VISTA MESA ASSISTED LIVING RESIDENCE

A certification complaint, prompted by #CO40156 and #CO42132, was completed on 4/28/26. Zero deficiencies were cited.

A licensure complaint, prompted by #CO40155 and #CO42131, was completed on 4/28/26. Deficiencies were cited.

Based on record review and interview, the residence failed to report suspected physical abuse to law enforcement within 24 hours of discovery pursuant to Colorado Revised Statutes (C.R.S.), affecting one of four sample residents (#3). Findings include:1. Record Review Resident #3 was admitted to the residence on 1/1/25 with a diagnosis of PARKINSON'S disease. An incident report dated 4/27/26, revealed that on 4/26/26, Resident #3 reported that Staff #2 attempted to move her feet while she was lying on the floor after a fall. The report further revealed that Resident #3 stated that Staff #2 pushed her on the ground. A progress note dated 4/27/26, revealed that Resident #3 experienced an assisted fall at approximately 6:30 a.m. Resident #3 reported that her legs became stiff prior to the fall and stated that Staff #2 pushed her when she could not move her legs. The note further revealed that staff assisted Resident #3 to the floor, obtained additional staff assistance, and assisted her to the restroom and back to bed. An assessment identified a small bruise to the left shin and no other significant injuries. The resident later requested evaluation in the emergency room, the family was notified, and the service plan was updated. 2. InterviewsOn 4/28/26 at approximately 2:45 p.m., the administrator stated that she became aware on 4/27/26 of the incident involving Staff #2 and Resident #3 regarding alleged abuse. She further stated that she investigated the incident and determined that the event involved an assisted fall to the ground. The administrator additionally stated that she did not report the incident to law enforcement because the findings of her investigation did not substantiate the allegation of abuse. On 4/28/26 at approximately 4:15 p.m., the residential services director (RSD) stated that, if the residence reported every complaint alleging that staff pushed residents or treated them unkindly, the residence would contact law enforcement on a daily basis. On 4/28/26 at approximately 4:50 p.m., the administrator acknowledged that she should have contacted law enforcement regarding the incident and stated that she would do so in the future.

Based on record review and interview, the residence failed to comply with occurrence report requirements required by state law, affecting 49 current residents. Findings include:1. Record ReviewOn 4/28/26 at approximately 3:00 p.m., during record and documentation reviews, the administrator did not provide an occurrence report for the incident that occurred on 4/26/26, in which Staff #2 allegedly pushed Resident #3 to the ground. As of 4/28/26 at approximately 5:00 p.m., the residence had not submitted an occurrence report to the department. 2. InterviewOn 4/28/26 at approximately 5:00 p.m., the administrator stated that she did not submit an occurrence report and was unsure whether she was required to do so because her internal investigation did not substantiate the allegation.

Based on observations, interview and record review, the residence failed provide therapeutic diets when the diet is prescribed by the resident's practitioner, affecting one of four sample residents (#3). Findings include:1. Record ReviewResident #4 was admitted to the residence on 7/23/21 with a diagnosis of SJOGREN syndrome, hypothyroidism, hypercalcemiaA residential assessment completed on 3/2/26 was reviewed and revealed that Resident #4 had a physician ' s order for a pureed diet and documented gluten and milk intolerances. 2. ObservationOn 4/28/26 at approximately 12:24 p.m., Resident #4 received a lunch meal consisting of pasta with white gravy sauce and broccoli; however, the meal was not pureed and contained gluten and milk despite the resident ' s documented dietary restrictions. 3. InterviewOn 4/28/26 at approximately 5:00 p.m., the administrator acknowledged the deficient practice and stated that she would update the documentation to align with the physician ' s new order.

A complaint revisit was completed on 5/13/25 for all previous deficiencies cited on 10/21/24. The residence is in compliance with all regulations surveyed. The deficiencies cited for Event M6D612 were cited prior to the regulation revision that was implemented on 3/17/25.

A licensure complaint, prompted by #CO37770, was completed on 10/21/24. Deficiencies were cited.

Based on record review and interview the residence failed to update the comprehensive assessment after a resident's condition changed from baseline status affecting one of two sample residents (#2) and one former resident (#3). (Cross-reference 1324)Findings include:Resident #2 was admitted to the residence on 8/1/12 with a diagnosis of adult failure to thrive, a history of falls, age-related osteoporosis, overweight, and hypertension. A nursing wound protocol, dated March 2024 read in part, left heel dressing to be changed by nursing staff. Wounds should be cleaned and dressed to prevent infection, off-load of heels to prevent future pressure and facilitate healing. Off-loading of coccyx and buttocks to prevent shearing and skin breakdown. Heels should be floated on pillows while in bed. Draw sheet used for bed mobility. Wrap feet in a trash bag during the shower to keep it dry. Monitor wounds routinely for healing progress and update family. Monitor for any signs of infection such as foul odor, purulent exudate, abnormal vital signs, increased pain, and worsening wounds. The current care plan for Resident #2, dated 4/28/24 read in part, that staff was to ensure the following interventions were available and properly utilized to prevent skin breakdown: air cushion on the wheelchair, encourage Resident #2 to lay down one to two times per day to relieve pressure, home health visits weekly, keep all open wounds covered at all times to prevent spread, discard all dressing in the red hazardous container, encourage Resident #2 to drink a protein-enriched drink daily, notification of administrator as soon as a change in skin condition occurs, Resident #2's spouse to apply skin barrier creams to excoriated non-open areas, apply a protective barrier to the right buttock area, weekly skin checks document special attention to groin, buttocks, skin folds, and lower legs and feet. Notify the nurse of any skin issues or wounds. A "Weekly Head to Toe Skin Check" for Resident #2, dated 6/6/24 read in part, the resident had a skin tear to the left buttocks. A "Weekly Head to Toe Skin Check" for Resident #2, dated 6/13/24 read in part, the resident had a skin tear to the left buttocks. A "Weekly Head to Toe Skin Check" for Resident #2, dated 6/20/24 read in part, the resident had a skin tear to the left buttocks. A comprehensive assessment for Resident #2, dated 9/25/24 read in part, that Resident #2 understood he was at risk of or had actual skin breakdown due to his decreased mobility, shearing, and pressure. To keep skin integrity intact interventions would be implemented. A practitioner order for Resident #2, dated 10/16/24, directed the residence to check the wound dressing daily and change if saturated or it fell off. To cleanse buttocks wound with normal saline, wound cleanser, apply skin prep to peri-wound areas, apply hydrofiber or silver alginate to wound beds, cover with an abdominal gauze pad, and secure with tape. Notify the supervisor of any issue with dressing or wound. A progress note for Resident #2, dated 10/16/24 read in part, that the dressing was saturated with blood. The buttock wound was cleansed without a wound cleanser. The open areas of the wound to both buttocks were red and "beefy looking". A progress note for Resident #2, dated 10/17/24 read in part, that the dressing was saturated with blood. A wound cleanser was used to clean the buttocks wound. The open areas of the wound on both buttocks were red inflamed and bleeding. The skin surrounding the wound was irritated and pink. A progress note for Resident #2, dated 10/18/24 read in part, that the dressing was saturated with blood. The buttock wound was cleansed without a wound cleanser. The wound beds to both buttocks were red and actively bleeding. The skin surrounding the wound was irritated and pink. A progress note for Resident #2, dated 10/20/24 read in part, the turning and repositioning schedule was as at 6:00 a.m., 10:00 a.m., 2:00 p.m., 4:00 p.m., 8:00 p.m., and donot disturb between 8:00 p.m. and 6:00 a.m. Staff were to reposition five times daily to promote buttock wound healing, encourage repositioning while in a wheelchair, and encourage to offload buttocks in the bed in the right or left side laying position. On 10/21/24 at 10:00 a.m., the administrator stated that the home health provider provided wound care to Resident #2. She stated staff occasionally provided additional care and then documented the care. However, the administrator stated the care staff provided was determined by the practitioner. On 10/21/24 at 4:30 p.m., the administrator stated that a skin issue was considered a change of condition and acknowledged that a comprehensive assessment must be updated when a change of condition is noted. Similarly deficient practice was observed with regard to former Resident #3.

Based on record review and observations the residence failed to protect the right to be free from neglect affecting one of three sample residents. (Cross-reference 1146)Specifically, the residence failed to assess Former Resident #3 who developed a pressure ulcer that progressed in severity over the course of a month prior to the residence developing and implementing strategies to prevent further development. The residence failed to complete a comprehensive assessment until after the pressure ulcer had progressed to the degree the residence was no longer able to care for the resident. 1. Record ReviewFormer Resident #3 was admitted to the residence on 5/16/23 with a diagnosis of hypothyroidism, hypertension, Parkinson's disease, atrial fibrillation, and pulmonary embolism. A care plan, dated 3/13/24 read in part, that Former Resident #3 was to receive skin integrity care through assistance with good peri care and toileting daily; provided meals and snacks, encourage hydration; encourage activity participation; perform weekly skin assessments and report any changes in skin condition to supervisor and family. A progress note, dated 8/1/24 read in part, that the external hospice provider removed the floatation mattress, and the residence would implement a rotation schedule to prevent recurrent skin breakdown. No breakdown was noted. A practitioner order form, dated 8/1/24 read in part, that Former Resident #3 was referred to external palliative care services. A practitioner order form, dated 8/2/24 directed the residence to apply ointment to buttocks, peri, and rectal area, topically four times a day for breakdown prevention, it may be kept at the bedside. A palliative care provider note, dated 8/6/24 read in part, that a physical examination of the skin found a wound to the dorsal aspect of the right second toe. The assessment did not make any note of the wound on the coccyx region. A progress note, dated 8/16/24 read in part, that Former Resident #3 was red and the area over a healed stage two pressure ulcer appeared to be near reopening. A progress note, dated 8/16/24 read in part, that the administrator discussed with the resident services director and other staff, the loss of supplies from hospice and would need to get an egg crate mattress and cushion for the wheelchair. A progress note, dated 8/17/24 read in part, that the coccyx wound was unchanged with scant drainage, the old bandage had fallen off, the area was cleansed and dried, and foam dressing was applied with paper tape but did not stick to used cloth tape. No pain was noted. A palliative care provider note, dated 8/23/24 read in part, that the residence reported that the sacral wound was previously on an alternating pressure mattress that helped to prevent her pressure injuries. Will order an alternating pressure mattress. Will start wound care at the next appointment. A progress note, dated 8/23/24 read, "Coccyx area with denuded dime-sized area scant drainage serous with a blister filled and intact. Mid spine with protruding vertebrae very thin skin over vertebrae, skin over mid vertebrae red protectant dressing intact, bolter in bed for positioning and pillows for comfort, repositioning every 2 hours, roho (pressure sore) cushion in (wheelchair), resident does turn back to her back when turned to the side."A progress note, dated 8/25/24 read in part, that staff changed the dressing to the coccyx, cleaned the wound, and added a new dressing. The resident moved to her side to relieve the pressure area. A progress note, dated 8/29/24 read in part, that Former Resident #3's sacral area dressing was soiled and needed to be changed. The old bandage was removed and the area was washed and cleaned. The open area measured 6.5 cm by 3.5 cm. The administrator was notified the palpating mattress had not yet arrived. A palliative care provider note, dated 8/30/24 read in part, change sacral wound dressing every other day or when soiled. A progress note, dated 9/1/24 read in part that,the old dressing was soiled and the wound measured 5.8 cm by 3.5 cm by 2 cm, and tunneling, foul odor, and slough were noted. The administrator was notified. A progress note, dated 9/2/24 read in part, change sacral wound dressing every other day or when soiled, effective. A progress note, dated 9/2/24 read in part, that the wound did have significant drainage on the old bandage as well as odor and slough noted. Former Staff #1's file included an "Employee warning notice" dated 9/2/24 read in part, Former Staff #1 was seen sitting in a recliner in the main area. The safety rounds and toileting were not completed. A practitioner order, dated 9/4/24 directed the residence to please start antibiotics for wound infection. A care plan, dated 9/5/24 read in part, the resident had coccyx skin breakdown, dressing changes done by nursing, and staff were required to do routine off-loading of coccyx and buttocks to prevent shearing and skin breakdown. Former Staff #2 ' s file included an "Employee warning notice" dated 9/4/24 read in part, Former Staff #2 was seen sitting on the recliner, using her phone, and sleeping from 1:30 a.m. to 4:00 a.m. Shift tasks not completed. A progress note, dated 9/5/24 read in part, that Former Resident #3's mattress had not yet been delivered. The coccyx wound was getting worse. A progress note, dated 9/6/24 read in part, that Former Resident #3 would be discharged due to the wound care specialist staging the wound as stage three. The discharge care plan meeting was scheduled for 9/10/24. A shift checklist dated 9/8/24 read in part, do not leave former Resident #3 on her back, reposition every two hours, and transfer to the wheelchair with a cushion on it. 2. InterviewOn 10/21/24 at 4:00 p.m., the interim resident services director (RSD) stated she split skin checks with the previous RSD. She also stated Former Resident #3 had two stage two pressure ulcers on her sacral area which healed with the wound care provided by the external hospice service provider. She further stated after Former Resident #3 graduated from external hospice in late July or early August 2024 the provider took the palpating mattress which was key in the healing of the pressure ulcers. She stated the administrator requested palliative care services and specialized equipment for wound prevention. The RSD stated we got a cushion for her wheelchair and it was unclear if the mattress was received. She stated the wound declined quickly over the course of the month. Further, she stated the administrator acted as Former Resident #3's primary care provider until the palliative care provider was assigned, and the administrator was notified and aware the entire time. The care plan should have been updated as soon as the change of condition was noted. On 10/21/24 at 4:30 p.m., the administrator stated that Former Resident #3 was discharged from external hospice care, and when the provider left they took the mattress and wheelchair cushion which helped to heal the previous pressure ulcers. She stated Former Resident #3 was referred to a palliative care provider. The administrator stated she was the practitioner from the time the external hospice left to the time the new palliative care provider was assigned. She also stated when the wound was first identified as changing in August 2024, first interventions should have been implemented which did not officially become care planned until September first. "We could have done better, staff should have turned her more ... staff need to turn residents, yes if they don't it would be neglect." Similar deficiencies were ongoing, as evidenced by Resident #2 ' s current condition, which required consistent wound care that had not been properly administered, accurate and updated assessment and care planning had not been created, and staff education and training had not been effective.

A certification complaint, prompted by #CO37771, was completed on 10/21/24. No deficiencies were cited.

A revisit survey was completed on 12/14/23 for all previous deficiencies cited on 8/8/23. No deficiencies were cited.

Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

A revisit survey was completed on 12/14/23 for all previous deficiencies cited on 8/8/23. No deficiencies were cited.

A relicensure survey, with complaint #CO32974, was completed on 8/8/23. Deficiencies were cited.

Based on observation, record review and interview, the residence failed to comply with authorized practitioner orders associated with medication administration, affecting one of three sample residents (#3). (Cross-reference Q1514)Findings include: 1. Residence PolicyThe residence's undated Medication Administration Policy, read in part: "qualified staff will administer medications to residents unable to self-administer."2. Resident #3 was admitted to the residence on 6/14/21.a. MelatoninA written practitioner's order, dated 7/23/22, directed the residence to administer melatonin 10 mg once at bedtime. However, the July 2023 electronic medication administration record (eMAR) for Resident #3 read the medication was not administered on 7/20/23 due to the medication being out of stock, for a total of one missed dose. b. AspercremeA written practitioner's order, dated 5/26/22, directed the residence to administer aspercreme lidocaine 4% topically twice daily. However, the July 2023 (eMAR) for Resident #3 read the medication was not administered once on 7/21/23 due to the medication being out of stock, for a total of one missed dose. 3. InterviewOn 8/8/23 at 4:09 p.m., the administrator stated that qualified medication administration persons (QMAPs) were responsible for contacting the pharmacy to ensure resident medications were in stock. The administrator stated she expected compliance with practitioner's orders. The administrator further acknowledged the above medications were out of stock and therefore, were not administered to Resident #3.

Based on record review and interview, the residence failed to accurately document each medication administration at the time the event was completed for each resident, affecting one of three sample residents (#2). (Cross-reference Q1514)Findings include:1. Residence PolicyThe residence's undated Medication Administration Policy, read in part: "the administration of medication shall be documented at the time of administration."2. Resident #2 was admitted to the residence on 5/20/21. A written practitioner's order, dated 2/2/23, directed the residence to administer 4 ounces of house supplement daily. However, the August 2023 electronic medication administration record (eMAR) revealed a blank on 8/2 and 8/3/23. 3. InterviewsOn 8/8/23 at 2:23 p.m., the resident services director stated blanks in the eMAR meant that a staff member had forgotten document medication administration for Resident #2. On 8/8/23 at 4:09 p.m., the administrator stated that a blank in the eMAR meant that a staff member had forgotten to document the medication as administered, refused or otherwise. The administrator stated that she expected residence staff to accurately document in the eMAR at the time of administration.

Based on record review and interviews, the administrator failed to, along with the qualified medication administration personnel (QMAP) supervisor, audit the accuracy and completeness of the medication administration records (MARs), controlled substance list, medication error reports, and medication disposal records, affecting 52 current residents. (Cross-reference Q1510 and Q1468)Findings include:On 8/8/23 at 7:06 a.m., quarterly medication audits were requested from the residence. At 10:59 a.m., only medication error reports were provided by the resident services director (RSD), which contained information about blanks in the electronic medication administration record (eMAR) and missed medications. An undated document titled May Medication Errors, did not include the name of the QMAP supervisor nor documentation about the accuracy and completeness of the MARs, controlled substance list, medication error reports, or medication disposal records. An undated document titled July Medication Errors, did not include the name of a QMAP supervisor nor documentation about the accuracy and completeness of the MARs, controlled substance list, or medication disposal records. Further, the audits did not contain evidence it had been completed with the administrator and the QMAP supervisor. On 8/8/23 at 10:51 a.m., the RSD stated she had completed the medication error reports as part of this requirement, however, did not sign off on the audits. The RSD also stated she signed off that she reviewed each order from practitioner's prior to transcribing them onto the eMAR, however, was unaware of all the requirements of a medication audit. On 8/8/23 at 4:09 p.m., the administrator acknowledged that she was not aware that medication audits were required to include how an audit ensures the accuracy and completeness of eMARs, controlled substance lists and disposal records. She stated she had completed medication audits; however, had not documented them as required. The administrator stated she was unaware that she was required to document that she participated in medication audits along with the RSD.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.10.1 The assisted living residence shall have readily available a roster of current residents, their room assignments and emergency contact information, along with a facility diagram showing room locations.

A recertification survey, with complaint #CO32975, was completed on 8/8/23. Deficiencies were cited.

Based on observations, record review, and interviews, the facility (residence) failed to follow written policies and procedures for the administration of medication in accordance with 6 CCR 1011-1, Chapter VII medication administration regulations, affecting 52 current residents. 1. Chapter VII regulations governing assisted living residences, part 14.21, require the residence to be responsible for complying with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers.a. Residence PolicyThe residence's undated Medication Administration Policy, read in part: "qualified staff will administer medications to residents unable to self-administer."b. Resident #3 was admitted to the residence on 6/14/21. MelatoninA written practitioner's order, dated 7/23/22, directed the residence to administer melatonin 10 mg once at bedtime. However, the July 2023 electronic medication administration record (eMAR) for Resident #3 read the medication was not administered on 7/20/23 due to the medication being out of stock, for a total of one missed dose. AspercremeA written practitioner's order, dated 5/26/22, directed the residence to administer aspercreme lidocaine 4% topically twice daily. However, the July 2023 (eMAR) for Resident #3 read the medication was not administered once on 7/21/23 due to the medication being out of stock, for a total of one missed dose. c. InterviewOn 8/8/23 at 4:09 p.m., the administrator stated that qualified medication administration persons (QMAPs) were responsible for contacting the pharmacy to ensure resident medications were in stock. The administrator stated she expected compliance with practitioner's orders. The administrator further acknowledged the above medications were out of stock and therefore, were not administered to Resident #3. 2. Chapter VII regulations governing assisted living residences, part 14.29, requires the residence to ensure each QMAP, nurse, or authorized practitioner document each medication administration or monitoring event at the time the event is completed for each resident.a. Residence PolicyThe residence's undated Medication Administration Policy, read in part: "the administration of medication shall be documented at the time of administration."b. Resident #2 was admitted to the residence on 5/20/21. A written practitioner's order, dated 2/2/23, directed the residence to administer 4 ounces of house supplement daily. However, the August 2023 electronic medication administration record (eMAR) revealed a blank on 8/2 and 8/3/23. c. InterviewsOn 8/8/23 at 2:23 p.m., the resident services director stated blanks in the eMAR meant that a staff member had forgotten document medication administration for Resident #2. On 8/8/23 at 4:09 p.m., the administrator stated that a blank in the eMAR meant that a staff member had forgotten to document the medication as administered, refused or otherwise. The administrator stated that she expected residence staff to accurately document in the eMAR at the time of administration. 3. Chapter VII regulations governing assisted living residences, part 14.31, requires the administrator and the QMAP supervisor to, on a quarterly basis, audit the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and medication disposal records. Any irregularities shall be investigated and resolved. On 8/8/23 at 7:06 a.m., quarterly medication audits were requested from the residence. At 10:59 a.m., only medication error reports were provided by the resident services director (RSD), which contained information about blanks in the electronic medication administration record (eMAR) and missed medications. An undated document titled May Medication Errors, did not include the name of the QMAP supervisor nor documentation about the accuracy and completeness of the MARs, controlled substance list, medication error reports, or medication disposal records. An undated document titled July Medication Errors, did not include the name of a QMAP supervisor nor documentation about the accuracy and completeness of the MARs, controlled substance list, or medication disposal records. Further, the audits did not contain evidence it had been completed with the administrator and the QMAP supervisor. On 8/8/23 at 10:51 a.m., the RSD stated she had completed the medication error reports as part of this requirement, however, did not sign off on the audits. The RSD also stated she signed off that she reviewed each order from practitioner's prior to transcribing them onto the eMAR, however, was unaware of all the requirements of a medication audit. On 8/8/23 at 4:09 p.m., the administrator acknowledged that she was not aware that medication audits were required to include how an audit ensures the accuracy and completeness of eMARs, controlled substance lists and disposal records. She stated she had completed medication audits; however, had not documented them as required. The administrator stated she was unaware that she was required to document that she participated in medication audits along with the RSD.

Based on record review and interview the facility failed to ensure there was at least one staff member for every 10 participants during the daytime hours, one staff member for every 16 participants during the nighttime shift and one staff for every six participants in the secured environment at all times, affecting 12 current participants who resided in the secure environment. Findings include:Regulations governing alternative care facilities 10 CCR 2505-10 section 8.495.6. I.3 read, an approved staffing waiver is only applicable for nighttime hours, with the exception for secured environments. b. A staffing waiver expires five years from the date of approval. Continuance of staffing waiver requires Department approval. The resident agreement read in part: "the facility would be staffed with either (2) twelve hour blocks from 6:00 a.m. to 6:00 p.m. and 6:00 p.m. to 6:00 a.m. or (3) eight hour blocks from 6:00 a.m.-2:00 p.m., 2:00 p.m. to 10:00 p.m. and 10:00 p.m. to 6:00 a.m."Additionally, the resident agreement read: "Ratios at the residence in the non-secured unit will be 1:10 from 6:00 a.m. to 6:00 p.m.; 1:16 from 6:00 p.m.-10:00 p.m.; and 1:23 from 10:00 p.m. to 6:00 a.m. Ratios in the secured unit are 1:6 from 6:00 a.m. to 6:00 p.m.; 1:10 from 6:00 p.m.-10:00 p.m.; and 1:12 ratio from 10:00 p.m. to 6:00 a.m."The residence had a staffing waiver, dated 9/9/02, almost 21 years old, for 1:12 staff from 10:00 p.m. to 6:00 a.m. in the secured environment and 1:23 staff from 10:00 p.m. to 6:00 a.m. in the non-secured environment. On 8/8/23 review of the current resident roster revealed there were 12 residents in the secure environment and 40 residents in the non-secure environment. The July and August 2023 staff schedules revealed there were two staff members in the non-secured unit from 10:30 p.m. to 6:30 a.m. and one staff member in the secured unit from 10:00 p.m. to 6:30 a.m. On 8/8/23 at 2:57 p.m. contrary to the roster, the administrator stated there were 11 residents in the secure environment. The administrator stated she has had a waiver that was approved in 2002 for only one staff to be in the secured unit overnight and two staff in the non-secured unit overnight. The administrator explained there were five staff total in the building until around 10:00 p.m. On 8/8/23 at 3:56 p.m., a department representative stated the waiver was null and void for staffing ratios since it was outdated. On 8/8/23 at 4:09 p.m., the administrator stated she was aware of the staffing ratio requirements and stated that she thought her staffing waiver was still accepted since she had not been informed otherwise.