Based on interview, record review and observation it was confirmed that the facility failed to have sufficient staff to meet the scheduled and unscheduled needs of the residents. Findings include the following:

During an unannounced site visit on 02/25/2022 in separate interviews with Staff #7-11 (S7-S11) staff indicated that there were 16 2-person transfers and 2 additional situational 2-person transfers. Staff also stated the following:

·We haven ' t had a med tech working NOC shift all week

·This is the 3rd day there hasn ' t been a med tech working at night

·NOC shift has been short a med tech last week and this week

·I had a resident ask for a PRN for pain last night, but there wasn ' t a med tech working so no one could administer it.  

·We can ' t lock the doors to the outdoor courtyard so we push the couches in from so residents can ' t go outside at night.

·We ' ve had a resident we couldn ' t find for a few hours and found them wondering outside at night before.

Compliance Specialist observed 5 staff members onsite at the time of entry. 1 staff member in 3 of the  ' neighborhoods '  and 2 staff in the 4th  ' neighborhood ' . There were no med techs and no one able to administer medications onsite. CS observed staff leaving locked  ' neighborhoods '  without staff to attend residents in order to provide support in another neighborhood. Staff had pushed couches in front of doors to courtyard to prevent residents from going outside at night because they can ' t keep an eye on residents that go outside as well as residents in the neighborhoods. CS observed a resident come inside into the common area from the outdoor courtyard and no staff were present in the common area and all the neighborhood doors were locked via key code.

CS reviewed February Medication Administration Records (MARs) for Residents #1-10 (R1-R10) and found instances of medications being administered late due to short staffing, meal monitoring not being completed due to short staffing and an indication of medications not being administered due to no NOC med tech working.

Based on interview, record review and observation it was confirmed that the facility failed to have sufficient staff to meet the scheduled and unscheduled needs of the residents. Findings include the following:

During an unannounced site visit on 02/25/2022 in separate interviews with Staff #7-11 (S7-S11) staff indicated that there were 16 2-person transfers and 2 additional situational 2-person transfers. Staff also stated the following:

·We haven ' t had a med tech working NOC shift all week

·This is the 3rd day there hasn ' t been a med tech working at night

·NOC shift has been short a med tech last week and this week

·I had a resident ask for a PRN for pain last night, but there wasn ' t a med tech working so no one could administer it.  

·We can ' t lock the doors to the outdoor courtyard so we push the couches in from so residents can ' t go outside at night.

·We ' ve had a resident we couldn ' t find for a few hours and found them wondering outside at night before.

Compliance Specialist observed 5 staff members onsite at the time of entry. 1 staff member in 3 of the  ' neighborhoods '  and 2 staff in the 4th  ' neighborhood ' . There were no med techs and no one able to administer medications onsite. CS observed staff leaving locked  ' neighborhoods '  without staff to attend residents in order to provide support in another neighborhood. Staff had pushed couches in front of doors to courtyard to prevent residents from going outside at night because they can ' t keep an eye on residents that go outside as well as residents in the neighborhoods. CS observed a resident come inside into the common area from the outdoor courtyard and no staff were present in the common area and all the neighborhood doors were locked via key code.

CS reviewed February Medication Administration Records (MARs) for Residents #1-10 (R1-R10) and found instances of medications being administered late due to short staffing, meal monitoring not being completed due to short staffing and an indication of medications not being administered due to no NOC med tech working.