resident did not use the call light. Falls were unavoidable. Will add frequent offers to toilet in the task and frequent checks. -9/26/23 at 2:45 PM Fall Investigation revealed Resident 57 was found in the doorway to her/his bathroom. Patient ambulated without assistance. Summary: The resident had a history of falls related to toileting. Resident 57 had medications that increased the risk of falls. Resident 57 was sensitive to light and had dark sunglasses. The resident did not use the call light. The resident had a history of self-toileting. Falls were determined to be unavoidable. Will add frequent offers to toilet in the tasks as well as frequent checks. Will schedule toileting before and after meals. -10/5/23 at 4:24 PM Fall Investigation revealed Resident 57 fell coming from her/his bathroom. The resident's walker was next to the toilet in the bathroom. The resident ambulated without assistance. Summary: The resident had a history of falls. Resident 57 exhibited impulsive/compulsive behaviors. Resident 57 frequently covered her/his eyes due to being sensitive to light and had dark sunglasses to help her/him ambulate more safely. The resident did not use the call light and had a history of self-toileting. Falls were determined to be unavoidable. No new fall care plan interventions were put in place. -10/28/23 at 7:30 PM Fall Investigation revealed Resident 57 attempted to transfer from her/his bed to the wheelchair and fell. Resident 57 stated her/his legs were too weak and she/he was unable to make it to the bed. The resident was transferring and ambulating without assistance. On 11/1/23, the care plan intervention, which directed staff not to leave the Resident 57 unsupervised while in the bathroom or on the commode, was discontinued and the supervision level was reduced to provide frequent checks on Resident 57 when she/he was in the bathroom. The facility failed to follow care plan interventions, re-assess current interventions and develop new interventions to ensure Resident 57 was adequately supervised and her/his falls were unavoidable. Resident 57 experienced eight falls from 1/10/23 to 10/28/23 and on 8/19/23 Resident 57 fell sustaining a fractured right hip. Resident 57 required surgical intervention to repair her/his broken hip. Random observations between 10/30/23 through 11/3/23 between the hours of 7:30 AM and 9:30 PM revealed the following concerns: -Resident 57 sat for hours on her/his bed with her/his privacy curtains drawn. Resident 57 was not visible from the hallway as staff passed by her/his room. -Staff frequently walked by Resident 57's room without checking on her/him. -No staff were observed using a gait belt with Resident 57 and her/his bed was never in the lowest position as per the care plan. -Staff did not provide two person assistance with transfers as per the care plan. -Resident 57 did not use a call light. -Resident 57 was never observed wearing her/his sunglasses. -Resident 57 was observed self-ambulating in her/his room and to/from the bathroom without staff noticing. In addition, the following concerns were observed: On 11/1/23 at 8:51 AM Resident 57 stood up and ambulated to the bathroom with Staff 6 providing SBA with a FWW. Staff 6 did not use a gait belt. Staff 6 left the resident in the bathroom and was picking up breakfast trays. At 9:11 AM Resident 57 exited the bathroom, walked to the sink and then returned to her/his bathroom without assistance. No staff were in the area to visualize Resident 57 ambulating from the bathroom. On 11/1/23 at 1:24 PM Resident 57 was standing at the door to her/his room yelling for assistance. A CNA intervened and walked the resident back to her/his bed then left the room. At 1:27 PM Resident 57 again ambulated to the door without assistance or using her/his FWW. The resident again yelled for assistance from the doorway. On 11/2/23 between 2:31 PM and 3:31 PM Resident 57 was observed ambulating with her/his FWW to the bathroom. During this time, Resident 57 ambulated to the bathroom, exited the bathroom, washed her/his hands at the sink and returned to her/his bed without staff noticing. No staff checked on the resident during this hour observation. On 11/1/23 at 9:33 AM Staff 4 (Agency RN) reported Resident 57 often fell because she/he had weak legs and got up on her/his own, a lot. She reported the resident did not have much space in her/his room which may contribute to her/his falls. Staff 6 stated staff were supposed to check on Resident 57 every time they passed by her/his room. Staff 6 reported the resident never used her/his call light. On 11/1/23 at 9:44 AM Staff 6 (CNA) stated it was difficult to provide adequate supervision to Resident 57 because there were only three CNA staff scheduled on day shift for 24-26 residents. On 11/1/23 at 10:53 AM Staff 7 (CNA) stated staff were supposed to check on Resident 57 every time they walked by the room but sometimes they were too busy to provide the level of oversight the resident needed. On 11/2/23 at 7:55 AM Staff 8 (LPN) reported Resident 57 had multiple falls due to self-transferring and ambulating without assistance. Staff 8 stated the resident's falls were a result of her/his psychotropic medications and light sensitivity. Staff 8 stated Resident 57 had sunglasses but the resident did not use them. She reported the resident required SBA of one person with a FWW for all ambulation. Staff 8 stated on 8/19/23, Resident 57 ambulated from her/his room all the way to the dining room without anyone noticing her/him until the CNA on the other end of the hallway saw him zig-zagging down the hallway without assistance. The resident fell, was sent to the hospital and diagnosed with a fractured hip. Staff 8 stated there were two CNAs working the evening Resident 57 fell and they were both in rooms helping other residents. On 11/2/23 at 9:08 AM Staff 10 (CNA) stated she worked the evening shift on 8/19/23 when Resident 57 fell. Staff 10 stated as she exited a different resident's room, she observed Resident 57 down the hallway, zig-zagging across the hall. She stated the resident was ambulating unassisted and without a FWW and fell. Staff 10 stated she screamed for help and it took some time before the nurse came. Staff 6 stated they had to wait for the CMA to return from a different floor before they were able to get Resident 57 off of the floor. On 11/3/23 at 12:19 PM Staff 3 (RNCM) stated Resident 57 had multiple falls. Staff 3 stated the resident did not utilize her/his call light for assistance. She reported staff were supposed to provide SBA with FWW for ambulation and complete frequent checks which she defined as peaking around Resident 57's curtain every time a staff member walked by the room. Staff 3 stated the only intervention that would keep Resident 57 safe would be one-to-one supervision but the facility could not provide that level of supervision because the facility did not have the staff. Staff 3 reported she did not complete an analysis of Resident 57's falls to determine any trends but was aware the resident typically fell when going to or from the bathroom. Staff 3 acknowledged the facility was responsible for keeping Resident 57 safe and the facility was not providing adequate supervision for Resident 57. On 11/3/23 at 2:09 PM and 11/6/23 at 10:04 AM Staff 2 (DNS) confirmed on 8/19/23 staff did not follow Resident 57's care plan which resulted in the resident sustaining a fractured hip requiring surgical intervention. Staff 2 acknowledged the level of supervision was not adequate to meet Resident 57's needs. She stated she needed to really drill down with Staff 3 and complete an analysis of Resident 57's falls and determine interventions with the assistance of the interdisciplinary team. Refer to F725.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Based on observation, interview and record review it was determined the facility failed to ensure sufficient staffing to meet resident care needs for 1 of 1 facility reviewed for sufficient and competent staffing. This failure resulted in Resident 57 having eight falls in ten months, one with serious injury which resulted in the resident sustaining a fractured hip requiring surgery. Findings include: The facility's 2/2017 Staffing Policy indicated the following: -The facility provided sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. -Staffing numbers and the skill requirements of direct care staff were determined by the needs of the residents based on each resident's plan of care. Resident 57 was admitted to the facility in 2020 with diagnoses including anxiety, depressive disorder and schizo-affective disorder (a mental health disorder). Resident 57's 7/3/23 Quarterly MDS indicated the resident had no cognitive impairments. Resident 57 required supervision for walking in her/his room, the hallway and for toilet transfers. Resident 57 was not on a toileting program. Resident 57's 8/27/23 5 Day MDS indicated the resident had severe cognitive impairment. Toileting and transfers required two person extensive assistance. The resident was not steady moving from a seated to standing position, walking was unsteady and she/he was only able to stabilize herself/himself with staff assistance. Resident 57 was not on a toileting program. Resident 57's 10/3/23 Quarterly MDS indicated the resident had no cognitive impairment. The resident required supervision to touch assistance when moving from a sitting to standing position and during toilet transfers. Resident 57 was not on a toileting program. From 1/10/23 through 10/31/23, 11 fall risk evaluations were completed. Resident 57 was typically identified to be at a moderate to high fall risk. Resident 57's 1/10/23 through 10/31/23 fall investigations revealed the resident experienced eight falls. On 8/19/23, Resident 57 sustained a right hip fracture which required surgical intervention: -1/10/23 (evening shift), 1/21/23 (day shift), 1/23/23 (night shift), 8/19/23 (evening shift), 9/18/23 (day shift), 9/26/23 (evening shift), 10/5/23 (evening shift), and 10/28/23 (evening shift). Random observations between 10/30/23 and 11/3/23 revealed the following concerns: -From 10/30/23 through 11/6/23 between the hours of 7:30 AM to 9:30 PM Resident 57 had her/his privacy curtains pulled and was not visible from the hallway on all observations. -On 10/31/23 at 1:37 PM a second floor resident smelled strongly of urine. -On 11/1/23 at 8:25 AM a call light was on in room [ROOM NUMBER] and the resident was yelling for help -On 11/1/23 between 8:51 AM and 9:11 AM Resident 57 ambulated to the bathroom, exited the bathroom, washed her/his hands at the sink and returned to her/his bed without assistance or being noticed by staff. -On 11/1/23 at 1:24 PM Resident 57 was standing at the door to her/his room yelling for assistance. A CNA intervened and walked the resident back to her/his bed then left the room. At 1:27 PM Resident 57 again ambulated to the door without assistance or using her/his FWW. The resident again yelled for assistance from the doorway. -On 11/2/23 between 2:23 PM and 2:47 PM the two second floor ICF evening CNAs were helping a resident who required two-person assistance with transfers, back to bed. No staff were visualized in the hallway for 24 minutes. -On 11/2/12 between 2:31 PM and 3:31 PM Resident 57, identified as a high fall risk (with a history of multiple falls), walked with her/his FWW to the bathroom, exited the bathroom and returned to her/his bed, unnoticed. During the 60 minute observation, no staff checked on the resident despite being care planned for frequent checks. -On 11/2/23 at 8:34 PM the call light in room [ROOM NUMBER] was activated for 34 minutes. No staff were visualized on the floor. -On 11/3/23 at 7:49 AM a strong urine smell was detected around room [ROOM NUMBER]. Interviews with staff revealed the following concerns: -On 11/1/23 at 9:44 AM Staff 6 (CNA) stated it was difficult to provide adequate supervision to the high fall risk residents, including Resident 57, because there were only three CNA staff scheduled on day shift for 24 to 26 residents. -On 11/1/23 at 10:53 AM Staff 7 (CNA) stated the second floor ICF unit had very heavy care residents and some behavioral residents, too. Staff 7 stated it was hard to provide oversight to high risk fall residents. Staff 7 stated staff were supposed to check on Resident 57 every time they walked by the room but sometimes they were too busy to provide the level of supervision the resident needed. Staff 7 stated the unit had at least 10 residents who required two-person assistance with transfers so often two staff were in a resident's room at one time. On 11/2/23 at 7:55 AM Staff 8 (LPN) stated on 8/19/23, Resident 57 ambulated from her/his room all the way to the dining room without anyone noticing her/him until the CNA on the other end of the hallway saw her/him zig-zagging down the hallway without assistance. The resident fell, was sent to the hospital and diagnosed with a fractured hip. Staff 8 stated there were two CNAs working the evening Resident 57 fell and they were both helping other residents. -On 11/2/23 at 8:31 AM Staff 9 (CNA) stated she typically worked day shift and was assigned the second floor ICF unit. Staff 9 stated the unit usually had 25 to 26 residents and only three CNAs scheduled on day shift. Staff 9 stated once in a while a float CNA was assigned to the unit but that did not occur very often. Staff 9 stated she notified the union regarding her staffing concerns. Staff 9 stated CNAs were unable to adequately supervise residents, unable to complete nail care when giving showers and unable to spend the time needed with residents because of low staffing. -On 11/2/23 at 9:08 AM Staff 10 (CNA) stated staffing was a big issue. Staff 10 stated agency staff were utilized almost every shift and they did not know the residents. Staff 10 stated she was typically assigned 12 to 13 residents on evening shift because only two CNAs were usually assigned on each ICF unit for evening shift. Staff 10 stated the facility determined staffing based on the State minimum staffing ratios and not to the acuity needs of the residents. Staff 10 stated it was difficult to provide good care. She reported some residents took a long time to care for so call light response times were often 30 minutes or more which made residents mad so they got up on their own and got hurt. Staff 10 stated she worked the evening shift on 8/19/23 when Resident 57 fell. Staff 10 stated as she exited a different resident's room, she observed Resident 57 down the hallway, zig-zagging across the hall. She stated the resident was ambulating unassisted and without a FWW and fell. Staff 10 stated she screamed for help and it took some time before the nurse came. Staff 10 stated they had to wait for the CMA to return from a different floor before they were able to get Resident 57 off of the floor. -On 11/2/23 at 8:39 PM Staff 40 (CNA) stated the second floor ICF unit had residents who required very heavy care. She stated there were usually two CNA staff assigned on the evening shift and there were many residents who required two-person assistance with transfers so two CNAs were often in residents' rooms at the same time. Staff 40 stated oftentimes the day shift did not have time to get residents requiring two-person assistance back to bed on their shift so it made it very busy on the evening shift. Staff 40 stated sometimes showers had to be bumped and there were times when she was too busy to take breaks. -On 11/2/23 at 8:40 PM Staff 41 (CNA) stated on the evening shift, third floor ICF unit there were several heavy care residents that required two-person assistance but due to staffing issues two people were often not available to provide the needed assistance which was dangerous. -On 11/2/23 at 8:52 PM Staff 18 (CNA) stated this evening, she spent over one hour trying to track down a resident's dinner tray. She stated the facility staffed float CNAs the past few days because the State was at the facility but usually they did not have float staff assigned or if there was a float staff assigned they were often pulled to cover call-ins. Staff 18 stated on the evening of 11/1/23, there was a resident on the second floor covered in feces, two different times, and the other CNA on duty was not available to help because she took frequent breaks which left Staff 18 running all night. Staff 18 stated a male resident in a wheelchair tracked her down to yell at her because the call light response times were so delayed. -On 11/2/23 at 8:53 PM Staff 16 (Agency CNA) stated this was the second time he worked at the facility and he was assigned a float position covering the second, third and fourth ICF floors. He reported when he arrived, he received a report regarding his second floor residents but not the third or fourth floor residents. Staff 16 stated he did not have access to the electronic health records until around 5:00 PM so he was unsure of the residents' needs, precautions or which residents were high fall risks. Staff 16 stated there was no way to communicate between the floors and no way to know when call lights were activated on his other units. On 11/2/23 at 10:11 AM Staff 13 (Staffing Coordinator) and Staff 14 (Staffing Assistant) reported staffing was determined based on the State minimum staffing ratios and not to the acuity needs of the residents. Staff 13 reported the ICF floors had high acuity residents and many residents required two-person assistance for transfers, one-to-one assistance with feeding and several residents were determined to be high fall risks. Staff 13 and Staff 14 reported staffing was not adequate on ICF units and the day and evening shifts would benefit from at least one additional CNA staff on each unit. Staff 13 stated staff from the Skilled unit asked for additional staffing help but she was unable to provide the requested help. Staff 13 stated she did not check agency staff competencies so she did not know if agency staff were competent to work in the nursing home setting but she tries them out and if they are not good then she blocks them. Staff 13 stated there was no formal orientation for agency staff but they used to have orientation notebooks at each nursing station. Staff 13 stated each floor nurse was responsible for orienting agency staff. On 11/3/23 at 12:19 PM Staff 3 (RNCM) stated the only intervention that would keep Resident 57 safe would be one-to-one supervision but the facility could not provide that level of supervision because the facility did not have the staff. Staff 3 acknowledged the facility was responsible for keeping Resident 57 safe and the facility did not provide adequate supervision to Resident 57. On 11/3/23 at 2:09 PM and 11/6/23 at 10:04 AM Staff 2 (DNS) confirmed on 8/19/23 staff did not follow Resident 57's care plan which resulted in the resident sustaining a fractured hip requiring surgical intervention. Staff 2 acknowledged the level of supervision was not adequate to meet Resident 57's needs. On 11/6/23 at 9:21 AM Staff 1 (Administrator) and Staff 2 (DNS) reported the facility staffed according to the State minimum staffing ratios and not to the acuity needs of the residents. Staff 1 and Staff 2 stated the facility did not review agency staff's competencies but assumed they were competent to work in the nursing home setting because they were licensed. 2. Based on interview and record review it was determined the facility failed to respond timely to residents' call lights for 1 of 3 sampled residents (#192) reviewed for staffing. This placed residents at risk for unmet care needs and accidents. Findings include: Resident 192 was admitted to the facility in 2023 with diagnoses including neck fracture. A review of Resident 192's call light response time record from 1/20/23 through 2/28/23 revealed call light wait times of 20 minutes or greater on the following dates: - 1/26/23 at 3:12 PM for 28 minutes. - 1/26/23 at 8:35 PM for 28 minutes. - 1/27/23 at 7:00 PM for 20 minutes. - 1/28/23 at 9:36 AM for 24 minutes. - 1/30/23 at 8:56 PM for 27 minutes. - 2/1/23 at 4:08 AM for 21 minutes. - 2/1/23 at 7:07 PM for 21 minutes. - 2/2/23 at 7:57 AM for 27 minutes. - 2/4/23 at 5:26 AM for 22 minutes. - 2/4/23 at 5:32 PM for 22 minutes. - 2/4/23 at 8:25 PM for 42 minutes. - 2/7/23 at 8:36 PM for 22 minutes. - 2/8/23 at 9:48 PM for 30 minutes. - 2/16/23 at 10:24 AM for 21 minutes. - 2/16/23 at 10:27 PM for 21 minutes. - 2/17 /23 at 9:05 AM for 21 minutes. - 2/18/23 at 3:44 PM for 30 minutes. - 2/27/23 at 3:22 PM for 21 minutes. - 2/27/23 at 6:36 PM for 21 minutes. On 11/3/23 at 12:05 PM Resident 192's call light record was reviewed with Staff 2 (DNS) who stated a 20 minute call light wait time was at the top of what they would like to see.