Based on record review and interview it was confirmed that the facility failed to promptly investigate all reports of abuse or suspected abuse and failed to document time, place, and individuals present; description of the events as reported; Response of staff at the time of the event; follow up action; and administrator's review. Findings include but not limited to:

During an unannounced site visit on 8/25/2022 Compliance Specialist (CS) reviewed an incident report dated 2/21/2022 #745 which revealed that Resident #1 (R1) had a witnessed fall and sustained an injury to the hip and was sent out to the Emergency Department by ambulance. There is no documentation of further investigation into this incident occurring or of abuse or neglect being ruled out.

During interview, Staff #5 (S5) indicated that they were unable to interview resident as they were at the hospital and that there was no further investigation into this incident.

These findings were reviewed with Staff #1, Staff #2 and S5 who were in agreement.

Facility POC: Wellness Director will include steps taken to rule out abuse and neglect and complete investigation, regardless of whether resident is in facility or not. Additionally, will interview all witnesses and document all staff last checks and recent ADL assistance provided in investigations.

Based on record review and interview it was confirmed that the facility failed to provide direct care staff sufficient in numbers to meet the resident's scheduled and unscheduled needs. Findings include but not limited to:

Compliance Specialist (CS) review of facility posted staffing plan and direct care staff schedules for July 2022 revealed multiple discrepancies. The posted staffing plan indicated the need for three Care Managers (CM) and 1 Med Manager (MM) on evening shift, however on 7/6/2022 only one CM and one MM were scheduled. On 7/29/2022 there were only two CMs and one MM scheduled for evening shift.

These findings were reviewed with and acknowledged by Staff #1, Staff #2, and Staff #3 on 8/25/2022 who were in agreement.

Facility POC: Facility has implemented the use of an Acuity Based Staffing Tool.