**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to provide a resident in a crisis condition the correct medication for 1 of 6 residents (R5) reviewed for medication errors in the sample of 50. This failure resulted in the R5 not receiving his Glucagon when needed resulting in his blood sugar dropping to a critical low and being transferred to the hospital and subsequently admitted to the Intensive Care Unit (ICU).The Immediate Jeopardy began on 9/10/25, when V6, Registered Nurse (RN), failed to appropriately respond to an emergent medical event, when R5 displayed symptoms of medical distress and presented with a blood glucose level of 33. V6 failed to follow physician's order of administering Baqsimi (Glucagon) for low blood sugar, and instead disassembled prefilled Epinephrine and Narcan cartridges, combining pieces of both medication cartridges, and administered Epinephrine injection nasally. On 9/16/25 at 2:15 PM, V1, Administrator, and V2, Director of Nursing (DON), were notified of the Immediate Jeopardy. The surveyor confirmed by interview, observation, and record review, the Immediate Jeopardy was removed on 9/17/25, but noncompliance remains at a Level 2 because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The Findings Include:R5's admission Record, dated 9/11/25, documents R5 was admitted to the facility on [DATE] with diagnosis of: Pneumonia, Chronic Obstructive Pulmonary Disease (COPD), Hypoxemia, Type 2 Diabetes Mellitus (DM), End Stage Renal Disease (ESRD), Dependent on Dialysis, Hypertension (HTN), anxiety disorder, and schizoaffective disorder.R5's Care Plan, dated 4/1/25, documents R5 has Diabetes Mellitus and Diabetic Neuropathy. Interventions: Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness, Monitor/document/report PRN any s/sx (signs/symptoms) of hypoglycemia: Sweating, tremor, increased heart rate (Tachycardia), pallor, nervousness, confusion, slurred speech, lack of coordination, staggering gait, Monitor/document/report PRN (as needed) any s/sx of hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, Kussmaul breathing, acetone breath (smells fruity), stupor, or coma.R5's Minimum Data Set (MDS), dated [DATE], documents R5 is cognitively intact and is dependent on staff for most Activities of Daily Living (ADLs). R5's Physician Order, dated 7/23/25, documents Baqsimi one pack nasal powder 3 MG (milligram)/dose (Glucagon) 1 pump in nostril as needed for low blood sugar. May repeat in 15-minutes.R5's Medication Administration Record (MAR)-Treatment Administration Record (TAR), dated September 2025, does not document that Baqsimi One Pack Nasal Powder 3 MG/Dose (Glucagon) was given to R5. There is no documentation of R5 receiving Narcan or Epinephrine (Epi).R5's SBAR (situation, background, assessment, and recommendation) Note, dated 9/10/25 at 8:08 AM, documents in part, Situation: The Change in Condition (CIC)/s reported on this CIC Evaluation are/were: Altered mental status. At the time of evaluation resident/patient vital signs and blood sugar were:- Blood Pressure: BP 120/70 - 9/10/25 at 8:09 AM,- Pulse: P 70 - 9/10/25 at 8:09 AM, Pulse Type: Regular- RR (respiratory rate): R 18 - 9/10/25- Temp: T 97 - 9/10/25 - Pulse Oximetry: O2 97.0 % - 9/10/25 Method: Oxygen via Nasal Cannula- Blood Glucose: BS 49.0 - 9/10/25 at 7:50 AM.Relevant medical history is: COPD Diabetes. Code Status: Full Code. Resident/Patient is on: Hypoglycemic medication(s)/Insulin. Outcomes of Physical Assessment: Positive findings reported on the resident/patient evaluation for this change in condition were:- Mental Status Evaluation: Altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse)- Neurological Status Evaluation: Altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse)Nursing observations, evaluation, and recommendations are:Primary Care Provider Feedback: Primary Care Provider responded with the following feedback:A. Recommendations: send for eval.On 9/11/25 at 11:05 AM, V6, Registered Nurse (RN), stated, I went in to see (R5) yesterday morning to check his blood sugar and he was lethargic, would only respond by opening his eyes when his name was called. His blood sugar was 49 at that time so I gave him some Ensure to drink, then got him some Glucagon spray from the E-Kit (Emergency Kit) and gave that to him. I then rechecked (R5's) blood sugar and it had dropped and was now reading 33. I called 911 to transport (R5) to the hospital. I do not recall giving (R5) anything else, including any injections. (V27, Licensed Practical Nurse (LPN) was the other nurse helping me with (R5).On 9/11/25 at 11:55 AM, V27, LPN, stated, (V6) asked me to come help her with (R5) and that she needed the E-Kit. I went and got the E-Kit and handed her a long tube-looking thing and a nasal spray. I saw her take out the long tube looking thing, then put the top from the nasal spray on the long tube thing and she gave it to (R5) in his nose. I did not give any drugs. If that was an Epi Pen, then yes, I handed it to her and that was my fault. I did an incident report, reported it to the NP (Nurse Practitioner) and the DON (Director of Nursing).On 9/11/25 at 1:41 PM, V28, Emergency Medical Technician Paramedic (EMTP), stated, When we arrived at the facility, we had a male unresponsive with a blood sugar of 42. We started an IV (intravenous catheter) and administered D10. When we were moving him from his bed to our stretcher, we found an Epi Pen with a Narcan nasal spray cap on top of it. When I asked the nurse about it, she said she gave him Glucagon. I had two other firefighters look at it and they both verified that it was an Epi Pen. Again, the nurse stated that she knew she gave Glucagon. We put the resident on the stretcher and left the facility and took him to the ER (emergency room). Upon our arrival to the ER, the resident was slightly more alert to verbal stimuli, and his glucose was up to 136. I told the ER and my EMS director about the Epi Pen, and they were going to report it.R5's Emergency Medical Service (EMS) Report, dated 9/10/25, documents in part: Arrived on scene, made entry into the facility and into pt (patient) room to find male pt lying in bed unresponsive. Nurse states pt is diabetic and his blood sugar was low. Nurse states she gave pt internasal glucagon and placed him on a non-rebreather mask with 15 LPM (liters per minute) of O2 (oxygen). No staff is bedside with pt upon arrival. ALS (advanced life support) had arrived first on scene. Obtained blood glucose level via finger prick method. Value of 42. Started 18g (gauge) angiocath in pt left hand and flushed with saline before locking and securing with Tegaderm. Pt skin is warm and clammy at this time. Started 250 ML (milliliter) bag of D10% (glucose solution) using macro drip tubing. While D10 is infusing, pt is moved to the stretcher from his bed using bed sheet and assistance from FD (fire department). While moving pt, an Epi Auto Injector pen is found in pt. bed. Placed on top was the nasal piece used for internasal Narcan. When staff nurse was asked why the Epi pen was in the bed, she stated that it was Glucagon, and she had administered it in an attempt to raise pt glucose level. Pen was handed to FD for confirmation. FD also confirmed that pen is an Epi pen and not Glucagon. Nurse continues to argue that it is Glucagon, and it must have been placed in the wrong spot, and she did not confirm before administration.On 9/11/25 at 9:50 AM, V24, Master Social Work (MSW)/Licensed Social Worker (LSW), stated I was working yesterday when (R5) arrived in the ER. The EMS guys gave us an Epi Pen that had a Narcan Cap from a intranasal administration unit on top of it and was told that the nurse at the facility gave this to (R5). The EMS told the ER staff that (R5) was unresponsive upon their arrival to the facility, they gave some D10 solution to raise his glucose and upon arrival to the ER, (R5) was awake, alert but still groggy. (R5) was admitted to the ICU for observation.On 9/11/25 at 12:05 PM, V6, RN, stated, I have to tell you what happened. I lied to you earlier. (V27) handed me the Epi Pen and Glucagon Nasal Spray and I did not even look at them to see what they were. I put the cap on the pen and tried to give it to (R5). Honestly, I don't even know if he got any of it. So much was going on at that time and the next thing I know, EMS was here and took over. I did give the EMS guys the Epi Pen and Nasal Spray. I'm not that familiar with these types of drugs. This was my first med error, and I feel horrible, especially about lying about it.On 9/11/25 at 2:40 PM, V2, DON, stated, There are tackle boxes with emergency medications in it, including Epi Pens, Narcan, and Baqsimi Nasal Powder. The nurses would grab this for emergency situations.On 9/15/25 at 10:25 AM, V3, LPN, stated, If I found a resident who was unresponsive, I would check their blood sugar, look for orders, and grab the medication that you put up their nose. I can't think of the name of it right now, but if I see it, I will know what it is. It is kept in the tackle box E-Kit. I would not give Epi because it is not an allergic reaction, nor would I give Narcan because it is not an overdose.On 9/15/25 at 10:30 AM, V11, LPN, stated If I found one of my residents unresponsive, I would check their vital signs and blood sugar. If the blood sugar is low and they are not able to take something by mouth, I would go to the E-Kit and get the Glucagon nasal spray and administer it to them to get their blood sugar up. I would not give Epi for something like this because it is not an allergic reaction.On 9/11/25 at 2:10 PM, V2 stated I would expect the nurses to use the five rights of medication administration and follow the physician orders.On 9/15/25 at 10:50 AM, V2 brought in an Epi Pen and a Narcan Nasal Spray and attempted to demonstrate how V6 was administering R5's medication. V2 stated I doubt that he got any of the medication the way she put this together. I feel this is simply incompetent nursing.V2's Investigation, dated 9/11/25, documents Nursing Description: Nurse called into room and found resident's blood sugar to be 39. Blood sugar was retaken and decreased to 33. Nurse then went to medication room to obtain Glucagon nasal spray and Narcan nasal spray was given in error. Immediate action taken: NP was made aware of the Epi spray being given. VS-120/70, 70, 18, 97.0. Nursing stayed with resident and 911 called to transport resident to ER via stretcher. Resident was alert leaving the unit. V2 stated she is not finished with the investigation and will be in-servicing the nurses.On 9/15/25 at 2:13 PM, V29, Physician/Medical Director, stated I was only notified of (R5's) hypoglycemic episode and that he was sent to the hospital. No one mentioned to me that he was not given his glucose and was given something else. I have standing orders for Glucagon to be given and that should have been given. When told of V6 giving R5 an Epi Pen with the Narcan top and spraying up R5's nose, V29 stated Oh my God, that is unbelievable. I have never heard of such a thing. This could have been detrimental to (R5) and could have been fatal to him. He didn't get his Glucagon that was ordered, and his glucose could have continued to drop. This is truly unbelievable; the lack of competency could have subsequently determined (R5's) outcome, which could have been death in this case. I would expect the Nurse to administer medications as per my orders, and per appropriate route.According to the NIH - National Library of Medicine; Nursing Rights of Medication Administration - StatPearls - NCBI Bookshelf at https://www.ncbi.nlm.nih.gov/books/NBK560654/. Nursing Rights of Medication Administration: Nurses have a unique role and responsibility in medication administration, in that they are frequently the final person to check to see that the medication is correctly prescribed and dispensed before administration. It is standard during nursing education to receive instruction on a guide to clinical medication administration and upholding patient safety known as the ‘five rights' or ‘five R's' of medication administration. The five traditional rights in the traditional sequence include: Right Patient, Right Drug, Right Route, Right Time, and Right Dose.According to the NIH - National Library of Medicine; SCOPE OF PRACTICE - Nursing Fundamentals - NCBI Bookshelf at https://www.ncbi.nlm.nih.gov/books/NBK610819. The Scope of Practice refers to services a trained health professional is deemed competent to perform and permitted to undertake according to the terms of their professional nursing license. Nursing scope of practice provides a legal framework and structured guidance for activities that practical nurses and registered nurses can perform based on their nursing license. Nurses must also follow standards when providing nursing care. Standards are set by several organizations, including your state's Nurse Practice Act, the American Nurses Association (ANA), agency policies and procedures, and federal regulators. These standards help guide nursing actions with the intent that safe, competent care is provided to the public. Nursing Process: The nursing process is a critical thinking model based on a systematic approach to client-centered care. Nurses use the nursing process to perform clinical reasoning and make clinical judgments when providing client care. The nursing process is based on the Standards of Professional Nursing Practice established by the American Nurses Association (ANA). These standards are authoritative statements of the actions and behaviors that all registered nurses (RNs), regardless of role, population, specialty, and setting, are expected to perform competently. Education: The registered nurse seeks knowledge and competence that reflects current nursing practice and promotes futuristic thinking. Quality of Practice: The registered nurse contributes to quality nursing practice. Resource Stewardship: The registered nurse utilizes appropriate resources to plan, provide, and sustain evidence-based nursing services that are safe, effective, financially responsible, and judiciously used.According to the NIH - National Library of Medicine; Nursing Rights of Medication Administration - Stat Pearls - NCBI Bookshelf at https://www.ncbi.nlm.nih.gov/book/NBK/560654/ documents in part Nursing Rights of Medication Administration. Nurses have a unique role and responsibility in medication administration, in that they are frequently the final person to check to see that the medication is correctly prescribed and dispensed before administration. It is standard during nursing education to receive instruction on a guide to clinical medication administration and upholding patient safety known as the ‘five rights' or ‘five R's' of medication administration. The five traditional rights in the traditional sequence include: Right Patient, Right Drug, Right Route, Right Time, and Right Dose. The Facility's Medication Administration Policy, dated 10/2024, documents in part Administration of Medications: Medications must be administered in accordance with a Physician's order, e.g., the Right Medication, Right Dosage, Right Route, and Right Time. The Immediate Jeopardy that began on 9/10/25 was removed on 9/17/25 when the facility took the following actions to remove the Immediacy: 1. All nurses were educated on the use of Emergency Medications by V2, DON, on 9/11/25.2. Any nurses that are not available in person have been contacted via phone. If not reachable, will be educated prior to taking shift by DON or designee.3. 9/15/2025, V2, DON, V30, LPN, and V31, RN, ADON reviewed the incident.4. 100% Nursing staff has been educated on the signs and symptoms of hypoglycemia and hyper glycemia by V2, DON, and V31, RN, ADON on 9/15/25.5. Any nurses that are not available in person have been contacted via phone. If not reachable, will be educated prior to taking shift by DON or designee.6. On 09/10/ 2025 NP was notified of the change in condition and MD notified of the resident being hypoglycemia and being sent to ER.7. V6 and V27 educated on ensuring right medication and dose prior to medication administration by V2, DON, on 9/15/25. 8. All nursing staff educated on the 5R's of medication administration by V2, DON, on 9/15/25.9. V6 and V27 were educated and completed competent in medication administration on Narcan, Epinephrine, and Baqsimi on 9/15/25.10. 100% of nursing staff was educated on medication administration on 9/15/25.11. DON or Designees will audit medication administration 2 times a week for 3 months. This began on 9/15/25.12. DON or Designee will audit 3 residents 2 times weekly to ensure blood sugar are within normal limit per MD orders for 3 months this began on 9/15/25.13. The emergency kits and the cart will be audit weekly to ensure educational material is in place. This started on 09/15/25. This will be on going for 3 month and review in our QA meeting. This will be monitor by ADON or designee.14. ADHOC QA completed with IDT regarding Policy and procedure on 9/15/25.15. QA to review policy and procedure as part of Quality Assurance Process; next QA meeting.16. This will be on going for 3 months.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to monitor and supervise a resident with severe cognitive impairment for 1 of 1 resident (R4) reviewed for supervision in the sample of 5. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 7/31/23 when the facility failed to identify that R4 was missing, last seen at around 11:00AM and discovered entrapped on the elevator at 10:30 PM. This Past Noncompliance occurred from 7/31/23 to 8/1/23. On 8/22/23 at 3:03 PM, the V1, Administrator, V2, Director of Nursing (DON) and V22, [NAME] President of Operations, were notified of the Immediate Jeopardy. Findings include: R4's Minimum Data Set, dated [DATE], documented R4 had severally impaired mental cognition, however, R4 recalls long term memory and not short-term memory but is able to speak and answer simple questions. R4's admission Record, dated 8/10/23, documented R4 had diagnoses of dementia, psychotic disturbance, mood disturbance, anxiety, heart disease and major depressive disorder. R4's Care Plan, dated 6/20/23, documented, R4 requires assistance with transfers due to being unaware of safety issues and a fall risk with an intervention of a 1-person assistance with transfers, including locomotion on and off the unit. R4's Care Plan documents R4 is incontinent of bowel and bladder, physical addiction to nicotine/smoking and a fall risk due to a medical condition of Dementia with the use of a medication to treat moderate to severe dementia of the Alzheimer type. R4's Facility documentation, untitled and dated 7/31/23, documents, On 7/31/23, the facility called a code pink at 20:30 PM, (8:30 PM) after not being able to locate a resident when completing a facility check. Staff verify that the resident was not out on pass. The Administrator was notified and instructed the nurse in charge to notify the police. Resident was in the facility in the small elevator. Fire department, (elevator service company) and Emergency Medical Transport called to the facility. Resident was removed from the elevator at approximately 11:00 PM. Resident refused to go to the hospital, therefore the facility nurse assisted and resident was given food and assisted to his room. R4's July 2023 Medication Administration Report (MAR) documented the following medications were not given to R4 on 7/31/23 during the 8:00 PM medication administration: Hydralazine HCl, 10 milligrams (mg) for hypertension with blood pressure not taken; Namenda, 5 mg, for dementia, psychotic disturbance, mood disturbance and anxiety; Lisinopril, 20 mgs, 1 tablet for hypertension; Tamsulosin HCl, 0.4 mg one capsule for benign prostatic hyperplasia. Tamsulosin capsule 0.4 milligram (mg) for benign prostatic hyperplasia. The MAR documented R4 should have vital signs every Monday on the evening shift, and these were not documented as completed. The MAR documented R4 should receive health shake, magic up, ensure or fortified pudding with meals at 5:00 PM and this was not documented as given. On 8/10/23 at 3:00 PM, V3, Licensed Practical Nurse (LPN), stated R4 is a smoker and will come and go. V3 stated R4 propels himself in his wheelchair, is a smoker and knows when its smoking time. V3 stated R4 answers short questions and has short term memory recall. V3 stated she worked the day of 7/31/23, 2:00PM -10:00 PM. V3 stated R4 has a blood pressure reading scheduled at around 7:30 PM. V3 stated R4 was not found in his room and there was an un-eaten supper tray at his bedside table. V3 stated a search was conducted down stairs where R4 likes to hang out, he was not found. V3 stated, at that point she notified V1, Administrator, that R4 was not to be found in the facility. V3 stated a whole outside ground and building search was performed. The emergency department, fire department, police and Elevator service were all notified and were present in the facility at approximately 9:30 PM. V3 stated at around 10:00 PM, R4 was found located in the elevator, but not retrieved from the elevator until 11:00 PM, by the Elevator Service Company. V3 stated she remained in the building until around 10:30 PM. On 8/10/23 at 2:30 PM, V1, Administrator, stated R4 was assessed after the incident. V1 stated R4 refused to go to the hospital and R4's physician was notified on 8/1/23. V2 stated labs were obtained as ordered for 8/1/23 and within normal limits. V1 stated she was at the small elevator door on the 2nd floor. V1 stated R4 did respond after V1 knocked on the elevator door at around 10:00 PM. V1 stated the emergency department stayed at the 2nd floor elevator door and she went down to the basement with the elevator maintenance personnel, where the mechanical issues were addressed. V1 stated they opened the small elevator door and released R4 from the elevator. On 8/10/23 at 3:15 PM, V5, Certified Nurse Aide, CNA, stated R4 takes all four scheduled smoke breaks, as R4 is aware of the smoking scheduled times. V5 stated she worked the day of the incident on 7/31/23 from 2:00 PM to 10:00 PM; however, she had the first half of the hall and R4 resides at the back end of the hall. V5 stated she saw R4 propel himself in his wheelchair and down the elevator but she did not follow-up to check on R4's whereabouts. The facility's entitled form, Smoking Times, undated, documented the following smoke times: 9:15 AM, 11:00 AM, 3:00 PM and 6:00 PM. On 8/14/23 at 9:40 AM, V8, Activity Aide, stated R4 requires supervision. V8 stated the activity staff go to his room and assist R4 from the 3rd floor down to 2nd floor for smoking times and activities. V8 stated R4 enjoys doing activity's; however, R4 will come down the elevator unassisted by himself. V8 stated she worked the day of 7/31/23. V8 stated R4 was assisted down at 9:30 AM smoke break. V8 stated after the smoke break the activity department serves morning coffee which R4 enjoys. V8 stated R4 arrived on the 2nd floor for 2nd smoke break at around 11:00 AM but that is the last she saw R4. V8 stated she worked until 5:00PM. V8 stated at 3:30 PM, during 3rd scheduled smoke break she realized R4 did not come down to smoke. V8 stated she did not go look for R4. On 8/14/23 at 10:04 AM, R3 stated that R3 does not smoke; however, he walks a lot down the hall and uses the elevator from the 3rd floor to the 2nd floor. R3 stated R4 uses a wheelchair, as he tries to propel himself, but it's hard for him. R3 stated he has assisted R4 to the elevator by pushing him in his wheelchair many times, and seen other residents assist him as well. On 8/14/23 at 10:15 AM, R5 stated R4 smokes along with him. R5 stated R4 can get himself in his wheelchair and take himself down to the 2nd floor for smoke breaks. R5 stated he heard about the incident with R4 and was wondering why R4 never returned to his room for a long time. R5 stated R4 can get in his wheelchair by himself, but he rolls along in his wheelchair slow, so other residents have help to push R4 to the elevator. On 8/14/23, at 2:00 PM, V9, CNA stated she was assigned to care for R4. V9 stated R4 is known to get up on his own into his wheelchair and take himself to the elevator as he likes to be downstairs. V9 stated at scheduled smoking times and activities the activity aide or the CNA retrieves R4 and assist him downstairs. V9 stated the last scheduled smoke break is at 6:30 PM. V9 stated, I should have checked on (R4), but did not check on him or his whereabouts and should have. V9 stated supper is delivered and served on the 3rd floor around 5:30-5:45PM. V9 stated about 8:00 PM, is when V9 was informed by V11, Licensed Practical Nurse to do a search inside and outside of the facility building for R4 with V10, CNA. V9 stated, she took the 3rd floor and V10 took the 2nd floor and R4 was not found. V9 stated V3 had notified V1, then the fire department, police department and elevator inspector service had all arrived at the facility. On 8/15/23 at 11:56 AM, V2, Director of Nursing, DON stated R4 should be supervised and checked on every 2-3 hours. On 8/15/23 at 2:00 PM, V1 stated she did not have a policy for resident requiring supervision/monitoring and she is aware R4's scheduled medication for 8:00P was not marked as given on the Medication Administration Record. V 1 stated, she couldn't find documentation that physician was informed of the medications R4 did not receive. On 8/21/23 at 2:57 PM, V28, R4's physician, stated he recalls receiving a call on 7/31/23 that R4 was trapped in an elevator but stated he was not informed R4 missed his scheduled 8:00 PM medication. V28 stated if informed he would asked the nurse the status of R4's vital signs (blood pressure/heart rate) and if vital signs were his normal range limit, would have given telephone orders to resume his normal medication the following day at scheduled time of 8:00 AM. On 8/23/23, at 9:10 AM, V16, Elevator Company Maintenance, stated he was called out to this facility due to a trapped resident (R4) and informed he is to continue weekly monitoring of the elevator functioning. V16 stated he was called out on 7/31/23 around 11:00 PM. V16 stated he went to the basement to check the coding issue of the elevator, went back upstairs, and opened the elevator door to the small elevator, and R4 was sitting in a wheelchair. V16 stated R4 was happy to see V16. V16 stated if the elevator by chance, has too many buttons pushed at one time, can shut off the memory to the elevator and shut it down. In this case V16 was unsure what happened but was present when the small elevator door was opened and R4 was sitting in a wheelchair and retrieved by the emergency department. The Immediate Jeopardy began on 7/31/23 when staff were unaware R4 was missing and located/entrapped in a non-functioning elevator and was removed on 8/1/23. Prior to the survey date, the facility took the following actions to remove the immediately and correct the noncompliance: 1)Immediate actions taken for those residents identified: Resident R4: Resident has been assessed for Psychosocial needs related to incident with no negative outcome noted. Resident's skin was assessed with no negative outcome noted. Resident remains at baseline. The facility will continue to provide needed care and services. Psychosocial Assessment was completed 08/01/2023 by V25, Social Service Director. Skin assessment was completed 07/31/2023 by V26 RN. Physical Assessment was completed 08/01/2023 by Nurse Practitioner. 2) Measures put into place/ System changes: All Staff have been educated on the definition of Supervision. If any staff are unable to be contacted, they will be taken off the schedule until education can be provided. Completed 08/01/2023 by Director of Nursing, Dietary Manager, Minimum Data Set/Care Plan (MDS/CP) Coordinator, Human Resource (HR) Director, and Administrator. All Staff have been educated on the following: Anytime a resident is not available for meals, smoke breaks, or medications, staff will immediately locate the resident. Completed 08/01/2023 by Administrator, Director of Nursing, Dietary Manager, MDS/CP Coordinator, HR Director. Two-hour resident checks have been implemented. Initiated 08/01/2023 and ongoing. Direct Care Staff Daily Elevator checks have been implemented. Maintenance Director, Dietary Manager, Social Service Director, Director of Nursing, Completed Daily Residents have been educated/reviewed with/on the Steps to use the Elevator Social Service Director 08/01/2023. Elevator was evaluated and repaired 7/31/2023. The Facility will contract with (Elevator company) to maintain a Weekly Check for Safety for 3 months then Monthly for 3 months then quarterly ongoing. 3) How the corrective actions will be monitored: Administrator/Designee will complete five random Resident Safety Checks a week for 12 weeks to ensure Supervision of residents. The results of these checks will be reviewed in Quality Assurance Meeting monthly x6 months or until an average of 90% compliance or greater is achieved x3 consecutive months. The QA Committee will identify any trends or patterns and make recommendations to revise the plan of correction as indicated. Date of compliance: 08/01/2023 On 8/23 and 8/24/23, the surveyor verified Past Noncompliance by the following: Reviewed staff in-service sign in sheets for Supervision with signature verification of completion; Interviews were conducted with V12, RN, V15, Transport Driver, V16, Elevator Repair Service, V17, Dietary Aide, V18, Activity Director, V20, CNA, V21, Maintenance Director, V24, Activity Aide, and V25, Social Service; Daily Elevator Checks were reviewed for dates of 8/1/23 through 8/23/23; R2, R3, R5, R6, R7, R8, R9 were all interviewed regarding if they received in-service to use the elevator and what to do if the elevator malfunctions with no issues noted; Elevator annual inspection of 3/21/23 and 7/31/23 were reviewed and weekly checks for safety were reviewed which were provided by the Outside Elevator maintenance; R4 was observed with staff providing supervision to smoking, activities and while on elevator; Review of documentation, entitled, Out facility, In facility, review dated from 8/1/23 through 8/21/23 of every resident room, documents residents were assured to be in the facility from the 2nd and 3rd floors, every 2 hours, starting at 6:00AM to 4:00AM following days; Quality Assurance Meeting documentation was reviewed for 8/1/23.