Based on interview and record review, conducted during a site visit on 09/24/24, it was confirmed the facility failed to have qualified awake direct care staff sufficient in number to meet the 24 hour scheduled and unscheduled needs of each resident for 1 of 1 sampled resident (#1). Findings include, but are not limited to:

In an interview, Resident 1 stated the following:

* Sometimes call light wait times were long.

* There was at least one instance where s/he waited for 40 minutes.

* There was at least one instance where s/he waited for an hour.

* S/he stated s/he has been left alone on the toilet for over an hour and when a CG returned they were alone, but s/he required two people and a hoyer lift.

A review of Resident 1's call light log, dated 03/01/24 to 04/10/24, showed 50 instances of his/her call light being on for 20 minutes or longer. Of those, there were three instances when his/her call light was on for 40 minutes or longer.

The findings were reviewed with and acknowledged by Staff 1 (Administrator) on 09/24/24.

The facility failed to have qualified awake direct staff sufficient in number to meet the 24 hour scheduled and unscheduled needs of each resident.

Verbal Plan of Correction: The facility was cited for staffing and ABST during their re-licensure survey in June 2024, so facility will default to their written plan of correction developed and approved by survey.